Roboti
ic myomeectomy -
tips & triicks
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Technology Update
Robotic myomectomy e tips & tricks
Rooma Sinha a,*, Madhumati Sanjay b, B. Rupa c, Samita Kumari d
a Senior Consultant, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiab Consultant, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiac Senior Registrar, Department of Minimally Invasive Gynecology, Apollo Health City, Hyderabad, Indiad Resident (DNB), Department of Obstetrics & Gynecology, Department of Minimally Invasive Gynecology,
Apollo Health City, Hyderabad, India
a r t i c l e i n f o
Article history:
Received 25 July 2014
Accepted 5 August 2014
Available online xxx
Keywords:
Robotic
Myomectomy
MRI
Hybrid technique
Barbed suture
* Corresponding author.E-mail addresses: drsanjaysinha@hotmai
Please cite this article in press as: Sinha R10.1016/j.apme.2014.08.003
http://dx.doi.org/10.1016/j.apme.2014.08.0030976-0016/Copyright © 2014, Indraprastha M
a b s t r a c t
Fibroid is a common problem in women of reproductive age group. Myomectomy remains
the gold standard method in treating fibroids where uterine conservation is desired. With
advent of minimally invasive techniques, laparoscopic myomectomy becomes the obvious
method of choice. However it is not a very popular surgery because of technical challenges
especially the need for extensive suturing. Introduction of robotic technology helps the
surgeon to follow open surgical steps and addresses the technical challenges of conven-
tional laparoscopic suturing and knot tying. Myomectomy is a suture-intensive surgery and
assistance with robotic arms makes suturing simple and easy. This article discusses some
of the tips and tricks of performing robotic myomectomy in the areas of pre operative
assessment & MRI, port placement & docking, hybrid procedure, dealing with associated
sub mucous fibroids and variations in suturing techniques. Pre operative MRI of the pelvis
is helps in identifying the number and location of all the fibroids. The primary port is
placed in the midline. The rest of the ports are placed 10 cms apart in an inverted “W”
fashion. Hybrid technique is a variation in robotic myomectomy where a conventional
laparoscopic enucleation of the myoma is followed by reconstruction with the da Vinci
robot. Assosciated submucous fibroids can be removed by hysteroscopy myomectomy,
however large type 2-sub mucous fibroid has been removed with robotic approach. Use of
unidirectional knotless barbed suture substantially facilitates closure of uterine defects
during minimally invasive myomectomy and may offer additional advantages such as
minimizing operative time.
Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
Fibroid is a common problem in women of reproductive age
group. Myomectomy remains an important option for fertility
& uterine preservation in young women. While uterine artery
embolization and MRI-guided focused ultrasound are also
methods that are becoming popular in managing fibroid
uterus, myomectomy remains the gold standard method.
l.com, drroomasinha@ho
, et al., Robotic myomec
edical Corporation Ltd. A
Myomectomy has being a part of medical management for
decades and we have long term data of good reproductive
outcome following it. With advent of minimally invasive
techniques, laparoscopic myomectomy becomes the obvious
method of choice. But the question remains e why still so
many open myomectomies are being performed all over the
tmail.com (R. Sinha).
tomy e tips & tricks, Apollo Medicine (2014), http://dx.doi.org/
ll rights reserved.
Fig. 1 e MRI T2 WEIGHTED IMAGE e sagittal image of
multiple fibroids.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e52
world? There is no doubt that a laparoscopic approach ismore
advantageous than laparotomy, however laparoscopic sutur-
ing is more demanding. This can be overcome by robotic-
assisted laparoscopic myomectomy.1 A retrospective case
study from the Cleveland Clinic confirmed these findings
when investigators compared surgical outcomes between the
robot-assisted laparoscopic approach, standard laparoscopy,
and open myomectomy. In an assessment of 575 cases (393
open, 93 laparoscopic, and 89 robot-assisted laparoscopic),
they found the robot-assisted laparoscopic approach to be
associatedwith the removal of significantly largermyomas (as
compared to standard laparoscopy), as well as lower blood
loss and shorter hospitalization when compared to open
myomectomy.2
It is accepted beyond doubt that minimally invasive gy-
necological surgeries have distinct advantages for the patient
for its minimal access and comfort. However laparoscopic
myomectomy is a technically challenging surgery and good
outcomes are possible only by high volume surgeons who
have exceptional skills. The need for extensive suturing in
myomectomy is the main limitation in its wide spread
acceptance by surgeons. Post operative implications in a myo-
mectomy surgery is also due to the fact that poor closure of in-
cisions or excessive use of diathermy can lead to uterine
rupture in future pregnancies.3,4 Robotic surgery is a natural
progress in the field of minimally invasive surgery. As robotic
surgery allows surgeon to perform detailed surgery due to
