Transcript Robotic Surgery in Gynaecological Oncology

The 2nd International Meeting of the ERC and ELG-RCOG,
Cairo, Egypt, 3rd&4th March 2012
Robotic Surgery in Gynaecological
Oncology
Ahmed Sekotory Ahmed MD MRCOG
Lead Consultant & Director of Gynaecological Oncology
University Hospital of South Manchester
The Christie NHS FT
Manchester-UK
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Karel Capek
1890-1938
Rossum's Universal Robots
1921
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“..Waldo, 1942….a science fiction story”
Robert A. Heinlein – Science Fiction Author
1907-1988
www.wikipedia.com
1942; Waldo published in the Astounding
Science fiction Magazine
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Laws of Robotics..!!
Asimov, 1950s
 Law 2: A robot must obey orders given to it by human
beings, except where such orders would conflict with a
higher order law.
 Law 3: A robot must protect its own existence as long as
such protection does not conflict with a higher order
law.
http://www.robotics.utexas.edu/rrg/learn_more/history/
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1980s; The era of
industrial Robots
www.google.com/images
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Important timelines:
1985
BUMA system: placing a needle for brain biopsy
1988
PROBOT: TURP
1992
ROBODOC: assistance with hip replacement
1997
da Vinci Robot: Tubal re-anastmosis
1999
Robotic Assisted Coronary Bypass
2001
Tele-Surgery: Cholecystectomy, Surgeon in New York;
Patient at Strasburg
2002
da Vinci Robotic Assisted Hysterectomy
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Da Vinci……
Leonardo da Vinci 1452-1519
self-portrait (circa 1512 to 1515)
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The “da Vinci” Robot?
Mechanical Night (Robotic Knight); 1495
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da Vinci® European Installed Base 1999 – 2010
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Courtesy of Intuitive
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da Vinci® Middle Eastern Installed Base 1999 – 2010
2003
2004
2006
2007
2008
2009
2010
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Courtesy of Intuitive
NHS Foundation Trust
da Vinci Robot
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The Console
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The Console
3-D Vision
 Filtered tremors
 7-df
 Multi-task
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Robotic surgical arms: Patient’s cart
Console unit
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Endo-Wrist Instruments & telescope
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Robotic Surgery
Advantages
Disadvantages
 Ergonomic
 Lack of tactile feedback
 3-D Vision
 Can’t change operating table
 Filtered tremors
position once arms are docked
 Improved dexterity; 7 degrees
to patient
of freedom
 Less fatigue
 Allows performing complex
procedure
 Set up time
 Cost
 Capital cost
 Maintenance
 Disposables
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• Open surgery techniques
• Laparoscopic (Keyhole) Surgery
• Robotic Surgery
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Robotics in Gynaecological Oncology
• Endometrial cancer staging
– Special conditions: e.g. obesity
• Cervical cancer treatment
– Radical surgery
– Radical fertility sparing surgery (i.e. Trachelectomy)
• Cost-effectiveness evaluation
• Other uses: ovarian cancer…etc.
• Future directions
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Robotic Surgery in Endometrial cancer
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Robotic Surgery in Endometrial cancer
Study
Pt N.
Diaz4
Arrastia et
al 2002
(all: 11)
(R)
Reynolds
et al 2005
(P)
4
(all: 7)
Marchal
et al 2005
(P)
5
(all: 30)
Proced
RAH+BSO
Op Time
4.5
(hrs)
ECS
257 (m)
ECS
181 (m)
(CT: 120)
EBL (ml)
300
(50-1500*)
50
83
HS
(d)
2
IOC
Remarks
(1/11*)
1st series (Recr.: 2001)
BMI: 28
Side Dock. (Redocked)
Set-up T: 45m8m
0
Recr.: 1999-2002
BMI: 27
LNC: 15 (Redocked)
0
Recr.: 1999-2003
LNC: 11
POC: 5 (17%)
2
8
Reynolds 2005: FU 4-24m No Recurrence
Marchal 2005: FU 2-23m No recurrence
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Seamon et al
2009
DeNardis et al
2008
Study
Robotic Surgery in Endometrial cancer
ECS
Proced
Robotic
Pt N.
