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: mtam@hmc.psu.edu

G. Harkins

e-mail: gharkins@hmc.psu.edu

M. Davies

e-mail: mdavies@hmc.psu.edu

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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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.

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(min)

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(day)

EBL

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