Master Class

Robot-Assisted Laparoscopic Tubal Reanastomosis


 

Surgery has an important role in the management of a patient's regret following tubal sterilization. While assisted reproductive technologies (ART) have made great strides in efficacy and patient acceptability, reanastomosis of the tubal segments remains an attractive option for couples who have no other fertility issues and who find the risk of multiple pregnancies unacceptable or the extensive medical treatment of ART impractical or undesirable. The re-establishment of some degree of reproductive tract function also can have important psychological and/or religious implications.

As with all gynecologic operations, there has been a trend toward the development and diffusion of minimally invasive (laparoscopic) versions of the classic microsurgical tubal reanastomosis.

The biggest problem with conventional laparoscopic tubal reanastomosis is that it is one of the most technically challenging gynecologic operations ever conceived. Before the full introduction of robotics at our institution, I have observed the struggle of skilled reproductive surgeons with every step of this operation.

It is no surprise, therefore, that laparoscopic tubal reanastomosis was among the first gynecologic operations for which robotic assistance was described. In fact, a feasibility study for tubal reanastomosis using the da Vinci surgical system (Intuitive Surgical Inc.) was published in 2000 by Dr. Michel Degueldre and colleagues in Belgium – 5 years before the Food and Drug Administration approved this surgical platform for gynecologic applications in the United States (Fertil. Steril. 2000;74:1020-3).

Two more recent case series compared robot-assisted tubal reanastomosis performed with the da Vinci surgical system to the “gold standard” of microsurgical reanastomosis by minilaparotomy. In a 2007 case-control study by Dr. Allison K. Rodgers and colleagues at the Cleveland Clinic, surgical times were significantly longer, and costs were higher, for the robot compared with open surgery. Hospitalization times were not significantly different, as patients undergoing minilaparotomy were discharged home on the day of surgery. Pregnancy rates also were similar (61% for robotic vs. 79% for minilaparotomy), as were ectopic pregnancy rates. Complications occurred less frequently in the robotic group, however, and the return to normal activity was shorter in this group by approximately 1 week (Obstet. Gynecol. 2007;109:1375-80).

A 2008 prospective cohort study by Dr. Sejal P. Dharia Patel and colleagues confirmed that surgical times are significantly longer for the robot group. This team did not practice outpatient minilaparotomy as did Dr. Rodgers' team, and patients undergoing robot-assisted laparoscopic surgery were discharged on the day of surgery. Hence, hospitalization times were significantly shorter in the robot-assisted group. Time to recovery was also significantly shorter. Pregnancy rates (62.5% for robotic vs. 50% for open) and ectopic pregnancy rates were not significantly different. Cost per delivery was similar between the two procedures (Fertil. Steril. 2008;90:1175-9).

These data indicate that robot-assisted tubal reanastomosis is safe and that its results are comparable to those obtained by classic tubal microsurgery performed by trained subspecialists. In terms of cost, it appears that even at the current high operating costs for the robot, open surgery is cost effective only if patients are sent home on the day of surgery, but not if they are admitted to the hospital.

Our robotic team performed the first successful robot-assisted tubal reanastomosis (with postoperative delivery) in New England in February 2007, and has since completely converted to the robotic approach. In our 4 years of experience, we have successfully completed approximately 350 robot-assisted reproductive surgeries, including robot-assisted tubal reanastomosis.

Setup

As in all laparoscopic procedures, patient positioning and port placement are vital. Robotic tubal reanastomosis is performed with the patient in dorsal lithotomy position on Allen stirrups. Preferably, all four robotic arms of the da Vinci patient-side cart are employed. The camera port is always placed within the umbilicus. The three 8-mm da Vinci ports are positioned as follows: Port 1 is 8-10 cm to the right of the camera port, port 2 is 8-10 cm to the left of the camera port, and port 3 is 8-10 cm to the left of port 2 (

Ports 1 and 2 are safely located in an area of the abdominal wall that is between the epigastric vessels (superficial and inferior) and the superficial circumflex vessels, making injury of any of these vessels extremely unlikely. Port 3 is located in the left lateral portion of the anterior abdominal wall. In women with a smaller abdomen, it is necessary to slide port 3 about 15-30 degrees caudal to port 2, while keeping the distance of 8-10 cm.

Optimal placement of robotic port 3 is undoubtedly the most challenging of the three 8-mm ports. Due to the obtrusive nature of the da Vinci patient-side cart, external interference between robotic arms 2 and 3 and between robotic arm 3 and the patient arm support systems (such as arm toboggans) is common during the learning curve of this operation. Moreover, internal interference between instruments in port 2 and port 3 is also possible (particularly if the degree of caudal shift of port 3 is excessive and the instrument crosses the pelvis transversely).

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