BMI
Op
Time
(m)
56
29
177
EBL
(ml)
HS
(d)
POC
%
Conv
%
105
1
3.6
5.4
Remarks
Bl Tr.: 0 v 8.5%
Open
106
34
79
241
3.2
Robotic
105
34
242
100
1
Laparosc.
76
29
287
250
2
20.8
12
26
ORT(m): 305 v 336
Bl. Tr.: 3 v 18%
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Bogess et al 2008
Study
Robotic Surgery in Endometrial cancer
P
ECS
Proced
Robotic
Pt N.
BMI
Op
Time
(m)
103
33
191
Laparosc.
81
Open
138
29
<0.001
EBL
(ml)
HS (d)
POC
%
75
1
4.9*
213
146
1.2
9.9
146
266
4.4
28.9
<0.001
<0.001
<0.001
<0.001
Remarks
LNC: 33 vs 23 vs 15
*Post-Op C.:
-PE:1
-Port site hernia:1
-Vaginal leak:1
-Lymphoecyst:1
-Lymphoedema:1
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Bogess et al 2008
Study
Robotic Surgery in Endometrial cancer
ECS
Proced
Pt N.
IOC
%
Conversion
Bl. Transfusion
%
Robotic
103
1*
2.9*
1
Laparosc.
81
3.7
4.9
2.5
Open
138
0.7
NA
1.5
Remarks
*Conversion RO:
Adhesions: 1
Extra-uterine D: 2
*IOC:
Sm. bowel injury: 1
Laparoscopic IOC: Sm Bowel injury x 1; Bladder injury x 1; IVC injury x 1
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For Robotics:
 > 50% Reduction in morbidity compared with
laparoscopic route
 5 times reduced morbidity compared with
standard abdominal route
Bogess et al 2008
Bogess et al 2008
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Robotic Surgery in Endometrial cancer
Study
N
BMI
OT
EBL
Conv
LNC
IOC
POC
LHS
Veljovich
et al
2008
25
26.3
283
67
-
17.5
-
-
1.7
Bell et al
2008
40
33
184
166
-
17
0
7.5
2.3
Hoekstra
et al
2009
32
29
195
50
3.1
17
6.2
12.5
1
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Robotic Surgery in Endometrial cancer
Study
ECS
Peiretti et
al 2009
Holloway
et al 2009
Pt N.
BMI
Op Time
(m)
Conversion
%
HS (d)
Remarks
80
25
181
3.7
2.5
Docking time: 4.5
minutes
-
LNC: 25
V. Cuff dehiscence:
16%0
100
203160
4
Robotic staging for endometrial cancer was feasible and safe
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Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients
Full Endometrial Cancer Staging (Pelvic & PALND): 72%
BMI
IOC
Conversion
Op Time
EBL (ml)
LNC
POC
32.4
3.5 %
6.7 %
171 (m)
88
16
14 %
Conversion to Laparotomy 6.7%
HS (d)
1.8
Intra-Op Complications 3.5%
Extra-Uterine D.
6 (1.5%)
Vascular injury (V)
5 (1.2%)
Large Uterus
10 ( 2.5%)
Bowel injury
4 (1%)
Ventilation Risk
4 (1%)
Bladder injury
3 (0.7%)
Adhesions
7 (1.7%)
Trocar injury
1 (0.2%)
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Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients
Full Endometrial Cancer Staging (Pelvic & PALND): 72%
Post-Operative Complications
Post-Operative Complications
Pyrexia
10 (2.5%)
Ileus
3 (0.7%)
UTI
7 (1.7%)
Vesico-Vaginal Fistula
2 (0.4%)
VTE
7 (1.7%)
Delayed vascular injury*
1 (0.2%)
Seroma
7 (1.7%)
Acute Renal F.
