1. Gynecologic Patient Education Seminar Know your options
Presented by
Michael Pitter, MD
Located at :201 Lyons Avenue  Osbourne Terrace, L - 2 Newark NJ Phone: (973)
Thank you for joining us today for this gynecology patient education seminar.
I’m Dr. __Michael Pitter__ and I’m a board-certified ____Obstetric & Gynecologic ____ here in ___Newark, New Jersey__.
I appreciate the opportunity to talk to you today, because there have been some exciting new advances in the treatment of many common gynecologic conditions. The primary advance that I want to talk to you about today is robotic-assisted surgery with the da Vinci Surgical System.
From my experience incorporating robotic surgery into my practice, I hope to give you a feeling on the many benefits of minimally invasive surgery.
Know your options

2. Gynecologic Conditions
Program
Gynecologic Conditions
Benign
Cancerous
Symptoms & Treatments
Surgical Options
da Vinci® Gynecologic Surgery
da Vinci® Hysterectomy
da Vinci® Myomectomy
da Vinci® Hysterectomy for Cancer
During the course of our program today, I will discuss different gynecologic problems, their symptoms and their treatment options, including surgical options. I will provide an overview of da Vinci Gynecologic Surgery, which in many situations is your most effective, least invasive surgical option. Common operations now available with robotic-assisted surgery include: da Vinci Hysterectomy, da Vinci Myomectomy and da Vinci Gynecologic Cancer Surgery.

3. The Uterus & Reproductive Organs
Uterus (womb)
Endometrium
Myometrium
Fallopian Tube
Uterus
Ovary
Fallopian tubes
Endometrium
Myometrium
Ovaries — contain eggs
Cervix — opening of uterus
Vagina — birth canal
A number of diseases and conditions that gynecologists treat affect various sites in the female reproductive system. Before I discuss these further, let’s quickly review the female reproductive system and its major organs.
The uterus is the muscular organ pictured here in the center of the diagram. The uterus is where the embryo and then the fetus develop during pregnancy. At the top end of the uterus or womb are the fallopian tubes which deliver the fertilized eggs to the uterus for implantation.
The ovaries are the reproductive organs which contain the eggs and also produce hormones. When an egg is fertilized, it travels down the fallopian tubes to the uterus.
The myometrium is the muscular wall of the uterus while the endometrium is the uterine lining that is shed every month during a menstrual cycle, unless of course a pregnancy develops.
At the bottom end of the uterus is the cervix or the mouth of the uterus, which opens into the vagina or birth canal.
Cervix
Vagina

4. Gynecologic Conditions
Fibroids
Pelvic masses
Abnormal bleeding
Endometriosis
Pelvic floor disorders
Pre-cancer
Cancer
Fallopian Tube
Uterus
Ovary
Bladder
Pubic Bone
Rectum
Urethra
Here we have listed some of the gynecologic conditions that we’ll talk about today. All of these conditions are usually treated with surgery.
These include fibroids, pelvic masses, abnormal bleeding, endometriosis, pelvic floor disorders, precancer, and cancer.
Vagina

5. What are Fibroids? Common Benign tumors Symptoms
Submucosal
Common
Benign tumors
Vary by size & location
Symptoms
Bleeding
Can cause infertility
Urinary frequency or constipation
Pressure & pain
Intramural
Pedunculated
Subserosal
Let’s talk a little bit more about fibroids. Fibroids or the medical term leiomyomas are very common. They are almost always benign and they arise from the muscular wall of the uterus. They can grow in different parts of the uterus and they can vary in size, location, and severity of symptoms. They can be as small as a pea or as big as a melon or even larger.
Pedunculated fibroids are when the fibroid comes off of a stock that is attached to the uterus. Subserosal fibroids usually bulge out from the outer aspect of the uterine wall, whereas submucosal fibroids bulge in towards the uterine cavity or the endometrial cavity. Fibroids within the myometrium or the muscular wall itself are usually called intramural fibroids.
Different types of fibroids can result in different types of symptoms. The most common symptoms of fibroids overall are heavy periods or irregular bleeding, difficulty getting pregnant or a sense of urinary urgency from the fibroids pushing on the bladder. Fibroids can also cause a bulging sensation in your pelvic area and they can also cause pain, particularly pain with intercourse.

