A fourth trocar (a 12- to 15-mm port that will facilitate the introduction of suture as well as instrumentation used for retraction, suction/irrigation, and other tasks of the assistant) can be placed between the camera port and either the left or right lower-quadrant port.
Just as with robotic hysterectomy, a fourth robotic arm can be added for patients who are obese or have a large uterus; this can be used for added retraction of tissues.
The key point to be made about setup is that the ports must be placed far enough away from each other and from the target tissue to avoid instrument-arm collisions.
We recommend that all patients undergo radiologic imaging prior to myomectomy. In our practice, we favor MRI for assessing the size, number, and location of the fibroids as well as for ruling out adenomyosis and for planning the location(s) of the hysterotomy incision. All of this information is particularly helpful given the absence of haptic (tactile) feedback with the robotic approach.
The Technique
Prior to hysterotomy, a dilute concentration of vasopressin is injected into the myometrium surrounding the myoma, as an adjunct for hemostasis. Once adequate blanching is noted, we begin each case with either a bipolar Maryland forceps or Gyrus ACMI Inc.'s PK dissecting forceps on the left arm, and hot shears or a permanent cautery hook (both monopolar devices) on the right arm. Our hysterotomy can be made in either a horizontal or vertical axis because we will be less limited with robotic instruments than we would be in a conventional laparoscopy.
The fibroid can then be enucleated while the bedside assistant provides additional traction/countertraction with a conventional laparoscopic tenaculum or corkscrew. An alternative is to use the fourth robotic arm with an EndoWrist tenaculum. Care must be taken to avoid excessive traction during the enucleation phase in order to maintain hemostasis and to not prematurely avulse the fibroid. Patience is key.
The removed fibroid is placed in the posterior cul-de-sac—or in one of the paracolic gutters if it is larger—for retrieval at the end of the surgery. When we remove multiple and smaller fibroids, it is important to maintain a myoma count. Tagging each of them with long suture can be helpful for retrieval at the end of the case.
At this point, we usually exchange our instruments for a large needle driver on the left arm and a mega needle driver with a high-force grip and integrated cutting mechanism on the right arm. We typically incorporate a multilayer closure for the myometrium, using either interrupted sutures of 0-Vicryl on CT-2 needles cut to 6 inches, or running sutures of 0-Vicryl on CT-2 needles cut to 11 inches.
With the increased articulation and dexterity of our instruments, our ability to repair a defect is affected much less by the orientation of the incisions or the location than it would be in conventional laparoscopy.
To close the uterine serosa, we use a running baseball stitch with 3-0 Vicryl on an SH needle. If multiple fibroids must be removed, we prefer to repair each uterine defect after enucleation before moving on to another tumor. This way, we're taking advantage of the effects of vasopressin at each site. We try to remove as many fibroids as possible through a given hysterotomy.
Before retrieving excised fibroids, the robot-assist device is undocked. Specimens are then retrieved via a tissue morcellator that is placed through the accessory port. Another option is to use the endoscopic port site, but this requires the use of a 5-mm 0-degree laparoscope placed through one of the lateral trocars.
All operative sites are irrigated, hemostasis is ensured under low-pressure settings, and an adhesion barrier is placed over all uterine incisions. We typically apply a slurry of finely chopped Seprafilm as an adhesion barrier (an off-label use).
With robotic myomectomy, as with any of the robotically assisted gynecologic procedures, the importance of the bedside assistant cannot be overestimated. In addition to providing traction/countertraction (we usually don't need to use a fourth robotic arm because our assistants are skilled), the assistant introduces and removes suture, provides irrigation, and manages any accessory port activity (J. Robotic Surg. 2007;1:69-74).
The Patients, the Outcomes
With robotics, there really are not many patients we cannot address. There are no absolute inclusion criteria, and no absolute cutoffs. It's all relative. We determine whether a patient is a candidate for a robotic myomectomy based on the size and mobility of her uterus as well as the size, number, and location of her fibroids.