robotic-assisted laparoscopic trachelectomy: a case series and review of surgical technique
TRANSCRIPT
ORIGINAL ARTICLE
Robotic-assisted laparoscopic trachelectomy: a case seriesand review of surgical technique
Teresa Tam • Gerald Harkins • Matthew Davies
Received: 28 December 2012 / Accepted: 4 February 2013
� Springer-Verlag London 2013
Abstract We present a retrospective case series of
patients who underwent robotic-assisted laparoscopic tra-
chelectomies from August 1, 2011 to August 30, 2012,
with a description of the surgical technique for successful
cervical removal. The patients, at the Department of
Obstetrics and Gynecology, Division of Urogynecology
and Minimally Invasive Surgery at Penn State Milton
S. Hershey Medical Center, were identified using ICD-9
coding for robotic-assisted trachelectomy. Of the 180
patients who had robotic-assisted gynecologic surgery
during the study period, eight underwent robotic-assisted
laparoscopic trachelectomy. The patients’ average age was
40.4 years, average parity was 1.5, and mean body mass
index was 28. The time interval from initial surgery of
supracervical hysterectomy to robotic-assisted trachelec-
tomy was 4 years. Pre-operative cervical cytology was
negative in all patients. The average length of stay was one
overnight admission. The primary indication for prior
supracervical hysterectomy was dense pelvic adhesions,
and the main indications for robotic-assisted trachelectomy
were pelvic pain due to endometriosis and cyclic vaginal
bleeding. Surgical outcomes included minimal blood loss
(\50 ml) and mean operative time of 1.15 h (74.88 min),
without any immediate intra-operative or post-operative
complications reported. Histopathology reports on all cer-
vical specimens were normal. Adnexectomy is the most
common concomitant procedure performed with trache-
lectomy. Robotic-assisted laparoscopic trachelectomy is a
viable option for patients requesting a minimally invasive
approach to cervical stump removal.
Keywords Gynecology � Trachelectomy � Robotics �Cervical stump � Laparoscopic trachelectomy
Introduction
Hysterectomy remains the most frequently performed major
gynecologic procedure in the USA. Although there are many
different surgical techniques for performing a hysterectomy,
the laparoscopic approach is gaining appeal due to the
introduction of minimally invasive procedures [1]. Laparo-
scopic supracervical hysterectomies are performed for
various reasons, with most procedures performed due to
intra-operative complexity in removal of a symptomatic
fibroid uterus [2, 3]. Cervical preservation continues to be a
patient’s choice and/or physician’s surgical preference.
Reduction in pelvic organ prolapse while maintaining sexual
function are some of the reported although controversial
advantages [4–6]. Though these possible benefits are
unsubstantiated by recent studies, supracervical hysterec-
tomy is being requested by patients and performed by sur-
geons with increasing frequency [7, 8].
With the growing appeal of supracervical hysterectomy,
the overall number of trachelectomies will most likely
Electronic supplementary material The online version of thisarticle (doi:10.1007/s11701-013-0397-0) contains supplementarymaterial, which is available to authorized users.
T. Tam (&) � G. Harkins � M. Davies
Division of Urogynecology and Minimally Invasive GYN
Surgery, Department of Obstetrics and Gynecology, Penn State
College of Medicine, Penn State Milton S. Hershey Medical
Center, 500 University Drive, P.O. Box 850, Hershey,
PA 17033-0850, USA
e-mail: [email protected]
G. Harkins
e-mail: [email protected]
M. Davies
e-mail: [email protected]
123
J Robotic Surg
DOI 10.1007/s11701-013-0397-0
increase as well. Although trachelectomies are commonly
performed through the vaginal or abdominal approach, more
complications are encountered with the latter approach [9].
The laparoscopic alternative to trachelectomy over the
abdominal route offers patients the greatest benefit, provid-
ing higher procedural safety and efficiency, shortened
hospitalization, and rapid patient recovery, while maintain-
ing the minimally invasive surgical approach [10–12].
Robotic technology has gained increasing adoption and
use in minimally invasive gynecologic surgery. Except for
one case report on a single patient [13], there are no pub-
lished studies, to date, on robotic-assisted trachelectomy
performed on benign gynecologic cases. In the published
literature, most robotic-assisted trachelectomies have been
performed on women with early-stage cervical cancer
[14–16], undergoing robotic radical trachelectomy for
fertility preservation. In benign gynecology, laparoscopic
removal of the cervical stump has been primarily indicated
due to pelvic pain from endometriosis [17, 18].
The purpose of this study is to present a case series of
robotic-assisted laparoscopic trachelectomies in benign
gynecology performed at our institution. It further identi-
fies contributing factors, indications, and outcomes using
this minimally invasive approach. A description of surgical
technique for successful removal of the cervix after a prior
supracervical hysterectomy is also given. A video of our
patient undergoing robotic-assisted laparoscopic trache-
lectomy is presented.
