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WJOLS

Robotic Gynecological Surgery: A Clinical Approach

LESS ROBOTIC SURGERY has increased the number and size of ports required so the
typical robotic surgical procedure should include three
Recently a less invasive alternative to conventional laparoscopy 28
or robotic surgery has been developed which is laparo- 8 mm ports and two 12 mm ports. Triangulation is needed
for proper dissection; at same time it provides effective
endoscopic single-site surgery (LESS), also known as single-
traction and counter traction, it is difficult with SPL and
port surgery. Single-port laparoscopy (SPL) enhances the
becomes easy with robotic surgery. Instrument crowding is
cosmetic benefits of MIS while minimizing the potential
the most important problem in single-port surgery not
morbidity associated with multiple incisions. The primary
advances in LESS as applied to urologic and gastrointestinal present with using robot. This is due to the development of
surgery demonstrate that the techniques are feasible provided streamlined profile camera systems which used instruments
of different lengths. Instrument and robotic arms crowding
that both optimal surgical techniques and optimal
instrumentation are available. 25 The principle concept of can also be overcomed by using 5 mm not 8 mm robotic
trocars and by using a 30º robotic camera down or up
LESS is to place all of the laparoscopic ports through the
depending on the case. This modification enables spacing
same incision. Now various devices designed to overcome
of the robotic arms as far possible from the camera arm.
the technical challenges for LESS have been developed and
Several single-port devices are available including the SILS
introduced in endoscopic surgery, those devices include
Port Multiple Instrument Access Port, GelPort, Uni-X
laparoscopic ports designed to apply multiple instruments
Single-Port System and ASC R-port laparoscopic access
through a single incision, flexible and long endoscopes and
device. The major problem with the various single-port
articulating variable length instruments. In addition, the Da
devices is gas leaking and structural integrity in response to
Vinci robotic platforms with articulating instruments can
be integrated into LESS for many surgical procedures. 26 the movement of robotic arms. There are also some patient-
related limitations because the surgeon used the umbilicus
The first experience with robotic LESS was reported by
as the entry point, this limit patient who would be appropriate
Haber et al then Kaouk et al who reported the first robotic
for robotic-assisted single site surgery. 29 Single port
single-port transumbilical surgery in urology by performing
laparoscopic Surgery (SPLS) is considered a feasible
a successful radical prostatectomy and nephrectomy.
approach for many endoscopic surgical fields especially in
The ability of the robotic arms to enable more degrees of
gynecological endoscopic surgery like single-port
freedom and triangulation at the surgical site facilitate the
hysterectomy and adnexectomy. SPLS is also used in the
surgical success.
field of gynecologic oncology; SPLS may be applied to
The robotic LESS is a novel technique which has
adnexal surgery in patients with adnexal tumors,
developed for performing various endoscopic surgical
prophylactic oophorectomy in patients with high risk of
procedures. The surgeons use advances in minimally
developing ovarian cancer, and hysterectomy in patients with
invasive techniques and technological innovation, including
preinvasive cervical carcinoma. With technical advances in
use of the newest generation of port systems that allow
the robotic system more complicated procedures in
several conventional laparoscopic or robotic instruments to
gynecologic oncology, such as radical hysterectomy and
be handled simultaneously through a single operating trocar.
endometrial cancer staging surgery might be conducted with
Other innovations that facilitated the single-port surgical
30
SPLS in the near future. Table 3 shows summary of trials
approach included articulating laparoscopes and instruments
of the operations done by robotic in gynecology.
and multifunctional 5 mm laparoscopic instruments such
as the LigaSure Advance™ which allow tissue fusion, vessel
DISCUSSION
sealing, spot coagulation and endoscissor functions in one
instrument. 27 Potential advantages of single-port robotic The numerous benefits of MIS are better cosmetic results,
surgery over conventional multiport laparoscopy include the reduced operative morbidity, reduced postoperative pain,
advantages of the robotic system and also the single-port and shorter length of hospital stay compared with
surgery which give better cosmoses from a hidden umbilical laparotomic surgery. MIS has taken the place of laparotomy
scar and a fewer trocar incisions has been used, a possible and became essential in many surgical fields. However,
decrease in morbidity related to visceral and vascular injury technical difficulties have prevented the widespread of MIS.
during trocar placement as well as decrease postoperative Over the last three decades, laparoscopic technologies have
wound infection, hernia formation and elimination of developed, and robotic surgery using the Da Vinci system
multiple trocar site closures, 3D visualization, improvement has been introduced. Although it is not evident that robotic
of dexterity are obtained by robotic system. No effect of surgery is superior to conventional laparoscopic surgery in
fulcrum is reported in LESS robotic surgery as well as micro- surgical outcomes, many studies demonstrate the positive
anastomosis become possible. But LESS robotic surgery feasibility of robot-assisted laparoscopic surgery in many
World Journal of Laparoscopic Surgery, September-December 2013;6(3):156-162 161