6. Treatment Options for Fibroids
Conservative management
If fibroids are not symptomatic
Shrink fibroids
Medications (GnRH agonists) induce menopause
Uterine artery embolization (UAE) stops blood flow to fibroid
Surgical Options
Resection
To remove fibroids inside uterus (submucosal) only
Myomectomy
To remove intramural or subserosal fibroids
If uterine and/or fertility preservation desired by patient
Hysterectomy
Removal of uterus
There are a number of treatment options for fibroids. If you have no symptoms, then most physicians elect to follow the fibroids conservatively, that is just keep an eye on them and make sure that they are not growing or causing problems.
Sometimes fibroids can be shrunk with medications. There are medications such as Lupron or GnRH agonists that can induce a temporary menopausal state. Without the hormones, the fibroids tend to shrink.
Another technique called uterine artery embolization will stop the blood flow to the fibroid often resulting in shrinkage of the fibroid. This requires a small procedure usually done by a radiologist to insert a small device into blood vessels blocking blood flow to the fibroid.
Surgical options include a removal of the fibroid by going through the cervix. This is called a hysteroscopic resection and is often done for submucosal fibroids. A myomectomy involves making an incision on the uterus and removing the fibroids but preserving the uterus.
Finally, hysterectomy is the definitive solution to fibroids which often can grow back after myomectomy.

7. Growth of endometrial tissue outside the uterus
What is Endometriosis?
Growth of endometrial tissue outside the uterus
Symptoms
Pain before/after periods
Chronic pelvic pain
Painful bowel movements during periods
Pain during/after intercourse
Infertility
Irregular vaginal bleeding
Now, let’s talk about endometriosis. Endometriosis is when there is growth of endometrial tissue outside of the uterus. The endometrial tissue normally lines the uterus and is shed every month during menstruation. However, a small amount of the tissue will back up during menstruation and can be found coming through the fallopian tubes and lodging on other organs in the pelvic area. This tissue can grow on the surface of the ovaries, the fallopian tubes, on the surface of the outside of the bladder or the intestines, and can also be found within the vagina or even sometimes in the rectum.
Symptoms of endometriosis include pain, particularly pain during periods. Sometimes this can develop into chronic pelvic pain. Women can also have painful bowel movements or pain during or after intercourse. Endometriosis can also cause difficulty getting pregnant.

8. Treatment Options for Endometriosis
Pain Management
Oral contraceptives
Pain medications, such as ibuprofen
Medical Therapy
GnRH agonists
Surgical Options
Resection
Ablation
Hysterectomy
Treatment options for milder cases of endometriosis often revolve around pain management. Oral contraceptives given continuously can often help the endometriosis deposits to shrink. Pain medicines such as ibuprofen or Naprosyn can also be effective.
For more difficult cases, medical therapy can help, again using GnRH agonists or Lupron, which induce a menopausal state. Without hormonal stimulation, the endometriosis tends to shrink away.
For much more severe cases, surgery maybe required. This can involve removing or resecting the endometriosis implants from the pelvic area. Some physicians will also use techniques such as laser ablation or ablation with other types of electrical energies to destroy the endometriosis implants.
Ultimately, the only true cure for endometriosis involves complete hysterectomy. When a woman no longer has menstrual periods, very often the endometriosis implants will regress. For very severe cases, hysterectomy along with the removal of the ovaries and tubes maybe required in order to completely remove all of the abnormal tissue and to control the symptoms.

9. What are Pelvic Floor Disorders?
Prolapsed bladder, vagina, uterus, rectum
Example: Prolapsed uterus
Uterus drops from normal position in pelvic cavity & descends into & sometimes outside of vagina
Next, I would like to talk about pelvic floor disorders. These occur when the muscular floor of the pelvis becomes weakened by trauma during a vaginal delivery or by chronic conditions that put stress on the pelvic floor like chronic coughing.
Pelvic prolapse is actually a type of hernia and when it occurs the bladder, the vagina, the uterus or the rectum can begin to drop through the pelvic floor and out through the vagina.

10. What are Symptoms of Pelvic Floor Disorders?
Pelvic heaviness or fullness
Feeling that something is falling out
Pain during intercourse
Anal pain or pressure
Low back pain
Incontinence or difficulty urinating
Symptoms of pelvic floor disorders can include a pelvic heaviness or a feeling of fullness, a feeling like something is falling out through the vagina, pain during intercourse, anal pain or pressure or low back pain, difficulty controlling the urine or urinary incontinence is a very common symptom of a pelvic floor disorder.

