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Robot-assisted Laparoendoscopic Single-site Myomectomy
posterior, and fundal location of myomas were ame- controversy over the use of electromechanical morcellator
nable to enucleation. 15,17,18 The mean operative time in and its recent ban by the US FDA, RA-LESS provides a
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minutes as mentioned by Choi et al was 135.98 ± 59.62 unique opportunity to mechanically retrieve the myoma
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(60–295) and 154.2 ± 55.2 by Gargiulo et al. None of the specimen using knife with the same incision, which, in
studies reported excessive blood loss or requirement of turn, saves operative time. This seems to be a benefit
intraoperative blood transfusion. There were no major over the robotic/laparoscopic multiport myomectomy
intraoperative complications noticed in any of the series where an additional minilaparotomy/or extension of the
and none of the patients had to be converted to other incision will be needed to extract the tissue if the use of
techniques for completion of surgery. electromechanical morcellator has to be avoided. All the
Lewis et al and Choi et al mentioned the surgical studies 15-18 in this review combined their technique of
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experience of their operating surgeons. Surgeons had RA-LESS with contained endobag mechanical morcella-
more than 8 years of experience of working with the da tion for tissue retrieval suggesting that this technique can
Vinci surgical system and performing more than 800 be easily adapted by gynecologic surgeons in the absence
robotic surgeries respectively. This suggests a long learn- of availability of morcellators.
ing curve required to safely perform this challenging Surgical access to multiple myomas might be a point
surgery. None of the studies performed a complete cost of concern while considering LESS owing to the technical
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analysis of the procedure. Only one study compared challenges associated with conventional LESS technique.
the cost of robotic-assisted single-site surgery with con- All the studies, however, suggested that myomas of all
ventional single-site myomectomy and found an overall types including intramural, subserosal, and submucosal
cost difference of $450 per surgery that accounted for the as well as all location anterior, posterior, fundal, broad
use of GelPOINT device for their technique. ligament, and retroperitoneal are amenable to dissection.
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Choi et al compared total operation time and EBL accord-
DISCUSSION ing to the type and size of myoma. The mean total opera-
tion time was 97.50 ± 2.12 minutes for intraligamentary
Since its approval by the FDA in 2013 for hysterectomy myomas, 140.25 ± 64.97 minutes for intramural myomas,
and adnexal surgery, RA-LASS for the da Vinci Surgical and 178.75 ± 52.66 minutes for mixed myomas and
System has been proved to be a safe surgery. 19-21 Also, it showed no statistical difference (p = 0.178). The mean EBL
can supposedly overcome some of the limitations like was 150.67 ± 152.20 mL for subserosal myomas, and 162.50
inferior ergonomics, limited maneuverability of instru- ± 94.65 mL for mixed myomas, and 195.25 ± 153.63 mL
ments, difficult intracorporeal suturing, and limited for intramural myomas with no statistical difference (p =
vision associated with conventional laparoscopic tech- 0.755). Currently, there are no available studies comparing
nique. This makes RA-LESS an attractive choice in the RA-LESS directly with conventional LESS to compare if
armamentarium of gynecologic surgeons for challenging RA-LESS offers any significant advantage in accessing
surgeries like myomectomy. a particular type or location of myoma. The number
It is notable that high BMI is usually considered a rela- of myomas also did not seem to be a limiting factor in
tive contraindication to LESS by some due to associated any of the studies. The maximum weight of the myoma
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technical difficulty and higher complication and conver- removed was 160.4 g as reported by Lewis et al in their
sion rates. 22,23 This knowledge may inhibit a surgeon to initial experience.
offer this minimally invasive technique to obese patients However, the present data are limited to comment
thus, limiting their surgical benefits. However, all the on the exact indications or contraindications for this
studies noticeably had a patient population with a higher procedure, and patient selection criteria in terms of type,
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BMI. The median BMI reported by Lewis et al was 30.75 location, or size of myoma will evolve with the growing
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kg/m with a range of 25 to 35 kg/m , whereas Choi experience.
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et al reported a mean BMI of 22.29 ± 4.05 kg/m with a The operating time of LESS surgery is usually longer
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range of 17.63 to 38 kg/m . This suggests that RA-LESS than that of the conventional multiport laparoscopic
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is feasible and can be safely offered in women with surgery. This is further increased in suture-intensive
higher BMI without apprehension of conversion. Also, surgeries like myomectomy. This fact is reflected in the
the deep umbilicus in obese women also provides the high operative times reported in all the studies. Choi
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benefit of cosmetically more acceptable surgical scar. The et al reported a mean total operative time of 135.98
RA-LESS technique is usually associated with a larger ± 59.62 minutes with the highest of 295 minutes, and
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incision when compared with the conventional multiport Gargiulo et al reported a similar high mean total opera-
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laparoscopic surgery. One of the studies reported the tive time of 154.2 ± 55.2 minutes. Choi et al divided their
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mean skin incision as 2.70 ± 0.19 (2.4–3.10) cm. With the patients into three groups based on the largest myoma
World Journal of Laparoscopic Surgery, January-April 2018;11(1):33-37 35