Learning curve, outcomes
My learning curve for Single-Site hysterectomy was marked by two turning points: At case 20, I felt noticeably more proficient, with improved operative times and significantly less difficulty. At the 50th case, my comfort and skill levels jumped again, and I began to feel at times like I was performing multiport surgery.
From the first 20 cases to cases 51-55, my average total operating room time fell from approximately 113 minutes to 60 minutes, my average console time dropped from 71 minutes to 36 minutes, and my average cuff closure time fell from 29 minutes to 14 minutes. The most challenging part of the journey involved vaginal cuff closure; my initial closures took 60-70 minutes as I tried different needles and methods to close. By incorporating what I learned early on, cuff closure times dropped to 20-30 minutes by case 10 and continued to decrease further as I performed more cases.
There were no complications in my first 20 Single-Site surgeries. After that, I had one case of incisional hernia, two cases of pelvic hematoma, and one case of ureterovaginal fistula. I have yet to see cuff dehiscence. My average estimated blood loss has been 60 mL. The ureterovaginal fistula occurred in a patient with a 430-gram uterus and stage IV endometriosis, in whom I encountered a lot of bleeding and struggled with coagulation. My lesson from this case: If extensive coagulation is needed, consider being proactive and place a ureteral stent.
Single-Site hysterectomy makes minimally invasive surgery even more minimally invasive – without sacrificing the quality of care. My patients uniformly have been extremely happy with the cosmesis, and anecdotally they have reported less pain than those undergoing multiport robotic hysterectomy. I have no doubt this is just the beginning of what robotic surgery will enable in the coming years. The journey has been worth it.
Dr. Im is director of the Gynecologic Oncology Center at Mercy Medical Center, and clinical assistant professor of obstetrics, gynecology, and reproductive services at the University of Maryland, both in Baltimore. Dr. Im reports that he is an educational consultant for Intuitive Surgical, manufacturer of the da Vinci Single-Site Technology, and SurgiQuest, manufacturer of AirSeal.