Faculty Bibliography

To focus on the recent adoption, patents, experience, and future of Robotic assisted surgery (RAS) applications in gynecologic surgery, a computer aided and manual search for clinical and systematic reviews, randomized controlled trials, prospective observational studies, retrospective studies and case reports published between 1970 and January of 2011 has been performed. The use of RAS in gynecologic patients includes hysterectomy, myomectomy, tubal reanastomoses, radical hysterectomy, lymph node dissection, and sacrocolpopexies. Although individual studies vary, gynecological RAS is often associated with longer operating room time but similar clinical outcomes, decreased blood loss, and shorter hospital stay. RAS procedures on women have, however, their own limitations: the patented equipment is very large, bulky, and expensive, the staff must be trained specifically on draping and docking the instruments, the lack of surgical haptic feedback, a limited vaginal access, a limited specific instrumentation, and the need for larger port incisions requiring fascial closure. The RAS significantly facilitates gynecologic surgery, even if well-designed, prospective studies are needed to fully assess the value of this equipments in particular studies with well-defined clinical and long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life. The future of robotic surgery in gynecology may be bright, but currently, caution is advisable and clinically meaningful long-term outcomes are needed. These recent patents, however, has exciting potential for future applications, especially in long-distance telesurgery and might change the paradigm of gynecologic surgery in the future.

Chylous ascites is an uncommon postoperative complication of gynecological surgery. We report a case of chylous ascites following a robotic lymph node dissection for a cervical carcinoma. A 38-year-old woman with IB2 cervical adenocarcinoma with a palpable 3 cm left external iliac lymph node was taken to the operating room for robotic-assisted laparoscopic pelvic and para-aortic lymph node dissection. Patient was discharged on postoperative day 2 after an apparent uncomplicated procedure. The patient was readmitted the hospital on postoperative day 9 with abdominal distention and a CT-scan revealed free fluid in the abdomen and pelvis. A paracentesis demonstrated milky-fluid with an elevated concentration of triglycerides, confirming the diagnosis of chylous ascites. She recovered well with conservative measures. The risk of postoperative chylous ascites following lymph node dissection is still present despite the utilization of new technologies such as the da Vinci robot.

OBJECTIVE: To compare the feasibility and safety of the laparoscopic management of adnexal masses appearing preoperatively benign with those suspicious for malignancy. METHODS: Retrospective study of 694 women that underwent laparoscopic management of an adnexal mass. RESULTS: Laparoscopic management of an adnexal mass was completed in 678 patients. Six hundred and thirty five patients had benign pathology (91.5%) and 53 (7.6%) had primary ovarian cancers. Sixteen patients (2.3%) were converted to laparotomy; there were 13 intraoperative (1.9%) and 16 postoperative complications (2.3%). Patients divided in 2 groups: benign and borderline/malignant tumors. Patients in the benign group had a higher incidence of ovarian cyst rupture (26% vs. 8.7%, p<0.05). Patients in the borderline/malignant group had a statistically significant higher conversion rate to laparotomy (0.9% vs. 16.9%, p<0.001), postoperative complications (1.9% vs. 12.2%, p<0.05), blood loss, operative time, and duration of hospital stay. The incidence of intraoperative complications was similar between the 2 groups. CONCLUSION: Laparoscopic management of masses that are suspicious for malignancy or borderline pathology is associated with an increased risk in specific intra-operative and post-operative morbidities in comparison to benign masses. Surgeons should tailor the operative risks with their patients according to the preoperative likelihood of the mass being carcinoma or borderline malignancy.

OBJECTIVE:To describe 3 cases of peritoneal mesothelioma associated with endometriosis that were managed laparoscopically. DESIGN/METHODS:Case series. SETTING/METHODS:University and community hospitals. PATIENTS/METHODS:Three women with well-differentiated papillary mesothelioma of the peritoneum associated with endometriosis. INTERVENTIONS/METHODS:Laparoscopic excision and treatment of mesothelioma and endometriosis. RESULTS:Three patients underwent laparoscopy for treatment of endometriosis and were found to have peritoneal mesothelioma. All 3 patients underwent total laparoscopic excision of the lesions and were followed up regularly for surveillance of possible recurrence. CONCLUSIONS:In selected cases of well-differentiated papillary mesothelioma associated with pelvic endometriosis, operative laparoscopy can be used effectively to diagnose and treat this condition.

