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Tips for set-up to prevent complications in robotic gynecologic cancer surgery
Abstract
Robotic surgery (RS) is a breakthrough in gynecologic oncology in the past decade and it is now part of the routine in many centers. Although there is a concern about the oncological outcomes after RS in cervical cancer, it is proven to be safe and effective in endometrial cancer. However, RS has some drawbacks such as the loss of tactile feedback. Complications can therefore occur, and are usually multi-factorial. These can be related to the nature of the operations, the physical fitness of the patients, the control and choice of the devices, and more importantly, the experience and knowledge of the surgical team. To minimise the risk of complications, we need to understand the limitations of RS and have a proper set-up of the operations. It is important to anticipate these potential complications before and during the operations. And a careful setup of the operations, including the instrument set-up, patients’ positioning, port placement, and communication with the anesthetists and surgical team, are crucial in ensuring the safety and success of robotic surgery. In this article, different complications and their preventive measures at set-up were discussed.
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Optic nerve sheath diameter (ONSD) is used as a surrogate parameter for intracranial pressure. This study was conducted to evaluate the effect of the anesthetics (sevoflurane and propofol) on ONSD in women undergoing robotic surgery. The 42 patients who were scheduled for robot-assisted gynecology surgery were randomly allocated to the sevoflurane group or the propofol group. ONSD was recorded at 10 min after the induction of anesthesia (T0); 5 min, 20 min, and 40 min after carbon dioxide pneumoperitoneum was induced and the patients were put in a steep Trendelenburg position (T1, T2, and T3, respectively); and at skin closure after desufflation of the pneumoperitoneum (T4). Patients were observed for postoperative nausea and vomiting (PONV) during the immediate postoperative period. The propofol group had significantly lower ONSD than the sevoflurane group at T3. Mean ONSD values continuously increased from T0 to T3 in both groups. Two patients in the sevoflurane group experienced PONV. This study suggests that propofol anesthesia caused a lower increase in ONSD than sevoflurane anesthesia.
Background
Our current study was performed aimed at determining the efficacy and safety profile of robotic surgery (RS) compared to laparoscopic surgery (LPS) and laparotomy (LT) in the treatment of endometrial cancer on the basis of relevant studies.Patients and methodsA systematic literature search was conducted based on appropriate keywords, using the Embase, Cochrane library, as well as PubMed. Our studiers also reviewed the key pertinent sources among the publications and included associated literatures published by June 2021. Odds ratios (ORs), mean difference (MD), as well as 95% confidence interval (95% CI) for each study were measured for further assessment and synthesis of outcomes.ResultsThirty studies involving a total of 12,025 patients were eventually included in the current meta-analysis. Compared with LPS, RS could significantly decrease the estimated blood loss, the incidence of intraoperative complications, the length of hospital stay, and the rate of conversion, and increased the rate of readmission. Compared with LT, RS significantly decreased the estimated blood loss, blood transfusion volume, the length of hospital stay, the rate of total, intraoperative and postoperative complications, and the rate of readmission and re-operation, and increased the operative time.Conclusion
Considering the effects and safety profile of RS in terms of treating endometrial cancer, our study suggest that RS exerts superior outcomes than that of LPS and LT.
Objectives:
Subcutaneous emphysema (SCE) is a complication associated with laparoscopic surgery. Severe SCE complicated by excessive hypercarbia may afford detrimental effects in surgical patients with cardiac dysfunction. Robotic-assisted laparoscopic radical prostatectomy (RALP) has several predisposing factors that contribute to SCE. The main purpose of our single-center retrospective study was to determine the preoperative and intraoperative predicting factors for SCE associated with RALP and to determine the actual incidence of SCE.
Methods:
In total, 229 adult male patients underwent standardized RALP for prostate cancer over the period of 1 May 2016 to 31 October 2018 at the Ehime University Hospital. We reviewed electronic clinical records for individual characteristics including age, body weight, height, coexisting disorders, preoperative ASA physical status, and the length of postoperative hospital stay. We also reviewed surgical and anesthetic records for the operation time, anesthetic method, and the partial pressure of end-tidal CO2 (PetCO2) during RALP. To determine the presence of SCE, we examined supine chest X-rays obtained after the completion of surgery.
Results:
We found 55 cases (24.0%) of SCE. Multiple logistic regression analysis showed that a BMI < 25 kg/m2 (OR: 3.0, 95% CI: 1.25-7.26) and a maximum value of PetCO2 of 46 mmHg or greater (OR: 23.3, 95% CI: 8.22-66.1) were independent predicting factors for SCE.
Conclusion:
These two predicting factors may be helpful to recognize the occurrence of SCE. Anesthesiologists should protect against SCE progression with the earlier detection of SCE for safe anesthetic management in patients undergoing RALP.
Study Objective
Obesity is a growing worldwide epidemic, and obese patients undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI pathway (HBP) for patients with a body mass index (BMI) of 40 or greater undergoing planned robotic hysterectomy. Our primary outcome was rate of all-cause perioperative complications in patients undergoing surgery with the utilization of the HBP.
Design
A retrospective cohort study.
Setting
An academic teaching hospital.
Patients
One hundred and thirty-eight morbidly obese patients (BMI ≥ 40 kg/m²) undergoing robotic hysterectomy.
Interventions
The HBP was developed by a multidisciplinary team and was instituted January 1, 2016 as a quality improvement project. Morbidly obese patients undergoing robotic hysterectomy after this date were compared to consecutive historic controls.
Measurements and Main Results
Seventy-two patients underwent robotic hysterectomies on the HBP and were compared to 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of HBP, there has been a decrease in anesthesia time (-57.0 min; p=.001), total operating room time (-47.0 min; p=.020), lower estimated blood loss (median 150 cc [IQR 100-200] vs 200 cc [IQR 100-300]; p=.002), and overnight hospital admissions (33.3% vs 63.6%; p < 0.001). There were fewer all-cause complications seen in HBP (19.4% vs 37.9%; p=.023) and infectious complications (8.3% vs 33.3%; p=.001) and no increase in readmission rates (p=.400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio [OR] 0.353; p=.010) after controlling for covariate (total time in OR).
Conclusion
HBP is a feasible method of optimizing outcome for morbidly obese patients undergoing major gynecologic surgery. Initiation of HBP can lead to decreased all-cause complications and overnight hospital admissions without increasing readmission rates.
Background:
Although robotics has shown to improve outcomes in some high-difficulty surgical category of patients, it is unclear if such approach may improve outcomes in endometrial carcinoma (EC) elderly patients.
Objective:
To compare robotic and laparotomic surgery in the treatment and staging of EC elderly patients.
Materials and methods:
A systematic review and meta-analysis was performed assessing the risk of overall, intra-operative and peri-operative complications associated to the surgical approach (laparotomic vs robotic) for EC elderly patients by relative risk (RR). Pooled means ± standard deviation (SD) of length of stay were compared with the unpaired T test. Subgroup analyses for overall complications were performed based on different age cut-offs (>70, >65 and >75 years) and severity of complications (minor and major). A p-value<0.05 was considered significant.
Results:
5 studies with 7,629 EC patients were included. Pooled RR for robotic compared to laparotomic surgery was 0.40 (p<0.00001) for overall, 0.46 (p=0.18) for intra-operative, and 0.43 (p<0.00001) for peri-operative complications. Pooled difference between means ± SD of length of stay for robotic vs laparotomic surgery was -3.34 (p<0.00001). At subgroup analyses, pooled RR of overall complications for robotic surgery vs laparotomic surgery was 0.34 (p<0.00001) in the "70 years", 0.51 (p<0.0001) in the "65 years", 0.20 (p =0.12) in the "75 years", 0.50 (p=0.1) in the "minor complications", and 0.42 (p=0.002) in the "major complication" subgroups.
Conclusion:
Robotics might be a viable alternative to laparotomic approach for EC elderly patients since it significantly decreases the risk of overall and peri-operative complications (mainly major complications), and the length of stay when compared to laparotomy. The decrease in risk of overall complication is greater with increasing patient age.
