Video ArticleRobot-assisted Transvaginal Single-site Sacrocolpopexy for Pelvic Organ Prolapse
ABSTRACT
Study Objective
To demonstrate stepwise techniques for the successful use of the laparoscopic single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse.
Design
Stepwise demonstration with narrated video footage (Canadian Task Force classification III).
Setting
Academic tertiary care hospital. The patient, aged 69 years gravida 2 para 2-0-0-2 with a history of SVD × 2, presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap −1). The preoperative vaginal length was measured at 9 cm.
Interventions
Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, the retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomic variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective.
Several helpful techniques in robot-assisted transvaginal single-site include the following:
(1)The use of a 30°-angled scope alternating between “facing up” and “facing down” depending on the need for dissection or suturing.
(2) The use of 3-dimensional visualization with a robotic camera that can highlight the depth of the surgical anatomy, therefore facilitating easier identification in the dissection of a surgical pedicle.
(3) The use of wristed instruments that permit increased articulation and triangulation that are lacking in traditional laparoscopic single-site surgery, allowing for much easier and proficient suturing and knot tying.
(4) Integration of the robotic platform that stabilizes the fine motor movement in a surgeon's hands improving the precision of the suturing and knot tying.
The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0.
Conclusion
Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse. Patients experience improved cosmesis, decreased postoperative pain, and faster recovery compared with abdominal sacrocolpopexy.
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Transvaginal natural Orifical transluminal Endoscopy for sacrocolpopexy: A case series report
2024, HeliyonTo describe the surgical technique and operative outcomes of transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for sacrocolpopexy with or without robotic surgical system in patients with pelvic organ prolapse (POP).
Patients with POP undergoing traditional transvaginal natural orifice transluminal endoscopic surgery (TV-NOTES) or robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) for sacrocolpopexy performed by one surgeon from Sep 2020 to Jan 2023 in our hospital were included in this study. The baseline demographics and operative outcomes were collected and analyzed. In addition, some surgical skills were presented. The operative outcomes of V-NOTES for sacrocolpopexy performed by three beginners were also presented.
Eight patients who underwent TV-NOTES, and two patients who underwent RV-NOTES were included in this study. The mean operative time was 180 ± 49 min, and the estimated blood loss was 107 ± 82 ml for these ten cases. Particularly, the operative time of the two patients who underwent RV-NOTES was 275 and 132 min, while the estimated blood loss (EBL) was 100 and 50 ml respectively. During the follow-up period, no mesh exposure and recurrence were observed. In addition, five cases of TV-NOTES for sacrocolpopexy by beginners were all successfully completed.
Both TV-NOTES and RV-NOTES appeared to be feasible and safe for sacrocolpopexy.
Robotic retroperitoneal para-aortic lymphadenectomy via single-site port
2023, Journal of Gynecology Obstetrics and Human ReproductionPara-aortic staging is sometimes a standard feature in the management of pelvic cancers. Minimal invasive approach is recommended. Several routes are possible: extra-peritoneal or intraperitoneal depending on the expertise of the surgeon. We performed several extraperitoneal para-aortic lymphadenectomy using the Da Vinci Xi robotic system through single-site incision. We have developed a step-by-step guide from patient installation, installation of the Gelpoint V monotrocar, docking of the robot arms, to surgery, with the aim of performing the most efficient and safest procedure.
The surgery does not differ from standard laparoscopic extraperitoneal lymphadenectomy. The advantages of minimally invasive robotic surgery in this indication are comparable to those of the standard laparoscopy approach. But through single-site incision, the Da Vinci Xi robot improves video quality, plus its wristed tools facilitates movements compared to conventional laparoscopy.
Advances in the application of robotic single-site laparoscopy in gynecology
2022, Intelligent SurgeryWith the recognition of the significant advantages of minimizing surgical trauma, laparoscopic single site surgery with robotic system has attracted more and more attention from surgeons because of its higher accuracy, stable vision and excellent ergonomics. Since gynecological surgery involves the female pelvic cavity, transumbilical or transvaginal natural cavity robotic laparoscopic single site surgery presents many advantages and possibilities. However, R-LESS in gynecological surgery is at the early stage of development and the specific advantages are still controversial. Here, we provided an overview of the application advancement of robotic single-site laparoscopic surgery in gynecology, and described indications and technique, highlighting the potential development direction and possibilities in the future.
Robotic transvaginal NOTES: A step-by-step approach to surgical technique
2022, Intelligent SurgeryRobotic vaginal natural orifice transluminal endoscopic myomectomy
2022, Fertility and SterilityTo describe a novel, minimally invasive technique for performing myomectomy, a fertility-sparing procedure.
