THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY Int J Med Robotics Comput Assist Surg (2015) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1668
ORIGINAL ARTICLE
Robotic hysterectomy or myomectomy without power morcellation: A single-port assisted threeincision technique with manual morcellation
Gun Oh Chong Yoon Hee Lee Dae Gy Hong Young Lae Cho Yoon Soon Lee*
Abstract
Department of Obstetrics and Gynaecology, School of Medicine, Kyungpook National University Medical Centre, Daegu, South Korea
Methods Between October 2010 and July 2014, 16 patients underwent robotic hysterectomy and 50 patients underwent robotic myomectomy using a single-port assisted three-incision technique. Manual morcellation through a single-port site without power morcellation was used to remove the uterus or uterine fibroids.
*Correspondence to: Y. S. Lee, Kyungpook National University Medical Centre, 807 Hogukno, Buk-gu, 702-210 Daegu, South Korea. Email: [email protected]
Background The purpose of this study was to evaluate the feasibility and safety of a single-port assisted three-incision robotic hysterectomy or myomectomy with manual morcellation using a scalpel, and to introduce our novel surgical technique.
Results The mean operative times were 130.2 ± 32.6 min in the hysterectomy group and 178.8 ± 77.9 min in the myomectomy group. Intraoperative complications, including a rectal serosa injury and a small bowel injury, occurred in two cases. Three febrile morbidities occurred postoperatively. Finally, no complications were associated with manual morcellation. Conclusions Uterine tissues could be removed without any complications by manual morcellation within an endobag, using a scalpel. Copyright © 2015 John Wiley & Sons, Ltd. Keywords incision
robot; hysterectomy; myomectomy; manual morcellation; three-
Introduction
Accepted: 12 April 2015
Copyright © 2015 John Wiley & Sons, Ltd.
Several studies have demonstrated the advantages of laparoscopic hysterectomy over open abdominal hysterectomy, in terms of decreased postoperative pain, faster return to everyday activities and cosmetic results (1,2). In addition, laparoscopic myomectomy has several advantages, including faster recovery, shorter hospital stay, less postoperative pain and reduced intra-abdominal formation of adhesions compared to laparotomy (3). Despite these advantages, many hysterectomies are still performed via laparotomy (4). The main reason for this discrepancy is the learning curve required for the development of advanced laparoscopic skills (5). Laparoscopic myomectomy is still performed, although infrequently, due to the technical difficulties involved (6). A recent
G. O. Chong et al.
survey demonstrated that 56% of hysterectomies performed for benign conditions were performed abdominally (7). Robotic-assisted surgery was developed to overcome the limitations of conventional laparoscopic surgery. Robotic surgery is potentially advantageous because it has a relatively short learning curve (8,9). Increased rates of robotic hysterectomy have led to decreasing rates of abdominal hysterectomy (8,9). In some complex cases and cases involving atypical locations, such as deep intramural fibroids, the advantage of robot-assisted surgery is that it can overcome the laparoscopic limitations (10). Minimally invasive surgery, such as laparoscopy and robot-assisted surgery, often requires the removal of large tissue specimens through small incisions, which may be facilitated by morcellation. Recently, the US Food and Drug Administration (FDA) issued a safety communication urging doctors not to use laparoscopic power morcellation for hysterectomies or for removal of uterine fibroids, because of concerns that the technique may disseminate uterine sarcomas beyond the uterus (11). Until now, however, power morcellation has been used during robotic surgery for removal of the uterus or uterine fibroids through a 12 mm assistant port. To avoid power morcellation, vaginal morcellation thorough culdotomy or colpotomy, or minilaparotomy-site morcellation using a scalpel, might be performed. However, a culdotomy cannot be used for women without a history of intercourse. Minilaparotomy may reduce the cosmetic benefits and lead to complications, such as bleeding or incisional hernia. In cases where a colpotomy is used, because the space between robot and patient is too narrow, it is very difficult for operators to remove the uterine tissues using vaginal morcellation. Therefore, we opted to remove the uterine tissues through the umbilicus by manual morcellation. A previous study demonstrated the safe and quick removal of a large uterus with manual morcellation during laparoscopic hysterectomy for uteri weighing 250–2100 g, with no rupture of the endobag (12). We performed a novel single-port assisted threeincision robotic hysterectomy or myomectomy with manual morcellation using a scalpel through a single-port site. The purpose of this study was to introduce this novel surgical technique and to evaluate the feasibility and safety of single-port assisted three-incision robotic hysterectomy or myomectomy using manual morcellation.
Materials and methods Between October 2010 and July 2014, a total of 66 consecutive patients underwent single-port assisted threeincision robotic hysterectomy (16 cases) or myomectomy Copyright © 2015 John Wiley & Sons, Ltd.