Background: Pressure-controlled ventilation volume-guaranteed (PCV-VG) is being increasingly used for ventilation during general anesthesia. Carbon dioxide (CO2) pneumoperitoneum in the Trendelenburg position is routinely used during robot-assisted laparoscopic gynecologic surgery. Here, we hypothesized that PCV-VG would reduce peak inspiratory pressure (Ppeak), compared to volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV). Methods: In total, 60 patients were enrolled in this study and randomly assigned to receive VCV, PCV, or PCV-VG. Hemodynamic variables, respiratory variables, and arterial blood gases were measured in the supine position 15 minutes after the induction of anesthesia (T0), 30 and 60 minutes after CO2 pneumoperitoneum and Trendelenburg positioning (T1 and T2, respectively), and 15 minutes after placement in the supine position at the end of anesthesia (T3). Results: The Ppeak was higher in the VCV group than in the PCV and PCV-VG groups (p=0.011). Mean inspiratory pressure (Pmean) was higher in the PCV and PCV-VG groups than in the VCV group (p<0.001). Dynamic lung compliance (Cdyn) was lower in the VCV group than in the PCV and PCV-VG groups (p=0.001). Conclusion: Compared to VCV, PCV and PCV-VG provided lower Ppeak, higher Pmean, and improved Cdyn, without significant differences in hemodynamic variables or arterial blood gas results during robot-assisted laparoscopic gynecologic surgery with Trendelenburg position.
Surgery is the mainstay treatment for endometrial cancer and complex atypical endometrial hyperplasia. These conditions are more common in the obese women and as such these patients pose additional risks and challenges to surgery. Laparoscopic hysterectomy (LH) is preferred over open surgery in obese patients as it reduces surgical morbidity. However, more recently, robotic-assisted hysterectomy (RH) has been used in morbidly obese patients to overcome the limitations of conventional laparoscopy. To compare the surgical outcomes of morbidly obese patients undergoing LH or RH for endometrial cancer or complex atypical hyperplasia. A retrospective analysis of morbidly obese patients (BMI > 40 kg/m2) who underwent LH or RH for endometrial cancer or complex atypical hyperplasia at the Chris O’Brien Lifehouse Gynaecological Oncology Unit from 2015 to 2019 was performed. Data was collected from the prospectively maintained gynaecology oncology database and descriptive analysis was performed. 33 (51.6%) underwent LH and 31 (48.4%) had RH. More LHs were performed 2015–2017 period, whereas there were more RHs performed in 2018–2019 period (p = 0.01). The difference between theatre time use and operating time for LH surgery compared to RH was significantly shorter (45.7 for LH versus 61.9 min for RH, p = 0.009). RH was performed more commonly when BMI was > 50 kg/m2 (p = 0.02). There has been an increase in the use of RH in morbidly obese patients, particularly for women with a BMI > 50 kg/m2.
To prospectively compare standard and valve-less insufflation systems on pneumoperitoneum-related complications in robotic-assisted laparoscopic partial nephrectomy. A prospective randomized controlled trial was conducted during a 1.5-year period to compare insufflation-related complications in partial nephrectomy surgery by a single surgeon. Thirty-one patients were recruited for each group: AirSeal insufflation system at 12 mmHg (AIS12), AirSeal at 15 mmHg (AIS15), and conventional insufflation system at 15 mmHg (CIS). Primary outcome assessed was rate of subcutaneous emphysema. Secondary outcomes included rates of pneumothorax, pneumomediastinum, shoulder pain scores, overall pain scores, pain medication usage, insufflation time, recovery room time, length of hospital stay and impact of surgical approach. Predictors for subcutaneous emphysema were assessed with univariate and multivariate logistic models. 93 patients with similar baseline characteristics were randomized into the three insufflation groups. Incidence of subcutaneous emphysema was lower in the AIS12 group compared to CIS (19% vs 48%, p = 0.03,). Mean pain score was less for AIS12 compared to CIS at 12 h (3.1 vs 4.4, p = 0.03). Shoulder pain was less in AIS12 and AIS15 groups compared to CIS at 8 h (AIS12 vs CIS: 0.6 vs 1.6, p = 0.01, AIS15 vs CIS: 0.6 vs 1.6, p = 0.02), and between AIS12 as compared to CIS at 12 h (0.4 vs 1.4, p = 0.003) postoperatively. There was no difference between morphine equivalent use, insufflation time, recovery room time, and length of hospital stay. Multivariable regression analysis showed AirSeal at 12 mmHg and the transperitoneal approach to be the only significant predictors for lower risk of developing subcutaneous emphysema (p < 0.001). Compared to standard insufflation, AirSeal insufflation at 12 mmHg was associated with reduced risk of developing subcutaneous emphysema in robotic partial nephrectomy. Furthermore, shoulder pain was reduced in both AirSeal groups compared to standard insufflation. The retroperitoneal approach increases the risk of developing subcutaneous emphysema.
Objective
To evaluate surgical outcomes and survival after primary robotic or open surgery in obese women with endometrial cancer (EC).
Methods
The study included obese women (BMI ≥ 30 kg/m²) with EC who underwent primary surgery before and after the introduction of robotics between 2006 and 2014. Data on complications, survival, and recurrence was obtained through the National Cancer Registry and medical files. Survival curves were calculated for overall (OS), relative (RS) and disease-free survival (DFS). Cox proportional hazards regression models to assess OS and DFS.
Results
In total, 217 patients were identified, 131 robotic and 86 open surgical procedures. Significantly lower estimated blood loss, surgical time and hospital stay were found in the robotic group and the relative risk ratio of complications grades II–V, using the Clavien Dindo classification, was 0.54 (95% CI 0.31–0.93) for the robotic compared to the open group. A significant difference in OS (p = 0.029) and RS (p = 0.024) in favor of robotics was shown in the univariable survival curves, using log rank tests. No difference was seen for DFS. The 5-year RS was 96.2% (95% CI 89.7–103.3) for the robotic and 81.6% (95% CI 72.1–92.3) for the open group. Multivariable analysis showed high risk histology to be an independent risk factor, for both OS (HR 2.90; 95% CI 1.42–5.93; p < 0.05) and DFS (HR 2.74; 95% CI 1.45–5.17; p < 0.05). Robotic surgery was not found a significant independent factor for survival.
Conclusions
Robotic surgery in obese women with EC had equivalent long-term and disease-free survival compared to open with significantly less complications, lower estimated blood loss, shorter surgical time and hospital stay.
Subcutaneous emphysema is defined as the unintentional introduction of air or carbon dioxide in the subcutaneous tissues. The use of robotic surgical techniques has greatly expanded over the past decade specifically to treat intraperitoneal pathology. In general, advantages of these minimally invasive procedures are reported to decrease operating time, patient morbidity, and shorten hospital stay providing a safe alternative to traditional surgery. However, as with any surgery, potential complications may occur. We describe an unusual case of massive subcutaneous emphysema involving the upper body and cervicofacial region, with bilateral pneumothoraces following robotic intraperitoneal surgery. Written authorization was obtained from the patient.
Background
There are limited data from retrospective studies regarding whether survival outcomes after laparoscopic or robot-assisted radical hysterectomy (minimally invasive surgery) are equivalent to those after open abdominal radical hysterectomy (open surgery) among women with early-stage cervical cancer.
Methods
In this trial involving patients with stage IA1 (lymphovascular invasion), IA2, or IB1 cervical cancer and a histologic subtype of squamous-cell carcinoma, adenocarcinoma, or adenosquamous carcinoma, we randomly assigned patients to undergo minimally invasive surgery or open surgery. The primary outcome was the rate of disease-free survival at 4.5 years, with noninferiority claimed if the lower boundary of the two-sided 95% confidence interval of the between-group difference (minimally invasive surgery minus open surgery) was greater than −7.2 percentage points (i.e., closer to zero).
Results
A total of 319 patients were assigned to minimally invasive surgery and 312 to open surgery. Of the patients who were assigned to and underwent minimally invasive surgery, 84.4% underwent laparoscopy and 15.6% robot-assisted surgery. Overall, the mean age of the patients was 46.0 years. Most patients (91.9%) had stage IB1 disease. The two groups were similar with respect to histologic subtypes, the rate of lymphovascular invasion, rates of parametrial and lymph-node involvement, tumor size, tumor grade, and the rate of use of adjuvant therapy. The rate of disease-free survival at 4.5 years was 86.0% with minimally invasive surgery and 96.5% with open surgery, a difference of −10.6 percentage points (95% confidence interval [CI], −16.4 to −4.7). Minimally invasive surgery was associated with a lower rate of disease-free survival than open surgery (3-year rate, 91.2% vs. 97.1%; hazard ratio for disease recurrence or death from cervical cancer, 3.74; 95% CI, 1.63 to 8.58), a difference that remained after adjustment for age, body-mass index, stage of disease, lymphovascular invasion, and lymph-node involvement; minimally invasive surgery was also associated with a lower rate of overall survival (3-year rate, 93.8% vs. 99.0%; hazard ratio for death from any cause, 6.00; 95% CI, 1.77 to 20.30).