1 (0.2%)
Abscess
6 (1.5%)
1 (0.2%)
Lymphoedema/Cyst
5 (1.2%)
Retro-peritoneal
Haematoma
Vault bleeding
3 (0.7%)
Superficial
Thrombophlebitis
1 (0.2%)
Vault dehiscence
3 (0.7%)
Total
57 (14%)
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Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients
Full Endometrial Cancer Staging (Pelvic & PALND): 72%
Mortality: 2 Cases 0.4%
Case 1: Delayed vascular thermal
injury
- Presented 3 days post surgery (2/
post discharge): abdo pain;
haemoperitonium
- Leaking EIA Stented
- Condition deteriorated within 24 hrs
Case 2: Cardiac event (MI)
- Post-op shortness of breath,
dizziness
- Abnormal ECG
- Sudden loss of consciousness
- Cardiac arrest
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Lee et
al 2010
Gocmen et al
2010
Study
Robotic Surgery in Endometrial cancer
ECS
Proced
Robotic
Pt N.
BMI
Op
Time
(m)
10
33
235
EBL
(ml)
HS
(d)
POC
Conv
%
95
2.8
-
0
Remarks
LNC: 42 vs 47
Open
12
30
169
255
8.8
-
-
Robotic
6
26
200
180
-
0
0
Small number: ?
Learning phase
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Lim et al 2010
Study
Robotic Surgery in Endometrial cancer
P
ECS
Proced
Pt N
148
BMI
Op Time*
(m)
EBL
(ml)
IOC
%
POC
%
LNC
HS
Conversio
n
Robotic
56
30
163
89
0
14
27
1.6
1.7
Laparosc
56
28
193
209
13
21
45
2.6
7.1
Open
36
29
137
266
0
19
56
4.9
-
Sig.
Sig.
Sig.
Sig.
Sig.
Sig.
NS
*Operative Time (Robotic), m: 183153149
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Robotic Surgery in Endometrial cancer
Lim et al 2010; Pt N. 56(R); 56(L); 36(O)
dVH Learning Curve
TLH Learning Curve
TAH Learning Curve
Reference: Lim PC, Kang E, PA-C, and Park DH. Learning curve and surgical outcome for robotic-assisted hysterectomy with
lymphadenectomy: case-matched controlled comparison with laparoscopy and laparotomy for treatment of endometrial cancer. Journal
of Minimally Invasive Gynecology, 2010;17(6):739-748.
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Cardenas-Goicoechea
et al 2010
Study
Robotic Surgery in Endometrial cancer
P
ECS
Proced
Pt
N.
BMI
Op Time
(m)
EBL
(ml)
IOC %
Ret. To
Theat. %
HS
Conver.
%
Robotic
102
32.3
237
109
2
1.9
1.8
1
Laparoscopic
173
32.7
178
187
3.5
1.2
2.3
5.2
NS
NS
S
S
NS
NS
NS
NS
Comparable LNC 22 vs 23
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Paley et al 2011
Study
Robotic Surgery in Endometrial cancer
ECS
Proced
Pt N.
BMI
Op Time
(m)
EBL
(ml)
POC
%
LNC
HS
Conver.