(50 cases), with manual morcellation using a scalpel. All surgical procedures were performed at the Gynaecological Cancer Centre at Kyungpook National University Medical Centre, Daegu, South Korea. The Institutional Review Board approved this retrospective study. The eligibility criteria for the patients were age ≥ 20 years, no evidence of gynaecological malignancy on imaging studies, an appropriate medical status for robotic surgery, a uterus size ≥ 200 g on preoperative pelvic ultrasound examination in total hysterectomy cases, and extraction of uterine tissues via an umbilicus wound retractor. The exclusion criteria included uterine size ≤ 200 g on preoperative pelvic ultrasound, vaginal extraction of uterine tissues and a suspicion of gynaecological cancer. All 66 cases were analysed based on the following parameters: age, body mass index, operative time, docking time, console time, time to manual morcellation, blood loss, haemoglobin change, length of postoperative hospital stay, weight of uterus or uterine fibroids, and intraand postoperative complications. We used an OctoPort (DalimSurgNet, Seoul, Korea), which consists of two parts, a 30 mm wound retractor and a detachable port cap with three access ports (two 12 mm ports and one 5 mm port; Figure 1A). The details of single-port system were described in our previous study (13). The surgical process was as follows. While under endotracheal general anaesthesia, patients who had a history of sexual contact were placed in the dorsal lithotomy position after the placement of a uterine manipulator. A vertical, transumbilical incision, 25–30 mm long, was made, extending to the peritoneum. The abdominal wall was elevated using Army–Navy retractors that were inserted into the opening of the incision. The OctoPort wound retractor was inserted into the covering of the peritoneal cavity from the skin to the peritoneum and the port cap was fixed to the wound retractor. The pneumoperitoneum was maintained at 12 mmHg. Two 8 mm lateral trocars were placed, 8–10 cm lateral to the umbilicus, for the two robotic arms. The white cap of the 5 mm port was removed and a 12 mm trocar was inserted (Figure 1B). The da Vinci surgical system robot (Intuitive Surgical, Sunnyvale, CA, USA) was then docked at the foot of the bed. The other two 12 mm ports at the OctoPort were used for assistance such as suctioning, irrigation, retraction, grasping or introduction of the needle (Figure 2A). For hysterectomy, all dissection and vessel control was performed with EndoWrist monopolar scissors (Intuitive Surgical), which were held in the right hand, and EndoWrist fenestrated bipolar forceps (Intuitive Surgical), which were held in the left hand. The round, ovarian and broad ligaments were dissected. The vesico-uterine peritoneal fold was opened and the bladder mobilized using a monopolar coagulator. The uterine vessels were Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
Robotic surgery without power morcellation
Figure 1. (A) OctoPort; the wound retractor and detachable port cap. (B) After the removal of a 5 mm white port cap, a 12 mm trocar was inserted
dissected and the vaginal wall was incised circumferentially. The robotic instrument was then exchanged for a needle driver. The vaginal cuff, including normal vaginal mucosa, was closed using an interrupted intracorporeal suture. In the case of myomectomy, myoma enucleation was accomplished via laparoscopy. The myometrial edges were approximated to at least two layers by interrupted and/or continuous 1–0 or 2–0 Vicryl sutures. After hysterectomy or myomectomy, the uterus or uterine fibroids were removed through manual morcellation within an endobag (LapBag, Sejong Medical, Seoul, South Korea), using a scalpel through a wound retractor of the OctoPort after dedocking the robot. We routinely employed 15 × 15 cm2 polyurethane endobags (LapBag). The endobags were opened intra-abdominally and the uterine tissues placed in the specimen bag using a grasper. In cases of uterine size ≥ 500 g, we used the 20 × 20 cm2 endobag. Traction of the uterus or uterine fibroids was applied using towel clips, and uterine tissues were circumferentially cored with a scalpel. The entire manual morcellation was performed in the extracorporeal space to minimize intra-abdominal injury from a scalpel or spillage of uterine tissues (Figure 2B). The peritoneum and fascia of the umbilicus were closed using 2–0 Vicryl and Copyright © 2015 John Wiley & Sons, Ltd.
the skin was closed with a 4–0 Vicryl subcuticular continuous suture (Figure 2C).