Conclusions
In this trial, minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy among women with early-stage cervical cancer. (Funded by the University of Texas M.D. Anderson Cancer Center and Medtronic; LACC ClinicalTrials.gov number, NCT00614211.)
Objective:
Upper paraaortic lymph node dissection (UPALD) to the infrarenal level is one of the most challenging robotic procedures. Because robotic system has the limitation in robotic arm mobility. This surgical video introduces a novel robotic approach, lower pelvic port placement (LP3), to perform optimally and simultaneously both UPALD and pelvic procedures in gynecologic cancer patients using da Vinci Xi system.
Methods:
The patient presented with high-grade endometrial cancer. She underwent robotic surgical staging operation. For the setup of the LP3, a line was drown between both anterior superior iliac spines. At 3 cm below this line, another line was drown and four robotic ports were placed on this line.
Results:
After paraaortic lymph node dissection (PALD) was completed, the boom of robotic system was rotated 180° to retarget for the pelvic lateral displacement. Robotic ports were placed and docked again. The operation was completed robotically without any complication.
Conclusion:
The LP3 was feasible for performing simultaneously optimal PALD as well as procedures in pelvic cavity in gynecologic cancer patients. The advantage of LP3 technique is the robotic port placement that affords for multi-quadrant surgery, abdominal and pelvic dissection. The LP3 is facilitated by utilizing advanced technology of Xi system, including the patient clearance function, the rotating boom, and 'port hopping' that allows using every ports for a camera. The LP3 will enable surgeons to extend the surgical indication of robotic surgical system in the gynecologic oncologic field.
Objective:
This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer.
Methods:
This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared.
Results:
Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer.
Conclusions:
In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.
Purpose of Review
There has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon.
Recent Findings
A structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice.
Summary
Robotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.
Robotic assisted surgery (RAS) represents a great challenge for anesthesiology due to the increased intraabdomial pressures required for surgical optimal approach. The changes in lung physiology are difficult to predict and require fast decision making in order to prevent altered gas exchange. The aim of this study was to document the combined effect of patient physical status, medical history and intraoperative position during RAS on lung physiology and to determine perioperative risk factors for hypercapnia. We prospectively analyzed 62 patients who underwent elective RAS. Age, co-morbidities and body mass index (BMI) were recorded before surgery. Ventilatory parameters and arterial blood gas analysis were determined before induction of anesthesia, after tracheal intubation and on an hourly basis until the end of surgery. In RAS, the induction of pneumoperitoneum was associated with a significant decrease in lung compliance from a mean of 42.5–26.7 ml cm H2O−1 (p = 0.001) and an increase in plateau pressure from a mean of 16.1 mmHg to a mean of 23.6 mmHg (p = 0.001). Obesity, demonstrated by a BMI over 30, significantly correlates with a decrease in lung compliance after induction of anesthesia (p = 0.001). A significant higher increase in arterial CO2 tension was registered in patients undergoing RAS in steep Trendelenburg position (p = 0.05), but no significant changes in end-tidal CO2 were recorded. A higher arterial to end-tidal CO2 tension gradient was observed in patients with a BMI > 30 (p < 0.001). In conclusion, patients’ physical status, especially obesity, represents the main risk factor for decreased lung compliance during RAS and patient positioning in either Trendelenburg or steep Trendelenburg during surgery has limited effects on respiratory physiology.
Subcutaneous emphysema is a known complication of carbon dioxide insufflation, an essential component of laparoscopy. The literature contains reports of hypercarbia, pneumothorax, or pneumomediastinum. However, isolated lower extremity subcutaneous emphysema remains a seldom-reported complication. We report a case of unilateral lower extremity subcutaneous emphysema following robotic-assisted hysterectomy, bilateral salpingooophorectomy, staging, and anterior/posterior colporrhaphy for carcinosarcoma and vaginal prolapse. On postoperative day 1, the patient developed tender crepitus and bruising of her right ankle. Radiography confirmed presence of subcutaneous air. Vital signs and laboratory findings were unremarkable. Her symptoms spontaneously improved over time, and she was discharged in good condition on day 2. In stable patients with postoperative extremity swelling or pain with crepitus on exam, the diagnosis of iatrogenic subcutaneous emphysema must be considered.
The aim of this study was to evaluate the surgical and oncological outcome of robotic hysterectomy (RH) plus or less pelvic and aortic lymphadenectomy in severely obese patients (BMI≥40 kg/m2) with endometrial cancer.
Between August 2010 and November 2014, patients with histologically confirmed endometrial cancer and BMI≥40 kg/m2 were deemed eligible for the study and underwent RH plus or less pelvic and aortic lymphadenectomy.
A total of 70 patients were divided into three groups according to their BMI: BMI between 40 and 45kg/m2 group A (50 patients), BMI between 45 and 50kg/m2 group B (10 patients) and BMI above 50kg/m2 group C (10 patients). No significant statistical differences were found between the three groups in terms of operative time, blood loss, hospital stay and oncological results. Pelvic lymphadenectomy was performed in 42%, 30% and 20% of patients in group A, B and C, respectively. Intra-operative complication occurred in one patient in group A, early postoperative complications in 4 patients in group A and in 1 patient in group C and late postoperative complication occurred in one patient in group A. No conversions to laparotomy were necessary while there were 3 conversions to laparoscopy in group A and 1 patient in both group B and C.
Our study showed that robotic surgery in severely obese patients with endometrial cancer is safe and feasible. Moreover, it seems that an increase in BMI does not change the surgical and oncological outcomes. However, randomized controlled trials are needed to confirm these results.
Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.
Robot-assisted laparoscopic radical prostatectomy (RALP) is a minimally invasive surgical procedure for prostate cancer. During RALP, the patient must be in a steep Trendelenburg (head-down) position, which leads to a significant increase in intraocular pressure (IOP). The association of RALP with visual field sensitivity, however, has not been prospectively studied. The purpose of this study was to evaluate prospectively the visual field, retinal nerve fiber layer (RNFL) thickness, and optic disc morphology in 50 normal eyes of 25 male patients that underwent RALP.
The subjects were 25 males among 33 consecutive patients who underwent uneventful RALP under general anesthesia in our hospital. Visual field tests using the Humphrey visual field analyzer 30-2 SITA-standard program were performed before, 7 days after, and 1-3 months after RALP. IOP was measured before, during, and after RALP; and ophthalmologic examinations, including slit-lamp, fundus examination, and optical coherence tomography (OCT), were scheduled before and 7 days after surgery.
IOP was significantly increased during RALP up to 29.4 mmHg (P<0.01). Postoperative local visual field defects were detected in 7 eyes of 7 subjects dominantly in the lower hemifield without abnormal findings in the optic nerve head or retina, and the visual field recovered to normal within 3 months after surgery. General factors associated with RALP, IOP, RNFL thickness, or optic disc parameters did not differ significantly between eyes with and without postoperative visual field defects, and parameters of OCT measurements were not altered after surgery.
Transient but significant unilateral visual field defects were found in 28% of the subjects examined. The probable cause are the increased IOP and altered perfusion during surgery and ophthalmologic examinations are therefore suggested before and after RALP.
Background:
The use of the steep Trendelenburg position and abdominal CO2-insufflation during surgery can lead to significant reduction in pulmonary compliance and upper airway oedema. The postoperative time course of these effects and their influence on postoperative lung function is unknown. Therefore, we assessed intra- and extrathoracic airway resistance and nasal air flow in patients with or without chronic obstructive pulmonary disease (COPD) during robotic-assisted prostatectomy.
Methods:
In 55 patients without and 20 patients with COPD spirometric measurements and nasal resistance were obtained before operation, 40 and 120 min, and 1 and 5 days after operation. We measured vital capacity (VC), forced expiratory volume in 1 s (FEV1), maximal mid-expiratory and inspiratory flow (MEF50, MIF50), arterial oxygen saturation, and nasal flow. The occurrence of postoperative conjunctival oedema (chemosis) was also assessed.