This technique was developed based on similar techniques for other surgeries that showed a benefit. Liu et al. (1) described vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy, in which a 6-cm myoma was resected transvaginally. An anterior colpotomy was made, and single-site surgical skills were used to perform the entire myomectomy without an abdominal incision and with minimal blood loss (1). Another study showed that this technique was also feasible in 8 patients with type 3–7 myomas, and the patients were discharged within a day (2). Robotic vNOTES surgery has been performed for various gynecologic procedures, including hysterectomy, sacrocolpopexy, and the resection of endometriosis (3–6). One study showed that robotic vNOTES was a viable alternative to traditional vNOTES for hysterectomy, with no differences in operative time, the length of hospital stay, postoperative pain levels, or conversions (3). This study in fact proposed that robotic vNOTES was beneficial because of the opportunity to use wristed instruments to increase an otherwise limited range of motion. Another study showed that if surgeons already have significant experience with laparoscopic single-site and abdominal robotic surgeries, only 10 cases of robotic vNOTES and 10–20 port placements with robotic docking are needed to become proficient in robotic vNOTES (7). Another study showed that robotic vNOTES was a safe and feasible approach for the treatment of endometriosis with hysterectomy and the resection of endometriosis, which may be technically challenging because of distorted anatomy or scar tissue due to endometriosis (4). This video demonstrates a robotic vNOTES for myomectomy, a novel, minimally invasive technique for performing myomectomy. Vaginal surgery is the preferred route for hysterectomy compared with other techniques, and this parallel can also be made for other gynecologic procedures, including myomectomy (8). The vaginal approach is preferred for hysterectomy because it is associated with shorter hospital stays and operative time as well as faster recovery. Given these factors, the vaginal approach is preferred over the more traditional umbilical or abdominal laparoscopy. However, visualization and fine movement can be difficult in vaginal surgery, given the lack of space. Robotic techniques in place of traditional or vaginal laparoscopy do not require the surgeon to have a large amount of space to make fine movements because the camera and small robotic instruments are docked close to the tissue. This allows for precision while suturing and performing more layers in the myometrium after myomectomy. This is more difficult to achieve with traditional umbilical laparoscopy and may potentially reduce the risk of uterine rupture in future pregnancies. Given the advantages of the robotic and vaginal approaches, the robotic vNOTES route was pursued for this procedure because it combines the benefits of robotic and vaginal surgeries and can be considered as a feasible alternative to open, vaginal, or laparoscopic techniques.
Academic-center hospital.
A 28-year-old presented with heavy periods and pelvic pain. Imaging showed a large, 8-cm posterior fibroid, and the patient strongly desired a fertility-sparing approach.
Robotic vNOTES for myomectomy for the 8-cm posterior uterine fibroid.
Feasibility and safety of using this technique for myomectomy.
Robotic vNOTES is a feasible option for performing minimally invasive myomectomy. In this technique, a posterior horizontal colpotomy was made and a gel port was placed through the incision. The DaVinci Robot was docked, and myomectomy was performed using single-incision surgical techniques. The uterine serosa was closed with the V-Loc suture, and an interceed adhesion barrier was placed over the incision. The surgeon should take care to notice that the entire surgery is essentially performed “upside down” compared with the traditional abdominal laparoscopic approach. With this change in perspective, the surgeon should have a very good understanding of the vaginal anatomy and the expected location of the uterine artery, ureter, and rectum to avoid any damage to surrounding structures (the uterus) or increased blood loss. The fibroid was morcellated out of the vagina using The Extracorporeal C-Incision Tissue Extraction technique, and the posterior colpotomy was closed (9). The patient was discharged for home on the same day, with minimal blood loss. A prelabor cesarean section was recommended for all future pregnancies to reduce the risk of uterine rupture. The rate of uterine rupture after myomectomy is approximately 0.6% (10). However, the rate of uterine rupture after classical cesarean section is approximately 1%–12% (11). Given that the incision made was similar to the classical incision, except on the posterior uterus, prelabor cesarean section was recommended, although the uterine cavity was not entered.
In this video, we demonstrate a myomectomy performed using the robotic vNOTES technique. The traditional vNOTES technique for myomectomy has been previously described (1); however, this technique can be very burdensome for suturing and does not allow for precision, and performing multiple layers is challenging. However, the robotic vNOTES approach solves this issue and can allow the surgeon to perform very precise suturing. While choosing the ideal patient for this procedure, the preoperative considerations include the desire for future fertility, the size and location of the fibroid, ideally 1 large posterior fibroid, and adequate space for vaginal port placement. This technique combines the advantages of both vaginal and robotic surgeries while maintaining low blood loss, and patients may be discharged for home on the same day.
Miomectomía robótica endoscópica transluminal de orificio vaginal natural.