Results Between October 2010 and July 2014, 16 patients underwent robotic hysterectomy and 50 patients underwent robotic myomectomy using single-port assisted three-incision technique with manual morcellation. The mean age of the patients was 45.3 ± 3.5 years for the hysterectomy group and 36.3 ± 7.2 years for the myomectomy group. The average body mass index was 23.1 ± 2.9 kg/m2 in the hysterectomy group and 21.4 ± 2.3 kg/m2 in the myomectomy group. There were nine patients (56%) in the hysterectomy group and six patients (12%) in the myomectomy group who had previously undergone abdominal surgery. The mean total operative time was 130.2 ± 32.6 min (docking time, 6.7 ± 2.0 min; console time, 95.3 ± 43.8 min) in the hysterectomy group and 178.8 ± 77.9 min (docking time, 7.1 ± 1.7 min; console time, 89.5 ± 51.0 min) in the myomectomy group. The average time to manual morcellation was 9.6 ± 8.1 min in the hysterectomy group and 10.7 ± 10.8 min in the myomectomy Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
G. O. Chong et al.
Figure 2. (A) The single-port assisted three-incision technique. (B) Manual morcellation was performed using a scalpel within an endobag through a wound retractor. (C) Postoperative skin wound
group. The mean blood loss was 32.2 ± 27.6 ml in the hysterectomy group and 57.1 ± 46.5 ml in the myomectomy group. The mean length of postoperative hospital stay was 4.6 ± 1.9 days in the hysterectomy group and 4.4 ± 1.4 days in the myomectomy group. The average weight Copyright © 2015 John Wiley & Sons, Ltd.
of the uterus was 333.1 ± 203.6 g and the average weight of the uterine fibroids was 251.7 ± 213.6 g. In the hysterectomy group, there was one case of rectal serosa injury that occurred due to endometriosis at the cul-de-sac; however, no postoperative complications occurred. In the Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
Robotic surgery without power morcellation
myomectomy group, there was one case involving a small bowel injury that occurred due to a small bowel adhesion to a previous myomectomy site. Primary repair of the small bowel was conducted using the robot. Finally, three febrile morbidities occurred as postoperative complications (Table 1). There were no complications related to manual morcellation performed using a scalpel.
Discussion Analysis of surgical data in the USA in 2009 showed that abdominal hysterectomy was performed in 56% of cases, laparoscopic hysterectomy in 20.4% of cases, vaginal hysterectomy in 18.8% of cases and robotic hysterectomy in 4.5% of cases (7). In addition, recent data have shown a decrease in the frequency of abdominal hysterectomy following the introduction of robotic surgical systems (14,15). A large retrospective study demonstrated that robotic-assisted laparoscopic myomectomy is associated with decreased blood loss and hospital stay compared to conventional laparoscopic myomectomy and open abdominal myomectomy (16). To remove a large uterus and uterine fibroid during robotic hysterectomy and myomectomy, power morcellation was usually used. This was performed using a 12 mm port for assistance, which is located in the left or right upper quadrants. During power morcellation, it can be difficult to prevent small tissue fragments from inadvertently becoming dispersed throughout the peritoneal cavity. Disseminated tissue fragments may implant on the organs in the abdominal cavity. This can potentially result in peritonitis, intra-abdominal abscesses or an intestinal obstruction that requires a repeat operation or additional interventions (17). Power morcellation may also lead to the disruption and possible dissemination of an unrecognized sarcoma, which can result in metastatic implants in the peritoneal
cavity. Such iatrogenic dissemination may have an adverse effect on patient prognosis. George et al. (18) demonstrated that intraperitoneal morcellation of a presumed leiomyoma resulted in a reduction in survival of women with uterine leiomyosarcomas. They concluded that, because there are no reliable pre-operative techniques that can be used to distinguish uterine leiomyosarcoma from benign leiomyoma, all efforts to minimize intraperitoneal uterine morcellation should be considered (18). A recent review of the Manufacturer and User Facility Device Experience database of the US FDA found 55 complications between 1993 and 2013, including six deaths, and injuries caused by the morcellator blade to almost every organ in the abdominal cavity, including the bowel, vena cava and aorta (17). In the case of a robotic hysterectomy or myomectomy, power morcellation is usually performed using a 12 mm trocar that is positioned in the upper abdomen. It is conceivable that an increased risk of organ injury may exist compared to conventional laparoscopy, in which morcellation is usually performed through the suprapubic area. However, it is unclear whether umbilical, suprapubic or lateral port placement is safe for power morcellation. We conducted manual morcellation using a scalpel within an endobag thorough a wound retractor located at the umbilicus. To minimize abdominal organ injury, traction of the uterus or uterine fibroids was applied using towel clips, and manual morcellation conducted at the extracorporeal space. An endobag was used to minimize the possibility of dissemination of the small tissue fragments. However, variability in the size, shape and weight of the uterine tissue makes placing the specimen into the endobag challenging; indeed, it was very difficult to place > 500 g uterine tissue into the endobag. Because two 12 mm ports of the OctoPort were used, no additional trocar was needed. Compared to conventional robotic techniques, our three-incision technique with manual morcellation has advantages in terms of preventing tissue
Table 1. Patients’ characteristics and surgical outcomes
Age (years) 2 Body mass index (kg/m ) Previous abdominal surgery history (n, %) Total operative time (min) Docking time (min) Console time (min) Time to manual morcellation (min) Blood loss (ml) Haemoglobin change (g/dl) Length of postoperative hospital stay (days) Weight of uterus or uterine fibroids (g) Intraoperative complications (n) Postoperative complications (n)
Copyright © 2015 John Wiley & Sons, Ltd.