Results:
In patients without COPD, MEF50/MIF50 increased and nasal flow decreased significantly after surgery (P<0.0001) and normalized within 24 h. VC and FEV1 decreased after operation with a nadir at 24 h and recovered to normal until the fifth day (P<0.0001). In patients with COPD, changes in MEF50/MIF50 and nasal flow were similar, while changes in VC and FEV1 lasted beyond the fifth day (P<0.0001).
Conclusions:
Robotic-assisted prostatectomy in the steep Trendelenburg position led to an increase in upper airway resistance directly after surgery that normalized within 24 h. The development of chemosis can be indicative of increased upper airway resistance. In patients without COPD, VC and FEV1 were reduced after surgery and recovered within 5 days, while in patients with COPD, the alteration lasted beyond 5 days.
Subcutaneous emphysema and gas extravasation outside of the peritoneal cavity during laparoscopy has consequences. Knowledge of the circumstances that increase the potential for subcutaneous emphysema is necessary for safe laparoscopy.
A literature review and a PubMed search are the basis for this review.
The known risk factors leading to subcutaneous emphysema during laparoscopy are multiple attempts at abdominal entry, improper cannula placement, loose fitting cannula/skin and fascial entry points, use of >5 cannulas, use of cannulas as fulcrums, torque of the laparoscope, increased intra-abdominal pressure, procedures lasting >3.5 hours, and attention to details. New additional risk factors acting as direct factors leading to subcutaneous emphysema risk and occurrence are total gas volume, gas flow rate, valveless trocar systems, and robotic fulcrum forces. Recognizing this spectrum of factors that leads to subcutaneous emphysema will yield greater patient safety during laparoscopic procedures.
Background/aim:
To compare the surgical outcomes of robotic and laparoscopic hysterectomy with or without pelvic lymphadenectomy among obese patients [body mass index (BMI) >30 kg/m2] with early-stage endometrial cancer.
Patients and methods:
We examined 42 obese patients with early-stage endometrial cancer who underwent laparoscopic (LH) or robotic hysterectomy (RH) between April 2014 and April 2020 in our institution. We analysed intraoperative and postoperative data for both procedures.
Results:
Of the 42 women, 22 and 20 patients underwent RH and LH, respectively, with or without pelvic lymphadenectomy. The operation times, harvested lymph nodes, and BMI did not differ between the groups. In the subset of patients who underwent pelvic lymphadenectomy, those in the RH group had shorter hospital stays (p=0.001) and less intraoperative bleeding (p=0.006).
Conclusion:
Obese patients with endometrial cancer who underwent robotic surgery had less blood loss and shorter hospital stays than those who underwent laparoscopic surgery.
Objective
To use a randomized, prospective, multi-institutional study to compare the safety and efficacy of conventional insufflation (CIS) and valveless insufflation (AirSeal Insufflation – AIS) at the conventional pressure of 15 mmHg in robot-assisted partial nephrectomy – a surgery where AIS has gained popularity for maintaining visualization despite suction. This study was also powered to evaluate the effect of decreasing pneumoperitoneum by 20% in the valveless system.
Materials and Methods
Three high-volume institutions randomized subjects into CIS 15, AIS 15, and AIS 12 mmHg cohorts. Endpoints included rates of subcutaneous emphysema (SCE), pneumothorax (PTX), pneumomediastinum (PMS), intraoperative end-tidal carbon dioxide (ET CO2), and peak airway pressure (PAP), as well as hospital stay, post-operative pain, and complications. Given the substantial proportion of retroperitoneal surgery, a secondary analysis evaluated the effect of surgical approach.
Results
202 patients were accrued. SCE was decreased in the AIS 12 mmHg group (p=0.003). PTX and PMS rates were not statistically significantly different across the three insufflation groups. Higher rates of SCE and PMS, although not PTX, were noted in all retroperitoneal surgery groups – with lower SCE rates for AIS 12 mmHg regardless of surgical approach.
Conclusions
AIS is often preferred for complex procedures including retroperitoneal and transperitoneal robotic-assisted partial nephrectomy, for its maintenance of pneumoperitoneum despite continuous suction necessary for visualization. This study shows that AIS is safe when compared to CIS at 15 mmHg, and shows improvement in outcomes when pneumoperitoneum pressure is reduced by 20% to 12 mmHg.
Background:
Robotic prostatectomy and robotic hysterectomy require steep Trendelenburg positioning. Many authors documented significant increases in intraocular pressure (IOP) during steep Trendelenburg. However, the long-term biological effect of a significant increase in IOP on the structural and functional ocular system is unknown. This study examines the effect of a significant increase in IOP on the visual acuity, retinal nerve fiber layer thickness (RNFLT), and ganglion cell complex (GCC) thickness in 52 patients without preexisting ocular disease of both genders before and 3 months after their procedures.
Methods:
This was a prospective cohort study. The total number of patients included was 56, then 3 females and 1 male case were excluded, totaling 28 robotic hysterectomies and 24 robotic prostatectomies were performed. Patients underwent complete eye examination before the procedure and 3 months after, measuring the main outcome of RNFLT and the secondary outcomes of GCC thickness, foveal threshold (FT), mean deviation (MD), and pattern standard deviation (PSD). These outcomes were analyzed using linear mixed-effects models. On the day of surgery, we examined the IOP after induction of anesthesia, at the end of steep Trendelenburg, and in the recovery room.
Results:
There were significant differences in IOP values at the end of steep Trendelenburg versus after induction and 45-60 minutes post-awakening (P < .001 for both groups). No difference between IOP 45 and 60 minutes post-awakening and IOP after induction was observed in either group. The highest IOPs occurred at the end of the steep Trendelenburg time point for both groups. The mean duration of steep Trendelenburg in robotic prostatectomy was 184.6 minutes (standard deviation [SD]= 30.8), while the mean duration in robotic hysterectomy was 123.0 minutes (SD = 29.8). All ophthalmologic examinations were normal preoperatively and 3 months postoperatively. The ocular parameters in the retina and optic disk did not differ significantly before surgery and 3 months after.
Conclusions:
There is a significant increase in IOP during steep Trendelenburg positioning. There was no significant difference in the ocular parameters examined 3 months after the procedure in this cohort.
Study Objective
Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic (LH) and robotic hysterectomy (RH) in endometrial cancer patients with obesity.
Design
We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000 to July 18, 2018) for studies of endometrial cancer patients with obesity (body mass index, BMI≥30 kg/m²) undergoing primary hysterectomy. We generated pooled proportions of conversion, organ/vessel injury, venous thromboembolism (VTE), and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Scale for double-arm studies.
Setting
N/A
Patients or Participants
N/A
Interventions
N/A
Measurements and Main Results
We identified 51 observational studies reporting on 10,800 endometrial cancer patients with obesity (study-level BMI: 31.0-56.3). The pooled proportions of conversion from LH and RH were 6.5% (95% CI 4.3-9.9) and 5.5% (3.3-9.1) respectively among patients with BMI≥30, and 7.0% (3.2-14.5) and 3.8% (1.4-9.9) among patients with BMI≥40. Inadequate exposure due to adhesions/visceral adiposity was the most common reason for conversion for both LH (32%) and RH (61%); however, intolerance of Trendelenburg caused 31% of LH conversions and 6% of RH conversions. The pooled proportions of organ/vessel injury (LH 3.5% [2.2-5.5]; RH 1.2% [0.4-3.4]), VTE (LH 0.5% [0.2-1.2]; RH 0.5% [0.1-2.0]), and blood transfusion (LH 2.8% [1.5-5.1]; RH 2.1% [1.6-3.8]) were low and not appreciably different between arms.
Conclusion
RH and LH have similar rates of perioperative complications in endometrial cancer patients with obesity, but RH reduces conversions due to positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.
Objective data:
Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2).
Study:
We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m2) who underwent primary hysterectomy.
Study appraisal and synthesis methods:
We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies.
Results:
We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m2). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m2, and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m2. Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms.
Conclusion:
Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.
Purpose
The purpose of the study was to evaluate the association between a nationwide introduction of robotic minimally invasive surgery (RMIS) and survival in women with early-stage endometrial cancer.