11. Treatment Options for Pelvic Floor Disorders
Pelvic floor exercises
Vaginal pessary
Surgical Options
Hysterectomy for uterine prolapse
Vaginal vault suspension for vaginal prolapse
Vaginal
Abdominal
Laparoscopic
da Vinci®
Bladder suspension for bladder prolapse
Disorders of the pelvic floor can be treated in a variety of ways. More mild cases can often be controlled with pelvic exercises or biofeedback. Sometimes the physician will place a device called a pessary in the vagina, which helps to hold the pelvic organs up and in the proper position.
Most commonly, however, surgery is required to fix the defect. A hysterectomy maybe required if the uterus itself is prolapsing through. However, doing a hysterectomy alone will not fix the hernia defect. Some type of suspension of the vaginal vault is required in order to restore the strength of the pelvic floor. These types of procedures can be performed through the vagina, but more traditionally are performed through an abdominal incision. Some surgeons offer a laparoscopic approach to suspend the vaginal vault.
A successful vaginal vault suspension requires strong sutures being placed in a good position that will result in a long-term cure for the problem. This can be technically difficult to perform laparoscopically.
Finally, bladder suspension or urethral sling procedures are commonly performed for prolapse of the bladder or for urinary incontinence.

12. What is Pre-Cancer? Common Condition Abnormal cells Symptoms
Screening to prevent cancer from occurring
Abnormal cells
Cervix (called dysplasia)
Endometrial lining (called hyperplasia)
Symptoms
Looking for abnormal cells that could predict future risk of cancer
Cervix (dysplasia) is asymptomatic
Diagnosed by PAP smear
Endometrial lining (hyperplasia) often cause abnormal bleeding
Diagnosed by office biopsy or D&C procedure
Pre-cancer is another common gynecologic condition that causes great anxiety for many women because of the fear of cancer.
Billions of dollars are spent in the United States each year treating millions of women for this problem, hopefully to prevent cervical or endometrial cancers from ever occurring.
Pre-cancerous cells are abnormal cells that can grow on the cervix or the endometrial lining. They can also occur in the lining of the vagina or on the skin of the vulva. These sites are much less common.
When you have a Pap smear, your gynecologist is looking for abnormal cells on the cervix that could predict a future risk for cervical cancer. However, pre-cancers unlike cancers cannot spread or invade other areas of the body. Therefore, in and of themselves they are not dangerous, but if left untreated they can become cancers over time.
Pre-cancers of the cervix are without symptoms, but pre-cancers of the endometrial lining can often cause abnormal bleeding. Your gynecologist will often order an ultrasound if she is concerned that you may have endometrial pre-cancer, but ultimately the diagnosis must be based on a biopsy, either done in the office or by a dilatation and curettage or D&C.

13. Pre-Cancer Treatment options
Cervix dysplasia often treated by removing part of the cervix
LEEP or cervical cone biopsy
Endometrial hyperplasia treated by hysterectomy
Hormonal treatment is an experimental, short-term option
Treatment options for pre-cancers of the cervix usually involve removing the abnormal part of the cervix. Occasionally, a freezing procedure can be performed to achieve the same results. Common procedures for removing the abnormal part of the cervix include a LEEP procedure or a cervical cone biopsy.
Endometrial hyperplasia on the other hand is usually treated with hysterectomy. However, there are some situations where hormonal treatment can be used. Side effects from the hormonal treatments can be severe and many women elect to proceed with hysterectomy.

14. Cancer of the Female Reproductive Organs
These cancers are very uncommon
Symptoms
Intermittent bleeding or spotting
Irregular periods (prolonged or more frequent)
Bleeding after menopause
Pink, watery, or bloody vaginal discharge
Pelvic discomfort or pain
Bleeding with intercourse
Irregular bowel/bladder function
Abdominal pressure, bloating
Cancers of the female reproductive organs are fortunately very uncommon. However, abnormal symptoms that could suggest a cancer of the female reproductive organs can cause great anxiety for many women.
Symptoms of gynecologic cancers can include irregular bleeding with prolonged or more frequent periods or any bleeding that occurs in a postmenopausal woman. A pink watery or bloody vaginal discharge can also be suggestive of a gynecologic cancer. Pelvic pain or discomfort can be from a variety of causes, but certainly it can be a sign of a cancer developing. Bleeding with intercourse is also abnormal and if it occurs repeatedly you should see your gynecologist right away. Irregular bowel or bladder function can also be caused by many different conditions but can be a sign of a gynecologic cancer.
Finally, abdominal pressure or bloating that persists over time should be evaluated by your physician.

15. The most common gynecologic cancer Usually detected in an early stage
Endometrial Cancer
The most common gynecologic cancer
Usually detected in an early stage
Commonly causes post-menopausal bleeding
Almost always treated with surgery
Endometrial Cancer
Endometrial cancer or cancer of the lining of the uterus is the most common gynecologic cancer. Fortunately, it’s usually detected at an early stage because it very commonly causes abnormal postmenopausal bleeding. When a woman notices this bleeding, she usually goes to see the doctor right away.
Endometrial cancers are almost always treated with surgery unless the patient has severe medical problems that preclude an anesthetic.

