Impact of Robotic Surgery in Minimally Invasive Management of Oncofertility Patients

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1 Impact of Robotic Surgery in Minimally Invasive Management of Oncofertility Patients Farr R. Nezhat, MD, FACOG Professor of Obstetrics and Gynecology Director, Gynecologic Robotic and Minimally Invasive Surgery Fellowship Division of Gynecologic Oncology Department of Obstetrics and Gynecology St. Luke's-Roosevelt Hospital Center Mt. Sinai School of Medicine

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3 Objectives Historical back ground Overview of Robotic Surgery and Indications Surgical Techniques and potential Complications Future Technology

4 18 th Century First successful laparotomy performed longitudinally Ephraim McDowell

5 President Polk s Surgery When Polk was a teenager, he suffered from urolithiasis McDowell performed a urolithotomy with a gorget through his prostate and bladder, extracting the stones

6 19th Century First transverse laparotomy Johannes Pfannenstiel

7 ABDOMINAL WOUND DEHISCENCE AFTER C- SECTION (vertical vs. Pfannenstiel) No. Dehiscence Rate Vertical % Transverse % Mowat J, Bonnar J. Br Med J 1971; 2 (756):

8 20 th Century Laparoscopy Dr George Kelling Dr Raoul Palmer Dr Victor Gomel Dr Kurt Semm

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10 Beginning of Videosurgery Nezhat et al, Advanced Operative Laparoscopy Principle & Techniques McGraw Hill 1995

11 Advantages of Video Laparoscopy

12 Video Laparoscopy Advantages Improved cosmesis Quicker recovery time Less blood loss Shorter hospitalization Decreased need for analgesics Less adhesions Better results

13 Videolaparoscopy Introduced to Literature Nezhat C, Crowgey S, Garrison C. Surgical treatment of endometriosis via laser laparoscopy. Fertil Steril 1985 as an abstract 1986 as a publication;25(6): Even advanced (stage IV) endometriosis was treated by this technique.

14 First Total Laparoscopic Radical Hysterectomy with Lymphadenectomy was performed in June 1989 Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE

15 February 12, 1990

16 "Wherever in the body a cavity exists or cavity can be created, operative laparoscopy is indicated and probably preferable. The limiting factors are: skill and experience of the surgeon and the availability of proper instrumentation Camran Nezhat Journal of Gynecologic Surgery 1992 Fertility and Sterility 1986

17 Looking to the Future One of the first cameras used for video-laparoscopic surgery by Camran Nezhat, MD

18 Looking to the Future

19 Advantages of VideoEndoscopy Smaller incisions Shorter hospital stay Lower blood loss Less need for analgesics Better Visualization More rapid recovery Less Adhesion formation Shorter interval to Chemo and Radiationtherapy (if indicated)

20 Advantages of VideoEndoscopy Smaller incisions Shorter hospital stay Lower blood loss Less need for analgesics Better Visualization More rapid recovery Less Adhesion formation Shorter interval to Chemo and Radiationtherapy (if indicated)

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22 Ovarian Cancer Right Diaphragm Metastases

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25 Disadvantages of VideoLaparoscopy Long learning curve Two-dimensional field, limited depth perception and view Limited dexterity Counterintuitive motion Ergonomic difficulty 8-12% of surgeons report pain or numbness with laparoscopy

26 Improvements Instrumentation Blood vessels sealing devices with cutting capabilities Staplers Articulating tips 3-dimensional imaging Robotics Simulators

27 Robotics Computer enhanced telesurgery

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29 Robot: The Console The console has 3 dimensional viewing Intuitive motions Improved ergonomics Pedals control camera and electrosurgical function Motion scaling: reducing tremor

30 Tremor Filtration Laparoscopic Robotic

31 Dexterity and the Robot 7 degrees of motion compared with the traditional 4 with laparoscopy

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35 Robot in General Gynecology Nezhat, C et al. feasability study: 15 patients undergoing gynecologic surgeries using both laparoscopy and roboticassisted laparoscopic surgery Assembly time to switch from laparoscopy to robotic assisted surgery was 18.9 minutes, disassembly time was 2.1 minutes Conclusion: Advantages: 3 dimensional field, greater surgical precision, decreased fatigue and tension tremor, and added wrist motion for improved dexterity, cases of suturing Disadvantages: cost, added operating time for assembly and disassembly Nezhat,C et al ASRM 2005

