da vinci gynecology wesley harris, m. d. da vinci gynecologic surgery
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da Vinci Gynecology
Wesley Harris, M. D.
da Vinci Gynecologic Surgery
da Vinci Gynecology
Open (abdominal) surgery
Minimally invasive surgery (MIS) Vaginal surgery Conventional laparoscopic surgery da Vinci® Hysterectomy (robotic-assisted surgery)
Surgical Approaches to Gynecologic Conditions
da Vinci Gynecology
MIS – Laparoscopic Surgery
Minimally invasive surgery (MIS)
Ability to operate through small keyhole incisions
The camera and instruments fit through the keyhole incisions
Better visualization than open surgery
da Vinci Gynecology
ACOG Committee OpinionNumber 444 – November 2009
“Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic and abdominal hysterectomy. When it is not feasible to perform a vaginal hysterectomy, the surgeon must choose between laparoscopic hysterectomy, robot-assisted hysterectomy or abdominal hysterectomy.”
da Vinci Gynecology
Things that make vaginal hysterectomy easier:
1. Prior vaginal delivery
2. No adnexal pathology
3. Uterus <250 gm
da Vinci Gynecology
Things that make vaginal hysterectomy more difficult:
1. Nulliparity
2. Prior cesarean section
3. Adnexal pathology
4. Severe pelvic adhesions
5. Morbid obesity
da Vinci Gynecology
Program
• Gynecologic Conditions• da Vinci® Surgical System• da Vinci Gynecologic Surgery
da Vinci Hysterectomy for Early Stage Gynecologic Cancer da Vinci Hysterectomy for Benign Conditions da Vinci Myomectomy da Vinci Sacrocolpopexy
da Vinci Gynecology
Gynecologic Conditions
•Pre-cancer•Cancer•Pelvic masses•Abnormal bleeding•Endometriosis•Fibroids •Pelvic floor disorders
Uterus
Fallopian
TubeOvary
Bladder
Urethra
Pubic Bone
Vagina
Rectum
da Vinci Gynecology
Benefits of Minimally Invasive Surgery (MIS)
•Reduced blood loss•Fewer complications•Shorter LOS•Faster recovery•Less scarring•Less risk of infection•Significantly less pain•Improved cosmesis
Circa. 1991
da Vinci Gynecology
Drawbacks with Conventional Laparoscopic Surgery
• Surgeon operates from a 2D image
• Straight, rigid instruments (limited range of motion)
• Instrument tips controlled at a distance
• Reduced dexterity, precision and control
• Unsteady camera controlled by assistant
• Dependent on assistant for surgical support through an accessory port
• Greater surgeon fatigue
• Makes complex operations more difficult
da Vinci Gynecology
How to overcome these drawbacks?
Improve visualization Improve instrument
control Enhance dexterity for
technically challenging aspects of the procedure
Use superior ergonomics
da Vinci Gynecology
da Vinci® Hysterectomy for Benign Gynecologic Conditions
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da Vinci Gynecology
Dexterity for complex dissections (e.g endometriosis)
Vaginal cuff suture closure with ease
Improved visualization and access around the cervix for a colpotomy
Video courtesy of Javier F. Magrina, M.D.
da Vinci Hysterectomy
da Vinci Gynecology
Enables GYNs to treat complex pathology endoscopically
Unsurpassed precision, dexterity and control offer potential for:
More precise and efficient dissections Ureters, vesico-uterine reflection, colpotomy
Quicker, easier vaginal cuff closure
Greater ability to perform MIS on more patient types
Compromised anatomy and tissue planes, e.g., due to endometriosis and adhesive disease from prior pelvic surgeries
Larger pathology Obese patients
Benefits of da Vinci Hysterectomy
da Vinci Gynecology
da Vinci® Sacrocolpopexy
da Vinci Gynecology
Easier, quicker and more precise suturing
Complete control of the camera and all three operative arms
A reproducible approach
Video courtesy of Anthony Visco, M.D.