16. Can be detected by an abnormal PAP smear
Cervical Cancer
Can be detected by an abnormal PAP smear
Symptoms include abnormal bleeding, discharge, or bleeding after intercourse
Early stages usually treated with surgery
Advanced stages treated with radiation/ chemotherapy
Cervical Cancer
Cervical cancer can be detected early and hopefully prevented by getting regular Pap smears. Early cervical cancers are usually detected by an abnormal Pap smear. In most cases, women are still without symptoms at the time of detection.
For more advanced cases of cervical cancer, women can begin to have symptoms including abnormal bleeding or abnormal vaginal discharge or bleeding after intercourse. 50% of advanced cases of cervical cancer occur in women who have never had a Pap smear in their entire life, and another 25% of advanced cases occur in women who have not had a Pap smear in the last four years or more.
Early stages of cervical cancer are usually treated with surgery, although radiation is just as effective. More advanced cases are always treated with radiation, sometimes in combination with chemotherapy.

17. Sometimes known as the “silent killer” Early cases are often curable
Ovarian Cancer
Sometimes known as the “silent killer”
Early cases are often curable
Most women are diagnosed with advanced disease
There is no screening test for ovarian cancer
Ovarian Cancer
Ovarian cancer is sometimes known as the silent killer, because it can grow without symptoms until it is very advanced.
If you are diagnosed with an early case of ovarian cancer, with proper surgery and chemotherapy you have an excellent chance of cure. Unfortunately, most women are diagnosed with more advanced staged disease. This is because there is no screening test for ovarian cancer.
You maybe confused by articles you read in women’s magazines or by information you see on television about a blood test called a CA However, this is not a screening test for ovarian cancer and is not designed to detect the disease in an early stage nor to distinguish between benign or cancerous conditions. Unfortunately, most of the symptoms of ovarian cancer do not become obvious until the cancer has grown and spread within the abdominal cavity.

18. Treatment Options for Cancer
Surgical Options
Remove cervix & leave uterus intact (trachelectomy)
Early-stage cervical cancer
Radical hysterectomy with pelvic lymph node removal
Cervical cancer
Hysterectomy with removal of ovaries, fallopian tubes and pelvic & para-aortic lymph nodes
Endometrial cancer
Additional tissues biopsied & removed for ovarian cancer
Radiation/chemotherapy
Appropriate for advanced stage cancers
There are a number of treatment options for women with gynecologic cancers, most of these involve surgery.
If you have an early stage cervical cancer, rarely you maybe a candidate for an operation called a trachelectomy. Otherwise, most cases of early cervical cancer are treated with an operation called a radical hysterectomy along with removal of the lymph nodes in the pelvic area.
Uterine cancers or endometrial cancers are usually treated with a complete hysterectomy as well as removal of the ovaries and fallopian tubes. In addition, the operation also includes removal of the pelvic lymph nodes and removal of lymph nodes higher up in the abdominal cavity called the para-aortic lymph nodes.
Surgeries for ovarian cancer can be much more extensive but usually involve a complete hysterectomy, removal of the ovaries and fallopian tubes, removal of the lymph nodes in the pelvic and para-aortic area, removal of a fatty pad called the omentum, and a number of biopsies from the abdominal cavity.
Radiation and chemotherapy often have important roles in the treatment of gynecologic cancers, but they are usually used for more advanced stages of cancer.

19. Most common female surgery
Hysterectomy Facts
Most common female surgery
Definitive solution for many uterine conditions
650,000 procedures annually
Most performed through abdominal (open) incision
Advances in minimally invasive surgery (MIS) for hysterectomy
More GYN surgeons performing MIS for hysterectomy
Some important things to know about hysterectomy are that it’s the most common surgical procedure performed on women. This is because it is the definitive solution for many types of common gynecologic conditions.
About 650,000 hysterectomies are performed annually in the United States alone. Most of these are still performed through abdominal incisions, either up and down between the belly button and the pubic bone or across, what many women refer to as a bikini incision.
Due to recent advances in minimally invasive approaches to hysterectomy, more and more gynecologic surgeons are performing these types of procedures either vaginally or using what’s called a laparoscopic approach.

20. 40,000 procedures performed annually
Myomectomy Facts
40,000 procedures performed annually
Most performed through abdominal (open) incision
Number and size of fibroids may require complete removal of uterus (hysterectomy)
Advances in minimally invasive surgery (MIS) for myomectomy
More GYN surgeons performing MIS for myomectomy
If uterine and/or fertility preservation is desired
Myomectomies are also quite common. About 40,000 procedures are performed in the United States every year. Most of these procedures are performed through abdominal incisions. Sometimes if there are many fibroids or the fibroids are very large, a hysterectomy maybe required.
Some gynecologic surgeons have begun performing myomectomies with minimally invasive surgical approaches. Myomectomies are indicated if you are still trying to get pregnant and a minimally invasive surgical approach offers many advantages for a shorter recovery.