Hysterectomy (n = 16)
Myomectomy (n = 50)
45.3 ± 3.5 23.1 ± 2.9 9 (56%) 130.2 ± 32.6 6.7 ± 2.0 95.3 ± 43.8 9.6 ± 8.1 32.2 ± 27.6 1.5 ± 0.6 4.6 ± 1.9 335.1 ± 203.6 1 0
36.3 ± 7.2 21.4 ± 2.3 6 (12%) 172.8 ± 77.9 7.1 ± 1.7 89.5 ± 51.0 10.7 ± 10.8 57.1 ± 46.5 1.6 ± 0.8 4.4 ± 1.4 251.7 ± 213.6 1 3
Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
G. O. Chong et al.
dissemination, improving the cosmetic result and reducing complications related to the trocar site, such as bleeding or incisional hernias. Recently, single-port robotic surgery has been introduced in the gynaecological field (19,20). We have previously used single-port robotic surgery using OctoPort (Figure 3). However, it was very difficult to perform single-port robotic surgery using conventional robotic instruments, owing to clashing between robotic instruments. Our trial may be helpful for developing the new single-port system. Few data were available on vaginal morcellation or umbilical manual morcellation in the bag during minimally invasive gynaecological surgery (12,21). Most reports have described the surgical technique and its feasibility; however, no detailed surgical outcomes, such as morcellation time, pain score and numbers of ports, have been documented. Further studies are therefore needed for detailed comparisons between umbilical manual morcellation and vaginal morcellation. The limitations of the present study include the retrospective design and the small study population. In addition, because of short follow-up period, we could not compare the incidences of long-term complications, such as iatrogenic myoma, with power morcellation. Moreover, there was no comparison of surgical outcomes between vaginal and umbilical morcellation. Despite these limitations, our novel technique may be an alternative to power morcellation, and could be effective in minimizing the spread of uterine tissues throughout the abdominal cavity. In conclusion, our novel single-port assisted threeincision robotic hysterectomy or myomectomy technique is feasible and is a safe treatment modality. Uterine tissues could be removed without the use of power morcellation during robotic surgery. Our surgical technique is an alternative to power morcellation that can minimize the spread of tissue fragments, which may be malignant tissues, throughout the abdominal cavity. It can thus reduce
Figure 3. Single-port robotic surgery using OctoPort Copyright © 2015 John Wiley & Sons, Ltd.
the frequency of life-threatening complications related to power morcellation, such as injury of the bowel, vena cava or aorta.
Conflicts of interest The authors have stated explicity that there are no conflicts of interest in connection with this article.
Funding No specific funding.
References 1. Garry R, Fountain J, Brown J, et al. EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy. Health Technol Assess 2004; 8: 1–154. 2. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; 8: CD003677. 3. Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996; 174: 654–658. 4. Wu JM, Wechter ME, Geller EJ, et al. Hysterectomy rates in the United States, 2003. Obstet Gynecol 2007; 110: 1091–1095. 5. Pulliam SJ, Berkowitz LR. Smaller pieces of the hysterectomy pie: current challenges in resident surgical education. Obstet Gynecol 2009; 113: 395–398. 6. Carbonnel M, Goetgheluck J, Frati A, et al. Robot-assisted laparoscopy for infertility treatment: current views. Fertil Steril 2014; 101: 621–626. 7. Cohen SL, Vitonis AF, Einarsson JI. Updated hysterectomy surveillance and factors associated with minimally invasive hysterectomy. J Soc Laparoendosc Surg 2014; 18: pii, e2014.00096. 8. Smorgick N, Patzkowsky KE, Hoffman MR, et al. The increasing use of robot-assisted approach for hysterectomy results in decreasing rates of abdominal hysterectomy and traditional laparoscopic hysterectomy. Arch Gynecol Obstet 2014; 289: 101–105. 9. Smorgick N, As-Sanie S. The benefits and challenges of roboticassisted hysterectomy. Curr Opin Obstet Gynecol 2014; 26: 290–294. 10. Lönnerfors C, Persson J. Pregnancy following robot-assisted laparoscopic myomectomy in women with deep intramural myomas. Acta Obstet Gynecol Scand 2011; 90: 972–977. 11. FDA safety communication: laparoscopic uterine morcellation in hysterectomy and myomectomy, 2014. www.fda.gov/ MedicalDevices/Safety/AlertsandNotices/ucm393576.htm [accessed 17 April 2014]. 12. Serur E, Lakhi N. Laparoscopic hysterectomy with manual morcellation of the uterus: an original technique that permits the safe and quick removal of a large uterus. Am J Obstet Gynecol 2011; 204: 566.e1–2. 13. Wang T, Chong GO, Park NY, et al. Comparison study of singleport (Octoport™) and four-port total laparoscopic hysterectomy. Eur J Obstet Gynecol Reprod Biol 2012; 161: 215–218. 14. Matthews CA, Reid N, Ramakrishnan V, et al. Evaluation of the introduction of robotic technology on route of hysterectomy and complications in the first year of use. Am J Obstet Gynecol 2010; 203: 499.e1–5. Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
Robotic surgery without power morcellation 15. Brenot K, Goyert GL. Impact of robotic surgery on obstetric– gynecologic resident training. J Reprod Med 2009; 54: 675–677. 16. Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-assisted, laparoscopic, and abdominal myomectomy: a comparison of surgical outcomes. Obstet Gynecol 2011; 117: 256–265. 17. Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invas Gynecol 2014; 21: 486–491. 18. George S, Barysauskas C, Serrano C, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014; 15: 3154–3158.
