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Robotics or not


 

The controversy regarding the use of robotics for benign gynecology is not going to be resolved in the near future. The issues are too complicated to address here.

However, there is a technique that is hardly mentioned but I think deserves more attention.

Hysterectomy
A number of us at our hospital perform most hysterectomies with two or three 5-mm ports using the retroperitoneal approach. The ureters are identified in the retroperitoneal space and traced into the pelvis. They often need to be lateralized in cases involving endometriosis or large fibroids. The uterine artery is then coagulated where it crosses over the ureter. The vessel is smaller and straighter here. This decreases blood loss with less need to fulgurate the vessels at the cervix. The ureter is very close to the vessels at the cervix and is vulnerable to injury.

Large uteri are morcellated transvaginally or through a 3-cm transverse suprapubic incision after placement of a protractor. Sixty percent of women with fibroids can have coexisting adenomyosis. This can be problematic when using the internal morcellator. Small pieces of tissue are usually lost. This tissue can reimplant and there are reports of malignant transformation.

Myomectomy
I place 600 mcg of Cytotec in the rectum at the beginning of the case. This is a very potent drug used to contract the uterus with a large safety margin. This helps to decrease blood loss. In addition, I place atraumatic vascular clips on the uterine vessels in the retroperitoneum and on the utero-ovarian ligaments. With the addition of Pitressin, these techniques markedly decrease blood loss.

A 3-cm, transverse suprapubic incision is then used with a protractor to remove the fibroids and repair the uterus.

Traditional laparoscopy enables the surgeon to change the degree of Trendelenburg and tilt the table, which is very helpful.

Our patients almost always go home several hours later. When I call them on POD#2, most patients are only requiring NSAIDS for pain, eating and ambulating well. In my experience, these patients have much less postoperative pain than after vaginal hysterectomies.

Last year in our hospital, we performed 97% of major gynecologic cases minimally invasively with a very low complication rate. This includes severe endometriosis, very large uteri, myomectomies, and endometrial cancers with node dissection.

Ray Wertheim
Director of COEMIGS
Inova Fair Oaks Hospita
l
Fairfax, Virginia

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