Technical modifications in the robotic-assisted surgical approach for gynaecologic operations.

To investigate the development of new technical approaches for improving the implementation of robotics in gynaecologic surgery, we conducted a prospective evaluation of five technical modifications developed during the implementation of a robotics program that included 171 robotic endometrial staging procedures from December 2007 until May 2010. Modification of the use of a Hohl uterine manipulator by applying only the intravaginal component minimizes the theoretical risk of spillage of endometrial cancer cells, without losing the capability of delineating the vaginal fornices. Entry to the peritoneal cavity under visual control using a left upper quadrant approach and a 5-mm endoscope through a 5-mm Endopath(®) trocar is quick and decreases the risk of bowel or vessel injury. Use of 12-mm Endopath(®) trocars with blunt tips without closure of the fascia was not associated with post-operative hernias. Positioning the Da Vinci(®) Surgical System at a 30° angle at the side of the patient allows easy access to the vagina for removal of large surgical specimens and does not interfere with proper movements of the robotic arms. Use of a tissue specimen bag introduced via the vagina at completion of surgery allows removal of large uteri vaginally to avoid (mini-)laparotomy and its morbidities. Finally, suturing of the vault using interrupted delayed absorbable monofilament sutures was not associated with vaginal cuff dehiscence. Early evaluation of evolving minor technical and surgical approaches was associated with low morbidity, and appears to benefit patients undergoing robotic surgery for gynaecologic cancers.