The tepid response is due largely to conventional laparoscopy having significant drawbacks. In a standing position, surgeons use a flat, 2-D image and instruments that are long and nonarticulating. Motions are counterintuitive and the learning curve, consequently, is long.
With the robotic technology currently available, such limitations are largely overcome. Advantages of the technology include a 3-D view, an increase in instrument “wrist” mobility from four to seven degrees, and movements that are significantly more intuitive.
These improvements facilitate better vision, easier suturing, and more precise dissection of tissue around sensitive areas such as major blood vessels and the ureters. And because the surgeon sits at a console unit instead of in an awkward position at the operating table, surgeon fatigue is significantly reduced.
This merging of the advantages of laparotomy and laparoscopy—and the more precise gynecologic surgery that results—is changing lymphadenectomy just as it is other types of gynecologic surgery.
The first laparoscopic radical hysterectomy was performed in June 1986; however, until recently, fewer than 1,000 cases of laparoscopic radical hysterectomy with lymphadenectomy had been reported. Now, with the availability of the da Vinci robotic system, more and more gynecologic oncologists in both teaching and community hospitals are routinely performing this procedure and other lymphadenectomies in patients with endometrial, cervical, early ovarian, fallopian tube, and other gynecologic malignancies.
In fellowship training programs specifically, the application of the technology has increased the usage of laparoscopy in gynecologic oncology—with learning curves documented as being significantly shorter than the learning curves associated with conventional laparoscopy.
Pelvic Lymphadenectomy
In terms of patient selection, there are no more limitations to the use of the robotic approach than with conventional laparoscopy. Robotic lymph node dissection can be offered to all patients for whom laparoscopy is deemed appropriate. It is advantageous, in fact, for women who are obese since the robotic approach bypasses the fulcrum effect that is especially challenging in patients with a thick abdominal wall.
As with other robotic-assisted gynecologic procedures, robotic lymphadenectomy is performed using the da Vinci system, an integrated computer-based system consisting of three interactive robotic arms and a camera arm with a remote control console. The system is the only robotic device with FDA approval for use in gynecologic surgery at the present time.
For pelvic lymphadenectomy, with the patient under general endotracheal anesthesia, we place our primary robotic trocar (a 12-mm port) through the umbilicus for the laparoscope. Two 8-mm trocars are placed 8–10 cm bilaterally and 2–3 cm lower than the umbilicus. Such placement enables optimal movement of the robotic arms and minimizes the risk of collisions (
A 10- to 12-mm assistant port is then placed on one side (most often the right side) of the umbilicus (between the camera port and one of the 8-mm trocars, 1–2 cm high). Through this port, the assistant can introduce suture and instrumentation used for retraction and suction/irrigation, as well as remove specimens. We use the Harris-Kronner Uterine Manipulator-Injector (Humi) for our gynecologic cancer patients whenever possible. Although some physicians believe its use during either conventional or robotic-assisted laparoscopy may cause dissemination of the cancer, we have found this not to be the case.
In a series of cases in which we performed laparoscopic staging for both cervical and endometrial cancer using the manipulator and compared it with conventional staging through laparotomy, we found no compromise in recurrence or in the survival rate (Int. J. Gynecol. Cancer 2007:17;1075–82 and J. Minim. Invasive Gynecol. 2008:15;181–7).
Once the trocars are placed, the patient is placed in a steep Trendelenburg's position and the robotic tower is docked between the patient's legs. The surgeon sits at a console, and the assistant stands to the patient's left or right side. Occasionally, we use a second assistant—most often when the assistant cannot adequately reach the vagina of an obese patient.
After a survey of the pelvic cavity to rule out any sign of metastases in the abdominal cavity and to identify any associated pathology that needs to be treated, such as adhesions that need to be lysed, we proceed with the lymphadenectomy.
The procedure is usually performed with bipolar forceps placed through the left robotic port, and a monopolar electrosurgical spatula, or scissors, placed through the right port. If necessary, a 10-mm clips applier or blood vessel sealing devices can be placed through the assistant's port.
Pelvic wall dissection involves coagulating and cutting the round ligaments on either side of the pelvic wall and then making an incision over the peritoneum between the infundibular pelvic ligament and the vessels in the pelvic side wall.