Describir una técnica nueva, mínimamente invasiva para realizar una miomectomía, un procedimiento para conservar la fertilidad.
Ésta técnica fue desarrollada basada en técnicas similares para otras cirugías que mostraron un beneficio. Liu et. al (1) describió una cirugía endoscópica transluminal de orificio vaginal natural (vNOTES) para miomectomía, en donde un mioma de 6-cm fue extirpado transvaginalmente. Una colpotomía anterior fue realizada, y se usaron habilidades quirúrgicas de un sólo sitio para realizar la miomectomía entera sin incisión abdominal y con una mínima pérdida de sangre (1). Otro estudio mostró que ésta técnica también fue viable en 8 pacientes con miomas tipo 3-7, y las pacientes fueron dadas de alta en un día (2). La cirugía robótica vNOTES ha sido realizada en varios procedimientos ginecológicos, incluyendo histerectomía, sacrocolpopexia, y la extirpación de endometriosis (3-6). Un estudio mostró que la vNOTES robótica fue una alternativa viable a la vNOTES tradicional para histerectomía, sin diferencias en el tiempo de operación, el tiempo de estadía en el hospital, niveles de dolor postoperatorio, o conversiones (3). De hecho este estudio propuso que la vNOTES robótica era beneficiosa por la oportunidad de usar instrumentos manuales para aumentar lo que de otra manera tendría un rango limitado de movimiento. Otro estudio mostró que si los cirujanos ya tenían experiencia significativa con cirugías robóticas laparoscópicas y abdominales de un sólo sitio, solo 10 casos de vNOTES robótica y 10-20 colocaciones de puerto con acoplamiento robótico son necesarias para convertirse en un idóneo en vNOTES robótica (7). Otro estudio mostró que vNOTES robótica era un abordaje seguro y viable para el tratamiento de endometriosis con histerectomía y la extirpación de endometriosis, lo cual puede ser técnicamente desafiante por la anatomía distorsionada o cicatriz debido a endometriosis (4). Este video demuestra una vNOTES robótica para miomectomía, una técnica nueva, mínimamente invasiva para realizar miomectomía. La cirugía vaginal es la ruta preferida para histerectomía comparada con otras técnicas, y este paralelo también se puede hacer para otros procedimientos ginecológicos, incluyendo miomectomía (8). El abordaje vaginal es preferido para histerectomía porque está asociado con una estadía en el hospital y tiempo operativo más corto como así también una recuperación más rápida. Dados estos factores, el abordaje vaginal es preferido sobre la más tradicional laparoscopía umbilical o abdominal. Sin embargo, la visualización y el movimiento fino pueden ser difíciles en cirugía vaginal, dado la falta de espacio. Las técnicas robóticas en lugar de la laparoscopía tradicional o vaginal no requieren que el cirujano tenga una gran cantidad de espacio para hacer movimientos finos porque la cámara y los pequeños instrumentos robóticos están acoplados cerca del tejido. Esto permite precisión mientras se sutura y realizar más capas en el miometrio después de miomectomía. Esto es más difícil de lograr con la laparoscopía tradicional umbilical y puede reducir potencialmente el riesgo de ruptura uterina en futuros embarazos. Dadas las ventajas de los abordajes robóticos y vaginales, la ruta vNOTES robótica fue seguida para este procedimiento porque combina los beneficios de la robótica y las cirugías vaginales y puede ser considerada como una alternativa viable para técnicas abiertas, vaginales o laparoscópicas.
Hospital Centro académico.
Una paciente de 28 años se presentó con períodos abundantes y dolor pélvico. Una imagen mostró un fibroma posterior de 8-cm de largo, y la paciente deseaba fuertemente un abordaje para conservar la fertilidad.
vNOTES robótica para miomectomía por el fibroma uterino posterior de 8-cm.
Viabilidad y seguridad al usar esta técnica par miomectomía.