Materials and methods
Prospective data on consecutive women with early-stage endometrial cancer who underwent surgery during January 2005 to June 2015 in Denmark were identified in the nationwide Danish Gynaecological Cancer Database. Data were linked with national registries regarding comorbidity, education, income and death. The cohort was divided according to the time they underwent surgery: Group 1 before RMIS introduction in their respective region and Group 2 after RMIS introduction. Five-year overall survival was compared by multivariate Cox proportional hazards models stratified by histopathological risk between Groups 1 and 2 and between surgical modalities within Group 2: total abdominal hysterectomy (TAH), laparoscopic minimally invasive surgery (LMIS) and RMIS.
Results
Women in Group 1 (N = 3091) had significantly lower overall survival compared with those in Group 2 (N = 2563; hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.05–1.42). Age, smoking, socioeconomic status, American Society of Anaesthesiologists (ASA) score, comorbidity and histopathological risk influenced the overall survival. Following RMIS adoption, TAH was associated with higher mortality compared with LMIS and RMIS (HR, 1.42; 95% CI 1.02–1.97 and HR, 1.70; 95% CI 1.31–2.19 for LMIS and RMIS, respectively). There was no significant survival difference between RMIS and LMIS (HR, 1.19; 95% CI 0.85–1.68).
Conclusion
The national introduction of robotic surgery for early-stage endometrial cancer was associated with improved survival irrespective of age, body mass index, ASA score, comorbidity, smoking, socioeconomic status and histopathological risk.
Objective:
The aim of this study was to evaluate the surgical and oncological outcome of robotic surgical staging with hysterectomy (RH) plus or less pelvic and aortic lymphadenectomy, compared to the same procedures performed by laparoscopic surgery (LH) in obese patients (BMI≥30 kg/m2) with endometrial cancer.
Material and methods:
From October 2001 to April 2017, obese patients (BMI > 30 kg/m2) with primary, histologically confirmed endometrial carcinoma who underwent LH or RH using the Da Vinci Si or Xi Surgical System® (Intuitive Surgical Inc®, 1266 Kifer Road, Building 101 Sunnyvale, CA) were eligible for the study.
Results:
We identified 655 women with endometrial cancer and BMI >30 kg/m2. Out of 655 patients, 249 (38%) underwent RH and 406 (62%) underwent LH plus or less pelvic and aortic lymphadenectomy. Our study showed that, compared to the 406 patients treated in LPS, 249 patients treated in robotics have a statistically significant difference in terms of increased operating time and a decreased conversion rate. In addition, the rate of pelvic lymphadenectomies in robotic surgeries is twice the one reported in LPS surgeries. Furthermore, a reduction in hospital stay was observed in the robotic group. We observed that the oncological outcomes do not vary according to the surgical approach and BMI variation.
Conclusions:
robotic surgery in severely obese women with endometrial cancer is feasible, safe, and reproducible and could be a valid alternative to laparoscopy in the treatment of these patients. Prospective studies could confirm our results.
The incidence of endometrial cancer (EC) is steadily increasing due in large part to an aging world population and rise in rates of obesity. Patients with obesity and advancing age can be seen as vulnerable populations, as they are both often subject to physician bias regarding surgical choices and assumptions regarding long-term outcomes. As we operate on an older and/or obese patient population, it is increasingly important that we adopt peri-operative management strategies and surgical techniques to best serve this complex patient population. Careful orchestration pre-, intra- and postoperatively is key to successful outcomes in robotic and laparoscopic surgery. Here, we review existing literature regarding EC in women with older age and/or obesity, outline recommendations for peri-operative management and common intra-operative issues-specifically common anesthetic issues surrounding cardiovascular, respiratory and neuromuscular systems-that are of heightened importance in women with older age and/or obesity. The goal of this review is to help define and mitigate common complications for these vulnerable patients with an EC diagnosis who, in accordance with carefully assessed health risks, can and should be offered standard of care surgery and treatment.
Study objective:
The aim of this study was to investigate how steep Trendelenburg positioning with pneumoperitoneum modifies brain oxygenation and autonomic nervous system modulation of heart rate variability during robotic sacrocolpopexy.
Design:
Prospective study (Canadian Task Force classification III).
Setting:
Rambam Health Care Campus.
Patients:
Eighteen women who underwent robotic sacrocolpopexy for treatment of uterovaginal or vaginal apical prolapse.
Interventions:
Robotic sacrocolpopexy.
Measurements and main results:
A 5-minute computerized electrocardiogram, cerebral O2 saturation (cSO2), systemic O2 saturation, heart rate (HR), diastolic blood pressure (BP), systolic BP, and end-tidal CO2 tension were recorded immediately after anesthesia induction (baseline phase) and after alterations in positioning and in intra-abdominal pressure. HR variability was assessed in time and frequency domains. Cerebral oxygenation was measured by the technology of near-infrared spectrometry. cSO2 at baseline was 73% ± 9%, with minor and insignificant elevation during the operation. Mean HR decreased significantly when the steep Trendelenburg position was implemented (66 ± 10 vs 55 ± 9 bpm, p < .05) and returned gradually to baseline with advancement of the operation and the decrease in intra-abdominal pressure. Concomitant with this decrease, the power of both arms of the autonomic nervous system increased significantly (2.8 ± .8 vs 3.3 ± .9 ms(2)/Hz and 2.5 ± 1.2 vs 3.2 ± .9 ms(2)/Hz, respectively, p < .05). All these effects occurred without any significant shifts in systolic or diastolic BP or in systemic or cerebral oxygenation.
Conclusion:
This study supports the safety of robotic sacrocolpopexy performed with steep Trendelenburg positioning with pneumoperitoneum. Only minor alterations were observed in cerebral oxygenation and autonomic perturbations, which did not cause clinically significant alterations in HR rate and HR variability.
Ever since the US Food and Drug Administration (FDA) approval of the use of Da Vinci Surgical Systems (Intuitive Surgical Inc., Sunnyvale, California) in gynaecology in 2005, robot-assisted surgery has been widely adopted in different countries. Some of the applications in benign and oncological gynaecology include myomectomy, sacrocolpopexy, tubal anastomosis, simple hysterectomy, radical hysterectomy, radical trachelectomy, pelvic and/or para-aortic lymphadenectomy, and even debulking surgery for ovarian cancer and pelvic exenteration for recurrent cervical and vaginal cancer. Although there is robust evidence on the safety and treatment outcomes in robot-assisted surgery, complications still rarely occur. Team approach is particularly important in robotic surgery and thorough communication between the bedside assistant and the console surgeon cannot be stressed any more. Thus complications can be due to miscommunication between the console surgeon and bedside assistant, positioning of the patients, the length of the operations, the malfunction of the instrument and the risks specific to the types of anaesthesia and surgery per se, leading to thromboembolism, haemorrhage, organ damage and so on. The most important strategies that can prevent complications are to have thorough pre-operative assessment of the patients’ fitness, good communication between surgical team members, caution regarding the positioning, a good knowledge of the pelvic and abdominal anatomy, careful and meticulous manipulation of the instrument, and early recognition of the complications. In this article, different types of complications and the preventive measures will be described.
We present a case of a patient in whom subcutaneous emphysema, pneumoperitoneum, and pneumothorax occurred on postoperative day 1 after robotic-assisted supracervical hysterectomy, bilateral salpingectomy, sacrocolpopexy, and retropubic midurethral sling placement for pelvic organ prolapse and stress urinary incontinence. This case demonstrates a rare complication of gynecologic laparoscopic procedures.
Objective:
To analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.
Data sources:
Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 to December 2014.
Study eligibility criteria:
All English language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.
Study appraisal and synthesis methods:
The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE) was used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.
Results:
Three hundred and seventy full text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%, 95% CI 0.50-0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. 87% of the bowel injuries were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Three patients (0.02%) (3/13,444, 95% CI 0.01%-0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.
Conclusion:
The overall incidence of bowel injury in robotic assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.
Objective:
To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types.
Methods:
A retrospective cohort study included data from women who underwent any robotic gynecologic procedures between January 1, 2011 and December 31, 2012 at a tertiary care referral center in the USA. Demographic data, perioperative data, and surgeon experience (monthly case volume) data were retrieved; potential risk factors were compared between robotic procedures that were converted to other procedures and those completed as robotic procedures.