21. Surgical Approaches to Hysterectomy
Open (abdominal) surgery
Minimally invasive surgery (MIS)
Vaginal surgery
Conventional laparoscopic surgery
da Vinci® Hysterectomy (robot-assisted surgery)
Now that we have talked about some common gynecologic conditions and their various treatment options, let’s discuss some of the approaches that are available when surgery is needed. As I alluded to earlier, if you need a hysterectomy, it can be done with a traditional approach, an open abdominal incision; this incision maybe vertical or transverse. Now, however, many physicians are offering minimally invasive surgery for hysterectomy. A minimally invasive approach could be vaginal with conventional laparoscopy or robotically with the da Vinci Surgical System.

22. Minimally Invasive Surgery (MIS)
Reduced blood loss
Fewer complications
Shorter Hospital stay
Faster recovery
Less scarring
There are many advantages to minimally invasive surgery. These include reduced blood loss, fewer complications, a shorter stay in the hospital, a faster recovery, and less scarring.
Circa. 1991

23. Vaginal Surgery Pros Minimally invasive Cons Difficult to perform
Minimal scarring
Short hospital stay
Less pain compared to abdominal hysterectomy
Cons
Difficult to perform
Reduced visualization
Not indicated for many patients
Nulliparious (women who have not given birth)
Multiple fibroids (or large masses)
Cancer
Adhesions, e.g., endometriosis, prior pelvic surgery
Vaginal surgery maybe appropriate for you for certain gynecologic problems. The pros of vaginal surgery include that it is less invasive. There is no scar on the abdomen and often you spend only one night in the hospital. There is also significantly less pain with a vaginal approach than there is with an abdominal hysterectomy. Cons to vaginal surgery are that it can be difficult to perform. The physician may not be able to see as well and it may be difficult to control bleeding from the vascular tissues that give blood supply to the pelvic organs.
In addition, vaginal surgery may not be indicated for certain types of patients. If you have never had children or have large fibroids or other types of large masses, you may not be able to have the surgery performed vaginally. Cancer operations are rarely performed vaginally as they usually require much more extensive surgery than a vaginal approach could offer.
Finally, if you have significant adhesions or scar tissue from endometriosis or prior surgeries, this could make vaginal surgery unfeasible.

24. Laparoscopic Surgery Minimally invasive
Ability to operate through small, keyhole incisions
Better visualization than open surgery
On the other hand, laparoscopic surgery is performed through very small keyhole incisions in the abdomen rather than one long continuous incision. One advantage to laparoscopic surgery is that the surgeon’s view is magnified. Laparoscopic surgery begins with the surgeon inserting a video telescope or camera through a small incision, usually in the belly button. This camera will often magnify the areas that the surgeon is examining and provide better visualization than open surgery.
With conventional laparoscopic surgery, after the surgeon has placed the camera, several additional small keyhole incisions are made. Through these small incisions cannulas or trocars are inserted. Through these trocars different types of instruments can be inserted that perform various functions like grasping, cutting or cauterizing.
Open Vertical Incision Open Transverse Incision Laparoscopic or
da Vinci® Incision

25. Drawbacks with Conventional Laparoscopic Surgery
Surgeon operates from a 2D image
Rigid instruments
Instruments controlled at a distance
Reduced dexterity, precision & control
Greater surgeon fatigue
Surgical assistance is limited
Makes complex operations more difficult to perform
Some of the drawbacks of conventional laparoscopic surgery include that the surgeon is operating while looking at a two-dimensional image usually on a flat screen monitor. The instruments themselves are rigid and can only be moved in a few directions in space. The instruments are controlled at a distance with the surgeon’s hand outside of the patient’s abdomen. This results in reduced dexterity, reduced precision, and reduced control of the instruments. It also results in greater surgeon fatigue. Assistance from the surgeon on the other side of the operating room table can also be difficult to coordinate.
With conventional laparoscopic surgery, very complex operations can be quite difficult or impossible to perform. However, conventional laparoscopic surgery is an excellent option for minor or straightforward surgical procedures like tubal ligations or removal of small ovarian cysts.

26. How can we overcome these drawbacks?
da Vinci® Surgical System
State-of-the-art robotic technology
Surgeon in control
Assistant has direct access
How can we overcome some of these drawbacks of conventional laparoscopic surgery? Many surgeons around the country like myself now have access to the da Vinci Surgical System. This system provides state-of-the-art robotic technology and allows me to be completely in control of the operation. My assistant also has direct access to the patient through traditional laparoscopic trocars or ports.

