Wesley Harris, M. D.
da Vinci Gynecologic Surgery
da Vinci Gynecology
Surgical Approaches to
Gynecologic Conditions
Open (abdominal) surgery
Minimally invasive surgery (MIS)
 Vaginal surgery
 Conventional laparoscopic surgery
 da Vinci® Hysterectomy (robotic-assisted surgery)
da Vinci Gynecology
MIS – Laparoscopic Surgery
 Minimally invasive
surgery (MIS)
 Ability to operate
through small keyhole
incisions
 The camera and
instruments fit through
the keyhole incisions
 Better visualization than
open surgery
da Vinci Gynecology
ACOG Committee Opinion
Number 444 – November 2009
“Evidence demonstrates that, in general, vaginal
hysterectomy is associated with better outcomes and
fewer complications than laparoscopic and abdominal
hysterectomy. When it is not feasible to perform a
vaginal hysterectomy, the surgeon must choose
between laparoscopic hysterectomy, robot-assisted
hysterectomy or abdominal hysterectomy.”
da Vinci Gynecology
Things that make vaginal
hysterectomy easier:
1. Prior vaginal delivery
2. No adnexal pathology
3. Uterus <250 gm
da Vinci Gynecology
Things that make vaginal
hysterectomy more difficult:
1. Nulliparity
2. Prior cesarean section
3. Adnexal pathology
4. Severe pelvic adhesions
5. Morbid obesity
da Vinci Gynecology
Program
•
•
•
Gynecologic Conditions
da Vinci® Surgical System
da Vinci Gynecologic Surgery




da Vinci Hysterectomy for Early Stage Gynecologic Cancer
da Vinci Hysterectomy for Benign Conditions
da Vinci Myomectomy
da Vinci Sacrocolpopexy
da Vinci Gynecology
Gynecologic Conditions
•Pre-cancer
•Cancer
•Pelvic masses
•Abnormal bleeding
•Endometriosis
•Fibroids
•Pelvic floor disorders
Fallopian
Tube
Uterus
Ovary
Bladder
Pubic
Bone
Urethra
Rectum
Vagina
da Vinci Gynecology
Benefits of Minimally Invasive
Surgery (MIS)
•Reduced blood loss
•Fewer complications
•Shorter LOS
•Faster recovery
•Less scarring
•Less risk of infection
•Significantly less pain
•Improved cosmesis
Circa. 1991
da Vinci Gynecology
Drawbacks with Conventional
Laparoscopic Surgery
•
Surgeon operates from a 2D image
•
Straight, rigid instruments (limited range
of motion)
•
Instrument tips controlled at a distance
•
Reduced dexterity, precision and control
•
Unsteady camera controlled by assistant
•
Dependent on assistant for surgical
support through an accessory port
•
Greater surgeon fatigue
•
Makes complex operations more difficult
da Vinci Gynecology
How to overcome these drawbacks?
 Improve visualization
 Improve instrument control
 Enhance dexterity for
technically challenging
aspects of the procedure
 Use superior ergonomics
da Vinci Gynecology
da Vinci® Hysterectomy for Benign
Gynecologic Conditions
da Vinci Gynecology
13
da Vinci Hysterectomy
 Dexterity for complex
dissections (e.g
endometriosis)
 Vaginal cuff suture closure
with ease
 Improved visualization and
access around the cervix for
a colpotomy
Video courtesy of Javier F. Magrina, M.D.
da Vinci Gynecology
Benefits of da Vinci
Hysterectomy
 Enables GYNs to treat complex pathology endoscopically
 Unsurpassed precision, dexterity and control offer potential for:
 More precise and efficient dissections
 Ureters, vesico-uterine reflection, colpotomy
 Quicker, easier vaginal cuff closure
 Greater ability to perform MIS on more patient types
 Compromised anatomy and tissue planes, e.g., due to
endometriosis and adhesive disease from prior pelvic surgeries
 Larger pathology
 Obese patients
da Vinci Gynecology
da Vinci® Sacrocolpopexy
da Vinci Gynecology
da Vinci Sacrocolpopexy
 Easier, quicker and more
precise suturing
 Complete control of the
camera and all three
operative arms
Double-click to view video
 A reproducible approach
Video courtesy of Anthony Visco, M.D.
