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Robotic Applications in Gynecologic Oncology

Robotic Applications in Gynecologic Oncology

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  • 1. Robotic Surgery in Gynecologic Oncology and Advanced Benign Gynecology
    • Javier F. Magrina, MD
    • Professor of Gynecology
    • Mayo Clinic Scottsdale
    • Scottsdale, Arizona
    JFM101603
  • 2. Objectives
    • Robotic results
    • Ovarian cancer
    • Advanced endometriosis
  • 3. Robotic Surgery at Mayo Clinic Arizona 2003-2011
    • Hysterectomy Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007 Jul; 197(1):113
    • Adnexectomy**Magrina JF, Espada M, Munoz R, Noble BN, Kho RM. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol 2009 Sep; 114(3):581-4
    • Myomectomy**Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009 Dec; 201(6):566
    • Presacral neurectomy. Int J Med Robot. 2011 Oct 07
    • Appendectomy Akl MN, Magrina JF, Kho RM, Magtibay PM. Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot 2008 Sep; 4(3):210-3
  • 4. Robotic Surgery at Mayo Clinic Arizona 2003-2011
    • Cervical cancer**Magrina JF, Kho RM, Weaver AL, Montero RP, Magtibay PM. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008 Apr; 109(1):86-91
    • Ovarian cancer** Magrina JF, Zanagnolo V, Noble BN, Kho RM, Magtibay P. Robotic approach for ovarian cancer: Perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecol Oncol. 2011 Apr; 121(1):100-5
    • Endometrial cancer**Magrina JF, Zanagnolo V, Giles D, Kho RM, Noble B, Magtibay PM. Robotic surgery for endometrial cancer: comparison with laparoscopy, vaginal/laparoscopy, laparotomy. Eur J Gynaecol Oncol. 2011; 32(5):476-80
  • 5. Robotic Surgery at Mayo Clinic Arizona 2003-2011
    • Robotic transperitoneal aortic lymphadenectomy Int J Gynecol Cancer. 2010 Jan; 20(1):184-7
    • Robotic extraperitoneal aortic lymphadenectomy Gynecol Oncol. 2009 Apr; 113(1):32-5
    • Robotic radical hysterectomy: Technical aspects. Gynecol Oncol. 2009 Apr; 113(1):28-31
    • Robotic radical parametrectomy Acta Obstet Gynecol Scand. 2010 Aug; 89(8):1108-10
    • Robotic transperitoneal infrarenal aortic lymphadenectomy for gynecologic malignancy: a left lateral approach. J Laparoendosc Adv Surg Tech A. 2011 Oct; 21(8):733-6
  • 6. Robotic Surgery at Mayo Clinic Arizona 2003-2011
    • Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol. 2009 Apr; 113(1):32-5
    • Robotic nerve-sparing radical hysterectomy: feasibility and technique. Gynecol Oncol. 2011 Jun 1; 121(3):605-9
    • Robotic nerve-sparing radical parametrectomy. Int J Med Robotics Computer-assisted Surg 2012
  • 7. Robotics vs. Laparoscopy PRT Total Hysterectomy
    • Laparoscopy Robotics p
    • n=36 n=39
    • Uterus, gm 158.3 157.3 NS
    • OR, min 160.5 130.3 NS
    • EBL, ml 73.3 73.8 NS
    • LOS, hr 24.3 21.2 NS
  • 8. Robotics vs. Laparoscopy Hysterectomy
    • Complications, %
    • Robotics Laparoscopy p
    • Intraop 0 0 NS
    • Postop 5.1 0 NS
  • 9. Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass
    • Robotic Laparoscopy p
    • n=85 n=91
    • OR, min 83 71 0.01
    • EBL, ml 39 41 NS
    • Hospital, >2 d, % 0 3 NS
    • Obstet Gynecol 2009, 114:581-4
  • 10. Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass
    • Complications,%
    • Robotic Laparoscopy P
    • Intraop 1 2 NS
    • Postop ≤ 6 wk 12 11 NS
    • Obstet Gynecol 2009, 114:581-4
  • 11. Robotic vs. Laparoscopic Myomectomy Mayo Clinic Arizona
    • Robotic Laparoscopy p
    • OR, min 141 166 NS
    • EBL, ml 100 250 0.02
    • Hospital > 2d,% 5 9 NS
    • Am J Obstet Gynecol 2009, 201:566
  • 12. Robotic vs. Laparoscopic Myomectomy Mayo Clinic Arizona
    • Complications,%
    • Robotic Laparoscopy p
    • n=40 n=41
    • Intraop 2 15 NS
    • Postop 12 10 NS
    • Conversion 0 5 NS
    • Readmissions 5 3 NS
    • Am J Obstet Gynecol 2009, 201:566
  • 13. Robotics vs. Laparoscopy for Endometriosis
    • Robotics Laparoscopy p