Copyright © 2015 John Wiley & Sons, Ltd.
19. Yoon A, Yoo HN, Lee YY, et al. Robotic single-port hysterectomy, adnexectomy and lymphadenectomy in endometrial cancer. J Minim Invas Gynecol 2015; 22: 322. 20. Bogliolo S, Mereu L, Cassani C, et al. Robotic single-site hysterectomy: two institutions’ preliminary experience. Int J Med Robot 2015; 11: 159–165. 21. Günthert AR, Christmann C, Kostov P, et al. Safe vaginal uterine morcellation following total laparoscopic hysterectomy. Am J Obstet Gynecol 2014; pii: S0002–9378(14)02250–9.
Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
ORIGINAL ARTICLE
Robotic hysterectomy or myomectomy without power morcellation: A single-port assisted threeincision technique with manual morcellation
Gun Oh Chong Yoon Hee Lee Dae Gy Hong Young Lae Cho Yoon Soon Lee*
Abstract
Department of Obstetrics and Gynaecology, School of Medicine, Kyungpook National University Medical Centre, Daegu, South Korea
Methods Between October 2010 and July 2014, 16 patients underwent robotic hysterectomy and 50 patients underwent robotic myomectomy using a single-port assisted three-incision technique. Manual morcellation through a single-port site without power morcellation was used to remove the uterus or uterine fibroids.
*Correspondence to: Y. S. Lee, Kyungpook National University Medical Centre, 807 Hogukno, Buk-gu, 702-210 Daegu, South Korea. Email: [email protected]
Background The purpose of this study was to evaluate the feasibility and safety of a single-port assisted three-incision robotic hysterectomy or myomectomy with manual morcellation using a scalpel, and to introduce our novel surgical technique.
Results The mean operative times were 130.2 ± 32.6 min in the hysterectomy group and 178.8 ± 77.9 min in the myomectomy group. Intraoperative complications, including a rectal serosa injury and a small bowel injury, occurred in two cases. Three febrile morbidities occurred postoperatively. Finally, no complications were associated with manual morcellation. Conclusions Uterine tissues could be removed without any complications by manual morcellation within an endobag, using a scalpel. Copyright © 2015 John Wiley & Sons, Ltd. Keywords incision
robot; hysterectomy; myomectomy; manual morcellation; three-
Introduction
Accepted: 12 April 2015
Copyright © 2015 John Wiley & Sons, Ltd.
Several studies have demonstrated the advantages of laparoscopic hysterectomy over open abdominal hysterectomy, in terms of decreased postoperative pain, faster return to everyday activities and cosmetic results (1,2). In addition, laparoscopic myomectomy has several advantages, including faster recovery, shorter hospital stay, less postoperative pain and reduced intra-abdominal formation of adhesions compared to laparotomy (3). Despite these advantages, many hysterectomies are still performed via laparotomy (4). The main reason for this discrepancy is the learning curve required for the development of advanced laparoscopic skills (5). Laparoscopic myomectomy is still performed, although infrequently, due to the technical difficulties involved (6). A recent