Results:
There were 942 robotic procedures during the study period. Conversion from robotic to any other type of procedure was recorded for 47 (5.0%, 95% confidence interval 3.8-6.6) procedures and robotic-to-open-surgery conversion occurred in 16 (1.7%, 95% confidence interval 1.0-2.7) procedures. Conversion from robotic surgery to another approach was associated with higher body mass index (P<0.001), previous laparotomy (P=0.042), and surgeons having a lower monthly robotic surgical case volume (P=0.011). Asthma (P=0.008), intra-operative bowel injury (P<0.001), intra-operative vascular injury (P=0.003), and single-port robotic surgery (P=0.034) were associated with increased odds of requiring conversion from robotic procedures.
Conclusion:
The overall incidence of conversion from robotic surgery to laparotomy was low. Higher body mass index, previous laparotomy, history of asthma, using a single-port approach, and surgeon case volume were associated with the risk of conversion.
Objective:
The mainstay of treatment for uterine corpus cancer is surgical, and the gold standard approach has become minimally invasive surgery. The aim of this study is to compare the perioperative complications and demographics of patients 80 years old or more undergoing robotic and laparoscopic hysterectomy for uterine cancer.
Materials and methods:
Using the Nationwide Inpatient Sample, we retrospectively identified all women aged 80 years or older who had hysterectomies for uterine cancer by either modality. The complication rates of surgery in both groups were adjusted for potential confounding and compared using logistic regression analyses.
Results:
There were 915 women aged 80 years or older identified with uterine corpus cancer who had either laparoscopic or robotic surgery. Robotically treated patients were more likely to be obese (8.8% vs 3.5%) but were otherwise similar in terms of mean age, comorbidities, income, ethnicity, and insurance status. Those undergoing robotic surgery were less likely to have admissions beyond 3 days (29.0% vs 38.2%; adjusted odds ratio, 0.66; P < 0.01) and had a lower composite incidence of any complication (24.3% vs 31.6%; adjusted odds ratio, 0.7; P < 0.05). When looking at those who had lymph node dissections, there was a lower rate of postoperative ileus, and a trend toward fewer venous thromboembolic events.
Conclusions:
Among octogenarians and nonagenarians with uterine corpus cancer, robotic surgery is associated with a shorter hospital admission and a better complication profile than laparoscopy.
Aim:
This study aimed to evaluate the surgical safety and clinical effectiveness of RH versus LH and laparotomy for cervical cancer.
Methods:
We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane library through May 2015, and checked references of relevant studies. We selected the comparative studies reported the surgical safety (overall; peri-operative; and post-operative complications; death within 30 days; and specific morbidities), and clinical effectiveness (survival; recurrence; length of stay [LOS]; estimated blood loss [EBL]; operative time [OT]) and patient-reported outcomes.
Results:
Fifteen studies comparing RH with OH and 11 comparing RH with LH were identified. No significant differences were found in survival outcomes. The LOS was shorter and transfusion rate was lower with RH compared to OH or LH. EBL was significantly reduced with RH compared to OH. Compared to OH, overall complications, urinary infection, wound infection, and fever were significantly less frequent with RH. The overall, peri-operative, and post-operative complications were similar in other comparisons. Several patient-reported outcomes were improved with RH, though each outcome was reported in only one study.
Conclusions:
RH appears to have a positive effect in reducing overall complications, individual adverse events including wound infection, fever, urinary tract infection, transfusion, LOS, EBL, and time to diet than OH for cervical cancer patients. Compared to LH, the current evidence is not enough to clearly determine its clinical safety and effectiveness. Further rigorous prospective studies with long-term follow-up that overcome the many limitations of the current evidence are needed.
Background Older patients are at increased risk of perioperative morbidity and mortality. There are limited data on the safety of a robotic approach in the staging for endometrial cancer. Objective We compared outcomes in women undergoing laparotomy or robotic surgical staging for endometrial cancer. Study Design Using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 through 2010, we abstracted records for patients who had surgery for endometrial cancer with either a robotic approach or laparotomy. Patients were categorized by age (<65 vs ≥65 years and 5-year increments). Medical comorbidity scores were calculated using the Charlson Comorbidity Index. Outcomes included intraoperative/perioperative/medical complications, death, length of stay (LOS), and discharge disposition. Student t and χ2 tests were used to compare groups and approach. Multiple analysis of variance models were used to compare differences between robotics and laparotomy and age groups. Results We identified 16,980 patients who had surgery for endometrial cancer with either a robotic approach (age ≥65 years, n = 1228; age <65 years, n = 1574) or laparotomy (age ≥65 years, n = 5914; age <65 years, n = 8264). Older patients had a higher Charlson Comorbidity Index score at the time of surgery (2.6 vs 2.5, P <.001). In laparotomy cases, intraoperative complication rates were similar (4.1% vs 3.7%, P =.17). Older patients had higher rates of perioperative surgical (20.5% vs 15.4%, P <.001) and medical (23.3% vs 15.5%, P <.001) complications, longer LOS (5.1 vs 4.2 days, P <.001), and lower rates of discharge to home (71.2% vs 90.1%, P <.001). In robotic cases, rates of intraoperative complications were similar (5.9% vs 6.8%, P =.32). Older patients had higher rates of perioperative surgical (8.3% vs 5.2%, P =.001) and medical (12.3% vs 6.7%, P =.001) complications, longer LOS (2.00 vs 1.67 days, P <.001), and lower rates of discharge to home (88.8% vs 96.8%, P <.001). With both approaches, as age increased, perioperative surgical and medical complications also increased in a linear fashion. In a subanalysis of older patients (n = 7142), there were lower rates of perioperative surgical (8.3% vs 20.5%, P <.001) and medical (12.3% vs 23.3%, P <.001) complications, death (0.0% vs 0.8%, P <.001), shorter LOS (2.00 vs 5.13 days, P <.001) and higher rate of discharge to home (88.8% vs 71.2%, P <.001) in robotic compared to laparotomy cases. Conclusion Although the risks of surgery increase with age, in patients age ≥65 years, a robotic approach for endometrial cancer appears to be safe given current selection criteria utilized in the United States.
Objective:
To identify specific comorbidities within the Charlson Comorbidity Index (CCI) that are associated with increased complication rates after robotic-assisted partial nephrectomy (RAPN).
Patients and methods:
After IRB approval, a consecutive series of 641 patients undergoing RAPN was retrospectively identified. Perioperative complications were defined and classified using the Clavien grading system. Fisher's exact test or chi square test was performed to evaluate the association of individual comorbidities with perioperative complications. Logistic regression was used for multivariable analysis to adjust for other non-CCI comorbidities and tumor-specific and patient-specific characteristics.
Results:
Of the 641 patients undergoing RAPN, complications occurred in 67 patients (10.5%), including 10 (14.9%), 28 (41.8%), 20 (29.9%), 5 (7.5%), and 4 (6.0%) patients with Clavien grade 1, 2, 3a, 3b, and 4 complications, respectively. Cerebrovascular disease [odds ratio 3.01 (95% CI 1.10-8.26) p=0.03] and chronic obstructive pulmonary disease [COPD; 3.12 (1.24-7.89) p=0.02] predicted complications in multivariable analysis of clinico-pathological characteristics including all CCI and non-CCI comorbidities. In additional modeling with only CCI comorbidities, similar results were observed, with cerebrovascular disease [2.93 (1.04-7.56) p=0.04] and COPD [2.69 (1.04-6.28) p=0.04] as the only two significant variables. No other variables reached statistical significance in either model, including nephrometry score or estimated blood loss (p>0.50 for both). COPD predicted major complications (Clavien grade 3 or 4) in multivariable analysis [3.19 (1.07-9.48) p=0.04].
Conclusions:
Cerebrovascular disease and COPD predict perioperative RAPN complications after robot-assisted partial nephrectomy. Identification of patients with these comorbidities preoperatively may afford improved counseling and risk stratification.
Objective:
To compare the complications and charges of robotic vs. laparoscopic vs. open surgeries in morbidly obese patients treated for endometrial cancer.
Methods:
Data were obtained from the Nationwide Inpatient Sample from 2011. Chi-squared, Wilcoxon rank sum two-sample tests, and multivariate analyses were used for statistical analyses.
