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![ROLE OF ROBOTICS IN
GYNECOLOGY
1. Suture-dependent procedures – 7 Degree of freedom and endowrist instruments
Myomectomy,
Tubal reanastomosis,
Sacrocolpopexy)
2. Procedures requiring fine dissection
Deeply infiltrating endometriosis [DIE]
Oncology
3. Procedures involving large patients and/or pathology](https://image.slidesharecdn.com/robotic-240317162508-280c56d9/75/ROBOTIC-SURGERY-CURRENT-STATUS-IN-GYNECOLOGY-19-2048.jpg)
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ROBOTIC SURGERY-CURRENT STATUS IN GYNECOLOGY
- 1. ROBOTIC SURGERY – CURRENTSTATUS DR MEGHA KANSARA FELLOW MINIMAL INVASIVE SURGERY GYNECOLOGY AIIMS JODHPUR
- 2. • History andCurrent trends – World wide and Indian scenario • Advantages and limitations • Platforms • Status in different benign surgeries- Hysterectomy, myomectomy, urogynecology, endometriosis • Status in gynecological malignancies- endometrial, cervical, ovarian • Recent advances future scopes.
- 3. History The word Robotis derived from Czech word ‘"robata’’ means drudgery. In 1985, the first-surgical robot called the Programmable Universal Machine for Assembly 560 (PUMA 560) -neurosurgical biopsy at Pittsburgh, Pennsylvania . 1988, Imperial College in London - ProBot (transurethral prostatectomies.) 1989- Automated Endoscope System for Optimal Positioning (AESOP) was developed that received approval from the FDA in 1994, making it the first telepresence surgical robot. 1990 ZEUS Robotic Surgical System(three remotely controlled arms.) 1990s, Integrated Surgical Solutions, -ROBODOC®- for hip replacement in human subjects in 1992. The first da Vinci robot in 2000 had three arms In 2009, the da Vinci Si model was released, allowing dual console surgery and improved training for non-expert surgeon. Robotic hysterectomy was first performed by Diaz-Arrastia et al. in 2002 In 2005, the FDA granted gynecological surgery approval for the Da Vinci surgical system Robotic radical hysterectomy was first performed by Sert et al. in 2006.
- 4. Distribution of roboticsurgery Sinha, Arvind.et.alVig,. Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme. Journal of Minimal Access Surgery 17(1):p 32- 36, Jan–Mar 2021. Robotic procedures for gynecologic procedures increased by 6.5% in 2022. 87% of the surgical robotic systems -US, Europe, and Japan.. 282,000 gynecologic surgery 138,000 urologic procedures, and 421,000 general surgery procedures were all carried out in the US using the da Vinci. 66 Robotic surgery centers in India where 71 robotic systems have been installed. More than 500 doctors trained in using robotic systems for surgical procedures. India-12,800 robotic surgeries have been conducted over the last 12 years.
- 5. Advantages • Better ergonomics •Intuitive handling of instruments. • 7 degrees of freedom • 3D optics • Less fatigue • Digital networking • No fulcrum surgery • Faster learning curve • Better dissection and suturing • Integrated fluorescence visualization (Firefly® System*)
- 6. limitations • Lack ofhaptic feedback • Cost • Additional learning curve • Additional time for docking.
- 7. MANTRA SSI Innovations,India ROBOTIC PLATFORMS
- 8. Robotic equipments The da VinciSurgical System has four main components: • 1. Surgeon Console • 2. Patient-Side Cart • 3. EndoWrist Instruments • 4. Vision System .
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- 11. Marchegiani F, et.al.NewRobotic Platforms in General Surgery: What's the Current Clinical Scenario? Medicina (Kaunas). 2023 Jul 7;59(7):1264.
- 12. Robotic platforms -davinci • Si- stationary arm • Xi-rotating boom
- 13. ROBOTIC PLATFORMS(da vinci) SiXi Stationary Rotating Side docking –patient’s right or left hip Side docking –perpendicular to torso Robotic arms –thick and bulky Robotic arms are thinner and longer. Manipulation of arms -during docking is limited. Manipulation of arms is easier.(more range of motion) Docking time - more Less docking time.