Materials and methods
This study is a retrospective chart review of eight patients
who underwent robotic-assisted laparoscopic trachelecto-
my from August 1, 2011 to August 30, 2012. They were
patients of the Department of Obstetrics and Gynecology,
Division of Urogynecology and Minimally Invasive Sur-
gery at Penn State Milton S. Hershey Medical Center.
Patients were identified using ICD-9 coding for robotic-
assisted trachelectomy. Data was de-identified in accor-
dance with Health Insurance Portability and Accountability
Act (HIPAA) regulations. The Office of the Institutional
Review Board at Penn State Milton S. Hershey Medical
Center approved this study.
Only patients who underwent robotic-assisted laparo-
scopic trachelectomy were included in the study. Trachelec-
tomies performed vaginally, abdominally, or laparoscopically
without using the da Vinci� robotic system were excluded
from the study.
Data abstracted from detailed electronic chart review
included patient demographics: age, parity, body mass
index (BMI), and past surgical history. Indications for prior
supracervical hysterectomy and subsequent robotic-
assisted laparoscopic trachelectomy, plus the time interval
between the two procedures, were also recorded. Operating
time (OT), estimated blood loss (EBL), complications,
length of hospital stay (LOS), concomitant surgical pro-
cedures, and histopathologic diagnosis were noted. The
surgical technique of robotic-assisted laparoscopic trache-
lectomy performed at this institution is also described.
Technique
All patients receive mechanical bowel preparation and pre-
operative antibiotics. After general anesthesia is given, the
patient is placed in a modified dorsalithotomy position. The
bladder is drained with a Foley catheter. An umbilical
incision is made and the Veress needle is inserted to
insufflate the abdomen. After pneumoperitoneum is
obtained, an 8.5-mm optically guided trocar is placed
through the umbilical incision and two 8-mm lateral ports
are placed under direct visualization. A 5-mm assistant port
is also inserted. Pneumoperitoneum is decreased from entry
pressure of 20 mmHg and maintained at 16 mmHg. The da
Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale,
CA, USA) is docked using three arms: camera port through
the umbilical incision and two robotic instrument ports
through the lateral incisions. A sponge stick is placed in the
vagina to manipulate the cervix from below, and facilitate a
colpotomy incision.
The Hot ShearsTM (monopolar curved scissors) is placed
in arm no.1 and the fenestrated bipolar forceps is inserted
in arm no. 2. Anterior adhesions from the cervix to the
bladder are sharply dissected with the monopolar scissors
to mobilize the bladder off the cervical stump. Posterior
adhesions from the cervix to the posterior cul-de-sac are
also sharply dissected if present.
Careful inspection and dissection of the ureters are
performed to lateralize their location. Once the bladder and
bowel are fully dissected off the cervix and upper vagina,
the monopolar scissors is replaced with the Harmonic ACE
curved shears in arm no. 1.
With the sponge stick in the vagina pushed upward, the
anterior cervicovaginal junction is delineated. An anterior
colpotomy is created at the cervicovaginal junction using
the active blade edge of the Harmonic ACE scalpel to enter
the anterior cul-de-sac.
To facilitate cervical amputation at the vaginal cuff
angle, the active blade of the harmonic scalpel is turned
vertically with the active blade against the cervicovaginal
tissue, transecting towards the uterosacral ligament at a 90�angle. The cervix is circumferentially excised off the
vaginal apex by hugging the cervicovaginal junction.
The uterosacral and cardinal ligaments are transected
bilaterally with the harmonic scalpel. Instrument swap
J Robotic Surg
123
could be done by placing the fenestrated bipolar grasper in
arm no. 1 and the harmonic scalpel in arm no. 2 to com-
plete the colpotomy on the contralateral side.
After the cervical stump is completely circumscribed off
the vaginal apex, the trachelectomy specimen is delivered
through the vagina. The sponge stick is replaced with a
pneumo-occluder balloon in the vagina to maintain
pneumoperitoneum.
For colpotomy closure, instruments are replaced with the
EndoWrist� needle holder in arm no. 1 and the ProGrasp�
forceps in arm no. 2. Fenestrated bipolar forceps could be
maintained in arm no. 2 to provide electrocautery in the event
of vaginal cuff bleeding. The vaginal cuff is closed with
V–LocTM barbed suture. All instruments are removed and
trocar port sites are closed with 2–0 monocryl sutures and skin
adhesive. Cystoscopy is often performed at the conclusion of
the trachelectomy procedure to ensure bladder and ureteral
integrity, primarily in patients with prior cesarean delivery.