magnified 3D vision and deep reach into the pelvis that a ro-
botic telescope can achieve. There fore a new technology of
robotic assistance is slowly gaining ground. The da Vinci has
EndoWrist technology with increased instrument range of
motion (7�) enabling the surgeon to mimic open surgical
techniques. Other advantages of robotic technology over
conventional laparoscopy are absence of tremor, superior in-
strument articulation, downscaling of movements, and com-
fort for the surgeon.5 The fact that robotic arms helps the
surgeon to follow open surgical steps, addresses the technical
challenges of conventional laparoscopic suturing and knot-
tying. But the robotic technology cannot just simplify the
challenges that leiomyoma's can pose, including enucleation
of large myomas and suturing. Although it has facilitated the
adoption of endoscopic myomectomy, the da Vinci system
requires an experienced gynecologic endoscopic surgeonwith
good knowledge of surgical anatomy. Compared with open
abdominal myomectomy, the robot-assisted laparoscopic
approach is associated with less blood loss, lower complica-
tion rates, and shorter hospitalization.6 Reproductive out-
comes in pregnancies and deliveries are similar to open
myomectomy. Pitter et al studied these outcomes, reporting
92 deliveries out of 107 patients studied with only 1 uterine
rupture.7 After robotic myomectomy successful term preg-
nancy has also been reported by Bocca et al., in 2007.8
Having being exposed to robotic technology for the last 2
years, today Robotic assisted myomectomy is one of our fa-
vorite surgeries. The reasons for this are that myomectomy is a
suture-intensive surgery and assistance with robotic arms makes
suturing simple and easy. Robotic myomectomy guarantees a pro-
cedure that is as effective as a classic open myomectomy. Robotic
assisted surgery is as safe and acceptable as a laparoscopic opera-
tion. This article discusses the tricks & tips of doing robotic
Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003
assisted myomectomy in a systematic, safe, and efficient
manner.
We shall discus these in the following areas-
1. Pre operative assessment & MRI
2. Port placement & docking
3. Hybrid procedure
4. Dealing with associated sub mucous fibroids
5. Variations in suturing techniques
1. Pre operative assessment
Careful patient selection and a good preoperative assessment
are vital for the success of the minimally invasive myomec-
tomy procedures. It gives details of size, location & number of
fibroids. It is difficult to assess this on a 2D scan and even on
3D scan if the fibroids are multiple and large volume, one can
miss locating them preoperatively. Pre operative MRI of the
pelvis is suggested before Robotic myomectomy. In fact we
would suggest reviewing the MRI scan at the console with an
experienced radiology collogue gives details that may other-
wise get missed by the surgeon. During surgery it becomes
difficult to remove all fibroids if the locations are not known
from before. This information also helps in the counseling
session before surgery, as womenwith solitary fibroid or a few
large fibroids, or pedunculated fibroids are good candidates
and full clearance is possible Fig. 1. Diffuse fibromas, adeno-
myoma, adenomyosis with very little normal myometrium,
are poor surgical candidates and these should be identified
preoperatively Fig. 2. Although there are no limits on the
number of fibroids that can be removed (maximum of 9 fi-
broids in our series), multiple seedlings disseminated
throughout the uterus are not the right candidates for myo-
mectomy. Adenomyomectomy is also possible with
tomy e tips& tricks, Apollo Medicine (2014), http://dx.doi.org/
Fig. 2 e MRI T2 WEIGHTED IMAGE e extensive
adenomyosis of anterior wall of uterus.
Fig. 4 e MRI depicting intramural and a separate
submucous myoma.
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 3
symptomatic women with the help of robotic assistance.
Preopertaive MRI gives an opportunity to take a decision for
HYBRID PROCEDURE. Thus helps in planning the port place-
ment and better instrument selection.
2. Port placement & docking
The primary port is placed in the midline. The initial port can
be at the umbilicus or above (2e5 cms), depending on the size
of the fibroid. As shown in the figure the primary port is 5 cms
above the umbilicus as the upper border of the fibroid is 5 cms
above the pubic symphysis (Fig. 3). The rest of the ports are
placed as shown in the figure, in an inverted “W” so that there
is about 10 cms space between the ports. This is important as
when port placements are not selected well the robotic arms
Fig. 3 e Diagramatic representation of surface anatomy of
port locations in robotic myomectomy.
Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003
tend to clash and the movements are hindered. The next step
is the selection of instruments in each port. We recommend
the hot shears in arm 1, bipolar forceps in arm 2 and tenacu-
lum in arm 3. Once the myoma enucleation is complete we
change the hot shears in arm 1 to needle driver. The tenacu-
lum can be changed to a prograsp in arm 3 for the myoma bed
suturing. The assistant port can be used for suction-irrigation,
passage of needle and for morcellation in the end.
