1. Applications of Robotic Surgery- Gynecology Tommaso Falcone, M.D. Professor & Chair Department of Obstetrics & Gynecology

2. Financial Disclosure I receive no grants/ honoraria / or other financial support from any robotics company

3. LEARNING OBJECTIVES At the conclusion of this presentation, the participant should be able to: Describe the current robotic system that is commercially available and describe the safe strategy for deployment Review the limitations and advantages of using a robot for a surgical procedure Assess the current clinical data in gynecology for the use of the robot Predict potential future applications of robotics when newer prototypes become available

4. Robots Active robots (autonomous) System completes a preprogrammed task with minimal human supervision Passive robots Computer-assisted surgery

8. Navigational devices Determine the surgical path Complex technology Robust and reliable

9. Target Guidance

10. Computer-assisted surgical planning Contrast-enhanced CT or MRI data to reconstruct a model (Fusion technology) Ex. veins and arteries around a tumor

12. Robot: Surgical Assistant Laparoscope holder Automated Endoscopic System for Optimal Positioning (AESOP) 1994 Voice activation

13. Robotics & Medicine-Cleveland Clinic Neurosurgery (Navigational) General Surgery (Morbid Obesity surgery) NOT USED AT ALL Urology ( Radical Prostatectomy) Cardiac surgery ( Coronary bypass surgery & mitral valve surgery) Gynecology

14. Robot hardware Surgical Cart Three-Four robotic arms: one holds the laparoscope; three robotic arms are instrument holders or tissue retractors Console for the surgeon Two handles that controls the robot arms

16. Robot advantages 3 D view of the operative field Manipulation of the robotic handles is transmitted to a computer that filters, scales and then translates the surgeon ’ s movements to the robotic arms

17. Advantages of robotic assistance Increases dexterity Scales surgeon ’ s movements Filters natural tremor

18. Advantages of robotic assistance Movement can be scaled Example: scaling ratio of 10:1 means that for every 1 cm the surgeon moves the handles at the console, the robotic instruments move 1 mm

19. 2:1 to 5:1 Motion scaling: 2:1 to 5:1 5 cm 1 cm

20. EndoWrist TM Instrumentation Modeled after the human wrist. Full range of motion High-strength cable system Transpose fingers to instrument tips

21. 7 Degrees of freedom instruments

22. Robotics & Gynecology Laparoscopic microsuturing Major challenge Principle is different from conventional microsurgery Optically magnified tremor Long operating times results in fatigue for the surgeon & laparoscope holder

23. First gynecologic procedure: Tubal Reversal using Robotic (Zeus) Assistance 10 mm laparoscope Three 5 mm ports Two ends were prepared conventionally 6-0 polygalactin for the mesosalpinx Two layered closure with 8-0 polygalactin 7 stitches per side

25. Results: Fertility & Sterility 2000;73:1040-2 Safe, no injuries occurred EBL 70 mL Patency in all tubes anastomosed HSG 6 weeks post-op 17/19 tubes still patent 5/10 patients after follow-up time of 12 months

27. The da Vinci™ Surgical System

29. Patient side surgical cart

31. da Vinci 4th Arm-previous model

43. Limitations Requires training Most important learning step is port placement Especially if using the fourth arm Angle of access may be difficult Need to adjust the port placement If convert to traditional laparoscopy ports may be inappropriate

44. Da Vinci: Limitations Hard to access the abdomen for accessory ports Assistants have difficulty moving around Disengage the system if changing patient position

46. Laparoscopic Tubal Anastomosis without robotic assistance Goldberg & Falcone Hum Reprod (2003;) No robot: Procedure time: 190 minutes –LOS:222 minutes Zeus robot: Procedure time:284 minutes –LOS:198 minutes Da Vinci ( Degueldre et al Fertil Steril 2000): Procedure time:181 minutes

47. Comparative Trial Compared Robot assisted laparoscopic Tubal reversal surgery with outpatient “ mini- laparotomy ” using traditional microsurgery techniques ( published Obstetrics & Gynecology 2007 ) No difference in pregnancy rates or ectopic pregnancy rates Main differences: OR time longer with robot Return to work time shorter with the robot

48. Robotic (N=26) Laparotomy (N=41) P Value EBL <100cc19 (73%)31 (80%)0.48 Surgical time (min.)226 ± 45186 ± 490.001 Anesthesia time (min.)279 ± 42209 ± 51<0.001 Hospitalization (min.)274 ± 412381 ± 4780.14 Costs (difference in median values) $1446 greater for Robotic 95% CI: ($1112, $1812) <0.001 Weeks to go back to work1.5 ± 1.32.5 ± 1.50.013

49. Myomectomy Closure of the uterine defect critical to prevent rupture during labor Advincula et al ( University of Michigan) JAAGL 2004-35 cases The mean weight of leiomyomata removed was 223 grams; mean number 1.6; mean diameter 7.9 cm The mean operative time was 230+ 83 minutes.

