Surgical techniques: robot-assisted laparoscopic myomectomy with the da Vinci(®) surgical system

Abstract

Myomectomy remains the surgical option of choice for women with symptomatic leiomyomata who desire uterine conservation or in particular future fertility. The ability to enucleate leiomyomata and repair the uterus with a multilayer-sutured closure is both crucial and technically challenging. Advanced gynecologic pathology and the surgical limitations of conventional laparoscopy have often been cited as impediments to not only these critical steps but also to converting a myomectomy from a procedure predominantly performed by laparotomy to one accomplished by laparoscopy. Recently, the use of robotic technology as a means to facilitate the laparoscopic completion of a myomectomy was introduced. Advantages to this approach have been the improved dexterity and precision of the instruments coupled with three-dimensional imaging. Published preliminary data have shown the feasibility and safety to this approach. This paper will outline a safe and efficient surgical technique for completing a robot-assisted laparoscopic myomectomy with the da Vinci(®) surgical system.

Keywords: Laparoscopy; Leiomyomata; Myomectomy; Robotics.

Fig. 1

ZUMI^® uterine manipulator (Cooper Surgical^®)

Fig. 2

Port placement (three-armed patient-side cart). The camera port (A) is 12 mm either in the umbilicus or above depending on size of the uterus. The lateral ports (B) are 8 mm da Vinci^® ports in the lower quadrants of the abdomen. A 10–12 mm assist port is placed between the camera port and the right lower quadrant port

Fig. 3

Endowrist^® instruments

Fig. 4

A dilute concentration of vasopressin is injected into the myometrium surrounding the myoma, as an adjunct for hemostasis

Fig. 5

Hysterotomy with an Endowrist^® permanent cautery hook

Fig. 6

Endowrist^® tenaculum providing counter-traction and facilitating enucleation of the leiomyoma

Fig. 7

Closure of the uterine serosa is accomplished with a running baseball stitch 3-0-vicryl suture on an SH needle is utilized

Fig. 8

A tissue morcellator is used to extract the enucleated leiomyoma

Fig. 9

A slurry of chopped Seprafilm^® (Genzyme^®) is applied over the myomectomy incision as an adhesion barrier