36 Conclusions Robotic procedures are useful teaching tools and facilitators for transition from open abdominal to laparoscopic approach Use of the robot may bridge the gap between laparotomy and laparoscopy, which is limited by a long learning curve

37 Indications Myomectomy Total Hysterectomy Sacrocolpopexy Sever Endometriosis and Adhesions Tubal Reanastomosis Difficult Adenaxal Masses

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39 Indications Staging for Endometrial Cancer(Hysterectomy and Pelvic and Para-Aortic Lympadenectomy) Radical Hysterectomy Radical Trachelectomy Staging for Ovarian cancer Limited Debulking primary and recurrent Ovarian cancer

40 First Total Laparoscopic Radical Hysterectomy with Lymphadenectomy was performed in June 1989 Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE

41 Patient: 39 yo, Para 3 Case Report Diagnosis:. Stage IA2 SCC CX Procedure: Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection Instruments Operative time EBL Bipolar Cautery CO 2 laser 7 hours 30 cc Total paraaortic LNs 5 Total pelvic LNs 14 Hospital stay 2 days

42 Evolution of Total Laparoscopic Radical Hysterectomy Over 900 cases have been reported to date No prospective randomized trials available Retrospective analysis shows comparable to laparotomy progression free and overall survival in cancer patients

43 Robotic Radical Hysterectomy: Review Comparisons of Robotic Radical Hysterectomies Author N OR Time LOS Nodes EBL Recurrence (mins) (days) (Avg) (ml) (mos) Sert and Abeler % (14) Nezhat et al % (24) Kim et al % (9) Magrina et al % (31) Boggess et al NR Fanning et al % (24) Ko et al NR Persson et al. * NR % Estape et al % Lowe et al NR Maggioni et al % Total

44 Robotic Radical Hysterectomy

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46 Robotic Assisted Gynecological Surgery: Technical aspects Semi-lithotomy position Four trocars are used: 12-mm transumbilical optical trocar two 8-mm robotic trocars, 10-mm assistant trocar. Trendelenburg to a maximum of 30 degrees Uterine manipulator

47 Port Placement

48 Results Operating Time Blood Lost Hospital Stay Complications Recurrence Quality of life( Recovery time and Post operative pain) Cost

49 Considerations Tissue margin and radicality Complications Recurrence Survival Quality of life Cost

50 New technologies for reproductive medicine:laparoscopy,endoscopy,r obotic surgery and gynecology. A review of the literature J.E. CHO,A Shamshirsaz,C.Nezhat,C.Nezhat,F.Nezhat Minerva gynecologica,2010

51 Robotic Radical Hysterectomy Versus Total laparoscopic Radical Hysterectomy With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer Nezhat F et al,2008 To compare intraoperative,pathologic and postoperative outcomes of robotic radical hysterectomy (RRH) to total laparoscopic radical hysterectomy (TLRH) in patients with early stage cervical carcinoma Farr R. Nezhat,, M. Shoma Datta, Connie Liu, Linus Chuang,,Konstantin Zakashansky,. Robotic Radical Hysterectomy Versus total laparoscopic Radical Hysterectomy With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer. JSLS (2008)12:

52 Methods Prospective analyses Cases of TLRH or RRH with pelvic lymphadenectomy performed for treatment of early cervical cancer between 2000 and TLRH + pelvic lymphadenectomy for cervical cancer No differences between groups for age, tumor histology, stage, lymphovascular space involvement or nodal status 13 RRH and pelvic lymphadenectomy for cervical cancer

53 Robotic Radical Hysterectomy Versus Radical Hysterectomy With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer Nezhat F et al,2008 No significant difference in major intra and post operative complications All patients in both groups are alive and free of disease at the time of last follow up(mean time 12 months for RRH and 29 months for TLRH)