Results
Of the 180 patients who had robotic-assisted gynecologic
surgery during the study period, eight underwent robotic-
assisted laparoscopic trachelectomy. Clinical features of
patients who underwent robotic-assisted trachelectomy at
our institution are shown in Table 1. Patients tended to be
older with an average age of 40.4 years, a mean parity of 2
and mean BMI of 28. The time interval from initial surgery
of supracervical hysterectomy to trachelectomy ranged
from 1 to 6 years with a mean interval of 4 years. Pre-
operative cervical cytology was negative in all patients.
Primary indications for prior supracervical hysterectomy
included leiomyoma, endometriosis, and pelvic adhesive
disease, with several patients having concurrent complaints.
Only one patient specifically requested cervical preserva-
tion. The main indications for trachelectomy were pelvic
pain due to endometriosis and cyclic vaginal bleeding.
Surgical outcomes included minimal blood loss
(\50 ml) and mean operative time of 1.15 h (74.88 min),
without immediate intra-operative or post-operative com-
plications reported. Histopathology reports on all cervical
specimens were normal. Concomitant procedures were
performed on all patients, with adnexectomy being the
most common additional procedure performed with tra-
chelectomy. Salpingectomy and excision of endometrial
implants were most commonly performed concurrently
with cervical stump removal. Intra-operative cystoscopy
was performed in three patients. The average length of stay
was one overnight admission (Table 2).
Discussion
Proper patient selection and counseling are imperative to
reduce reoperation on patients who elect to have a supr-
acervical hysterectomy. The supracervical approach is not
a superior approach to hysterectomy for benign disease
[19]. Although some patients elect to retain their cervix
during a hysterectomy for various reasons, they must to be
forewarned of the high incidence of cyclic bleeding
(19–25 %) after supracervical hysterectomy [20, 21].
Women need to be reassured that removal of the cervix
during a hysterectomy does not decrease sexual satisfaction
nor is it detrimental to urinary function [22–24]. Patients
choosing the supracervical approach must continue with
recommended cervical cytology screening and be prepared
for the possibility of future trachelectomy [19].
Although trachelectomies are performed infrequently,
renewed interest in cervical preservation could trigger
increased incidence of trachelectomy after supracervical
hysterectomy. Removal of the cervical stump after a
supracervical hysterectomy could be a challenging proce-
dure. A thorough patient assessment and formulation of a
systematic surgical approach need to be established prior to
performing a laparoscopic or robotic-assisted trachelecto-
my procedure.
Although the study was limited to only eight cases, there
is limited published data on robotic-assisted trachelectomy
outcomes. Extensive searches on Ovid, PubMed, Cochrane
and Medline databases in the English language were per-
formed, using the search terms ‘‘robotic’’ and ‘‘robotic-
assisted’’ in combination with ‘‘trachelectomy’’. Only one
case of robotic trachelectomy for benign indication was
reported [13]. Comparison of the three different surgical
approaches to trachelectomy, i.e. open versus laparoscopic
versus robotic, could further strengthen this study.
This retrospective case series concurs with previous
studies attributing endometriosis and pelvic pain as pri-
mary indications for laparoscopic trachelectomy [17, 18].
Okaro et al. [17] concluded that 24.3 % of patients with
prior supracervical hysterectomy required further surgery.
Table 1 Summary of patient demographics
Variables Mean Range
Age (years) 40.4 24–48
Parity 1.5 0–3
BMI (kg/m2) 28 23.8–40
Supracervical indications No. 1 C/S
No. 2 Endometriosis
Interval (years) 4 1–6
BMI body mass index, C/S cesarean section, interval time interval
from supracervical hysterectomy to trachelectomy
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123
Conclusion
Surgical planes could occasionally be indistinct and pelvic
adhesions encountered in patients with endometriosis and
prior surgeries. Manual dexterity and articulation provided
by the robotic wristed instruments, in addition to the 3D
visual field magnification, have aided surgeons in tackling
complex gynecologic procedures. Moreover, the use of
barbed sutures obviates the need for knot tying or reliance
on assistance, making vaginal cuff closure quicker and more
efficient compared to conventional laparoscopic suturing.
These advantages potentially encourage gynecologic
surgeons to confidently implement a safe and minimally
invasive approach to trachelectomy. Robotic-assisted lap-
aroscopic trachelectomy is a viable option for patients
requesting a minimally invasive approach to cervical stump
removal.
Conflict of interest The authors have full control of all primary data
and they agree to allow the journal to review their data if requested.
Dr. Tam and Dr. Davies declare that they have no conflict of interest.
Dr. Harkins is a consultant to Ethicon and Intuitive Surgical.
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Case
no.
Pre-operative diagnosis OT
(min)
LOS
(day)
EBL
(ml)
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