1. Robot chirurgie in de Gynaecologische Oncologie
Verpleegkundigen in de oncologie: update
11 februari Oostkamp
Philippe Van Trappen, MD PhD MRCOG(Gyn Onc)
Head Gynaecology/Oncology Bruges
AZ St. Jan Hospital Bruges
BELGIUM

2. Evolutie gynaecologische chirurgie
Wertheim
Laparoscopy
Robot
Telesurgery
1898
1994
2003

3. ROBOTIC SURGERY

4. Robot console 3D View Ergonomic position surgeon Telesurgery
Endowristed instruments
Controle of Camera and all instruments

5. Plaatsen trocars + docking aan Robot

6. Plaatsen trocars + docking aan Robot

7. Robotic Surgery in Gynaecological oncology
Welke patienten:
Endometrium carcinoom (FIGO-stadium I)
Cervix carcinoom (FIGO-stadium IA2-IB1)
Ovarium carcinoom (FIGO-stadium IA)

8. Robotic Surgery in Gynaecological oncology
Welke operaties:
Robot hysterectomie +/- pelviene klieren
Robot radicale hysterectomie (Wertheim-Meigs)
Robot para-aortale klierdissectie
Robot radicale cervixamputatie/trachelectomie met pelviene klierdissectie

9. Robotic Assisted vs Straight Stick (Laparoscopy)
No haptic feedback
Three dimensions
More degrees of freedom
No tremor
Telesurgery
Telementoring
Easier
Quicker to learn
?cost
? More breakdown
Haptic Feedback
Two dimensions
Less degrees of freedom
Max tremor
No telesurgery
No telementoring
Less easy
Slower to learn
Less cost
Less risk of op breakdown

10. Robotic Assisted vs Straight Stick
Endometrial cancer
Overweight
Cervix Cancer
Complex Surgery
Ovarian Cancer

11. Obesity 2009

12. Obesity

14. Endometrial Cancer
1985
13.5

15. Endometrial Cancer
1995
13.9

16. Endometrial Cancer
2001
16.5

17. Endometrial Cancer
2010
20.5

18. Endometrial Cancer
/ 100,000
/ 100,000
x 2

19. Risico factoren voor endometrium carcinoom

20. Laparoscopic vs Open Hysterectomy for Endometrial Cancer
COMPLICATIONS
Just RCTs

21. Laparoscopic Vs Open Surgery Endometrial Cancer
Recurrence %
Overall Survival %
Disease-free survival %
Kalogiannidis et al LH
8.7 93 91 AH 16 86 84
Zullo et al 20
82.5 NR
18.4
84.2
Nezhat et al
5.9
88.5
7.8 85
Malzioni et al
8.6
93.2
91.4
11.5
91.1

22. Laparoscopic Vs Open Surgery Endometrial Cancer
Level 1 evidence
Longer operating time
Shorter hospital stay
Less blood loss
Less post-operative complications

23. National statistics for endometrial cancer
Acknowledgment to Osama Abughazza

24. Robotic Surgery Endometrial Cancer

25. Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer
Pats
ORT (min)
LOS (days)
EBL (ml) LN
ALN
PLN
Conv (%)
Comps (%)
Boggess 2008 RH
103
191 1 75
32.9 12
20.5
2.9
5.8 LH 81
213
1.2
146
23.1
6.3
17.4
4.9
13.6 AH
138
4.4
266
14.9 3
11.5
29.7
Veljovich 2008 25
283
1.7
66.6
17.5 20 4
255
20.3
131
139
5.3
198
13.1 29
Bell 2008 40
184
2.3
166 17
7.5 30
171 2
253
17.1
109
316
27.5
DeNardis 2008 56
177
105
19.8
6.5
13.3
106 79
3.2
241 19
6.6
12.4

26. Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer
Pats
ORT (min)
LOS (days)
EBL (ml) LN
ALN
PLN
Conv (%)
Comps (%)
Gaia 2010 RH
424
219
1.4 92
28.8
10.3
18.5
4.9 LH
396
209
1.9
182
25.6
7.8
17.8
9.9
333
207
1.2
101
27.4
9.4 18 AH
606
130
3.9
291
20.2
5.7
14.5
Seamon 2009
105
242 1 88 31 10 21
12.4 76
287 2
200 33 11 22
26.3
109
228 27
8.5
15.6
191
143 3
394
25.9
7.2
18.7
Coronado 2012 71
189
3.5 99
2.8
21.2 84
218
4.6
190
8.1
28.5
192
157
231
34.9

27. Robotic Surgery For Endometrial Cancer
COSTS ???
Robotic Surgery For Endometrial Cancer

28. Costs Before & After

29. Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer – Lau et al
Acknowledgement – Slide provided by Walter Gotlieb, Canada.

30. Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer – Lau et al
Apr Nov 2007
L-tomy+L-scopy
(n=160)
Dec 2007 – May 2010
Robotic
(n=143)
p-value
BMI (mean)
Obese ( )
Morbidly Obese (>40)
27.6
31.9%
8.8%
29.8
33.6%
16%
0.005
Age (mean)
<56
56-65
66-75
>75
65.3 20 36 23 22
65.7 18 21 25
0.9
Complications > gr2
41.9%
13.3%
<0.0001
Wound complications
15.6%
3.5%
Acknowledgement – Slide provided by Walter Gotlieb, Canada.

31. Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer – Lau et al
Apr Nov 2007
L-tomy+L-scopy
Mean (P25-P75)
(n=160)
Dec 2007 – May 2010
Robotic
(n=143)
p-value
Time (skin to skin, min.)
207( )
241 ( )
<0.0001
EBL (ml)
266 ( )
73 (20-100)
Hospital stay (days)
5 (4-6)
1 (1-2)
Overall Cost per surgery
Including amortization
10368
( )
8370
( )
0.0002
Acknowledgement – Slide provided by Walter Gotlieb, Canada.

32. Summary for Robotic Less complications Shorter hospital stay
Longer time in theatre
Cheaper

33. Robotic surgery with staging for endometrial cancer: multi-institutional experience
Lowe et al, Obstet Gynecol 2009
n patients
Oper. time
Blood loss
n LNs
Hosp. stay
Intraoper. compl
Postoper. compl.
405
170.5 min
87.5 ml
15.5
1.8 days
3.5%
14.6%

34. Robotic hysterectomy + LND versus Laparoscopic hysterectomy + LND: case-matched controlled study on surgical outcome
Robot
N = 122
Oper. Time
147.2 min LN
N = 19.2
Blood loss
81.1 ml
Hosp.
1.5 days
Laparoscopy
186.8 min
N = 24.7
207.4 ml
3.2 days
Lim et al, Gynecol Oncol 2011

35. Robotic hysterectomy + LND versus Laparoscopic hysterectomy + LND: surgical outcomes at a minimally invasive surgical center
Cardenas et al, Gynecol Oncol 2010
Robot
N= 102
Oper. Time
237 min
Blood loss
109 ml
Laparoscopy
N = 173
178 min
187 ml
n LNs and
complications equal

36. Robotic surgery for patients with low and high BMI in a
German Gynecological Cancer Center
Kannisto et al, Arch Gynecol Obstet, 2014 July
Retrospective study
N=116 patients
Operations: Robot (radical) hysterectomy, Adnexectomy, LN dissection, etc
Complications overall: 15/116 (12.9%)
Perioperative complications: normal BMI = high BMI
- vascular injury (2)
- intestinal injury (2)
- not well exposed paraaortic field (1)
- bladder injury (1)
Late complications: vaginal dehiscence (2), vaginal hemorrhage (1), cuff hematoma (4),
Lymphocyst (1), urinary tract injuries, ureter (2)