vNOTES robótica es una opción viable para realizar miomectomía mínimamente invasiva. En esta técnica, una colpotomía horizontal posterior fue realizada y un puerto de gel fue ubicado a través de la incisión. El Robot DaVinci fue acoplado, y la miomectomía fue realizada usando técnicas quirúrgicas de una sola incisión. La serosa uterina fue cerrada con la sutura V-Loc, y una barrera de adhesión interceed fue colocada sobre la incisión. El cirujano debería tener cuidado en notar que la cirugía entera es esencialmente realizada "boca abajo" comparada con el abordaje tradicional laparoscópico abdominal. Con este cambio en perspectiva, el cirujano debe tener un muy buen entendimiento de la anatomía vaginal y la ubicación esperada de la arteria uterina, uréter, y recto para evitar cualquier daño a las estructuras circundantes (el úteros) o aumentar la pérdida de sangre. El fibroma fue morcelado fuera de la vagina usando la técnica de "La Extracción Extracorporeal de Tejido de Incisión C", y la colpotomía posterior fue cerrada (9). La paciente fue dada de alta el mismo día, con pérdida de sangre mínima. Se recomendó una cesárea antes del trabajo de parto para todos los embarazos futuros para reducir el riesgo de ruptura uterina. La tasa de ruptura uterina después de miomectomía es aproximadamente 0.6% (10). Sin embargo, la tasa de ruptura uterina después de la clásica cesárea es aproximadamente 1%-12% (11). Dado que la incisión hecha fue similar a la incisión clásica, experto en el útero posterior, se recomendó una cesárea antes del trabajo de parto, a pesar que no se entró en la cavidad uterina.
En este video, demostramos una miomectomía realizada usando la técnica robótica vNOTES. La técnica tradicional vNOTES para miomectomía ha sido previamente descrita (1); sin embargo, esta técnica puede ser muy molesta para suturar y no permite precisión, y realizar múltiples capas es desafiante.
No obstante, el abordaje vNOTES robótico soluciona este problema y puede permitirle al cirujano realizar una sutura muy precisa. Al elegir la paciente ideal para este procedimiento, las consideraciones preoperatorias incluyen el deseo de fertilidad futura, el tamaño y ubicación del fibroma, idealmente 1 fibroma posterior grande, y un espacio adecuado para colocar un puerto vaginal. Esta técnica combina las ventajas de ambas cirugías vaginal y robótica mientras se mantiene una baja pérdida de sangre, y las pacientes pueden ser dadas de alta para ir a casa el mismo día.
Robotic assisted vaginal natural orifice transluminal endoscopic surgery high uterosacral ligament suspension (NOTES-HUS) for uterine prolapse with and without uterine preservation
2022, Intelligent SurgeryTo demonstrate stepwise techniques for the successful use of the robotic-assisted transvaginal natural orifice transluminal endoscopy surgery high uterosacral ligament suspension (RvNOTES-HUS) technique for pelvic organ prolapse with and without uterine preservation.
Stepwise demonstration with narrated video footage (Canadian Task Force classification III).
An academic tertiary care hospital. Case 1: A 62-year-old G0P0 with a symptomatic stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. The preoperative vaginal length was measured at 9 cm. Case 2: A 42-year-old G3P2 with a symptomatic fibroid uterus with stage Ⅱ anterior vaginal prolapse and Stage Ⅱ uterine prolapse. The preoperative vaginal length was measured at 8 cm.
Since the approval of the robotic platforms in gynecologic surgery by the Food and Drug Administration in 2005,1 robotic assisted surgery has been proliferating in the treatment of benign gynecological diseases including sacrocolpopexy, hysterectomy, myomectomy and endometriosis resection.2, 3, 4, 5 In recent years, publications have demonstrated the feasibility and safety of traditional laparoscopic assisted high uterosacral ligament suspension for pelvic organ prolapse with long term follow up.6, 7, 8 However, robotic assisted RvNOTES-HUS has yet to be investigated in a publication. Utilizing the RvNOTES-HUS technique with or without uterine preservation operations greatly reduces the difficulty of intraperitoneal suture for the surgeon and postoperative pain for the patient. Nevertheless, this approach may be technically challenging.
For patients requesting uterine preservation, posterior colpotomy is required to place the port. Contrasting with hysterectomy, after the uterine removal the port was placed through the vaginal cuff; the remaining steps show great similarities. The succeeding techniques were adopted to perform RvNOTES-HUS: the bilateral uterosacral ligaments were tagged with sutures prior to the vNOTES port placement, highlighting the ureters, plucking the tagged uterosacral ligament to aid in identifying the high uterosacral ligament, elevating the uterosacral ligament while suturing, and pulling on the suture post-placement to determine the correct location.
The results were as follows:
Case 1: The procedure was successfully performed with a postoperative vaginal length of 8 cm. Her pain level was 4/10 in the first week, 2/10 in the second week, 0/10 in the third week, 0/10 in the fourth week. Postoperative pelvic organ prolapse quantification was stage 0.
Case 2: The procedure was successfully performed with a postoperative vaginal length of 7 cm. She had one day of post-operative pain. Postoperative pelvic organ prolapse quantification was stage 0.
RvNOTES-HUS is a practical technique in women with uterine prolapse while choosing whether to preserve the uterus. This technique allows for the better exposure of the ureter, while the articulating robotic joints allow for increased precision of dissection and suturing.
The authors declare that they have no conflict of interest.
This video has been waived by the institutional review board review at our institution.