Single port robotic hysterectomy technique improving on multiport procedure.

The benefits of laparoscopic surgery over conventional abdominal surgery have been well documented. Reducing postoperative pain, decreasing postoperative morbidity, hospital stay duration, and postoperative recovery time have all been demonstrated in recent peer-review literature. Robotic laparoscopy provides the added dimension of increased fine mobility and surgical control. With new single port surgical techniques, we have the added benefit of minimally invasive surgery and greater patient aesthetic satisfaction, as well as all the other benefits laparoscopic surgery offers. In this paper, we report a successful single port robotic hysterectomy and the simple process by which this technique is performed.

INTRODUCTION

As surgeons, there has been a continued push toward decreasing the complications associated with large surgical incision sites and its other associated disadvantages. With the advent of laparoscopic surgery, we can now minimize the size of the incision, however, at times we may have to do this at the expense of visibility and maneuverability.[12] The Laparoscopic Robot has accorded the benefit of mobility with each of the Robot arms having seven degrees of mobility and great visualization with the high definition (HD) 3D (dimensional) laparoscopic camera.[3] The single port laparoscopic system allows several ports to be introduced into the abdomen via one central incision.[4] The size of the port is about 4 cm and fits through a 2 cm incision. Once healed, the scar is virtually unnoticeable. We have found that the single port robotic technique gives the best results if done on a patient whose uterus is less than sixteen weeks size and the operator is proficient in robotic laparoscopy.

CASE REPORT

A 46 year old white female presented to the office for surgical management of menorrhagia and fibroid uterus. She was a physically fit aerobics instructor who had one previous pregnancy, no medical problems other than chronic anemia, and a negative hematologic work-up. Ultrasound showed a 13 week size uterus with multiple leiomyoma varying in size however no significant endometrial pathology. She had previously undergone, hormonal therapy management, Hysteroscopy, Dilatation and Curative and Nova sure endometrial ablation without success. Endometrial biopsy pathology revealed disordered proliferative endometrium, however, no evidence of atypia or malignancy. The patient had been given an Invasive Radiology consult for possible Uterine Artery Embolization, however wished to have the uterus removed robotically. The patient wished to minimize any abdominal scars as she prided herself on her figure and bikini modeling. She underwent a single port robotic hysterectomy. There were no intraoperative or postoperative complications. Blood loss was 25 milliliters and the average operative time was 180 minutes.

PROCEDURE

There are currently several single port systems on the market however the single incision laparoscopic surgery (SILS) port was chosen due to its small size and maneuverability. A 2 centimeter (cm) vertical umbilical incision is made through the umbilicus which gives a more aesthetically pleasing closure to the patient once healed. The SILS port is inserted, the 8 millimeter (mm) camera port is placed, followed by incretion of the 8 mm robot camera. The camera port is placed posterior to the two 8 mm robot arm ports which are crossed anteriorally. An 8 mm port is placed in the left lateral pubic region to visualize insertion of the Robot instruments. The robot is center docked to increase mobility of the robot arms. The robot arms are angled in a ‘chopstick’ like fashion so that the corresponding instrument will cross the midline and function on the opposite side of the body. Switching arm controls on the robot console will allow the left hand to control the right robot arm which is angled to the patients left pelvis and the right hand to control the left robot arm which is angled and to the right pelvis. This will also alleviate any awkwardness perceived by this change. We have found that mapping the arm trajectory and position on the patient's abdomen prior to port insertion greatly improves the ease of insertion and operation. The remainder of the procedure is performed in the usual robotic fashion. The vaginal cuff is closed by using either a v-lock suture or 0-vicryl suture on a straightened large needle to fit through the 8 mm port.

DISCUSSION

Hysterectomies, which once required large abdominal incisions with long hospital stays and extensive recovery time leading to man power economic losses in the billions each year, can now be done without those previous drawbacks.[5] Laparoendoscopic single-site surgery (LESS) is now a safe and effective approach across surgical disciplines with the benefits of decreasing postoperative pain, better cosmesis and decreased hospital stay, in addition to offering virtually scar less surgery.[6] Some of the drawbacks of traditional straight stick laparoscopic hysterectomy remain including reliance on the surgical assistant abilities and limited instrument dexterity. Additionally, visualization is limited to traditional 2D visualization optics. The robot offers better fine instrument control with 7 degrees of instrument arm mobility, superior HD 3D visualization and less blood loss than most abdominal surgical procedures including laparoscopic surgery.[4] The robot surgeon has control of all three instruments of the robot and therefore has less dependence on a surgical assistant. There are drawbacks to single port surgery such as the arms often colliding with each other and poor mobility in cases where the uterus is bulky. With our patient, the satisfaction rating was excellent.

CONCLUSION

As laparoscopic gynecologic hysterectomy becomes the standard for performing hysterectomy, continued innovations and collaboration with existing processes will greatly improve patient satisfaction, safety and decrease operative time. As the race is on to make more flexible and articulating laparoscopic instruments to assist in gynecologic surgery, we must utilize those instruments that afford us the best and safest outcome. The single port robotic procedures are already used in multiple surgical specialties and with the advent of patient satisfaction being part of the reimbursement matrix, single port robotic hysterectomy will be a significant addition to this growing mantra.