50. Myomectomy Conversion to laparotomy-3 Pneumonia-1 Port site infection-1 Cardiogenic shock (from vasopressin)-1 Length of stay-median=1 day (0-5 days)

51. Robot versus Laparotomy Advincula et al 2007 N=58 (29 in each group) 2 conversions Uterine weight: robot (227+247g) and laparotomy (223+228 g ) OR time: Robot (231+85 minutes) and laparotomy (154+43 minutes) LOS: robot (1.5 days) and laparotomy (3.6 days)

52. Technical considerations Uterine manipulator 8-10 cm between the endoscope and the top of the elevated uterus Accurate myoma “ mapping ” No tactile feedback Keep your instruments in view You may have 2 energy sources at one time Use your wrist often

54. 15 ° 10 cm

55. 45° 8-10 cm

56. Hysterectomy video

61. Robot-assisted laparoscopic hysterectomy 7 case series reported 2002-2007 Total-94 patients in 6 case series & 91 cases in 1 ( Mayo clinic-Arizona) Age-median 38-55 BMI-26-28 Indications-Mostly non-malignant conditions (uterine weights-30-327 g)

62. Robot-assisted laparoscopic hysterectomy: Operative Time 1.270-600 minutes 2.148-277 minutes 3.170-368 minutes (Median=254 min) 4.43-315 minutes (Median=185 min) 5.170-432 min ( Median= 242 minutes ) 6.110-290 min (Median= 192 minutes )

63. Robot-assisted laparoscopic hysterectomy Hospital stay- US study=1-2 days French study=8 days

64. Robot-assisted laparoscopic hysterectomy: Operative Time Mayo Clinic experience Uterine weight 135 g (67) 53 % menometrorrhagia or pelvic pain Surgery time 127 + 35 minutes

67. Ochsner Clinic Experience (Baton Rouge, Louisiana) AAGL-2007 Washington) abstract “ Robotic equivalence to laparoscopic skin to skin times was achieved after 75 cases ”

68. Robot-assisted laparoscopic hysterectomy: Complications Conversion to open surgery- 5 cases 12 operative/postoperative Hemorrhage-3 Vaginal cuff/pelvic hematoma-3 Cystotomy-1 Thermal bowel injury-1 Pneumonia/UTI/Venous phlebitis/lymph collection

69. Robot-assisted cancer procedures 2005-Reynolds et al JSLS 7 patients ( 4 endometrial/2 ovarian/1 tubal cancer) Mean OR time 257 minutes, median lymph node count 15/ EBL 50 mL/LOS 2 days Kim et al Gynecol Oncol 2007 10 patients-radical hyst 1A2-1B1 cervix Mean OR time 207 minutes

70. Robot-assisted cancer procedures Sert & Abeler Int J Med Robotics & Computer Assisted Surgery 2007 7 patients-robotic (Stage 1A & 1 B cases) 3 robotic & 2 conventional ports Mean console time 241 (160-445) minutes Docking time was 25 minutes 7 patients-laparoscopic Mean OR time 300 ( 225-375) minutes

71. Robot-assisted cancer procedures Boggess JF Am J Obstet Gynecol 2008 Robotic versus open radical hysterectomy Boggess JF Obstet Gynecol 2008 Robotic versus conventional laparoscopy for cervix cancer Boggess JF Obstetr Gynecol 2008 Robotic versus conventional laparoscopy for endometrial cancer

72. Sacrocolpopexy Suture of a mesh to the vagina and sacral promontory Multiple interrupted 1.0 Gore-Tex sutures were used to secure the mesh to the vagina and sacral promontory. The average operative time was 3 hours 42 minutes.

73. Ovarian Transposition: Molpus et al JSLS 2003

74. Ovarian Transplantation Autologous transplant to orthotopic site Small ovarian tissue pieces Sutured with 6-0 PDS to ovarian bed

75. Next phase in computer aided surgery Tactile & Force feedback (Science of Haptics) Automation of surgical Tasks

76. Autonomous knot tying ( Bauerschmitt et al Germany)