- 14. • Making robotic surgeriesaffordable - Dr Sudhir Prem Srivastava, Founder, Chairman and CEO of SS Innovations with SSI MANTRA, the first and only Made-in- India surgical robot. • Central Drugs Standard Control Organization (CDSCO) has approved it.
- 15. Total surgeries performed-500 Total installation in India -17 Surgeons trained- 80
- 16. Instruments available inSSI Mantra
- 17. Davinci vs SSIMantra SSI mantra Da vinci Surgeon console Open face,3D HD 32’’ monitor Closed, small HD view, Hand controls and foot pedal Visible while operating Not visible Patient side cart Slim, more flexible, needs more OT space All arms mounted on single beam Potential collision Vision system 32’’3D screen for assistant &trainees 24’’ 2D monitor for patient side team , no depth perception Instruments Multifire clip applicators Single fire clip applicators Cost Low (5-8 crores) High(10-20crores) Number of platforms and surgeries(India) 17 and 500 90 and 50,000
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- 19. ROLE OF ROBOTICSIN GYNECOLOGY 1. Suture-dependent procedures – 7 Degree of freedom and endowrist instruments Myomectomy, Tubal reanastomosis, Sacrocolpopexy) 2. Procedures requiring fine dissection Deeply infiltrating endometriosis [DIE] Oncology 3. Procedures involving large patients and/or pathology
- 20. Robotic surgery –current status for benign pathology • Gynecological surgeries that can be performed robotically- • Hysterectomy and bilateral salpingectomy, • Myomectomy/adenomyomectomy, • Endometriosis excision, • Sacrocolpopexy. • Tubal anastomosis ACOG: Robot-Assisted Surgery for Noncancerous Gynecologic Conditions: ACOG COMMITTEE OPINION, Number 810. Obstet
- 21. Not recommended - •Procedures of short duration and low complexity are unlikely to benefit from robot-assisted surgery. • Due to a lack of advantages and potential disadvantages, both ACOG and SGS recommend against (in most routine cases) the use of a robotic approach for the following procedures (if not performed as part of another surgical procedure): 1.Tubal ligation 2.Simple ovarian cystectomy 3.Surgical management of tubal ectopic pregnancy 4.Bilateral salpingo-oophorectomy 5.Bilateral salpingectomy 6.Diagnostic laparoscopy or other surgeries when diagnosis is unknown
- 22. ROBOTIC HYSTERECTOMY • 12randomised con- trolled trials (RCTs), on effectiveness and safety of RAL vs. CL in benign and malignant gynaecological disease concluded that surgical complication rates are comparable in benign disease. • HAS ROLE IN- 1. Complex hysterectomies are being performed robotically like stage III-IV endometriosis, 2. Previous multiple laparotomies, 3. Cases with severe adhesions, 4. Uterus -larger in size and weight. Lawrie TA, Liu D, Dowswell T, Song H, Wang L, Shi G. Robot- assisted surgery in gynaecology. Cochrane Database Syst Rev. 2019;4:CD011422.
- 23. Retrospective study 397 –totalsample size RH-197 CLH-200 Conclusion-No significant differences in operating time, perioperative complications, hospital stay and blood loss.