3. Hybrid technique
It is a technique in which conventional laparoscopic enucle-
ation of the myoma is followed by reconstruction with the
Fig. 5 e MRI picture showing large sub mucous fibroid
which was removed by robotic assistance.
tomy e tips & tricks, Apollo Medicine (2014), http://dx.doi.org/
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e54
da Vinci robot. This is a technique used in situations where
myomas are more than 10 cms as such myomas are often
beyond pelvis. Deep intramural myomas or highly vascular
myomas can also be tackled by this technique. Additionally
with large myomas inadequate countertraction due to insuf-
ficient torque during enucleation can be a significant chal-
lenge.6,7,9,10 The advantage of this technique is that it
preserves tactile sensation as large myomas are heavy and
surrounded by delicate reproductive structures like the tubes,
and every attempt should be made to preserve the tubal
function. Rigid (not articulated) Myoma screw & Suction can-
nula exerts significant pull at every angle with the benefit of
haptic feedback (without risk of equipment damage). It is also
effective inmanipulation outside the pelvis and into the upper
abdominal quadrants.11 We use arm 2 & assistant port for
hybrid procedure as laparoscopic procedurewhile standing on
the left side of the patient using ipsi-lateral ports is easier to
handle and operate. The initial ports are all robotic ports. Once
myomectomy is done, the robot is swiftly docked and suturing
of the uterus undertaken. It is important to keep this quickly
as the raw edges continue to ooze a little. This technique
Fig. 6 e Showing the relevant steps in robotic myomectomy. (A
the fibroid capsule. (C) Enucleation of the fibroid. (D) Putting the
multiple layers with V Loc suture. (F) The final view after sutur
Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003
entails a variable time lag between the completion of the
conventional laparoscopic myoma enucleation and the time
when the operator sits at the console to start the next step.
This “docking time” should be as minimal as possible and
depends on the team's coordination & efficiency. Hybrid ro-
botic myomectomy is regarded as an advanced robotic
technique.
4. Dealing with associated submucousfibroids
Some women have intramural fibroids associated with sub-
mucous fibroids. Hysteroscopy myomectomy is needed to
remove the submucous fibroids either in the same sitting or as
a two-stage procedure. The size of the sub mucous myoma as
well as the hemoglobin status of the patient determines
whether it should be one stage or two stages. Fig. 4 depicts the
MRI of a case with 3 � 2 cms sub mucous myoma associated
with large intramural myoma with 6 gms % of hemoglobin
which was operated as two stage procedure. However we also
) The initial incision at the fibroid capsule. (B) Dissection of
fibroid in a bag for morcellation & retrieval. (E) Suturing in
ing.
tomy e tips& tricks, Apollo Medicine (2014), http://dx.doi.org/
a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e5 5
have experience of approaching large type 2-sub mucous
fibroid with robotic approach. Reasons for choosing Robotic
approach in the case illustrated by Fig. 5 was that type 2 sub
mucous fibroids are difficult to remove completely by hyster-
oscopy. The intramural component often remains partially
resected necessitating a second procedure. Hysteroscopic
resection takes longer operative time with little control on
bleeding and many of these women are already anemic.
5. Suturing techniques
The use of unidirectional knotless barbed suture substantially
facilitates closure of uterine defects during minimally inva-
sive myomectomy and may offer additional advantages such
asminimizing operative time.12 Barbed sutures are easy to use
for myoma bed repair as they can hold the two edges of
myometrial tissue in adequate tension for suturing. We use
30 cm No 1 V loc suture. This length although long at the
beginning, we find that one suture is often sufficient for
multilayer closure. There are fewer needle passes and cost is
also less. Curve of the needle helps to take good deep bites for proper
approximation. With arm 1 & 2 actively used for suturing, arm
three with prograsp forceps can be used to keep adequate
tension on the suture. Hence skillful use of all the 3 arms helps in
quick and effective suturing. After taking 2e3 multiple layers, we
finally take an inverted (baseball) suture to invert the raw edges as
well as the barbed suture (Fig. 6).
6. Conclusion
Ultimately openmyomectomywill be replaced byminimally invasive
myomectomy. Due to its ease in performance of myomectomy, ro-
botic technology will slowly replace the laparoscopic method. Ro-
botic approach helps surgeons to extend their boundaries in
terms of the size and number of myomas that can be removed
in minimally invasive way.2,13 This also helps to remove my-
omas in odd locations as well. Improvements in robotic
technology are also expected in near future. Affordability and
miniaturization of the equipment will increase its acceptance
widely. Presence of haptic feedback and assisted docking will
enable the surgeon to include this in day to day practice.
Single incision applications are already in use atmany centers
and will further add to the benefits of robotic technology in
gynecological surgeries.
Please cite this article in press as: Sinha R, et al., Robotic myomec10.1016/j.apme.2014.08.003
Conflicts of interest
All authors have none to declare.
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