da Vinci Gynecology
Benefits of
da Vinci Sacrocolpopexy
da Vinci Sacrocolpopexy is considered the gold
standard for vaginal vault prolapse
• <5% are performed with laparoscopy
• This procedure typically requires difficult dissections and
extensive suturing
da Vinci enables an endoscopic approach
for sacrocolpopexy
The unsurpassed visualization, depth perception,
dexterity and control offered by the da Vinci
System provide:
• Improved access to the pelvis compared to open and
conventional laparoscopic approaches
• Easier, more precise rectovaginal and presacral dissections
• Improved handling of suture and mesh for more accurate graft
placement and attachment
da Vinci Gynecology
da Vinci® Gynecology
Improving the Quality
of Life for Women
As with any surgery, these benefits cannot be guaranteed, as surgery is patient- and procedure-specific. 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 871180 Rev. A 6/08
da Vinci Gynecology
da Vinci Hysterectomy Minimizes TAH
and Conversion Rates
Data from Drs. Thomas Payne and Ralph Dauterive
Ochsner Clinic, Baton Rouge, LA
Retrospective Review of Hysterectomy: Pre-Robotic versusLastda
Vinci
25
Pre-robotic (n=100)
da Vinci (n=100)
Age (years)
43.5
43.2
BMI
28.8
28.8
Estimated blood loss (ml)
113
61
Hospital stay (days)
1.6
1.1
TAH rate
20%
4%
0%
Conversions (subset of TAH)
9%
4%
0%
Avg uterine weight of conversions
359.5
1387.5
TAH due to adhesions
8%
0%
Operative times (skin-to-skin)
92.4
119
da Vinci
78.7
Source: Oral presentation by Dr. Thomas Payne at AAGL 2007.
da Vinci Gynecology
Robotic
Surgery
Conventional
Laparoscopy
da Vinci Gynecology
Less Conversions for Robot as
compared to conventional
laparoscopy
Matthews
LH
RH
Payne
12%
57
cases
LH
9%
0%
70
cases
RH
4%
•Sarlos – review
Mixed Reports
da Vinci Gynecology
Complication Rates
Matthews
AH
LH
RH
VH
23%
7.0%
4.3%
11.1%
EQUAL
EQUAL
8.8%
8.4%
Sarlos
Landeen
14.0%
8.0%
da Vinci Gynecology
Complication Rates
•
Complication Rates for the minimally invasive
procedures are relatively equal
•
Minimally invasive procedures have a lower
complication rate than open procedures
da Vinci Gynecology
OR Time
AH
LH
RH
Pasic
169
193
Giep
90
90
Sarlos
83
109
213
192
118
117
Barnett
147
Landeen
84
VH
99
da Vinci Gynecology
OR Time
•
Operating times are fairly equal between laparoscopic
and robotic hysterectomy
•
Open laparotomy does lead to a decrease in OR time
compared to laparoscopic and robotic procedures
da Vinci Gynecology
Length of Stay
AH
VH
LH
RH
Matthews
3.34
1.8
1.7
1.6
Landeen
2.7
1.9
1.8
1.3
Pasic
1.4
1.4
Giep
1.2
1.0
Sarlos
3.9
3.3
Payne
1.6
1.0
da Vinci Gynecology
Length of Stay
•
Length of stay NOT significantly different among
minimally invasive procedures
•
Length of stay for all minimally invasive procedures is
significantly less than for open surgery
da Vinci Gynecology
Direct Cost
•
Equipment
•
•
Capital
Non Capital
•
Operative Time
•
Post Operative Time
da Vinci Gynecology
Sarlos
LH
RH
Personnel Costs
1824
2434
Material Costs
1128
3152
Total Costs
2952
5583
da Vinci Gynecology
Surgical Supplies
AH
VH
LH
RH
Landeen
156
283
890
1859
Barnett
198
1138
2210
da Vinci Gynecology
Total Cost – NO Depreciation
AH
LH
RH
Barnett
7009
6581
7478
Landeen
4025
4475
6129
da Vinci Gynecology
Societal Perspective Model
of Barnett
Conventional
Laparoscopic
10,128
Robotic
11,476
Laparotomy
12,847
da Vinci Gynecology