Advancements in robotic hysterectomy
Common techniques for cuff closure include tying the suture with figure-of-eight stitches, running the suture with Lapra-Ty anchors (Ethicon Endosurgery, Nokesville, Va.), or completing the closure with barbed suture.
Dual-site technique
Patient positioning, placement of the uterine manipulator, and insufflation are all performed as previously described. However, with the two-port technique we strongly recommend using the RUMI II, which provides an added degree of manipulation as a result of its articulating tip.
The 8-mm camera port is placed midline 8-10 cm above the uterine fundus when pushed cephalad during EUA. Following the arched port arrangement described above, one additional 8-mm port is placed on the surgeon’s dominant hand side 8-10 cm lateral to the camera port in the mediolateral position. A 2-mm portless alligator grasper is placed 8-10 cm from the camera port on the opposite side (the surgeon’s nondominant side) in the mediolateral position after the robotic surgical system is docked.
The surgical cart is side docked on the surgeon’s dominant hand side, which is the same side as the working port for the robotic instrument. The 8-mm camera is then placed into the camera port and the endowrist one vessel sealer is placed under direct visualization into the robotic working port. Next, the 2-mm alligator grasper is punched through the dermis in needlelike fashion under direct visualization in the location as just described.
(For the system to correctly count instrument lives in the active robotic instrument arm, a "dummy" trocar [locked into the robotic arm but not inserted into the patient’s abdomen] must be placed into an inactive robotic arm opposite the vessel sealer.)
We use the camera arm and one robotic arm for this technique and employ three robotic instruments and a portless 2-mm grasper. Currently, we have successfully performed the two-port technique on uteri up to 16 weeks without the use of additional arms or open conversion.
The order of steps to complete the dual-site hysterectomy generally resembles that of the multisite approach, with several nuances.
The technique for lateral attachments is generally the same, except that the surgeon employs an articulating endowrist one vessel sealer for sealing and cutting tissue, while the first assist uses the 2-mm alligator grasper to proactively present and retract the adnexa for the surgeon (see image 4).
Once the round ligaments are transected, the vessel sealer is replaced with the monopolar scissors. The first assist uses the 2-mm grasper to tent the anterior leaf of the broad ligament, and the surgeon utilizes the scissors to outline and develop the bladder flap as described above. An advanced uterine manipulation skill-set is highly recommended.
After the development of the bladder flap is completed, the anterior and posterior colpotomies are completed as described above (see image 5).
Following completion of the colpotomies, the monopolar scissors are removed and the endowrist one vessel sealer is reinserted. The first assist grasps the round ligament remnant and retracts it to provide a clear view of the uterine sidewall and vessels while cephalad pressure is maintained on the manipulator. The surgeon uses the articulating vessel sealer to create pedicles as described above. Once progress is made to the level of the Koh ring, the vessel sealer is replaced with the scissor and the scissors are used to complete the circumferential colpotomy.
The vast majority of two-port hysterectomy specimens will be removed transvaginally and intact. For the supracervical approach, endoscopic morcellation is applied. With TLH and large uteri, endoscopic or traditional transvaginal morcellation may be applied. If morcellation is performed endoscopically, the robotic patient cart is undocked, the camera is moved to the mediolateral 8-mm port, and the morcellator of choice is placed midline through an expanded umbilical incision.
Following removal of the uterus, the mega suture-cut needle driver and barbed suture are used to close the vaginal cuff. Successful vaginal cuff closure with the two-port technique requires coordinated teamwork between the surgeon and an experienced first assistant. Closure is facilitated with the first assistant grasping the anterior and then the posterior cuff close to the point of needle entry that is chosen by the surgeon.