54 Robotic Radical Hysterectomy Versus Radical Hysterectomy With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer Nezhat F et al,2008 Conclusion. With respect to operative time, blood loss, hospital stay, and oncological outcome RRH=TLRH

55 Robotic Radical Hysterectomy Versus Radical Hysterectomy With Pelvic Lymphadenectomy for Treatment of Early Cervical Cancer Nezhat F et al,2008 Advantages of Robotic approach: Better magnification Dexterity Flexibility Significant reduction in surgeon s fatigue

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57 152 patients meeting criteria of inclusion 110 patients consented Exclusion of: - 9 patients converted to minilaparotomy - 10 patients who withdrew from the study Total enrolled N =91 Laparoscopic n=52 Robotic n=39 2-week follow-up n=51 6-week follow-up n=43 2-week follow-up n=37 6-week follow-up n=25 Figure 1: Flow of enrolled subjects through the study

58 Laparoscopic n=52 Robotic n=39 Age, years, mean (SD) (13.58) (12.31).019 BMI, Kg/m2, mean (SD) (6.07) (8.87) <.001 Race, n (%) Caucasian AA Hispanic Asian Indian Prior abdomino-pelvic surgeries, n (%) Table 1: Demographic Data 27 (52%) 9 (17%) 11 (21%) 4 (8%) 1 (2%) 14 (36%) 14 (36%) 9 (23%) 2 (5%) 0 (0%) P (79%) 26 (67%).192 Psychiatric history, n (%) 13 (25%) 8 (21%).662 Preoperative narcotic use, n (%) 3 (6%) 2 (5%) Drug use, n (%) 2 (4%) 1 (3%) Data shown as mean (SD), median (range)or n (%)

59 Laparoscopy n= 52 Robotic n= 39 Operating time, min, mean (SD) (75.84) (83.75) <.001 Blood loss, ml, mean (SD) (81.56) (384.61).065 Complex procedures, n (%) 28 (54%) 23 (59%).626 Concurrent hysterectomy, n (%) 22 (42%) 25 (64%).040 Cumulative incision length, cm, mean (SD) Table 2: Surgical Data 2.40 (0.76) 3.96 (0.54) <.001 IOP complications, n (%)¹ 0 (0%) 3 (8%).075 P Postoperative complications, n (%) Minor² Major³ Length of hospital stay in days, median [range] 8 (15%) 3 (6%) 6 (15%) 4 (10%) [1,5] 3 [1, 26] <.001 Data shown as mean (SD), median [range] or n (%)

60 Figure 2: Postoperative mean NRS pain scores over time There is a trend for a higher level of postoperative pain in robotic patients compared to laparoscopy patients, but the difference is not statistically significant p= Error bars indicate standard error

61 Postoperative Narcotic Requirements Figure 3: Postoperative narcotic doses in MSE There is no significant difference over time between laparoscopic and robotic procedures, p=0.393

62 Table 3: Pain and Recovery Time Outcomes Laparoscopi c n= 52 Robotic n= 39 Peak pain scores, mean (SD) 6.75 (2.37) 7.46 (1.64).480 P Days to being off narcotics, median [range] Days to return to baseline activities, median [range] 4 [0,15] 4.5 [0, 49] [3, 42] 21 [3, 56].021 Data shown as mean (SD) or n (%) or median [range]

63 Robotic approach confers the same amount of post-operative pain over time and need for analgesia and sheds a doubt on the presumption that robotic surgery decreases postoperative pain when compared with laparoscopy. Robotically assisted laparoscopy has significantly longer operating time, hospital stay, and return to baseline activities compared with conventional. In the hands of an experience laparoscopic surgeon, roboticallyassisted laparoscopy does not seem to offer any advantages to conventional laparoscopy in terms of postoperative pain and recovery. El Hachem et al, Obstet Gynecol 2013;121:547

64 Cost

65 da Vinci HD S Surgical System da Vinci Standard Surgical System da Vinci Si Surgical System April 2009: da Vinci Si System released (dual console) January 2006: da Vinci HD S System released April 2005:FDA Clears da Vinci System for Gynecologic Procedures July 2000: FDA Clears da Vinci System for Laparoscopic Surgery Robotic Timeline

