For example, a patient whose height is 4 feet 10 inches and who is obese with a short truncated torso, a uterus that is not very mobile, and an 8-cm fibroid located over the broad ligament may be a poorer candidate than would a taller patient of average weight with an 8-cm intramural fibroid in a uterus that is extremely mobile. This is where the art of medicine comes into play.
Overall, however, the robotic approach overcomes challenges like obesity, and puts us at a greater advantage as surgeons—giving us an ability to suture more effectively and to approach complex pathology much more aggressively—than does conventional laparoscopy.
It takes some time to get used to the dramatic paradigm shift of operating remotely from the patient through a robotic interface. Learning to overcome the lack of tactile feedback is also part of the learning curve. The key is to not attempt more than you can handle early in the learning process. Then, as your experience grows, your ability to tackle complex gynecologic pathology will come. In other words, start with a symptomatic 4- to 5-cm fundal subserosal fibroid before approaching the 10-cm broad-ligament fibroid.
We started doing robotic myomectomies in 2001. In our first published series of 35 cases, the mean myoma weight was 223.2 g. The mean number of myomas removed was 1.6, and the mean diameter was 7.9 cm. The average estimated blood loss was 169 mL and no blood transfusions were necessary. Three of the cases were converted to laparotomy, two because of the absence of tactile feedback and a third because of cardiogenic shock secondary to vasopressin (J. Am. Assoc. Gynecol. Laparosc. 2004;11:511-8).
Since that early experience, we have not had to convert a patient to a laparotomy secondary to an absence of tactile feedback.
When we later compared surgical outcomes with those of traditional laparotomy through a retrospective case-matched analysis of 58 patients, we found that although operative times were significantly longer in the robotic group (a mean of 231 minutes vs. a mean of 154 minutes), postoperative complication rates were higher in the laparotomy group.
In all, there were 14 postoperative complications in 12 patients in the laparotomy group, including wound dehiscence; hematoma; blood loss and anemia requiring transfusion; and deep vein thrombosis followed by respiratory arrest and renal failure. In the robotic group, there were three postoperative complications: aspiration pneumonia, port-site cellulitis, and chest pain.
Estimated blood loss was significantly higher in the laparotomy group than in the robotic group (a mean of 365 mL v. 196 mL), and transfusions were required in two patients who underwent laparotomy. Length of stay was also higher: 3.6 days in the laparotomy group, compared with 1.5 days in the robotic group. (J. Min. Invasive Gynecol. 2007;14:698-705).
We have also analyzed the effects of our experience over time and have presented these data at the AAGL annual meeting in November 2007. We found a notable trend toward both lower blood loss and shorter operative time with experience. Additionally, we evolved from an average length of stay of 1.5 days to a completely outpatient procedure. We even noted an increasing ability to tackle more complex fibroid cases over time, particularly those involving submucosal and deep intramural fibroids.
More recently, we have begun long-term follow-up of our patients. Preliminary pregnancy data show us that women who have undergone a robot-assisted laparoscopic myomectomy in the past 5 years have indeed become pregnant and have carried their pregnancies through with no complications and no uterine ruptures.
A hysterotomy is underway with an EndoWrist cautery hook and Gyrus dissecting forceps.
A fibroid enucleation is facilitated by an EndoWrist tenaculum.
A myometrial defect is repaired with EndoWrist needle drivers and 0-Vicryl suture. Photos courtesy Dr. Arnold Advincula
Robotic Myomectomy: The Time Has Come
In the last edition of the Master Class in gynecology, Dr. Javier Magrina, professor of ob.gyn. and director of female pelvic medicine and reconstructive surgery at the Mayo Clinic in Scottsdale, Ariz., ably described the benefits and technique of robotic-assisted hysterectomy.
In this second installment on robotic-assisted surgery, I have asked Dr. Arnold P. Advincula, clinical associate professor of ob.gyn. at the University of Michigan, Ann Arbor, to discuss robotic-assisted laparoscopic myomectomy.
Other than laparoscopic tubal anastomosis, there is no procedure in minimally invasive gynecologic surgery that is more dependent on the ability to be facile with laparoscopic suturing techniques than laparoscopic myomectomy. Certainly, the physician's need to visualize the repair on a television screen while using limited wrist motion for suture placement limits the vast majority of gynecologists from routinely and effectively performing this procedure.