%
Robotic
377
27-33
247
47
6.4
18
1.4
3.45
Open
(P&PALND:
55%)
131
-
-
198
20.6
13
5.3
-
*Operative Time (Robotic), m: 304207
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Robotic Surgery in Endometrial cancer
Proportion of patients treated with MAS compared with Open technique:
Increased from 6.4% to 80.5% over a 4-year period
Paley et al; Am J Obstet Gynecol 2011
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Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications
Complication
Cardiac
Pulmonary
Category
DVT/PE
Infections
ARF/ureteral injury
Wound dehiscence/separation
Admission to ITU
Major vessel injury
Anemia requiring transfusion
Labile blood sugar
Ileus/SBO
Mortality
Cystotomy
Chylous ascites
Cuff dehiscence
Total
Robotic, n = 377
1 (0.26%)
3 (0.79%)
Robotic,
n=377
3 (0.79%)
4 (1.1%)
0
0
0.5
1 (0.26%)
2 (0.53%)
2 (0.53%)
2 (0.53%)
10.27
(0.26%)
1 (0.26%)
4 (1.1%)
24/377 (6.4%)
Open, n = 131
P value
5 (3.8%)
1 (0.76%)
1Open,
(0.76%) n=131
6 (4.6%)
4 (3.0%)
9 (6.9%)
3.8
0
1 (0.76%)
0
0
0 1.5
0
0
27/131 (20.6%)
< .0001
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Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging
OT in T1, T2 and T3 for robotic ECS with pelvic and peri-aortic lymphadenectomy (n = 109)
Year
Mean OT (range), min
Mean node count
2006-2007, n = 20
304(189–443)
19.6
2007-2008, n = 29
230(105–314)
15.0
2008-2009, n = 60
207(100–364)
18.8
OT in T1, T2, T3 for robotic ECS with pelvic lymphadenectomy +/- periaortic LNS (n = 138)
Year
Mean OT (range), min
Mean node count
2006-2007 (T1), n = 10
228 (179-275)
13.1 (2–25)
2007-2008 (T2), n = 28
190 (93–296)
14.4 (2–45)
2008-2009 (T3), n = 100
171 (78–296)
12 (5–39)
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Robotic Surgery in Endometrial cancer
Comparison of complications in robotic and open surgery
obese endometrial cancer cohorts (body mass index ≥30 and <40)
Complication (BMI≥30 and <40)
Infection
Wound dehiscence/separation
Anemia requiring transfusion
Pulmonary
Cystotomy
Cardiac (MI, AF)
ARF
Ureteral injury
Total
Robotic
n = 136
1 (0.7%)
0
1 (0.7%)
2
1 (0.7%)
0
0
0
5 (3.7%)
Paley et al 2011
Open
P
n = 47
4 (8.5%)
5 (10.6%)
1 (2.1%)
1 (2.1%)
0
2 (4.2%)
1 (2.1%)
1 (2.1%)
15 (31%) < .0001
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Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications
Comparison of major complications in robotic and open morbidly obese
cohorts (body mass index >40)
Complication
Robotic, n = 53
Open, n = 23
0
6 (26%)
3 (5.7%)
2 (8.7%)
0
2 (8.7%)
Pulmonary
1 (1.9%)
0
DVT/PE
1 (1.9%)
0
Labile BP
1 (1.9%)
0
Total
6 (11.3%)
10 (43.5%)
Wound dehiscence/separation
Infection
ARF
P value
The.0006
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Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications
Conversion to laparotomy in robotic endometrial cancer cohort
by body mass index category
BMI category
N=377
Total % of EC
patients
Conversions
Normal weight
93
24.7%
2.1%
Overweight
94
24.9%
4.2%
Obese
138
36.6%
2.9%
Morbidly obese
52
13.8%
5.8%
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Robotic Surgery in Endometrial cancer
Robotic staging in Obese patients (TRH+BSO+BPLND+/-PALND/Omentectomy)
Lau S et al 2011
Pt N.=108
BMI < 30
n=52
BMI 30 – 39.9
n=33
BMI ≥ 40
n=23
P
% Radical Hysterectomy
7.7
0
2
NS
N. Pelvic LNC
10.4
10.8
10.5
NS
% PALND
42.3
27.3
4.4
S
N. PA LNC
7
6.2
5
NS
15.4
9.1
4.3
NS
50
57.6
34.8
NS
Uterine Wt. (g)
138.5
149.8
204
S
EBL
64.1
95.9
94
S
Post-Op Hb
116.4
118
115.9
NS
OT, skin to skin (min)
237
255
257
NS
OT, console time (min)
168
174
183
NS
% Mini-Lap
6
3
10.5
NS
LHS
1
2
2
% Partial/Infracolic Oment.
