Endometriosis Foundation of America
Endometriosis 2013 / Managing Endometriosis of the Bowel
Elizabeth Poyner, MD, PhD
Good morning everybody. I have a bad throat today so I was just going to once again reiterate what we just talked about in the last couple of lectures. Again, showing the robotic approach to endometriosis surgery, once again not saying that robotics is the only way to operate, it is one of the two sets available that makes for access to harder spaces and difficult areas sometimes, and also makes the access to suturing a little bit easier. Having done laparoscopic surgery for many, many years it is an additional tool that one can implement.
This is a video just once again showing a lot of areas of dissection, posterior cul-de-sac, right pelvic sidewall with endometriosis and once again showing how we need to isolate the ureter that we talked about. Then getting to the area where the ovary is attached to the pelvic sidewall and endometriosis over the ureter. The key today was to talk about - once this video is a little bit over I am going to go back and talk about just some of the key steps.
In talking about the pros and cons of the robotic approach robotics allows for 360° movements, 7° of movement and wristed type of movement. It is also not a 2-D approach it is a 3-D approach so it helps in surgery when you are dealing with difficult anatomy. But there are tons of good laparoscopic surgeons here and I have operated laparoscopically for several years and it is very, very possible to do the same things laparoscopically.
What are some of the complications and features that are unique to robotics? Bleeding, abscess, port side hernia, vaginal cuff dehiscence, these are some of the things that you will see anyway. But one of the complications that is very unique to robotics is that the surgeon is remote from the patient. And I have to tell you, even now after doing robotic surgery for several years; it is a sense of disconnection. It is a feeling of a loss in the sense that you are away from the patient and what if something happens and you are not right at the patient's bedside? You have to rely on a very good bedside team. The trocars are fixed and rigid, they are 8 mm trocars. I do think that laparoscopically the incisions are 5 mm incisions so robotic incisions are a little bit larger. You have additional ports that you may need to, at times, close the fascial openings; again, as Dr. Kho just now talked about, relying on some visual cues. The more you do robotics the more you become better and able to rely on those visual haptics and cues that give you the idea that whether this tissue is good tissue versus the tissue is inflamed, and particularly in the cases of endometriosis, whether this is an endometriotic lesion. The biggest thing with robotics is that you have to understand and be prepared for is not to move the instruments outside of the visual field, particularly if you are using a fourth arm. Using the fourth arm and moving the fourth arm without being in the visual field can be very dangerous. The last thing with robotics that it is very hard when I used to do mostly laparoscopic surgery is with obese patients. Sometimes you can go back and forth with Trendelenburg. If the anesthesiologist tells you that we are having a little trouble you can kind of bring them out of Trendelenburg for a little bit and then go back into Trendelenburg. The limitation with robotics is once you are...and you are in a certain amount of Trendelenburg you are stuck there, you are...there. You want to do or find out our maximal or minimal place where you want to have a patient. Last, but not the least, the most important thing is to have an anti-skid material to prevent sliding, particularly when you are in Trendelenburg because your patient can move and you are going to be in trouble, particularly if you are using a mini plater and your mini plater is now hitting the table and you are unable to move the instrument around.
Things to consider at the end are optimizing placement of robotic instruments. I am still somebody who does not use a fourth arm very regularly. I like to keep an accessory laparoscopic port as the fourth incision because I feel like I have an easy, quick access to the patient just in case something should happen. We can move an instrument and quickly put a grasper or suction or whatever it may be, maintaining pneumoperitoneum, stabilizing the camera trocar, not moving instruments that you do not see. Always bringing your last instruments into view by having the bedside assistant help you bring that into view. I cannot emphasize the fourth arm's view and use because I have seen some bad things happen there. Do not use instruments to retract vessels or retract major structures. If you are using the fourth arm dock the fourth arm first.
As in anything, as in laparoscopy, with robotics also, there is a learning curve and be prepared for that. You are not going to be an excellent surgeon on the very first case, it does take time. Slow, deliberate movements are important. Excess retraction and tissue can tear the small vessels, and as we have heard throughout the morning that micro-surgery on minimal access surgery does not mean that just because you have minimal access you can be rough with the tissues. You can still get adhesions. At the end of the surgery, for any surgery, it is important what the surgical skills are, what the surgeon's skills are and how you have left the pelvis at the end of the surgery.
I believe in, and I have learned from Dr. C.Y. Liu, I was his fellow 12 years ago, that a clean, hemostatic pelvis with minimal tissue damage is the key to adhesion prevention. Always keep those microsurgical techniques and principles in mind.
Whenever you are closing anything always remember that you are doing it under extreme magnification. Using very small tissue bites I think has been one of the reasons why there has been increased risk of even post-surgical vaginal cuff dehiscence that has been noticed with robotic surgery. It is because it is so magnified that one thinks that you have to take a small bite but really you have to take a good purchase of the tissue in order to close anything or suture. Be aware of that - you are looking at tissue under magnification. Whenever you have any technical issues and your mobility is limited check your drapes, check collision with the arms and you may then advance your trocar.
As you can see right here the rectum is attached to the very distal posterior cul-de-sac, once again, using precise and minimally invasive technique of excising. It looks like a small lesion from above but then always having a rectal probe in place in identifying the entire region, dissecting out the ureter. As you can see the lesions can look very small and that is one of the characteristics of endometriosis, the lesions can come together and you just see the tip of the iceberg. When you starting excising you see how deep it goes and that you may have to open up the rectosigmoid space there. Again, visual haptics and looking at the tissue more closely and knowing, beginning to understand, and know that that tissue is abnormal versus tissue that is left behind. A small amount of bleeding as you can see that I am using monopolar scissors but in most of the places it is a cold cut. Whenever you feel you are close to vital organs and vital tissue you want to see some bleeding tissue, that is a good sign, that is good, healthy tissue. The entire left pelvic sidewall with the uterosacral ligament had to be completely excised. As you can see those micro or small endometriomas that are throughout the tissue there along the sidewall that need to be - were done. As you can see at the end it is a major dissection area that - and feel for every little area, and feel for good tissue versus bad endometriotic tissue.
With that, thank you very much for giving me the opportunity.