• 1. Preoperative Setup
  • A. Patient Positioning
  • B. Port Placement
  • C. Patient cart positioning and instrumentation
  • D. Procedures
  • E. Postoperative

1. Preoperative Setup

A. Patient Positioning

After general anesthesia, place the patient in low dorsal lithotomy position with arms padded and tucked at their sides. Both legs need to be lowered and thighs should be roughly parallel to the floor in order to avoid collisions with the robotic arms. Flex the knees to less than 60 degrees to prevent femoral nerve compression. Use shoulder braces and pads to avoid patient slippage during the Trendelenburg position.

(Figure 1) ?lithotomy position

B. Port Placement

In our institution, we use 3 robotic arms and 1 assistant port. Robot-assisted surgery using 3 arms was identified to be a feasible method in staging operation. (YW Jung, et al. J Surg Oncol. 2010 Feb 1;101(2):116-2)

- For simple hysterectomy, the 12-mm camera port is placed transumbilically, and for radical hysterectomy or staging operation, the 12-mm camera port is placed above the umbilicus depending on the size of the uterus. The camera port accommodates the dual optical endoscope.
- Two 8-mm lateral ports are mounted directly to the operating arms that are placed 2 to 3 cm medial and superior to the anterior superior iliac spine, with modification based on the size of the uterus.
- The assistant port is placed between the camera port and the left lower quadrant port in order to facilitate introduction of suture as well as instruments used for retraction, suction/irrigation and specimen removal.

a. Port placement for simple hysterectomy: 3 arms

da Vinci Endoscope Port, 12mm (Blue) : Place through the umbilicus after making a vertical intraumbilical incision
Right da Vinci Instrument Port, 8mm(Yellow) : Place on Patient's right side, 8-10 cm lateral and 1-2cm inferior to the endoscope port.
Left da Vinci Instrument Port, 8mm(Green) : Place on patient's left side, 10-12 cm lateral and 2-3cm inferior to the endoscope port.
Assistant Port, 12 mm (White) : Place 1-2cm superior to the endoscope port and the same distance from endoscope and left da Vinci port.

b. Port placement for staging operation: 3 arms

Place the patient in steep Trendelenburg once all ports are in place. Bring the surgical cart with 3 robotic arms between the patient’s legs. Dock the robotic arms by attaching each port to the assigned robotic arm with the exception of the assistant port. The bedside assistant is responsible for EndoWrist instrument exchanges and any accessory port activity.
Multifunctional EndoWrist instruments such as Maryland dissector, PK Dissecting Forceps (bipolar), Hot Shears (monopolar curved shears), Cobra Grasper, and Mega Needle Driver are available for efficient completion of robotic surgery with minimal instrument exchanges. Traditional surgical instrumentation such as DeBakey forceps, permanent cautery hook (monopolar) and curved scissors are also available.

C. Patient cart positioning and instrumentation

Place the patient in steep Trendelenburg once all ports are in place. Bring the surgical cart with 3 robotic arms between the patient’s legs. Dock the robotic arms by attaching each port to the assigned robotic arm with the exception of the assistant port. The bedside assistant is responsible for EndoWrist instrument exchanges and any accessory port activity. Multifunctional EndoWrist instruments such as Maryland dissector, PK Dissecting Forceps (bipolar), Hot Shears (monopolar curved shears), Cobra Grasper, and Mega Needle Driver are available for efficient completion of robotic surgery with minimal instrument exchanges. Traditional surgical instrumentation such as DeBakey forceps, permanent cautery hook (monopolar) and curved scissors are also available.