G. O. Chong et al.
survey demonstrated that 56% of hysterectomies performed for benign conditions were performed abdominally (7). Robotic-assisted surgery was developed to overcome the limitations of conventional laparoscopic surgery. Robotic surgery is potentially advantageous because it has a relatively short learning curve (8,9). Increased rates of robotic hysterectomy have led to decreasing rates of abdominal hysterectomy (8,9). In some complex cases and cases involving atypical locations, such as deep intramural fibroids, the advantage of robot-assisted surgery is that it can overcome the laparoscopic limitations (10). Minimally invasive surgery, such as laparoscopy and robot-assisted surgery, often requires the removal of large tissue specimens through small incisions, which may be facilitated by morcellation. Recently, the US Food and Drug Administration (FDA) issued a safety communication urging doctors not to use laparoscopic power morcellation for hysterectomies or for removal of uterine fibroids, because of concerns that the technique may disseminate uterine sarcomas beyond the uterus (11). Until now, however, power morcellation has been used during robotic surgery for removal of the uterus or uterine fibroids through a 12 mm assistant port. To avoid power morcellation, vaginal morcellation thorough culdotomy or colpotomy, or minilaparotomy-site morcellation using a scalpel, might be performed. However, a culdotomy cannot be used for women without a history of intercourse. Minilaparotomy may reduce the cosmetic benefits and lead to complications, such as bleeding or incisional hernia. In cases where a colpotomy is used, because the space between robot and patient is too narrow, it is very difficult for operators to remove the uterine tissues using vaginal morcellation. Therefore, we opted to remove the uterine tissues through the umbilicus by manual morcellation. A previous study demonstrated the safe and quick removal of a large uterus with manual morcellation during laparoscopic hysterectomy for uteri weighing 250–2100 g, with no rupture of the endobag (12). We performed a novel single-port assisted threeincision robotic hysterectomy or myomectomy with manual morcellation using a scalpel through a single-port site. The purpose of this study was to introduce this novel surgical technique and to evaluate the feasibility and safety of single-port assisted three-incision robotic hysterectomy or myomectomy using manual morcellation.
Materials and methods Between October 2010 and July 2014, a total of 66 consecutive patients underwent single-port assisted threeincision robotic hysterectomy (16 cases) or myomectomy Copyright © 2015 John Wiley & Sons, Ltd.
(50 cases), with manual morcellation using a scalpel. All surgical procedures were performed at the Gynaecological Cancer Centre at Kyungpook National University Medical Centre, Daegu, South Korea. The Institutional Review Board approved this retrospective study. The eligibility criteria for the patients were age ≥ 20 years, no evidence of gynaecological malignancy on imaging studies, an appropriate medical status for robotic surgery, a uterus size ≥ 200 g on preoperative pelvic ultrasound examination in total hysterectomy cases, and extraction of uterine tissues via an umbilicus wound retractor. The exclusion criteria included uterine size ≤ 200 g on preoperative pelvic ultrasound, vaginal extraction of uterine tissues and a suspicion of gynaecological cancer. All 66 cases were analysed based on the following parameters: age, body mass index, operative time, docking time, console time, time to manual morcellation, blood loss, haemoglobin change, length of postoperative hospital stay, weight of uterus or uterine fibroids, and intraand postoperative complications. We used an OctoPort (DalimSurgNet, Seoul, Korea), which consists of two parts, a 30 mm wound retractor and a detachable port cap with three access ports (two 12 mm ports and one 5 mm port; Figure 1A). The details of single-port system were described in our previous study (13). The surgical process was as follows. While under endotracheal general anaesthesia, patients who had a history of sexual contact were placed in the dorsal lithotomy position after the placement of a uterine manipulator. A vertical, transumbilical incision, 25–30 mm long, was made, extending to the peritoneum. The abdominal wall was elevated using Army–Navy retractors that were inserted into the opening of the incision. The OctoPort wound retractor was inserted into the covering of the peritoneal cavity from the skin to the peritoneum and the port cap was fixed to the wound retractor. The pneumoperitoneum was maintained at 12 mmHg. Two 8 mm lateral trocars were placed, 8–10 cm lateral to the umbilicus, for the two robotic arms. The white cap of the 5 mm port was removed and a 12 mm trocar was inserted (Figure 1B). The da Vinci surgical system robot (Intuitive Surgical, Sunnyvale, CA, USA) was then docked at the foot of the bed. The other two 12 mm ports at the OctoPort were used for assistance such as suctioning, irrigation, retraction, grasping or introduction of the needle (Figure 2A). For hysterectomy, all dissection and vessel control was performed with EndoWrist monopolar scissors (Intuitive Surgical), which were held in the right hand, and EndoWrist fenestrated bipolar forceps (Intuitive Surgical), which were held in the left hand. The round, ovarian and broad ligaments were dissected. The vesico-uterine peritoneal fold was opened and the bladder mobilized using a monopolar coagulator. The uterine vessels were Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
Robotic surgery without power morcellation
Figure 1. (A) OctoPort; the wound retractor and detachable port cap. (B) After the removal of a 5 mm white port cap, a 12 mm trocar was inserted
dissected and the vaginal wall was incised circumferentially. The robotic instrument was then exchanged for a needle driver. The vaginal cuff, including normal vaginal mucosa, was closed using an interrupted intracorporeal suture. In the case of myomectomy, myoma enucleation was accomplished via laparoscopy. The myometrial edges were approximated to at least two layers by interrupted and/or continuous 1–0 or 2–0 Vicryl sutures. After hysterectomy or myomectomy, the uterus or uterine fibroids were removed through manual morcellation within an endobag (LapBag, Sejong Medical, Seoul, South Korea), using a scalpel through a wound retractor of the OctoPort after dedocking the robot. We routinely employed 15 × 15 cm2 polyurethane endobags (LapBag). The endobags were opened intra-abdominally and the uterine tissues placed in the specimen bag using a grasper. In cases of uterine size ≥ 500 g, we used the 20 × 20 cm2 endobag. Traction of the uterus or uterine fibroids was applied using towel clips, and uterine tissues were circumferentially cored with a scalpel. The entire manual morcellation was performed in the extracorporeal space to minimize intra-abdominal injury from a scalpel or spillage of uterine tissues (Figure 2B). The peritoneum and fascia of the umbilicus were closed using 2–0 Vicryl and Copyright © 2015 John Wiley & Sons, Ltd.