- 24. Robotic myomectomy • Firstrobotic myomectomy -Da Vinci robot was by Advincula et al., in 35 patients • The mean diameter of fibroids was 7.9 ± 3 cm • Mean weight was 223 ± 244 g, • The conversion rate from robotic to laparotomy was 8.6%, comparable to that of conventional laparoscopic myomectomy. • EBL to be 169 ± 198 ml with average operative times of 230 ± 83 min. • Advincula AP, Song A. Endoscopic management of leiomyomata. Semin Reprod Med. 2004;22:149–55
- 25. Comparison between lapvs robotic myomectomy Conventional Laparoscopic myomectomy Robotic myomectomy 2D Vision(but now 3D camera is available) 3D vision Compromised depth perception Good depth perception Suturing requires practice Suturing is easy – endowrist instruments Difficult to close vertical incision Any incision can be sutured Conversion to open 11.3% Conversion to open 0-3% Cost effective Costly
- 26. Capozzi VA, ScarpelliE, Armano G.et.al. Update of Robotic Surgery in Benign Gynecological Pathology: Systematic Review. Medicina
- 27. Robotic surgery forendometriosis Robotic surgery -Indicated in conditions -heterogeneity of lesions, which makes it difficult to identify them, difficulties in precisely forecasting surgical complexity, and extended operating times for severe patients. Advantages- • Better visualization • Better dissection- less blood loss • Better identification of Deep infiltrating endometriosis • Advantages over laparoscopy for early stage is unclear. • Limitations • Longer operative time • Becker CM, Bokor A, Heikinheimo O, Horne A, Jansen F, Kiesel L, et al. ESHRE guideline: endometriosis. Hum Reprod Open 2022;2022
- 28. Robotic Sacrocolpopexy • Major limitationof laparoscopic sacrocolpopexy- requires extensive suturing for fixation of mesh. • Robotic sacrocolpopexy- • Advantages- • Shorter learning curve • Intracorporeal suturing is straightforward. • Short time outcomes of robotic and lap sacrocolpopexy are comparable.
- 30. Glass Clark S,Shepherd JP, Sassani JC, Bonidie M. Surgical cost of robotic-assisted sacrocolpopexy: a comparison of two robotic platforms. Int Urogynecol J. 2023 Jan;34(1):87-91 Conclusion-Despite longer operating times, total cost of robotic- assisted sacrocolpopexy was significantly lower when using the Senhance compared to the DaVinci system.
- 31. Robotic tubal anastomosis •manipulation of the previously transected fallopian tubes with subsequent dissection of the separated proximal and distal segments followed by meticulous reconnection using very fine suture. • Advantages- • Enhanced depth perception • magnified operative field • tremor filtration, • motion scaling, • use of wristed instruments facilitate performing microsurgical tasks. • Open, lap, robotic pregnancy rates 68%, 65%, and 65%(similar) Van Seeters J.A., Chua S.J., Mol B.W.J., Koks C.A. Tubal anastomosis after previous sterilization: A systematic review. Hum. Reprod.
- 32. Robotic surgery- Endometrial cancer Recent Cochrane review– state that robotic approach is safe, feasible and has comparable outcomes in early stage endometrial cancer . Galaal K, Donkers H, Bryant A, et al. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database Syst Rev 2018;10:CD006655. Advantages over laparoscopy- 1. Better dissection of retroperitoneal space. 2. 3D view – better dissection of lymph nodes. 3. ICG (indigo carmine green dye) for identification of sentinel lymph nodes. 4. Less conversion rate to laparotomy .
- 33. 2 Systematic review studieshave concluded that– compared to laparoscopy, robotic surgery had significantly decreased – 1.blood loss, 2. shorter hospital stay, and fewer overall complications. 3.The conversion rate was found to be significantly decreased for robotic compared to laparoscopic surgery, ranging from 0– 15%. Ind T, Laios A, Hacking M, et al. A comparison of operative outcomes between standard and robotic laparoscopic surgery for endometrial cancer: a systematic review and meta-analysis. Int J Med Robot 2017;13 Park DA, Lee DH, Kim SW, et al. Comparative safety and effectiveness of robot- assisted laparoscopic hysterectomy versus conventional laparoscopy and laparotomy for endometrial cancer: a systematic review and meta-analysis. Eur J Surg Oncol 2016;42(9):1303–1314. ENDOMETRIAL CANCER
- 35. POPULATION WITH INCREASEDSURGICAL RISK In the LAP2 study, the overall conversion rate from laparoscopy to laparotomy was 25%, but increased to 57% in patients with a BMI >40 LAP2 study, the conversion rate increased by 30% for every additional decade of life The pooled conversion rates when including all patients were similar between the two groups, being 6.5% and 5.5% for laparoscopic and robotic surgery, respectively. However, a subgroup analysis for BMI ≥40 revealed pooled conversion rates of 7.0 and 3.8%, respectively. 1.OBESITY 2.ELDERLY Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol 2009;27(32):5331–5336. Cusimano MC, Simpson AN, Dossa F, et al. Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications. Am J Obstet Gynecol 2019;221(5):410–428.e19.