% Lap. Adhesolysis
NS
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ROBOTIC SURGERY IN CERVICAL CANCER
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Surgery for Cervical Cancer
1652
Pares & Talipius
1801-1808
Osiander
1813
Langenbeck
1878
Freund
1895
Ries & Clark
Cervical
Amputation
Cervical
Amputation x 8
Vaginal
Hysterectomy
Abdominal
Hysterectomy
Radical Hyst and
LND
1900
Wertheim
1902
Suhauta
1907
Bonney
1943
Taussig
1944
Meigs
Radical Abdo
Hysterectomy
Radical Vag
Hysterectomy
Large series of
Radical Hyst
Surgery &
Radiation
Rad Hyst & LND
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Surgery for Cervical Cancer
1987
Dargent
1988
Sakamoto
1990
Canis
1991
Querleu
1992
Nezhat
Coelio-Schauta
Extraperit. LND
Nerve Sparing
Rad. Hyst
Laparoscopic
Rad Hyst
Coelio-Schauta
Transperit LND
Laparoscopic
Rad Hyst
1994
Dargent
1997
Smith
1998
Shepherd
1998
Maas
2006
Sert
Radical Vag.
Trachelectomy
Radical Abdo
Trachelectomy
Modified
RVT
Nerve Sparing
Rad. Hyst
Robotic Radical
Hysterectomy
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Robotic Surgery in Cervical Cancer
HS
*POC %
(d)
Study
Pt N.
LNC
Op Time
EBL (ml)
Marchal
et al 2005
7
(all: 30)
11
185
83
8
17
All complications
7
RRH
13
241
71
4
4/8
*POC
UTI: 1 each
Lymphocyst: 2R vs 3L
Bladder Inj: 1 each
Compart. S.: 1L
27.6
207
355
-
1/10
*Pneumonia: 1
Sert &
Abeler
2007
Kim et al
2008
8
LRH
10
Remarks
Robotic surgery in early cervical
cancer
is feasible
and
safe
15
300
160
8
6/7
Sert et al 2007: FU 13-18 months No recurrence
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Robotic Surgery in Cervical Cancer
Study
Pt N.
LNC
Op Time
EBL
(ml)
HS
(d)
*POC
%
Remarks
Fanning et
al 2008
20
18
310
300
1
2/20
Bladder injury:1
Uretero-Vag. Fist: 1
32 ARH
17
219
665
4.9
21.9
Ko et al
2008
Robotic surgery in early cervical
cancer
is feasible
and1.7safe..but
16 RRH
16
290
82
18.8*
Vag. cuff abscess x 1
took a long time!
Uret.-Vag Fist x 1 (Temp)
Lymphocyst x 1
Fanning 2008: FU 7-36 m 90% alive without disease.
Ko 2008: ARH Intraop. ureteric injury; wound inf. x 3; PE x 2
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Nezhat et al 2008
Study
Robotic Surgery in Cervical Cancer
Pt N.
Op Time
(m)
EBL
(ml)
IOC*
POC
%
RRH
13
323
157
2/13
30
LRH
30
318
200
2/30
20
Procedure
LNC
HS
24.7 2.7
31
3.8
*Remarks
Cystotomy
x2
Cystotomy
x2
No conversion to laparotomy in either group
F/U: No recurrence (R: 12m; L: 29m)
RRH is comparable to LRH
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Bogess et al 2008
Study
Robotic Surgery in Cervical Cancer
Procedure
Pt
N.
BMI
Op Time
(m)
EBL
(ml)
Bl
Transf.
POC
%
LNC
HS
Conver.