OBJECTIVES: To describe our experience with laparoscopic primary or interval tumor debulking in patients with presumed advanced ovarian, fallopian tube, or peritoneal cancers. METHODS: This is a retrospective analysis of a prospective case series. Women with presumed advanced (FIGO stage IIC or greater) ovarian, fallopian tube, or primary peritoneal cancers deemed appropriate candidates for laparoscopic debulking by the primary surgeon(s) were recruited. RESULTS: The study comprised 32 patients who underwent laparoscopic evaluation. Seventeen underwent total laparoscopic primary or interval cytoreduction, with 88.2% optimal cytoreduction. Eleven underwent diagnostic laparoscopy and conversion to laparotomy for cytoreduction, with 72.7% optimal cytoreduction. Four patients had biopsies, limited cytoreduction, or both. In the laparoscopy group, 9 patients have no evidence of disease (NED), 6 are alive with disease (AWD), and 2 have died of disease (DOD), with mean follow-up time of 19.7 months. In the laparotomy group, 3 patients are NED, 5 are AWD, and 3 are DOD, with mean follow-up of 25.8 months. Estimated blood loss and length of hospital stay were less for the laparoscopy group (P=0.008 and P=0.03), while operating time and complication rates were not different. Median time to recurrence was 31.7 months for the laparoscopy group and 21.5 months for the laparotomy group (P=0.3). CONCLUSIONS: Laparoscopy can be used for diagnosis, triage, and debulking of patients with advanced ovarian, fallopian tube, or primary peritoneal cancer and is technically feasible in a well-selected population

The objectives of this article were to review the published scientific literature about robotics and its application to gynecologic oncology to date and to summarize findings of this advanced computerenhanced laparoscopic technique. Relevant sources were identified by a search of PUBMED from January 1950 to January 2009 using the key words Robot or Robotics and Cervical cancer, Endometrial cancer, Gynecologic oncology, and Ovarian cancer. Appropriate case reports, case series, retrospective studies, prospective trials, and review articles were selected. A total of 38 articles were identified on the subject, and 27 were included in the study. The data for gynecologic cancer show comparable results between robotic and laparoscopic surgery for estimated blood loss, operative time, length of hospital stay, and complications. Overall, there were more wound complications with the laparotomy approach compared with laparoscopy and robotic-assisted laparoscopy. There were more lymphocysts, lymphoceles, and lymphedema in the robotic-assisted laparoscopic group compared with the laparoscopy and laparotomy groups in patients with cervical cancer. Infectious and lung-related morbidity, postoperative ileus, and bleeding or clot formation were more commonly reported in the laparotomy group compared with the other 2 cohorts in patients with endometrial cancer. Computer-enhanced technology may enable more surgeons to convert laparotomies to laparoscopic surgery with its associated benefits. It seems that in the hands of experienced laparoscopic surgeons, final outcomes are the same with or without use of the robot. There is good evidence that robotic surgery facilitates laparoscopic surgery, with equivalent if not better operative time and comparable surgical outcomes, shorter hospital stay, and fewer major complications than with surgeries using the laparotomy approach

Laparoscopy was used for a second-look assessment in ovarian cancer patients back in the 1970s. However, it is only with the advent of new developments in equipment in the late 1980s and early 1990s along with the vision of pioneers in laparoscopic surgery that has made operative laparoscopy in gynecologic oncology feasible. Laparoscopy has multiple benefits in the cancer patients, including image magnification to visualize metastatic or recurrent disease and improved dissection in challenging areas such as the paravesical and pararectal spaces. There is limited bleeding from small vessels because of the pressure from pneumoperitoneum, decreased hospital stay, and rapid recovery. Postoperative chemotherapy or radiation can be initiated earlier, and radiation complications from bowel adhesions are minimized. Significant progress has been made in the last 2 decades in gynecologic malignancy. In this study, the application of laparoscopy in cervical, endometrial, and ovarian cancer will be presented

OBJECTIVE:To analyze the feasibility, safety, advantages, and disadvantages of using robotic technology for gynecologic surgeries in a large group of patients. DESIGN/METHODS:Retrospective study (Canadian Task Force classification II-3). SETTING/METHODS:Tertiary endoscopic referral centers. PATIENT(S)/METHODS:Eighty-seven patients requiring laparoscopic treatments for benign gynecologic conditions. INTERVENTION(S)/METHODS:Charts reviewed from robotic-assisted gynecologic operative laparoscopies. MAIN OUTCOME MEASURE(S)/METHODS:Length of surgery, time for robot assembly and disassembly, rate of conversion to laparotomies, and complications. RESULT(S)/RESULTS:Between January 2006 and August 2007, 137 robotically assisted gynecologic procedures were performed in 87 patients. The da Vinci Surgical System was used. The average length of the surgeries was 205 minutes (60-420 minutes). Assembly of the robot lasted 16 minutes (10-27 minutes) when disassembly took 2.5 minutes (2-6 minutes). There were no conversions to laparotomy. There were three complications. CONCLUSION(S)/CONCLUSIONS:Robotic-assisted technology, in its present state, is enabling more surgeons to perform endoscopic surgery. Its advantages are 3D Vision and a faster learning curve for suturing and operating while sitting. It's an exciting enabling technology with a great future.