- 36. Berek and hackertext book of gyne oncology 7th edition
- 37. Robotic surgery-cervical cancer Asystematic review comparing 932 robotic, 373 laparoscopic, and 892 open radical hysterectomies showed that the robotic approaches had significantly less blood loss, transfusion requirements, and intraoperative complications, with a shorter hospital stay and similar oncologic outcomes to the open radical hysterectomy cases . This randomized controlled noninferiority trial showed lower rates of progression-free and overall survival in those treated with MIS compared to open laparotomy . The role for MIS in the treatment of early-stage cervical cancer has become controversial since the recent publication of the LACC trial. Zhang SS, Ding T, Cui ZH, et al. Efficacy of robotic radical hysterectomy for cervical cancer compared with that of open and laparoscopic surgery: a separate meta- analysis of high-quality studies. Medicine (Baltimore) 2019;98(4):e14171.
- 38. FERTILITY PRESERVING SURGERY RADICALTRACHELECTOMY-for early cervical cancer has been shown to have similar efficacy and safety when compared with radical hysterectomy. A systematic review showed that the fertility rates for those trying to conceive were higher for trachelectomies done with either MIS or vaginally than with laparotomy (65%, 57%, and 44%, respectively Bentivegna E, Maulard A, Pautier P, et al. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertil Steril 2016;106(5):1195–1211.e5
- 39. ADVANCED TECHNIQUES Nerve-sparing techniquesfor radical hysterectomy and radical trachelectomy require meticulous dissection to preserve the hypogastric nerve plexus -to reduce postoperative bladder and rectal dysfunction. Precision and stereotactic vision of robotics may help facilitate these nerve- sparing approaches . Other advanced procedures that have been performed robotically include extraperitoneal para-aortic lymphadenectomy up to left renal vein (and transperitoneal infrarenal aortic lymphadenectomy. Fujii S, Takakura K, Matsumura N, et al. Anatomic identification and functional outcomes of the nerve sparing Okabayashi radical hysterectomy. Gynecol Oncol 2007;107(1):4–13. Narducci F, Lambaudie E, Mautone D, et al. Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy in gynecologic oncology: preliminary experience and advantages and limitations. Int J Gynecol Cancer 2015;25(8):1494– 1502.
- 40. Robotic surgery- ovariancancer •Limited role • Robotics has been successfully applied to the treatment of early-stage ovarian cancer with comparable outcomes . • Under research-primary debulking surgery with radical dissections such as supracolic omentectomy, diaphragmatic stripping, bowel and liver resections, and splenectomy • Based on published data, the benefits of robotics have not been seen in patients requiring more than two major procedures, such as bowel resection, full-thickness diaphragmatic resection, liver resection, or splenectomy . • Robotics may serve as a tool for interval debulking after neoadjuvant chemotherapy for advanced disease. Berek and hacker text book of gynecological oncology 7th edition
- 41. RECENT ADVANCES Fluorescent imagingwith ICG dye represents one of the first technologies to be merged with the 3D high- definition robotic imaging systems. Future robotic platforms may provide more advanced augmented reality by incorporating radiologic images into the image visor, and possibly layering real-time radiologic images onto the live visual field. Another advancement in MIS has been the development of single-site systems, in which all the operative arms are introduced through one single port. Telesurgery, artificial intelligence and artificial neuronal networks.-
- 42. SUMMARY Robotic surgery issafe, feasible and has better or comparable outcomes for benign diseases . It has added benefit of improved ergonomics, vision and suturing dependent surgeries. Robotics has been successfully applied to the treatment of endometrial cancer, with similar oncologic outcomes demonstrated. Its use in cervical cancer is currently undergoing further research. It is technically feasible, but the oncologic outcomes have been questioned. In ovarian cancer, it appears to be useful for early-stage disease and for interval debulking following neoadjuvant chemotherapy for advanced disease.
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