ROBOT ASSISTED LEFT OVARIAN CYSTECTOMY

Dr.  Manisha Singh 

1. The patient for robotic ovarian cystectomy should be performed under General Anesthesia

2. The patient is identified & side and site marking for surgery are confirmed.

3. The patient is positioned supine, with the arms tucked by the side & pressure points padded.

4. A bladder catheter is placed or the patient is asked to void just prior to surgery. Patient is administered General Anaesthesia.

5. A per vaginum examination under general anaesthesia is performed before commencement & fidings are noted.

6. Initial step are those for diagnostic Laparoscopy. The Laparoscopic monitor is positioned at the foot of the bed towards the side of the cyst and the surgeon stands opposite to the side.

7. The placement, position and adequate contact area of patient return plate is confirmed.

8. The sites of ports are marked & instilled with local anaesthesia 2% Xylocaine 5 ml each site. An infraumbilical 2 mm incision is placed and Verees Needle is inserted. Correct intra-abdominal position is confirmed with a saline filled syringe. Initial aspiration, followed by instillation of 5 ml saline and reaspiration of bubbles. Finally a hanging drop test is performed.

9. An insufflation gas tube is connected to the Verees needle and the flow rate is started at 1 L/min. Pressure changes in the insufflator device is monitored.

10. As per patient body habitus Approx 1.5 - 6 L CO2 is insufflated with an end point of reaching set pressure of 15mm Hg.

11. Once the pneumoperitoneum is established, the 2 mm incision is extended to 10 mm and a sharp 10 mm port is inserted. A 30 degrees 10 mm scope is then introduced & intra-abdominal cavity is visualized along with any signs of injury while establishing pneumoperitoneum or access.

12. Patient is positioned in the Trendelenburg head-low position in order to move the small bowel out of the surgical field.

13. Using base ball diamond concept two ports of 10 mm are placed under vision at the distance of 10cm from the telescope.These would be used for introduction of Robotic Arms.

14. The diagnostic laparoscopy is concluded by examination of the site of pathology, involvement of surrounding structures & The opposite side.

15. Once the diagnostic Laparoscopy confirms the pathological findings & operability the da Vinci Robot is used.

16. Docking of the da Vinci Robot patient cart is done from the side of the pathology, in place of the Laparoscopy Vision cart.

17. 2 Endo-instruments are used: Bipolar Graspers in the left and endo scissors in right.

18. A nick is placed  superficially on the cortex of the left ovary with bipolar grasper.

19. The upper margin of the cut cortex is held and separate the cortex using dissecting endo scissors.

20. Care should be taken not to puncture the cyst to avoid uncontrolled spillage into abdominal cavity.

21. In case of very large cyst, it is punctured & the contents are aspirated & lavage is given.

22. In case of adherence / involvement of surrounding structures a careful dissection is carried out with sharp instrument & cautery current combination.

23. Stripping of the cortex is done using bipolar grasper and scissors alternatively till ovarian cyst is completely enucleated.

24. Check the cyst and look out for any left out part.

25. One may need to perform a formal oophoretomy if the remanent is very small or in case of bleeding.

26. At this stage the robotic arms are undocked and the Laparoscopic Vision cart is repositioned. The Laparoscopic instruments are reintroduced

27. Introduce an endo bag inside the abdominal cavity from right side port.

28. Put the enucleated cystic structure inside the bag.

29. Catch the open ends of the endo bag with grasper and pull it out through the incisional site of the right port.

30. Enlarge the incision as required. Rarely a Pfannensteil incision needs to be placed & contents removed without spillage.

31. Suction and irrigation from the right port into the abdominal cavity done.

32. A thorough lavage done.

33. Hemostasis is confirmed. No drains are routinely placed.

34. CO2 insufflation is stopped and the Pneumoperitoneum is evacuated. The trocars are removed under direct vision. And the optical port is removed last with camera in the port to prevent any herniation.

35. The patient position is made supine. The defect of the sub-umbilical trocar site (& the pfannensteil incicion, if made) is closed under direct visualization using an absorbable suture.

36. Skin is closed with suture / stapler / Glue and dressing applied.

37. Ryles tube is removed, if inserted, provided the bowel handling & adhesiolysis was minimal.