    • OR time, min 159 179 NS
    • EBL, ml l 88 103 NS
    • Hospital, d 1 1.1 NS
  • 14. Robotics vs. Laparoscopy for Endometriosis
    • Robotics Laparoscopy p
    • Complications
    • Intraop 0.1 0 NS
    • Postop 6 8 NS
    • Conversion 2 0 NS
  • 15. Mayo Clinic Arizona
    • Robotics vs. Laparoscopy
    • No major differences in perioperative results
  • 16. Conclusion
    • Robotics is preferable to laparoscopy for:
    • Areas of difficult access
    • Extensive suturing
    • Complex dissection
    • Precision
    • Bleeding
    • Obesity
  • 17. Robotics for Ovarian Cancer
    • Primary debulking
    • Interval debulking
    • Recurrent cancer
    • Disease localized to pelvis and one or two other areas
  • 18. Patient Selection for Robotics in Ovarian Cancer
    • Primary tumor excision (Hyst + BSO + omentectomy + lymphadenectomy) + 1 or 2 major procedures
    • Modified posterior pelvic exenteration
    • Diaphragm resection
    • Small bowel resection
    • Other
  • 19. Types of Debulking
    • Type
    • I Hyst + staging + 1 major
    • procedure
    • II Hyst + staging + 2 major
    • procedures
    • III Hyst + staging + 3 or more
    • major procedures
  • 20. Type I Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparoscopy Laparotomy p
    • n=15 n=20 n=41
    • OR, min 282 249 230 NS
    • EBL, ml 152 222 1005 <0.001
    • Hosp, d 3 3 7 <0.001
    • Gynecol Oncol ; 121:100, 2011
  • 21. Type I Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparoscopy Laparotomy p
    • Complications,%
    • Intraop 20 10 10 NS
    • Postop 20 5 17 NS
  • 22. Type II Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparoscopy Laparotomy p
    • n=8 n=7 n=46
    • OR,min 345 267 259 0.02
    • EBL,ml 191 389 1261 <0.001
    • Hosp,d 5 5 11 <0.001
    • Gynecol Oncol ; 121:100, 2011
  • 23. Type II Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparoscopy Laparotomy p
    • Complications,%
    • Intraop 0 14 11 NS
    • Postop 25 0 54 0.01
  • 24. Type III Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparotomy
    • n=2 n=32
    • OR, min 443 305
    • EBL, ml 150 1775
    • Hosp, d 11 10
    • Gynecol Oncol ; 121:100, 2011
  • 25. Type III Debulking in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparotomy
    • Complications,%
    • Intraop 0 22
    • Postop 100 56
  • 26. Survival in Ovarian Cancer Mayo Clinic Arizona
    • Robotics Laparoscopy Laparotomy p
    • n=25 n=27 n=119
    • OS 3-yr,% 67 76 66 NS
    • OS vs. debulking
    • Complete 71 78 82 NS
    • Incomplete 50 50 45 NS
    • Gynecol Oncol ; 121:100, 2011
  • 27. Robotic Disadvantages for Ovarian Cancer
    • OR table rotation
    • Additional trocars
    • Increased OR time with increased number of procedures
    • Incision for anastomosis or removal of large specimens
  • 28. Turning OR Table 180
  • 29. Head Docking
  • 30. Head Docking
  • 31. R Upper Docking
  • 32. R Upper Docking
  • 33. assistant assistant Pubis camera Camera umbilicus assistant
  • 34.  
  • 35.  
  • 36. Infrahepatic and Anterior Diaphragm Right ribs Assistant Assistant 2 nd assistant
  • 37. Posterior Diaphragm xyphoid
  • 38. Need for Incision
  • 39. Neoadjuvant Chemotherapy
    • Increases % MIS for debulking
  • 40. Sigmoid and Left Ovary
  • 41. Infracolic Omentum Before After
  • 42. Omentum Before After
  • 43. Stomach Before After
  • 44. Right Diaphragm Before After
  • 45. Splenic Omentum Before After
  • 46. Pelvis Before After
  • 47. Right Pelvis Before After
  • 48. Ascending Colon Before After
  • 49. Hepatic Omentum Before After
  • 50. Right Diaphragm and Liver Before After
  • 51. Liver After
  • 52. Left Diaphragm and Liver After After
  • 53. Robotic Excision Liver Metastasis
  • 54. Excision Diaphragm Peritoneum
  • 55.  
  • 56. Robotic Full-thickness Diaphragm Resection
  • 57. Robotic Excision Diaphragm Endometriosis
  • 58. Robotic Resection L Diaphragm Recurrence
  • 59. Infracolonic Omentectomy
  • 60.
    • Thank you