%
Robotic
RH
51
29
211
97
0
7.8
34
1
0
Open
RH
49
26
248
417
8%
16.3 23 3.2
Robotic Radical Hysterectomy is feasible and may offer better
outcome compared with open; still need further studies
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Magrina et al 2008
Study
Robotic Surgery in Cervical Cancer
Procedure
RRH
Pt N.
Op Time (m)
EBL (ml)
LNC
HS
27
190
133
26
1.7
26
2.4
FU: 10-50 monthsNo recurrence
LRH
31
220
208
Robotic Radical Surgery was technically superior
Open RH
35
167
443
28
3.6
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Maggioni 2009
Study
Robotic Surgery in Cervical Cancer
Procedure
Robotic
RH
Pt
N.
BMI
Op Time
(m)
EBL
(ml)
IOC %
LNC
HS
POC
40
24
272
5
20
Recurrence:
12.5%
in78both cohorts
3.7
20/40
Post-operative
function
tend 12.5
to be better
Open
RH
40 bladder
24
199
221
26
5in RRH
31/40
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Robotic Surgery in Cervical Cancer
Early PostOperative
Complications
RRH
N=40
ARH
N=40
SC Emphysema
4
0
Bl Transfusion
3
9
Pyrexia
3
12
Infection
PV discharge
Late PostOperative
Complications
RRH
N=40
ARH
N=40
Mild
Lymphoedema
2
0
Vaginal
Robotic
surgery
in
early cervical3
1
3
dehiscence
cancer
1
is0feasible
and safe 1
Incisional hernia
Ileus
0
1
Obt. N. palsy
2
3
Pl. effusion
1
Re-intervention
1
0
3
Lymphocyst
1
6
2
Re-admission
4
5
1
Re-intervention
3
5
Maggioni et al 2009
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Robotic Surgery in Cervical Cancer
Persson et al 2009: Analysis of 64 patients with Cervical cancer
Stages
Op Time
(m)
EBL (ml)
LNC
Re-intervention
 Re-suturing vaginal vault x 5
IA1-IIA
262
475132
150
(25-1300)
26
(15-55)
 Repair port-site hernia x 2
 Cystoscopy and stenting x 1
14% needed 60 days or more to resume spontaneous voiding
The Christie
NHS Foundation Trust
Study
Robotic Surgery in Cervical Cancer
Procedure
Estape et al 2009
RRH
Pt
N.
BMI
Op Time
(m)
EBL
(ml)
32
30
144
130
IOC %
LNC
HS
POC %
32
2.6
18.8
Positive margins: RRH: 16%; LRH: 18%; ARH: 21%
RRH is feasible,
may be209
preferable to
& ARH
LRH
17 safe
28 and132
19LRH2.3
23.5
ARH
14
30
114
621
26
4
28.6
The Christie
NHS Foundation Trust
Geisler et al 2010
Study
Robotic Surgery in Cervical Cancer
Procedure
Pt N.
BMI
Op Time
(m)
EBL
(ml)
LNC
HS
RRH
30
34
154
165
25
1.4
ARH
30
32
166
323
26
2.8
Remarks
Bladder took
longer to recover
in RRH
RRH is feasible; recommended further prospective studies
The Christie
NHS Foundation Trust
Robotic Surgery in Cervical Cancer
Lowe et al: Multi-Institutional study; Retrospective analysis of 42 Patients with
cervical cancer who underwent Type II-III RRH
Stages
IA1-IB2
BMI
25
Op Time
(m)
215
EBL
(ml)
50
Bl
Trans.