the skin was closed with a 4–0 Vicryl subcuticular continuous suture (Figure 2C).
Results Between October 2010 and July 2014, 16 patients underwent robotic hysterectomy and 50 patients underwent robotic myomectomy using single-port assisted three-incision technique with manual morcellation. The mean age of the patients was 45.3 ± 3.5 years for the hysterectomy group and 36.3 ± 7.2 years for the myomectomy group. The average body mass index was 23.1 ± 2.9 kg/m2 in the hysterectomy group and 21.4 ± 2.3 kg/m2 in the myomectomy group. There were nine patients (56%) in the hysterectomy group and six patients (12%) in the myomectomy group who had previously undergone abdominal surgery. The mean total operative time was 130.2 ± 32.6 min (docking time, 6.7 ± 2.0 min; console time, 95.3 ± 43.8 min) in the hysterectomy group and 178.8 ± 77.9 min (docking time, 7.1 ± 1.7 min; console time, 89.5 ± 51.0 min) in the myomectomy group. The average time to manual morcellation was 9.6 ± 8.1 min in the hysterectomy group and 10.7 ± 10.8 min in the myomectomy Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
G. O. Chong et al.
Figure 2. (A) The single-port assisted three-incision technique. (B) Manual morcellation was performed using a scalpel within an endobag through a wound retractor. (C) Postoperative skin wound
group. The mean blood loss was 32.2 ± 27.6 ml in the hysterectomy group and 57.1 ± 46.5 ml in the myomectomy group. The mean length of postoperative hospital stay was 4.6 ± 1.9 days in the hysterectomy group and 4.4 ± 1.4 days in the myomectomy group. The average weight Copyright © 2015 John Wiley & Sons, Ltd.
of the uterus was 333.1 ± 203.6 g and the average weight of the uterine fibroids was 251.7 ± 213.6 g. In the hysterectomy group, there was one case of rectal serosa injury that occurred due to endometriosis at the cul-de-sac; however, no postoperative complications occurred. In the Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
Robotic surgery without power morcellation
myomectomy group, there was one case involving a small bowel injury that occurred due to a small bowel adhesion to a previous myomectomy site. Primary repair of the small bowel was conducted using the robot. Finally, three febrile morbidities occurred as postoperative complications (Table 1). There were no complications related to manual morcellation performed using a scalpel.