66 Intuitive Surgical Simulator 2 nd Console

67 davinci Surgical System U.S. Installed Base Alaska Hawaii Puerto Rico

68 Complications

69 Loss of Heptic

70 Tunnel View

71 Robotic-Assisted Laparoscopic Transection and Repair of an Obturator Nerve During Pelvic Lymphadenectomy for Endometrial Cancer F Nezhat et al,2012 Case report 76-year-old woman with stage IA endometrial adenocarcinoma sustained a left obturator nerve transection during pelvic lymphadenectomy, was recognized immediately Reapproximated left obturator nerve with 4.0 polyglactin suture Robotic-assisted laparoscopic repair was performed successfully No residual neuropathy 6 months postoperatively Nezhat F, Chang JS,Acholonu U,Vetere P.Robotic-Assisted Laparoscopic Transection nd Repair of an Obturator Nerve During Pelvic Lymphadenectomy for Endometrial Cancer. Obstet Gynecol 2012;119:462 4

72 Electrocautery- Associated Injury During Robotic-Assisted Surgery

73 Electrocautery-AssociatedVascular Injury During Robotic- Assisted Surgery Cormier B,Nezhat F,Sternchos J,Sonada Y,Leito M, vascular injuries during robotic pelvic lymphadenectomy reported in 2012 Case1: Injury to external iliac vein while using cutting mode with scissors,by a spark through the intact protective sheath of the monopolar scissors onto an adjacent metallic suction irrigator that was retracting the external iliac vein;required laparotomy for repair Case 2: Injury to external iliac artery by accidental activation of monopolar coagulation scissor rather then bipolar forceps ;repaired robotically. Case 3: Injury to the right external iliac artery caused by a spark spreading through the scissors insulating plastic sheath while applying monopolar coagulation type current;repaired robotically In all cases the scissor insulating sheet was intact All patient post op follow up was uneventfull Cormier B,Nezhat F,Sternchos J,Sonada Y,Leito M. Electrocautery-AssociatedVascular Injury DuringRobotic-Assisted Surgery.Obst & gyn:12;2,2012

74 Risk factors increasing monopolar injury Defects in insulation Insulation sheet defect Direct coupling with another Instrument Probe activation at a distance from tissue ( open circuit ) Overheating of the active electrode tip (when covered with dried blood or debris) The use of coagulation-type current to achieve the same effect achievable with cutting current

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77 Future

78 Beginning of Videosurgery Nezhat et al, Advanced Operative Laparoscopy Principle & Techniques McGraw Hill 1995

79 Robotics Computer-Enhanced Telesurgery

80 Improvements Instrumentation Blood vessels sealing devices with cutting capabilities Staplers Articulating tips 3-dimensional imaging Robotics Simulators

81 Mimic Simulator

82 Mimic Simulator

83 The Future of Surgery Peoria Boston Mayo Boise Little Rock Frankfurt Hopkins Paris CCF Fresno Istanbul Tokyo New York San Francisco Barcelona

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85 6 th annual seminar on Minimally Invasive Gynecologic Surgery with hands-on workshop on laparoscopic suturing and knot-tying HIGHLIGHTS BEST Comprehensive Overview on Prevention and Management of Complications Save the Date DECEMBER Laparoscopic & Robotic Hysterectomy: Step-by-Step Enhance Performance and Achieve Proficiency in Suturing and Knot-Tying Techniques Improve Surgical Efficiency, Patient Outcomes and Satisfaction, Decrease Risks of Complications, and Cut Costs Safe n Simple: Create Bladder Flap, Remove Cervix, Repair Bladder, Bowel & Ureter Injury Advances in Gynecologic Surgery: Technology and Instruments in Robotic Surgery Open Forum Discussions with Experts: Tips & Tricks, Pearls & Pitfalls of Suturing Live Surgery Telecasts and Video Sessions da Vinci Robot Test Drive & Mimic Simulation Training General Chair: Scientific Program Co-Chairs: The Roosevelt Hotel New York, New York For more information, please visit: Farr R. Nezhat, MD Camran Nezhat, MD Ceana Nezhat, MD