D. Procedures

a. Robot-assisted laparoscopic hysterectomy and bilateral salpingo-oophorectomy 

1. Identify the ureter and iliac vessels.
2. Create a window in the posterior leaf of the broad ligament and skeletonize the infundibulo-pelvic (IP) ligament.
3. Transect the IP ligament.
4. Transect the round ligament.
5. Incise the anterior and posterior leaves of the broad ligament inferiorly towards the colpotomizer ring to skeletonize the uterine vessels.
6. Developing the bladder flap.
  ? Push the colpotomizer against the cervix, to ensure proper location to create the bladder flap.
  ? Elevate the peritoneum, make horizontal incision , and push flap against colpotomizer towards vagina
7. Anterior colpotomy
  ? Push the colpotomizer against the vaginal fornices to stretch vagina.
  ? Make an incision along the cup rim to the anterior vaginal wall.
8. Transect the uterine vessels
  ? Push the colpotomizer against the fornix, which pushes the uterine vessels upward and away from ureters.
  ? Coagulate and transect the uterine vessels
  ? Extend dissection to the endopelvic fascia over the vaginal fornices
9. Transect uterosacral ligament.
10. Posterior colpotomy
  ? Make incision along the cup rim to the posterior vaginal wall
11. Removal of uterus
  ? Deflate the pneumo-occluder
  ? Attach a tenaculum to the cervix
  ? Remove uterus vaginally
12. Closure of vagina
  ? Reinsert the pneumo-occluder into the vagina and inflate it.
  ? A surgical glove containing sterile water can be used for vaginal occluder.
  ? Use a 30 cm long 0 vicryl suture with a CT-1 needle
  ? The vaginal cuff is closed using a continuous running or interrupted suture from the left side to the right side.
  ? The assistant should grasp the suture after each suture throw to maintain tension
  ? Tie off the running suture with a surgeon’s knot after the last bite to complete the closure
  ? The assistant should help tie the suture by grasping one end.

 

b. Robot-assisted laparoscopic pelvic lymphadenectomy 

1. Open the peritoneum along the external iliac artery.
2. The pararectal and paravesical spaces should be developed. Dissect lymph nodes along the external iliac artery while preserving the genitofemoral nerve.
3. Remove pelvic nodes from the bifurcation of the common iliac artery to the deep circumflex iliac vein.
4. After further developing the pararectal space and the obturator fossa, dissect the internal iliac and obturator lymph nodes. The obturator space may be entered either medially or laterally to the external iliac vessels. The obturator nerve should be identified before dissecting the obturator lymph nodes.
5. Dissected lymph nodes are removed immediately by the assistant or placed in the endopouch bag.
6. The lateral extent of dissection is the psoas muscle, and the distal extent is the deep circumflex iliac vein. The superior vesical artery is the medial boundary and the obturator nerve is the lower boundary.

 

c. Robot-assisted laparoscopic paraaortic lymphadectomy 

1. Incise the peritoneum over the right common iliac artery just proximal to the right ureter.
2. Extend the incision superiorly along the aorta up to the inferior duodenal fold. The assistant can grasp the cut edge of the peritoneum to retract and aid in exposure.
3. After blunt dissection of the lymphatic bundles, identify the right ureter and the psoas muscle. The ureter can be retracted anterolaterally by the assistant.
4. Elevate the lymphatic bundle on the ventral surface of the vena cava, and carefully dissect the lymphatic tissues from the right common iliac artery to the right paraaortic area.
5. Dissect and pull the right common iliac lymphatic bundles caudally by electrocautery.
6. Incise the preaortic lymphatic tissue by sharply creating the adventitial plane of the aorta.
7. Dissect the precaval lymphatic tissue along the aorta and the vena cava. Watch for the fellow’s vein arising from the vena cava.
8. Dissect the right paraaortic lymph nodes along the vena cava. The assistant can laterally place the right ureter at this time.
9. Dissect the presacral lymph node on the sacral promontory from the right side to the left. Take caution when dissecting near the common iliac vein or the middle sacral vessels.
10. Isolate the inferior mesenteric artery which originates from the anterior surface of the aorta, three to four centimeters above the aortic bifurcation. The inferior mesenteric artery is usually preserved.
11. After dissecting the left paraaortic lymph nodes in a similar method, the upper paraaortic lymph nodes are dissected as superiorly as possible.
12. Desiccate and transect the proximal end of the paraaortic node bundle below the left renal vein.
13. Beware of the left ureter and vertebral vessels coming off the posterior surface of the aorta.
14. Watch for the right ovarian vessel when dissecting the lymphatic tissue lying on the upper vena cava.

 

E. Postoperative

- The fascia of the 12-mm camera port is repaired with 1-0 Vicryl to prevent incisional hernia.
- Adhesive skin closure tapes such as Steri-strips™ can be applied to the rest of the skin incisions.