Discussion Analysis of surgical data in the USA in 2009 showed that abdominal hysterectomy was performed in 56% of cases, laparoscopic hysterectomy in 20.4% of cases, vaginal hysterectomy in 18.8% of cases and robotic hysterectomy in 4.5% of cases (7). In addition, recent data have shown a decrease in the frequency of abdominal hysterectomy following the introduction of robotic surgical systems (14,15). A large retrospective study demonstrated that robotic-assisted laparoscopic myomectomy is associated with decreased blood loss and hospital stay compared to conventional laparoscopic myomectomy and open abdominal myomectomy (16). To remove a large uterus and uterine fibroid during robotic hysterectomy and myomectomy, power morcellation was usually used. This was performed using a 12 mm port for assistance, which is located in the left or right upper quadrants. During power morcellation, it can be difficult to prevent small tissue fragments from inadvertently becoming dispersed throughout the peritoneal cavity. Disseminated tissue fragments may implant on the organs in the abdominal cavity. This can potentially result in peritonitis, intra-abdominal abscesses or an intestinal obstruction that requires a repeat operation or additional interventions (17). Power morcellation may also lead to the disruption and possible dissemination of an unrecognized sarcoma, which can result in metastatic implants in the peritoneal
cavity. Such iatrogenic dissemination may have an adverse effect on patient prognosis. George et al. (18) demonstrated that intraperitoneal morcellation of a presumed leiomyoma resulted in a reduction in survival of women with uterine leiomyosarcomas. They concluded that, because there are no reliable pre-operative techniques that can be used to distinguish uterine leiomyosarcoma from benign leiomyoma, all efforts to minimize intraperitoneal uterine morcellation should be considered (18). A recent review of the Manufacturer and User Facility Device Experience database of the US FDA found 55 complications between 1993 and 2013, including six deaths, and injuries caused by the morcellator blade to almost every organ in the abdominal cavity, including the bowel, vena cava and aorta (17). In the case of a robotic hysterectomy or myomectomy, power morcellation is usually performed using a 12 mm trocar that is positioned in the upper abdomen. It is conceivable that an increased risk of organ injury may exist compared to conventional laparoscopy, in which morcellation is usually performed through the suprapubic area. However, it is unclear whether umbilical, suprapubic or lateral port placement is safe for power morcellation. We conducted manual morcellation using a scalpel within an endobag thorough a wound retractor located at the umbilicus. To minimize abdominal organ injury, traction of the uterus or uterine fibroids was applied using towel clips, and manual morcellation conducted at the extracorporeal space. An endobag was used to minimize the possibility of dissemination of the small tissue fragments. However, variability in the size, shape and weight of the uterine tissue makes placing the specimen into the endobag challenging; indeed, it was very difficult to place > 500 g uterine tissue into the endobag. Because two 12 mm ports of the OctoPort were used, no additional trocar was needed. Compared to conventional robotic techniques, our three-incision technique with manual morcellation has advantages in terms of preventing tissue
Table 1. Patients’ characteristics and surgical outcomes
Age (years) 2 Body mass index (kg/m ) Previous abdominal surgery history (n, %) Total operative time (min) Docking time (min) Console time (min) Time to manual morcellation (min) Blood loss (ml) Haemoglobin change (g/dl) Length of postoperative hospital stay (days) Weight of uterus or uterine fibroids (g) Intraoperative complications (n) Postoperative complications (n)
Copyright © 2015 John Wiley & Sons, Ltd.
Hysterectomy (n = 16)
Myomectomy (n = 50)
45.3 ± 3.5 23.1 ± 2.9 9 (56%) 130.2 ± 32.6 6.7 ± 2.0 95.3 ± 43.8 9.6 ± 8.1 32.2 ± 27.6 1.5 ± 0.6 4.6 ± 1.9 335.1 ± 203.6 1 0
36.3 ± 7.2 21.4 ± 2.3 6 (12%) 172.8 ± 77.9 7.1 ± 1.7 89.5 ± 51.0 10.7 ± 10.8 57.1 ± 46.5 1.6 ± 0.8 4.4 ± 1.4 251.7 ± 213.6 1 3
Int J Med Robotics Comput Assist Surg 2015. DOI: 10.1002/rcs
G. O. Chong et al.
dissemination, improving the cosmetic result and reducing complications related to the trocar site, such as bleeding or incisional hernias. Recently, single-port robotic surgery has been introduced in the gynaecological field (19,20). We have previously used single-port robotic surgery using OctoPort (Figure 3). However, it was very difficult to perform single-port robotic surgery using conventional robotic instruments, owing to clashing between robotic instruments. Our trial may be helpful for developing the new single-port system. Few data were available on vaginal morcellation or umbilical manual morcellation in the bag during minimally invasive gynaecological surgery (12,21). Most reports have described the surgical technique and its feasibility; however, no detailed surgical outcomes, such as morcellation time, pain score and numbers of ports, have been documented. Further studies are therefore needed for detailed comparisons between umbilical manual morcellation and vaginal morcellation. The limitations of the present study include the retrospective design and the small study population. In addition, because of short follow-up period, we could not compare the incidences of long-term complications, such as iatrogenic myoma, with power morcellation. Moreover, there was no comparison of surgical outcomes between vaginal and umbilical morcellation. Despite these limitations, our novel technique may be an alternative to power morcellation, and could be effective in minimizing the spread of uterine tissues throughout the abdominal cavity. In conclusion, our novel single-port assisted threeincision robotic hysterectomy or myomectomy technique is feasible and is a safe treatment modality. Uterine tissues could be removed without the use of power morcellation during robotic surgery. Our surgical technique is an alternative to power morcellation that can minimize the spread of tissue fragments, which may be malignant tissues, throughout the abdominal cavity. It can thus reduce
Figure 3. Single-port robotic surgery using OctoPort Copyright © 2015 John Wiley & Sons, Ltd.
the frequency of life-threatening complications related to power morcellation, such as injury of the bowel, vena cava or aorta.
Conflicts of interest The authors have stated explicity that there are no conflicts of interest in connection with this article.
Funding No specific funding.
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