Robotic-assisted surgery has been both celebrated as "revolutionary" and defamed as a "crutch." No matter where your loyalties lie in this debate, what is not debatable is the dramatic increase in minimally invasive surgery (MIS) rates for hysterectomy since robotic-assisted surgery was approved for gynecology in 2005. Rates vary across samples and sources, but according to 2011 data from Solucient and 2010 data from the Agency for Healthcare Research and Quality, approximately 27% of hysterectomies are performed with the robot, 26% with standard laparoscopy, and 12% vaginally.
It should be clear to all in 2013 that a total abdominal hysterectomy approach (TAH) is the least favored route for hysterectomy in terms of global cost, invasiveness, and overall complication rate. Therefore, as the AAGL has stated, we should all strive to improve our MIS skill-set – whether it is by the vaginal, laparoscopic, or robotic-assisted approach (J. Minim. Invasive Gynecol. 2011;18:1-3).
Personally, I prefer robotic-assisted techniques. As a community gynecologist, I believe that the marriage of high-tech computerization with the surgical sciences allows for more reproducibility than the traditional vaginal or laparoscopic approaches (J. Minim. Invasive Gynecol. 2008;15:286-91; Obstet. Gynecol. 2010;115:535-42).
In my experience, there are now three reproducible techniques for performing robotic-assisted hysterectomy. The first is a robotic total laparoscopic hysterectomy (TLH) technique involving 4-5 ports, which incorporates some of the steps familiar to surgeons performing TAH. This approach was initially described by Dr. Charles Koh after the advent of the Koh colpotomizer (J. Am. Assoc. Gynecol. Laparosc. 1998;5:187-92) and was then modified and adapted to the robotic platform with my colleagues at the Ochsner Clinic in Louisiana.
The second is a reduced two-port technique that was developed last year with my colleagues at the Texas Institute for Robotic Surgery in Austin.
Last, clearance by the Food and Drug Administration in February 2013 for a da Vinci single-site instrumentation package for use in benign hysterectomy and salpingo-oophorectomy makes the single-site technique a third reproducible approach for performing hysterectomy with the robotic platform. Use of the instrumentation package is currently being launched at Celebration Health Florida Hospital, the Cleveland Clinic, Newark (N.J.) Beth Israel Medical Center, and the Texas Institute for Robotic Surgery.
In addition to being more reproducible, the robotic route to hysterectomy now affords a "see-and-treat" approach, by which we can insert an endoscopic camera, assess the difficulty of the operation (pathology, uterine size, adhesions, etc.), and then select the robotic technique that is best for the patient.
In positioning the patient, precautions are taken to prevent patient slippage on the operating table during steep Trendelenburg. Most commonly, we place a gel pad or egg crate mattress directly onto the operating table, secure it with tape, and follow with direct placement of the patient onto the gel pad or egg crate. The patient’s arms are then padded and tucked by the sides and the legs are placed in Allen stirrups.
The actual procedure is begun by placing the uterine manipulator of choice. I prefer the RUMI II System with articulating tip or the Advincula Arch with the Koh colpotomizer ring (CooperSurgical, Trumball, Conn.). Other popular options are the VCare manipulator with cup (ConMed Endosurgery, Utica, N.Y.) and the McCarus-Volker Fornisee (LSI Solutions, Victor, N.Y.).
The vaginal pneumo-occlusion balloon can be placed on all three manipulators and is critical for maintaining the pneumoperitoneum that allows for the success of this technique. The importance of properly placing the uterine manipulator of your choice cannot be overemphasized.
For insufflation, I use a Veress needle placed intraumbilically or in the left upper quadrant (LUQ), depending on the patient’s surgical history. The LUQ is preferred if the patient has a history of a prior midline incision. (The stomach must be desufflated first.) The intraumbilical approach is preferred if the patient has a history of LUQ or bariatric surgery.
For port placement, the 8-mm camera port can be placed 8-10 cm above the fundus of the uterus when pushed cephalad on examination under anesthesia (EUA). The robotic camera or a separate camera with a 5-mm laparoscope is introduced (hand-held), and a four-quadrant inspection is undertaken. Direct visualization is used to place two or three additional 8-mm ports in an arch configuration. An 8-mm assistant port is placed on the patient’s side opposite the surgeon’s dominant hand. All ports are spaced 8-10 cm away from each other.
The patient is placed in sufficiently steep Trendelenburg to allow the small bowel to be displaced from the pelvis. The surgical cart is straight docked between the patient’s legs or side docked on the surgeon’s dominant hand side. The 8-mm camera is placed into the camera arm, and then two or three (per the surgeon’s preference) 8-mm robotic instruments are placed under direct visualization.