Results:
Of 1,087 morbidly obese (BMI ≥40kg/m(2)) endometrial cancer patients (median age: 59 years, range: 22 to 89), 567 (52%) had open surgery (OS), 98 (9%) laparoscopic (LS), and 422 (39%) robotic surgery (RS). 23% of OS, 13% of LS, and 8% of RS patients experienced an intraoperative or postoperative complication including: blood transfusions, mechanical ventilation, urinary injury, gastrointestinal injury, wound debridement, infection, venous thromboembolism, and lymphedema (p<0.0001). RS and LS patients were less likely to receive blood transfusions compared to OS (5% and 6% vs. 14%, respectively; p<0.0001). The median lengths of hospitalization for OS, LS, and RS patients were 4, 1, and 1 days, respectively (p<0.0001). Median total charges associated with OS, LS, and RS were $39,281, $40,997, and $45,030 (p=0.037).
Conclusions:
In morbidly obese endometrial cancer patients, minimally invasive robotic or laparoscopic surgeries were associated with fewer complications and less days of hospitalization relative to open surgery. Compared to laparoscopic approach, robotic surgeries had comparable rates of complications but higher charges.
Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure.
Retrospective, institutional review board approved.
Operating room.
N = 186 males, American Society of Anesthesiologists 2-3, with prostatic carcinoma undergoing robotic-assisted laparoscopic radical prostatectomy.
Arterial blood gases and noninvasive respiratory measurements were recorded for those patients (n = 32) in whom a radial arterial catheter had been inserted intraoperatively, specifically timed to different phases of the procedure: supine lithotomy, steep Trendelenburg, and return to supine. Ventilatory parameters were standardized.
Systemic blood pressure, heart rate, respiratory rate, Pao2, Paco2, oxygen saturation as measured by pulse oximetry, and end-tidal carbon dioxide pressure.
Although no patients developed perioperative respiratory complications, the Pao2 invariably fell (395 vs 316 mm Hg; P = .001) while the patients were in steep Trendelenburg, and the Paco2-end-tidal carbon dioxide pressure rose (10.0 vs 13.4 mm Hg; P < .0001). Upon return to supine, patients' respiratory measurements promptly returned to within 15% of baseline. Subgroup analysis for high-BMI vs low-BMI patients as well as for patients with pulmonary disease and/or a smoking history showed similar individual effects and only small, although significant, respiratory gas exchange aberrations.
Positioning patients with a CO2 pneumoperitoneum in steep Trendelenburg for several hours imposes restriction of diaphragmatic and chest wall movement sufficient for respiratory gas exchange to be adversely affected. Return of function to within 15% of baseline occurred within minutes after return to supine and release of the CO2 pneumoperitoneum. No patients during the study period developed pulmonary complications that required alteration in their level of care.
Copyright © 2015. Published by Elsevier Inc.
The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications following laparoscopic and robotic hysterectomy.
Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by CPT code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses utilizing Chi-squared, Fisher's exact, and one-way ANOVA tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications.
Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than one center or research group).
American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP.
None, retrospective database study.
Of the 7,630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (SSI; 1.0%), and blood transfusion (1.0%). Return to the operating room (OR) was required in 97 patients (1.3%) and there were 4 deaths, for a mortality rate of 0.05%. Complications increased steadily with longer operative time. Operative time ≥240 minutes was associated with increased overall complications (13.8% versus 4.6%, p<.001), surgical complications (5.4% versus 1.5%, p<.001), medical complications (10.4% versus 3.2%, p<.001), return to the OR (2.7% versus 1.2%, p=.002), deep venous thrombosis (DVT; 0.5% versus 0.06%, p=.011), pulmonary embolism (PE; 0.7% versus 0.1%, p=.012), and blood transfusion (3.4% versus 0.8%, p<.001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (OR 1.4, 95% CI 1.28 to 1.54, p<.001), medical complications (OR 1.42, 95% CI 1.28 to 1.57, p<.001), surgical complications (OR 1.32, 95% CI 1.17 to 1.49, p<.001), VTE (OR 1.47, 95% CI 1.12 to 1.92, p=.005), UTI (OR 1.20, 95% CI 1.05 to 1.36, p=.006), blood transfusion (OR 1.42, 95% CI 1.18 to 1.71, p<.001), and return to the OR (OR 1.25, 95% CI 1.08 to 1.45, p=.003).
We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy in order to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.
Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.
Background:
Older patients are at increased risk of perioperative morbidity and mortality. There is limited data on the safety of a robotic approach in the staging for endometrial cancer.
Objectives:
We compared outcomes in women undergoing laparotomy or robotic surgical staging for endometrial cancer.
Study design:
Utilizing the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008-2010, we abstracted patients who had surgery for endometrial cancer with either a robotic approach or laparotomy. Patients were categorized by age (<65 years vs ≥65 years and five year increments). Medical comorbidity scores were calculated using the Charlson Comorbity Index (CCI). Outcomes included: intraoperative/perioperative/medical complications, death, length of stay (LOS) and discharge disposition. Student's t and chi-square tests were used to compare groups and approach. Multiple analysis of variance (MANOVA) models were used to compare differences between robotics and laparotomy and age groups.
Results:
We identified 16,980 patients who had surgery for endometrial cancer with either a robotic approach(≥65, n=1,228; <65, n=1,574) or laparotomy (≥65, n=5,914; <65, n=8,264). Older patients had a higher CCI at the time of surgery (2.6 vs. 2.5, p<0.001). In laparotomy cases, intraoperative complication rates were similar (4.1% vs. 3.7%, p=0.17). Older patients had higher rates of perioperative surgical (20.5% vs. 15.4%, p<0.001) and medical complications (23.3% vs. 15.5%, p<0.001), longer LOS (5.1 vs. 4.2 days, p<0.001) and lower rates of discharge to home (71.2 vs. 90.1%, p<0.001). In robotic cases, rates of intraoperative complications were similar (5.9% vs. 6.8%, p=0.32). Older patients had higher rates of perioperative surgical (8.3% vs. 5.2%, p=0.001) and medical complications (12.3% vs. 6.7%, p=0.001), longer LOS (2.00 vs. 1.67 days, p<0.001), and lower rates of discharge to home (88.8% vs. 96.8%, p<0.001). With both approaches, as age increased, perioperative surgical and medical complications also increased in a linear fashion. In a sub-analysis of older patients (n=7,142), there were lower rates of perioperative surgical (8.3% vs. 20.5%, p<0.001) and medical complications (12.3% vs. 23.3%, p<0.001), death (0.0% vs. 0.8%, p<0.001), shorter LOS (2.00 vs. 5.13 days, p<0.001) and higher rate of discharge to home (88.8% vs. 71.2%, p<0.001) in robotic compared to laparotomy cases.
Conclusion:
Although the risks of surgery increase with age, in patients ≥65 years, a robotic approach for endometrial cancer appears to be safe given current selection criteria utilized in the U.S.
This study aimed to assess the safety of robotic surgery for older women undergoing surgery for endometrial cancer.
A retrospective chart review of women undergoing surgery for endometrial cancer between October 2010 and December 2012 was conducted at the authors' institution. This cohort was divided by age (≥65 vs <65 years) and surgical approach (laparotomy vs robotic surgery). Postoperative morbidity and mortality were compared using standard statistical analysis.
Of 228 patients identified, 73 (32 %) were 65 years old or older, and 98 (43 %) had undergone robotic surgery. Among the robotic surgery patients, women 65 years old or older had a higher Charlson comorbidity score (7.6 vs 4.9; p < 0.01) and were more likely to undergo pelvic lymphadenectomy (73 vs 39 %; p < 0.01). The complication rates did not differ between the groups except for increased urinary retention in the older group (15 % vs 3 %; p = 0.04). Older patients had a longer hospital stay (2.2 vs 1.3 days; p < 0.01) and a similar rate of discharge home (100 vs 96 %; p = 0.09). For the patients 65 years old or older, robotic surgery was associated with less blood loss (131 vs 235 ml; p = 0.03), a lower rate of ileus (0 vs 15 %; p = 0.04), a lower perioperative surgical complication rate (4 vs 30 %; p = 0.01), a shorter hospital stay (2.2 vs 4.4 days; p < 0.01), and a similar rate of discharge home (96 vs 91 %; p = 0.45) compared with laparotomy.