Double-click to view video
da Vinci Sacrocolpopexy
da Vinci Gynecology
da Vinci Sacrocolpopexy is considered the gold standard for vaginal vault prolapse• <5% are performed with laparoscopy• This procedure typically requires difficult dissections and
extensive suturing
da Vinci enables an endoscopic approachfor sacrocolpopexy
The unsurpassed visualization, depth perception, dexterity and control offered by the da Vinci System provide:• Improved access to the pelvis compared to open and
conventional laparoscopic approaches• Easier, more precise rectovaginal and presacral dissections• Improved handling of suture and mesh for more accurate graft
placement and attachment
Benefits of da Vinci Sacrocolpopexy
da Vinci Gynecology
da Vinci® Gynecology
Improving the Quality of Life for
WomenAs with any surgery, these benefits cannot be guaranteed, as surgery is patient- and procedure-specific. This program presents the opinions of and techniques used by an independent surgeon and not those of Intuitive Surgical. Intuitive Surgical does not provide clinical training nor does it provide or evaluate surgical credentialing or train in surgical procedures or techniques. While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits. © 2006 Intuitive Surgical. All rights reserved. Intuitive, Intuitive Surgical, da Vinci, da Vinci S, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their respective holders. PN 871180 Rev. A 6/08
da Vinci Gynecology
da Vinci Hysterectomy Minimizes TAH and Conversion Rates
Data from Drs. Thomas Payne and Ralph DauteriveOchsner Clinic, Baton Rouge, LA
Source: Oral presentation by Dr. Thomas Payne at AAGL 2007.
Pre-robotic (n=100) da Vinci (n=100)Last 25da Vinci
Age (years) 43.5 43.2
BMI 28.8 28.8
Estimated blood loss (ml) 113 61
Hospital stay (days) 1.6 1.1
TAH rate 20% 4% 0%
Conversions (subset of TAH) 9% 4% 0%
Avg uterine weight of conversions 359.5 1387.5
TAH due to adhesions 8% 0%
Operative times (skin-to-skin) 92.4 119 78.7
Retrospective Review of Hysterectomy: Pre-Robotic versus da Vinci
da Vinci Gynecology
Robotic
Surgery
Conventional
Laparoscopy
da Vinci Gynecology
Less Conversions for Robot as compared to conventional laparoscopy
Matthews
LH 12%57
cases
RH 0%70
cases
Payne
LH 9%
RH 4%
•Sarlos – review
Mixed Reports
da Vinci Gynecology
Complication Rates
AH LH RH VH
Matthews 23% 7.0% 4.3% 11.1%
Sarlos EQUAL EQUAL
Landeen 14.0% 8.8% 8.4% 8.0%
da Vinci Gynecology
Complication Rates
• Complication Rates for the minimally invasive procedures are relatively equal
• Minimally invasive procedures have a lower complication rate than open procedures
da Vinci Gynecology
OR Time
AH VH LH RH
Pasic 169 193
Giep 90 90
Sarlos 83 109
Barnett 147 213 192
Landeen 84 99 118 117
da Vinci Gynecology
OR Time
• Operating times are fairly equal between laparoscopic and robotic hysterectomy
• Open laparotomy does lead to a decrease in OR time compared to laparoscopic and robotic procedures
da Vinci Gynecology
Length of Stay
AH VH LH RH
Matthews 3.34 1.8 1.7 1.6
Landeen 2.7 1.9 1.8 1.3
Pasic 1.4 1.4
Giep 1.2 1.0
Sarlos 3.9 3.3
Payne 1.6 1.0
da Vinci Gynecology
Length of Stay
• Length of stay NOT significantly different among minimally invasive procedures
• Length of stay for all minimally invasive procedures is significantly less than for open surgery
da Vinci Gynecology
Direct Cost
• Equipment• Capital
• Non Capital
• Operative Time
• Post Operative Time
da Vinci Gynecology
Sarlos
LH RH
Personnel Costs 1824 2434
Material Costs 1128 3152
Total Costs 2952 5583
da Vinci Gynecology
Surgical Supplies
AH VH LH RH
Landeen 156 283 890 1859
Barnett 198 1138 2210
da Vinci Gynecology
Total Cost – NO Depreciation
AH LH RH
Barnett 7009 6581 7478
Landeen 4025 4475 6129
da Vinci Gynecology
Societal Perspective Modelof Barnett
Conventional
Laparoscopic10,128
Robotic 11,476
Laparotomy 12,847