One also should be cognizant of the fact that placement of robotic port 3 in the lateral abdominal wall introduces the risk of a rarely observed complication of gynecologic laparoscopy: injury of the deep circumflex artery and vein (stemming from the external iliac artery and vein). The course of these vessels is significantly lateral to that of the inferior as well as superficial epigastric vessels, and is usually lateral to typical port sites in gynecologic surgery. Therefore, at the end of any robotic case employing a third instrument port in such a lateral location, all port sites (particularly the site of robotic port 3) should be re-evaluated laparoscopically for possible occult vessel injury after removal of the trocars, since the release of tamponade from the trocar may allow reactivation of bleeding.
To help prevent injury to the deep circumflex vessels, we also recommend exclusive use of blunt nondisposable robotic trocar obturators (instead of semisharp single-use obturators) for all robot-assisted procedures employing lateral placement of the third instrument arm.
Placement of the bedside surgical assistant port in robotic surgery has traditionally been high in the abdominal wall at either side of the umbilicus. However, we feel strongly that for the main reproductive surgery applications (namely, tubal reanastomosis and uterine myomectomy), the assistant port must be placed in one of the lower quadrants. Such placement is based on considerations of patient safety, assistant safety, and surgical ergonomics.
Reproductive microsurgery is suture intensive, and needle exchanges should never occur beyond the visual field of the console surgeon; loss of a 6.0 or an 8.0 needle between loops of bowel in the upper abdomen can turn an elegant procedure into a surgical nightmare.
In terms of assistant safety, placement of the assistant port as the most lateral port (instead of between the robotic camera arm and a robotic instrument arm) avoids the possibility that the assistant's hand could be caught between colliding robotic arms.
Finally, placing the assistant port in the lower quadrant allows for an overall port configuration that is compatible with any advanced conventional laparoscopic maneuvers that may be needed during the case (approximating the “ultralateral” port placement previously described for conventional laparoscopy).
Our right lower quadrant assistant port is always a 12-mm port. Even though it may be tempting to use a small-caliber assistant port in a microsurgical case like this, we have experienced problems with micro-needles becoming stuck in the plastic valve of assistant ports smaller than 12 mm in diameter. Ideally, a valve-free assistant port should be used for these cases.
Tubal reanastomosis is often performed best with the uterus in anteversion, so it is essential to employ a manipulator that allows the uterus to be fixed in any desired position between 0 and 90 degrees of anteversion. Such a manipulator should provide reliable chromopertubation. Several nondisposable devices work perfectly for this application, such as the Hayden Uterine Manipulator (Hayden Medical Inc.), the Pelosi Uterine Manipulator (Apple Medical Corp.), the Valtchev Uterine Mobilizer (Conkin Surgical Instruments Ltd.), and the RUMI Uterine Manipulator (CooperSurgical Inc.).
In our experience, the degree of anteversion provided by these devices is more than enough to complete a reanastomosis procedure without the need for an assistant to actively support the manipulator. Clearly, a vaginal delineator is never required for this procedure, and all of these manipulators can be assembled without the delineator.
As in all robot-assisted reproductive surgery techniques, we prefer lateral docking of the patient-side cart: This allows ample space for access to uterine positioning devices (
Our philosophy in transitioning from the gold-standard minilaparotomy approach to the laparoscopic approach has been that three essential aspects of the operation could not be compromised: 1) Reanastomosis should occur over a tubal stent; 2) secure orientation should be achieved by applying more than two reanastomosis sutures per tube; and 3) the thinnest safely employable suture should be chosen. At this point, our surgical protocol for robot-assisted laparoscopic tubal reanastomosis is identical to the one that we used for minilaparotomy.
The robotic microinstruments employed in this operation are shown in
The choice of whether to use the Potts scissors in port 1 (right-sided) or port 2 (left-sided) depends on how important it is for the surgeon to have the opportunity to use two graspers at the same time for tissue manipulation. With the robotic arm configuration described here (one robotic port on the patient's right, and two robotic ports on the patient's left), the surgeon has to toggle between instruments 2 and 3 on the left side. By keeping the scissors on the left side, the surgeon can have the ProGrasp and the micro-bipolar forceps at his disposal at the same time when needed. This means, however, that most surgeons would have to operate the robotic Potts scissors with the nondominant hand. In our experience, the accuracy of operation is not compromised as long as the robotic console scaling setting is at very fine (1:3) or ultrafine (1:5) (the latter is preferred for this operation but is not available at this time on the latest version of the da Vinci system).