27. Surgeon immersed in 3D image of the surgical field
Vision System
Surgeon immersed in 3D image of the surgical field
Rather than a two-dimensional flat image, I am immersed in a three-dimensional image of the surgical field.

28. The Surgeon Directs the Instruments
Surgeon directs precise movements of the instruments using Console controls
I direct the instruments at all times while controlling the arms on the console. Even small or very precise movements of my hands are transmitted to the instruments inside the patient’s abdomen in real time.

29. Wrist and Finger Movement
Conventional minimally invasive instruments are rigid with no wrists
EndoWrist® Instrument tips move like a human wrist
Allows surgeon to operate with increased dexterity & precision
Conventional laparoscopic instruments are rigid and do not have the ability to rotate like a human wrist. The EndoWrist instruments, part of the da Vinci Surgical System, move like a human wrist with seven degrees of freedom. This allows me to operate with increased dexterity and precision.

30. Small Instruments, Small Incisions
EndoWrist® Instruments fit through dime-sized incisions
A wide range of instruments are available
These EndoWrist instruments fit through small dime-sized incisions or keyhole incisions. A wide range of instruments are available to perform almost any type of task that might be required.

31. da Vinci® Surgery Surgeon has… Improved visualization
Better instrumentation, surgical control & precision
Better surgical dexterity for complex aspects of procedure
Easier & faster suturing
Better ergonomics
Double-click to view video
In addition to the number of many benefits to the patient, there are many benefits to me the surgeon as well. These include improved visualization, better control of the instruments, improved surgical dexterity for complex aspects of the operation, easier and faster suturing, and I’m more comfortable while I’m operating.

32. Robot-Assisted Surgery Access
This slide shows a picture of the typical configuration of these small keyhole incisions that might be used for access to perform a robotic-assisted surgery.
Open Vertical Incision Open Transverse Incision da Vinci® Surgical Incision

33. Potential Patient Benefits
da Vinci® Surgery
Open Surgery
Benefit
4-6 dime-sized incisions with minimal scaring
Long incision with visible scaring
Incision size
Days
Weeks
Pain or discomfort
1-2 days
3-5 days
Hospital stay
1-3 weeks
4-6 weeks
Recovery
When you compare the benefits of different surgical approaches, you can see that the da Vinci Surgical System offers many advantages. In general, smaller incisions result in less scarring, less pain, a shorter hospital stay, shorter recovery, and quicker return to normal activities.
Days
Weeks
Return to normal activities

34. da Vinci® Gynecologic Surgery Indications
da Vinci® Surgery appropriate for a broader range of gynecologic conditions & patient situations compared to conventional laparoscopy
Cervical cancer
Conventional laparoscopy not widely accepted
Endometrial cancer
Conventional laparoscopy accepted, but technically difficult to perform
Vaginal or uterine prolapse
Conventional laparoscopic suturing not reliable
Endometriosis
Uterine fibroids
Obese patients
da Vinci Gynecologic Surgery is not indicated for everybody. It does allow me to perform a broader range of surgeries for different gynecologic conditions and for different patient situations than was ever available before. For example, radical hysterectomy done with conventional laparoscopy has not been widely accepted by gynecologic oncologists. The concern is that the lack of surgical precision results in a less than adequate cancer operation. However, the da Vinci radical hysterectomy is being performed by a small number of gynecologic oncologists around the United States with excellent surgical results.
Endometrial cancer has been treated with conventional laparoscopy for sometime now with good surgical results, but it can be technically difficult to perform and quite exhausting for the surgeon. The da Vinci surgical approach offers better ergonomics for the surgeon and better precision. Surgery for vaginal or uterine prolapse can be performed with conventional laparoscopy, but as we discussed before the laparoscopic suturing may not be reliable. da Vinci laparoscopic suturing is reliable and easy. In addition, surgery for endometriosis can be quite complex and the da Vinci System provides the increased precision often required to perform these surgeries safely.
Surgery for large uterine fibroids can be difficult or impossible to perform with conventional laparoscopy, but now they can be performed by experienced robotic surgeons.
Finally, surgery on obese patients can be difficult for a number of reasons. However, these are the patients that benefit the most from a minimally invasive approach due to a decreased risk of wound infection and decreased risk of wound healing problems. The da Vinci Surgical System allows me to offer minimally invasive surgery to a much greater number of obese patients.

