Robotic surgery in gynecology

Abstract

Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.

Keywords: Robotic surgery; cost efficiency; gynecological oncology; laparoscopy; surgical training.

Figure 1

a, b. Da Vinci Si system with its central optical arm (12 mm diameter) and 3 working trocars, each 8 mm in diameter (a). The Da Vinci Xi system is markedly smaller with four identical flexible arms (8 mm each) (b). The camera and working trocars can be exchanged as desired. The simpler handling of the console and the instruments is not visible here.

Figure 2

a, b. Single-site laparoscopy with the Da Vinci Xi system. An overview of the robot arms lying close to each other and the better distance because of the much smaller Xi system (a) Intraabdominal operations can be performed with angulated optical instruments and surgical instruments within a very small space without loss of quality (b). The single port is placed in the navel and additional working trocars can be placed at various sites in the abdominal wall to support the operation.

Figure 3

Trends in the use of hysterectomy methods in Western countries

Figure 4

a–d. Operation site after laparoscopic sterilization on the right side (a) and the left side (b). After freshening the wound edges in the distal aspect and mobilization of the mesentery, a thin and blunt catheter is inserted into the distal end; the catheter protrudes from the fimbrial funnel of the fallopian tube (c). The other end of the catheter is pushed into the freshened proximal end so that it almost serves as a bridge (d).

Figure 5

a–d. The first suture is made, strictly in the seromuscular aspect, omitting the mucosa. Very thin suture material or even monofilament sutures (at least 4–0) are suitable for this purpose (a). Four to eight sutures (b) that may then be knotted consecutively (c). Final situs on the left side after complete re-anastomosis (d). Bland suture and successful chromopertubation; no contrast medium emerges from the suture area and contrast medium is drained promptly through the fimbriae.

Figure 6

a–d. Schematic diagram of a lymph node. Several afferent lymph vessels from the peripheral aspect, central blood supply, and one or two efferent lymphatic vessels (a). Sentinel lymph nodes in endometrial cancer, here at the level of the common iliac artery on the right side, color-marked with methylene blue (b). In comparison: sentinel lymph node intraoperatively in endometrial cancer (c), partly marked with the fluorescent dye indocyanine green (d), here at the level of bifurcation of the common iliac artery on the right side.