Robotic surgery appears to be associated with less postoperative morbidity than laparotomy for endometrial cancer staging in women 65 years old or older. The complication rates after robotic surgery were similar between the two age groups.
Objective
To assess the rate and risk factors for position-related injury in robotic gynecologic surgery.
Methods
A prospective database from 12/2006 to 1/2014 of all planned robotic gynecologic procedures was retrospectively reviewed for patients who experienced neurologic injury, musculoskeletal injury, or vascular compromise related to patient positioning in the operating room. Analysis was performed to determine risk-factors and incidence for position-related injury.
Results
Of the 831 patients who underwent robotic surgery during the study time period, only 7(0.8%) experienced positioning-related injury. The injuries included minor head contusions (n = 3), two lower extremity neuropathies (n = 2), brachial plexus injury (n = 1) and one large subcutaneous ecchymosis on the left flank and thigh (n = 1). There were no long term sequelae from the positioning-related injuries. The only statistically significant risk factor for positioning-related injury was prior abdominal surgery (p = 0.05). There were no significant associations between position-related injuries and operative time (P = 0.232), body mass index (P = 0.847), age (p = 0.152), smoking history (P = 0.161), or medical comorbidities (P = 0.229 – 0.999).Conclusions
The incidence of position-related injury among women undergoing robotic surgery was extremely low (0.8%). Due to the low incidence we were unable to identify modifiable risk factors for position-related injury following robotic surgery. A standardized, team-oriented approach may significantly decrease position-related injuries following robotic gynecologic surgery.
The introduction of robot-assisted surgery, and specifically the da Vinci Surgical System, is one of the biggest breakthroughs in surgery since the introduction of anaesthesia, and represents the most significant advancement in minimally invasive surgery of this decade. One of the first surgical uses of the robot was in orthopaedics, neurosurgery, and cardiac surgery. However, it was the use in urology, and particularly in prostate surgery, that led to its widespread popularity. Robotic surgery, is also widely used in other surgical specialties including general surgery, gynaecology, and head and neck surgery. In this article, we reviewed the current applications of robot-assisted surgery in different surgical specialties with an emphasis on urology. Clinical results as compared with traditional open and/or laparoscopic surgery and a glimpse into the future development of robotics were also discussed. A short introduction of the emerging areas of robotic surgery were also briefly reviewed. Despite the increasing popularity of robotic surgery, except in robot-assisted radical prostatectomy, there is no unequivocal evidence to show its superiority over traditional laparoscopic surgery in other surgical procedures. Further trials are eagerly awaited to ascertain the long-term results and potential benefits of robotic surgery.
Objectives
The objective of this study was to evaluate heart rate variability and hemodynamic parameters following steep Trendelenburg positioning during robotic sacrocolpopexy.
Study design
For 19 women, median age 57 (range: 45–72), blood pressure and ECG were recorded during surgery. From the ECG signals interbeat intervals were used to assess heart rate variability, analyzed in time and frequency domains using the Fast Fourier transform. The low frequency and high frequency spectral bands were used to assess sympathetic and parasympathetic pathways respectively.
Results
All women underwent robotic supracervical hysterectomy and sacrocolpopexy. A statistically significant decrease in the mean values of the low-frequency and high-frequency spectral bands, representing sympathetic and parasympathetic activity, respectively were demonstrated 5 min following Trendelenburg positioning of the patients (from 3.6 ± 1.4 to 2.9 ± 0.8 ms2/Hz, and from 3.5 ± 1.4 to 2.9 ± 1 ms2/Hz, P < 0.05). These changes correlated with a mean 20% decrease in heart rate, which lasted for 30 min, and with a second drop in sympathetic and parasympathetic activity and heart rate, commencing 2 h from the start of surgery, and lasting until the end of the operation.
Conclusions
Steep Tredelenburg positioning during robotic urogynecology surgery results in significant changes in the autonomic nervous system modulation of heart rate variability and in other hemodynamic parameters.
Positioning injuries in the perioperative period are one of the inherent risks of surgery, but particularly in robot-assisted urologic surgery, and can result in often unrecognized morbidity. Injuries such as upper or lower extremity peripheral neuropathies occur via neural mechanisms and injuries such as compartment syndrome, rhabdomyolysis, ischemic optic neuropathy, and acute arterial occlusion occur via vascular mechanisms. The risk of injury may be exacerbated by operative and patient-related risk factors. Patient-related risk factors include ASA class and BMI, while surgery-related risk factors include physical orientation of the patient and operative length. These injuries can be prevented or reduced by joint effort of the surgeon, anesthesiologist, and operating room staff.
To evaluate the adverse events encountered during robotic gynecologic surgery, as reported to the FDA MAUDE database from January 2006 to December 2012.
A search of the FDA MAUDE database was performed by brand name 'da Vinci' and manufacturer 'Intuitve Surgical'. Reports reflecting gynecologic procedures either by description or procedure name were included. A record of reports was kept to ensure no duplicates were added. The date and type of event (operator-related error, technical system failures, or surgical injuries attributed to the use of the robot) as well as the clinical outcome were recorded.
Twenty six percent of the reported events (n=73) resulted in injury, and 8.5% (n=24) resulted in death. Notably, while adnexal procedures accounted for less than 3% of the cohort, they compromised 20% of the fatality cases. Twenty-one percent of injuries were attributed to operator-related error, 14% to a technical system failure, and 65% were not directly related to the use of the robot.Fifteen fatal cases were reported during planned hysterectomy. Four of those cases resulted in an injury to a major blood vessel (three iliac and one aortic injuries), although detailed description of how the injury occurred was absent from the event description.
It is important to continue to evaluate the occurrence of injuries during robot-assisted surgery in an effort to identify unique challenges associated with this advanced technology.
Background and purpose:
Because of recent advances in minimally invasive surgical techniques, robot-assisted radical prostatectomy (RARP) has become the primary treatment option in prostate cancer. RARP, however, necessitates patients to be placed in a steep Trendelenberg position, which presents multiple opportunities for complications relating to the positioning of the patient. Our study aims to study the prevalence and demographic predictors of these positioning complications and assess their impacts on length of stay (LOS) and total cost.
Patients and methods:
We included patients who underwent RP from 2008 to 2009 using data extracted from the Nationwide Inpatient Sample database. Positioning complications (eye, nerve, compartment syndrome/rhabdomyolysis) were identified using patient-level diagnosis and procedural International Classification of Disease, 9th edition, Clinical Modification codes. Logistic regression models assessed relationships between demographic factors and occurrence of complications and the effects of them on prolonged LOS and total inpatient cost.
Results:
Positioning complications occurred in 0.4% of cases with eye complications contributing the most to this frequency. Laparoscopic RP procedure (odds ratio [OR]=2.88, P<0.01) and comorbidities (OR=2.34, P<0.01) were highly associated with increased odds of positioning complication occurrence, whereas RARP procedures (OR=0.93, P>0.4) were not associated with positioning complications. Having positioning complications increased a patient's odds of having increased inpatient costs and extended LOS by almost 400% and 300%, respectively.
Conclusion:
The steep Trendelenberg position used in RARP was not shown to be associated with patient positioning-related complications in this sample. The occurrence of positioning-related complications, however, places huge burdens on total inpatient costs and LOS.
Compartment syndrome (CS) of the lower leg is a rare but severe complication of operations in the lithotomy (LT) position after urologic, gynecologic and general surgery. A delay in diagnosis and treatment can lead to loss of function and even life-threatening complications. The pathophysiology is still not fully understood but it is believed that ischemia as a result of increased compartment pressure and decreased perfusion pressure may lead to CS. The type of leg support and the intraoperative hypotension have been discussed as risk factors but evidence is mainly based on case reports and expert opinion. Studies suggest that time spent in the LT position and the addition of head-down tilt are associated with CS. As these positions are routinely applied during various gynecologic procedures, forensically CS has to be considered as a specific complication of gynecologic surgery in the LT position. Despite the low incidence there is a need for prospective studies and guidelines for its prevention. Sixteen case reports describing 19 cases of CS following gynecologic surgery in lithotomy position were found during a literature search. This review is based on 14 of these case reports (17 cases), which describe a postoperative compartment syndrome in a previously healthy leg. We summarize the reported cases and literature on CS after gynecologic procedures in order to increase awareness among medical staff and to give careful recommendations regarding perioperative management based on available information.