37. 50 Robot Robot versus Laparoscopic nerve-sparing radical hysterectomy
for early-stage cervical cancer
Chong et al, Int J Gynecol Cancer, 2013 July
Robot
N = 50
Oper. Time
230.1 min LN
N = 25
Blood loss
54.9 ml
Normal res. urine
9.6 days
Laparoscopy
211.2 min
N = 23.1
201.9 ml
Normal res. urine.
11 days
50 Robot
P<0.001

38. Robot versus Laparoscopic nerve-sparing radical hysterectomy
for early-stage cervical cancer
Chong et al, Int J Gynecol Cancer, 2013 July
Complication rate!!:
- ROBOT: 0%
- LAPAROSCOPIC: 8%

39. Robotic vs Laparoscopic Surgery Endometrial Cancer
Operative Time

40. Robotic vs Laparoscopic Surgery Endometrial Cancer
Days Stay

41. Robotic vs Laparoscopic Surgery Endometrial Cancer
EBL

42. Robotic vs Laparoscopic Surgery Endometrial Cancer
Complications

43. Robotic vs Laparoscopic Surgery Endometrial Cancer
Conversions

45. GYNAECOLOGY/ONCOLOGY in AZ St. Jan BRUGES
ROBOTIC PROCEDURES IN
GYNAECOLOGY/ONCOLOGY in AZ St. Jan BRUGES
CONSOLE OPERATIVE TIMES (average):
Robot Hysterectomy (large/myomatous uteri): 60 min
Robot Hysterectomy (endometrial cancer): 45min
Robot Hysterectomy + Pelvic Lymph Node Dissection (endometrial cancer): 90min
Robot Radical Hysterectomy + Pelvic Lymph Node Dissection: 150min
Robot Pelvic and Para-aortic Lymph Node Dissection: 60-90min

49. Vessel Sealer for lateralising ureter

50. BLADDER
Vessel Sealer for dissecting Para-Vesical and Para-Rectal space in Robot Radical Hysterectomy
Para-Vesical Space
UTERUS
LEFT
OVARY

51. Vessel Sealer for opening space between bladder and cervix/vagina
Left uterine artery
Vessel Sealer for opening space between bladder and cervix/vagina
Left ureter

52. Vessel Sealer for opening para-rectal space Identification of splanchnic (Hypogastric) nerves in meso-ureter during Radical Hyterectomy.
Splanchnic nerves in meso-ureter

53. Vessel Sealer for Pelvic Lymph Node Dissection (iliac vessels)
LYMPH NODE TISSUE
Right External Iliac
Artery/Vene

54. Vessel Sealer for dissecting lymph node tissue (obturator fossa)

55. Aorta
Lymph node tissue
Left Coimmon Iliac
Artery
Vessel Sealer for lymph node dissection at Para-aortic region (here left side)

56. Left Para-aortic region

57. Aorta Left Ureter Inferior Mesenteric Artery Left Para-aortic Region
after removal LN

58. Aorta
Vena Cava
Right Ureter
Lymph nodes

59. Aorta-Vena Cava-Ureter Right
Right Common Iliac Artery
Aorta-Vena Cava-Ureter Right

60. Radical Hysterectomy (end of procedure)
BLADDER
Ureters

61. after PLND and Radical Hysterectomy
BLADDER
PUBIC BONE
after PLND and Radical Hysterectomy
Obliterated
Hypogastric
Artery
Vaginal swab
OBTURATOR
NERVE
VAGINA
open
EXT ILIAC
VESSELS
RIGHT URETER

62. VAGINA closed RIGHT URETER PUBIC BONE BLADDER Obliterated Hypogastric
Artery
OBTURATOR
NERVE
VAGINA
closed
EXT ILIAC
VESSELS
RIGHT URETER

63. Fibrin/collagen patch on iliac vessels after lymph node dissection

64. 4-arm da Vinci Xi
Single arm
da Vinci Sp