35. Goals of da Vinci® Hysterectomy
Enable minimally invasive surgery (MIS) approach
Easier to learn & perform compared to conventional laparoscopic surgery
da Vinci (robotic-assisted) Surgery will enable:
More Gynecologists to perform minimally invasive surgery
Gynecologists to perform more advanced operations & more types of procedures using a minimally invasive approach
Provide benefits of MIS to hysterectomy candidates
Short hospital stay
Minimal pain & scarring
Quick recovery & return to normal activities
Now, let’s talk in more detail about some of the goals of da Vinci Hysterectomy.
This allows a minimally invasive approach for hysterectomy. It’s much easier to learn than conventional laparoscopy and enables the gynecologist to perform the surgery for more advanced types of gynecologic problems. Again, the benefits to you include a shorter hospital stay, less pain and scarring, and a quicker return to normal activities.

36. Goals of da Vinci® Myomectomy
Enable minimally invasive surgery (MIS) approach
Most myomectomies performed through open incision
Conventional laparoscopy for myomectomy is very difficult to learn & perform
Enable women to retain their uterus*
Provide means for women to preserve their fertility
Provide benefits of MIS to myomectomy patients
Short hospital stay
Minimal pain & scarring
Quick recovery & return to normal activities
Now, let’s take a look at the goals of da Vinci Myomectomy. Again, it enables the surgeon to offer a minimally invasive approach to the removal of uterine fibroids while preserving the uterus for fertility. Most myomectomies are currently performed through open incisions and conventional laparoscopy can be very difficult to learn and perform, particularly due to the difficulty of conventional laparoscopic suturing. da Vinci Myomectomy enables you to retain your uterus and therefore your ability to have children. In addition, you can reap the many benefits of a minimally invasive approach.
*Assumes patient is a candidate for myomectomy.

37. Goals of da Vinci® Gynecologic Cancer Surgery
Traditional open approach resulted in large incisions
da Vinci enables minimally invasive surgery (MIS) approach
Conventional laparoscopy may fall short in adequately removing & treating gynecologic cancers
Conventional laparoscopic (minimally invasive) surgery is difficult to learn & perform
With da Vinci, Gynecologic Oncologists can perform more advanced operations using a minimally invasive approach
Provide benefits of MIS to cancer patients
Short hospital stay
Minimal pain & scarring
Quick recovery & return to normal activities
I’d like to say a few words about how the da Vinci Surgical System can be used for different types of gynecologic cancer surgery. Traditionally, surgery for gynecologic cancers like many other types of cancers have involved large incisions with extensive operations that can result in a feeling of disfigurement. By employing a minimally invasive surgical technique even for cancer operations, patients can maintain a greater self-esteem and quality of life.
In the past, conventional laparoscopy has fallen short of being an adequate surgical approach for complex cancer operations. In addition, conventional laparoscopic surgery can be difficult to learn and perform. With the da Vinci Surgical System, more advanced operations can be performed with a minimally invasive approach. The benefits we discussed before of shorter hospital stay, minimal pain and scarring, and quick recovery can also apply to women with conditions as serious as cancer.

38. Radical Hysterectomy for Cervical Cancer
Fallopian Tube
Pelvic
Lymph
Nodes
Ovary
Uterus
Parametrium
Cervix
Upper Third of Vagina
A radical hysterectomy, which is a complex pelvic operation for cervical cancer, involves removing the uterus, the cervix, the tissue around the cervix called the parametrium, and the upper third of the vagina. Sometimes it will also include removing the fallopian tubes and ovaries, but this is not necessarily a part of a radical hysterectomy. In addition, removal of pelvic lymph nodes is also performed.
Some surgeons have reported performing radical hysterectomies with traditional laparoscopy, but the gynecologic oncology community has not embraced this operation as being reliable enough to adequately treat and potentially cure cervical cancer. With the added dexterity and three-dimensional visualization of the da Vinci Surgical System, I can now perform radical hysterectomies with all of the benefit of minimally invasive surgery.

39. Surgical Staging for Endometrial Cancer
Para-Aortic Lymph Nodes
Fallopian Tube
Ovary
Uterus
Pelvic Lymph Nodes
Cervix
On this slide, surgical staging for endometrial cancer is shown. With this operation, removal of the uterus, cervix, both ovaries and tubes, lymph nodes in the pelvis, and sometimes lymph nodes in the lower abdomen are also removed. The da Vinci Surgical System provides an excellent way of performing surgical staging for endometrial cancer.
SAMPLE ELABORATIVE STATEMENT:
As a surgeon who has performed hundreds of operations for endometrial cancer using conventional laparoscopy, I have noticed an improvement in tissue handling with the da Vinci Surgical System. With gentler handling of the tissues, I think my patients experience less postoperative pain and a shorter recovery.

40. Patient Information da Vinci® Hysterectomy educational brochure
da Vinci® Myomectomy educational brochure
Intuitive Surgical has a number of patient brochures available that can provide additional information about da Vinci Hysterectomy and da Vinci Myomectomy.