0
LNC
25
IOC POC
% %
4.8
12
Con
%
2.4
HS
1
Remarks
Uret. Injury:
2.4%
DVT: 2.4%
RRH offers low morbidity rates and may be an alternative to Open
procedures
Postoperative adjuvant treatment
was required for 14% of patients
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NHS Foundation Trust
Radical Abdominal Hysterectomy:
Intraoperative morbidity profile
Roy et al 1996
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NHS Foundation Trust
Radical Abdominal Hysterectomy:
Functional outcome
Kenter et al 1989; Bergmark et al 1999; Perrille & Jensen 2003
The Christie
NHS Foundation Trust
Radical Abdominal Hysterectomy:
Functional outcome
Maas et al 2006
Loss of labial sensation: 3%; 74%; 81%; 79% at above intervals
The Christie
NHS Foundation Trust
Nerve Sparing Radical Hysterectomy
Maas et al 2003
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NHS Foundation Trust
Nerve Sparing Radical Hysterectomy
• Advantages:
–Preserve bladder compliance
–Less bladder over-activity
–Less incontinence
–Preserve rectal function
–Preserve vaginal lubrication:
• Less dyspareunia
• Better libido
Kenter 2007
The Christie
NHS Foundation Trust
Nerve Sparing Radical Hysterectomy
• Feasible in approx. 80% of surgical cases:
–No extra Blood loss
–Little extra time
–No increased complication rate
–Relatively difficult cases:
• High BMI
• Barrel shaped tumours
Kenter 2007
The Christie
NHS Foundation Trust
Nerve Sparing Radical Hysterectomy
Kenter; data compiled from ESGO 2007
The Christie
NHS Foundation Trust
Robotic Surgery in Cervical Cancer
Magrina et al 2011: Nerve sparing RRH; prospective evaluation of 6 patients
who underwent NS RRH (3 Pt has had Pelvic and PA LND)
Stages
BMI
27.8
Ib1-Ib2
(23-35)
Op Time
(m)
EBL (ml)
LNC
238.6
23.6
135
(207-256) (100-150) (19-29)
IOC POC*
0
1/6
CTL
0
HS
Remarks
*POC:
2
Ileus x 1
(1-4) Void. Dysf x 1
NS RRH is feasible and safe; urinary dysfunction may occur (transient)
17% Transient voiding dysfunction
The Christie
NHS Foundation Trust
Robotic Surgery in Cervical Cancer
Fertility preservation options: Robotic Radical Trachelectomy
Study
N
Stage
Op Time (m)
EBL (ml)
LNC
Persson 2008
2
IA2,IB1
387359
100-150
1835
POC
0
Complications (all studies):
Geisler et al
1
IB1
Robotic
2008 Radical Trachelectomy is
 Bleeding from abdominal wall
Chuang et al
refinement
2008
1
 Incisional hernia
IA2
Burnett
al
Largeretcollaborative
work
is
6
IB1
2009
172
100
26
feasible;
technique
needs
x
1
345
200
43
0
(278-396)
108
(50-250)
-
2/6
340
(245-416)
63
(50-75)
20
(18-27)
1/4
x
needed360
1
Medium
LL sensory
neuropathy
1
and
long term outcome is xstill awaited
Ramirez et al
2010
4
IA1-IA2
0
NB: one patient required hysterectomy based on final histology
Yim et al 2011
The Christie
NHS Foundation Trust
Robotic surgery in Ovarian cancer staging
• MAS is safe and effective in borderline ovarian
tumours and early ovarian cancer
• No sufficient evidence to support its use in
advanced disease
• Concern remains regarding:
– Adequate abdominal exploration & staging
– Cyst/Tumour rupture
– Port site metastasis
Iglesias 2011
The Christie
NHS Foundation Trust
Robotic surgery in Gynaecology/Gynaeoncology
Vaginal cuff dehiscence
Paley et al 2010: Evaluation of 832 Robotic Gynae/GO procedure involving vault closure
Year
N
Cuff dehiscence
N
Cuff dehiscence
%
Mean BMI (range)
2006-2007 T1
113
3
2.6%
26.5 (17.4–49.4)
2007-2008 T2
277
2
0.72%
29.5 (14.6–69.2)
2008-2009 T3
442
1
0.22%
30.1 (15.9–70.1)
Zapardiel et al 2010: No dehiscence in 42 cases after technique refinement; FU:
4 months (0 vs 7% control group)
The Christie
NHS Foundation Trust
Robotic Hysterectomy: Comparative cost
Cost in USD*
(average total)
Robotic
(n=40)
Laparoscopic
Direct Cost
$ 6002.10
Indirect Cost
Open (n=40)
P
$ 5564.00
$ 7403.80
>0.05
$ 2209.90
$ 2005.80
$ 5539.80
<0.05
Total Cost
$ 8212.00
$ 7569.80
$ 12,943.60
<0.05
Days to return to
normal activity
24.1 ± 6.9
31.6 ± 11.2
52.0 ± 71.8
<0.0001
<0.005
Estimated lost
wages/productivity
$ 3495.00
$ 4582.00
$ 7540.00
(n=30)
*DaVinci Surgical System cost is included as well as depreciation and maintenance
Bell et al 2008
The Christie
NHS Foundation Trust
Robotic surgery in Gynaecological Oncology
• May be superior to either Open or ordinary MAS
• Offers clear advantage in technically difficult cases
(e.g. morbidly obese; endometrial cancer patients)
• Potentially improved outcome in Cervical cancer
patients (e.g. Nerve sparing surgery)
• Role in Trachelectomy needs further evaluation
The Christie
NHS Foundation Trust
Robotic surgery in Gynaecological Oncology
Still awaiting:
 Larger multi-centre & prospective studies
 Evaluation of long term Outcome & Prognosis
 Evaluation of Self-reported patients’ Outcome
 New innovations to enhance performance & reduce
cost!
The Christie
NHS Foundation Trust
Robotics; Future directions
Teaching and Training
 Central register for training
 Objective and uniform
assessment
Courtesy: Karlsruhe
 Easy access to training
 Tele-Mentoring
 Tele-Surgery
Courtesy: Surgical Science
The Christie
NHS Foundation Trust
Robotics; Future directions
• Reduced bulk of equipment
• Ceiling Mounted Robotic arms
• Robotic Integrated OR
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
• Augmented Reality
• Real time data fusion
Courtesy: CBYON
The Christie
Courtesy of Intuitive
NHS Foundation Trust
Robotics; Future directions
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
Instruments
• Additional types of instruments
• Reusable instruments
• Use of the CO2 laser
Courtesy of intuitive
Courtesy of Intuitive
Robotic Needle holder
The Christie
NHS Foundation Trust
Robotics; Future directions
• Integrated Energy Instruments (current)
–
–
–
–
–
–
Monopolar Energy
Bipolar Energy
Advanced Bipolar
Harmonic
Advanced Graspers
Laser
• Future Tissue
Interaction Concepts*
– Linear Cutters
– Seal and Cut
– Suction/Irrigation
* Research only. Not FDA approved.
*
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
Image Guidance - Fluorescence
ICG
• Central venous
• Interstitial
Specific antibodies plus
fluorescing markers
Vasculature
Lymph Node Mapping
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
Fluorescence Imaging - Vasculature
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
In Vivo Microscopy
• Sub-micron in vivo histology
• Real-time functional and molecular imaging and diagnosis
• Tissue information (cancer, endometriosis, etc)
Courtesy of intuitive
The Christie
NHS Foundation Trust
Robotics; Future directions
Single Port
Advanced Single Port or
NOTES
• Natural orifice /
trans-umbilical
• da Vinci-like capability
• Large range of motion (multiquadrant capability)
Flexible
Systems
Instruments and accessories shown have not been
approved by the FDA
The Christie
Courtesy of intuitive
NHS Foundation Trust
The Christie
NHS Foundation Trust
The 3rd Annual Conference of the British & Irish
Association of Robotic Gynaecological Surgeons
6th – 7th September 2012
Manchester-UK
The Christie
NHS Foundation Trust
Thank you
Ahmed Sekotory Ahmed
[email protected]
The Christie
NHS Foundation Trust