Robotic Hysterectomy

For the assistant, a 10-mm trocar is placed 3 cm cranial and right between the umbilicus and the left robotic trocar. Through this port, the assistant performs the functions that are not yet available robotically: vessel sealing, suction, irrigation, tissue retraction, specimen retrieval, and the introduction and retrieval of sutures and needles. When a fourth robotic arm is used, that trocar is placed 10 cm lateral and 10 cm caudal to the right robotic trocar.

The robotic tower with three arms is situated between the patient's legs. We have noticed that if the column is parked very close to the patient's perineum, there is inadequate space for the scrub nurse to mobilize and manipulate a vaginal probe, maintain the pneumoperitoneum during vaginal incision, and retrieve specimens vaginally. Ideally, the robotic column should rest at about the level of the patient's feet and not any closer.

The middle robotic arm is attached to the umbilical trocar where the laparoscope has been inserted. A monopolar spatula, or scissors, is inserted through the right lateral trocar, and a plasma-kinetic dissecting forceps is inserted through the left lateral trocar. When needed for suturing, a needle-holder replaces the spatula. When a fourth robotic arm is needed, a robotic instrument called a Prograsp is used.

The surgeon sits, unscrubbed, on a console that in our operating suite is about 12 feet away from the patient. Here the surgeon can manipulate the robotic arms that maneuver the instruments and the laparoscopic camera, as well as communicate verbally with the assistant. When the surgeon is playing the role of assistant and the trainee is at the console, the surgeon can direct the trainee by means of telestration to pinpoint anatomical structures and planes of dissection, or to indicate areas of potential visceral damage by drawing circles, arrows, or dots.

When the ovaries are to be removed, which in our practice is more common than not, our first step with robotic simple hysterectomy is to incise the pelvic peritoneum at the level of the pelvic brim to identify the ureters and the points at which they cross the ovarian vessels. We then coagulate and divide the infundibulopelvic ligament that contains the ovarian vessels.

The ureters are then traced and followed to the point where they cross the uterine arteries. Because we cannot palpate the tissues in robotic surgery and therefore need to see, we dissect the ureters anytime they appear close to the cervix or if there is parametrial pathology. Doing so prevents injury.

After this, the bladder must be dissected from the cervix and upper vagina, and at least 2 cm caudal to the anterior vaginal fornix. A vaginal probe that is inserted into the vagina by the scrub nurse is used to identify where the vagina joins the cervix and to define the level of incision on the vagina.

A vessel-sealing device is used to coagulate and transect the uterine arteries and the cardinal ligaments. At that point—and not any sooner—the vagina is transected immediately distal to the cervix and the uterus is detached and removed, along with the ovaries in most cases, through the vaginal opening. (When the ovaries are not removed, they are left attached to the ipsilateral round ligament.) The scrub nurse holds the labia majora to the midline over the surgical instrument used to remove the uterus, and that is enough to maintain the pneumoperitoneum.

Inflation of a sterile occluding balloon with 60 mL of saline is used to maintain the pneumoperitoneum after removal of the specimen vaginally.

The right monopolar spatula is then removed and replaced with a needle-holder, and the vaginal cuff is closed with a 15-cm precut 0 continuous polyglyconate absorbable suture starting at the right angle and going toward the midline. A similar 15-cm suture is applied from the left to the midline until it meets the other suture. The uterosacral ligaments are incorporated at each vaginal angle and at the midline in order to support the vagina. We use a LapraTy suture clip at each end of the sutures to eliminate the need for intracorporeal knot tying.

Using these small precut sutures is most helpful. A suture that is 30 cm long simply takes too long to pull through the tissues. In general, the use of smaller, shorter sutures is essential in robotic surgery.

For robotic hysterectomies as well as any other robotic gynecologic surgery, I also advise using slow, deliberate, precise movements. Such pacing alleviates the risk of bleeding, which dramatically slows the procedure down when it occurs.