41. Frequently asked questions
What physical limitations will I have after the operation and when will I be able to resume activities such as working, driving and exercise?
Now, let me address a few questions that patients frequently ask me about da Vinci Gynecologic Surgery.
Q: What physical limitations will I have after the operation and when will I be able to resume activities such as working, driving, and exercise?
A: After da Vinci Gynecologic Surgery, most patients are able to resume normal activities in one or two weeks. With da Vinci Surgery, we only make a few incisions which are only the size of a dime; tissue is not spread during the procedure. This shortens your healing and recovery time, lowers your risk of infection and minimizes pain after surgery.
Because da Vinci Surgery is the least invasive surgical treatment, you will be able to go home earlier and return to your regular activities more quickly than with open surgery.

42. Frequently asked questions
Is this a standard operation?
How safe is da Vinci Gynecologic Surgery?
Q: Is da Vinci Gynecologic Surgery a standard operation? How safe is da Vinci Gynecologic Surgery?
A: While da Vinci Surgery involves a relatively new technique and approach to gynecologic surgery, the da Vinci System has been used in tens of thousands of procedures worldwide for more than five years. Essentially, da Vinci is minimally invasive or laparoscopic surgery that can achieve significantly better results due to the application of robotic technology. The features of the da Vinci System enhance the surgeon’s capabilities, which make it possible to provide you with all the benefits of a minimally invasive procedure, including reduced risk of infection and complications.
This technology can also help the surgeon’s capabilities, potentially making da Vinci Surgery as safe or possibly safer than conventional approaches. For example, the superior, high magnified, three-dimensional vision helps the surgeon to see the target anatomy better without the need for a large incision.
The robotic instruments that move like a human wrist provide unparalleled precision and dexterity making it possible to perform more complex dissection and repair. With the da Vinci System, the surgeon is seated at a console and always in full control of the instruments micro movements. This makes the operation intuitive for the surgeon and lets him or her fully concentrate on the target anatomy. Another advantage of using the da Vinci System is that the assistant has complete access to the surgical site and can assist during complex steps of the procedure. Surgical tasks can be greatly facilitated with this support.

43. Frequently asked questions
Isn’t open surgery safer for many patients?
Q: Isn’t open surgery safer for many patients?
A: More difficult or complex gynecologic surgery with heavy adhesions due to endometriosis or prior pelvic surgery are often difficult to perform laparoscopically, which can lead to conversion to open surgery. Some surgeons perform more complex gynecologic surgery through open incisions for precisely this reason. da Vinci helps to overcome the limitations of laparoscopy by enabling the surgeon to visualize and dissect compromised anatomy and tissue planes, giving the gynecologic surgeon a better tool to perform a minimally invasive endoscopic surgery for the majority of their surgical candidates.

44. Frequently asked questions
How soon can I expect to be able to have sexual relations after surgery?
Q: How soon can I expect to be able to have sexual relations after surgery?
A: As with any surgery, it will take time for your body to heal and return to normal function. The extent and length of recovery depends on a number of factors including the type of surgery you had, your age, and on the level of functionality you had before surgery. That said, the general rule of thumb after hysterectomy is about six weeks.

45. Summary
da Vinci® Surgery is rapidly becoming the most effective, least invasive surgical option for patients
For more information on da Vinci® Surgery, visit
If you or someone you love has a gynecologic condition that may require surgery, contact my office to arrange a consultation, PHONE.
Or, to locate a da Vinci® GYN Surgeon in your area, visit the hospital locator on
In summary, da Vinci Surgery is rapidly becoming the most effective and least invasive surgical option for patients for many types of gynecologic procedures.
For more information on da Vinci Surgery, visit the website If you or someone you love has a gynecologic condition that may require surgery, feel free to call my office to arrange a consultation. Or, to locate a da Vinci surgeon in another area visit the surgeon locator on

46. Gynecologic Patient Education Seminar INSERT NAME HERE
Presented by
INSERT NAME HERE
Title
Practice address
Practice phone
da Vinci® … Changing the Experience of Gynecologic Surgery
I appreciate you spending some time with me today to learn more about da Vinci Surgery. I hope this program was helpful and stimulates you to think about different options that are available if your gynecologist recommends surgery. It is important to ask questions, be involved, and work with your doctor to find the surgical approach that is best for you.
This program presents the opinions of and techniques used by an independent surgeon and not those of Intuitive Surgical. Intuitive Surgical does not provide clinical training nor does it provide or evaluate surgical credentialing or train in surgical procedures or techniques. While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits.
© 2006 Intuitive Surgical. All rights reserved. Intuitive, Intuitive Surgical, da Vinci, da Vinci S, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their respective holders. PN Rev. A 9/06