Medical opinion
This case demonstrates a number of issues. (We will discuss the credentials for the surgeon and hospital privileges in the legal considerations section.) From the medical perspective, the rate of urologic injury associated with all hysterectomies is 0.87%.1 Robotic hysterectomy has been reported at 0.92% in a series published from Henry Ford Hospital.1 The lowest rate of urologic injury is associated with vaginal hysterectomy, reported at 0.2%.2 Reported rates of urologic injury by approach to hysterectomy are1:
- robotic, 0.92%
- laparoscopic, 0.90%
- vaginal, 0.33%
- abdominal, 0.96%.
Complications by surgeon type also have been addressed, and the percent of total urologic complications are reported as1:
- ObGyn, 47%
- gyn oncologist, 47%
- urogynecologist, 6%.
Intraoperative conversion to laparotomy from initial robotic approach has been addressed in a retrospective study over a 2-year period, with operative times ranging from 1 hr, 50 min to 9 hrs of surgical time.1 The vast majority of intraoperative complications in a series reported from Finland were managed “within minutes,” and in the series of 83 patients, 5 (6%) required conversion to laparotomy.2 Intraoperative complications reported include failed entry, vascular injury, nerve injury, visceral injury, solid organ injury, tumor fragmentation, and anesthetic-related complications.3 Of note, the vascular injuries included inferior vena cava, common iliac, and external iliac.
Mortality rates in association with benign laparoscopic and robotic procedures have been addressed and noted to be 1:6,456 cases based upon a meta-analysis.4 The analysis included 124,216 patients. Laparoscopic versus robotic mortality rates were not statistically different. Mortality was more common among cases of undiagnosed rare colorectal injury. This mortality is on par with complications from Roux-en-Y gastric bypass procedures. Procedures such as sacrocolpopexy are equated with higher mortality (1:1,246) in comparison with benign hysterectomy.5
Infectious complications following either laparoscopic or robotic hysterectomy were reported at less than 1% and not statistically different for either approach.6 The series authored by Marra et al evaluated 176,016 patients.
Overall, robotic-assisted gynecologic complications are rare. One series was focused on gynecological oncologic cases.7 Specific categories of complications included7:
- patient positioning and pneumoperitoneum
- injury to surrounding organs
- bowel injury
- port site metastasis
- surgical emphysema
- vaginal cuff dehiscence
- anesthesia-related problems.
The authors concluded, “robotic assisted surgery in gynecological oncology is safe and the incidence of complications is low.”7 The major cause of death related to robotic surgery is vascular injury–related. The authors emphasized the importance of knowledge of anatomy, basic principles of “traction and counter-traction” and proper dissection along tissue planes as key to minimizing complications. Consider placement of stents for ureter identification, as appropriate. Barbed-suturing does not prevent dehiscence.
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