Date: Tue, 10 Nov 2009 19:45:30 -0500 From: “Philippe R. Koninckx and Anastasia Ussia” Subject: Laparoscopic hysterectomy on the large fibroid uterus
Find below some comments to the discussion on large uteri and on robotic surgery on the AAGL listserv.
1. The first and single most important instrument for a large uterus is a decent manipulator. The uterine rotator, which I patented back in 1991, and which only recently has been finalised into a strong manipulator, permits in addition to other movements as push/pull, ante/retroflexion, rotation of the uterus. The bigger the uterus the more important this is. (This manipulator is actually distributed by Storz ; for videos of its use
2. Ligation of the uterine artery at the origin is a technique which is mandatory to master when really big uteri are tackled. Occasionally, the uterine artery at the level of the uterus can be very difficult to reach, especially when a myoma in the broad ligament makes its access difficult
3. We do appreciate and want to endorse John’s comments on robotic surgery (see below). I have a robot in Leuven and still have not found out what I could use it for, except eventually for tubal reanastomosis. Considering the results (eg of Charles Koh and ours) of laparoscopic reanastomosis it will be very hard to prove superiority of the robot. I do not need it for ureter reanastomosis, and also for endometriosis or myoma’s I do not see its utility. The major problem in Belgium is that the Da Vinci robot is used without proof of superiority and without any economic principle. If the cost of the robot and of the equipment would not been paid by the community , I do not think any gynecologist would pay for a robot. If established endoscopists do not need a robot, its use by non-endoscopists is a step backwards since for every complication they will have to do a laparotomy.

Philippe R. Koninckx and Anastasia Ussia
Uiversity of Leuven, Belgium and Gruppo Italo-Belga, Roma Italia

*** below the comment of John Steege
Date: Mon, 9 Nov 2009 22:59:16 -0500 From: John Steege Subject: Laparoscopic hysterectomy on the large fibroid uterus

Initially, I joined the enthusiasm for the robot, but after doing about 100 cases, I’ve come to feel that in benign gynecology, with a modicum of
experience, there really are no advantages to using the robot. Taking them one by one:
1) 3-D: Maybe it’s a little easier to learn laparoscopy with the robot, but the experienced operator doesn’t need it. My cerebellum has been used to
the “conventional laparoscopy” approach for so long that I don’t even see the 3-D.
2) wristed instruments: Yes, easier to sew, but now with the Quill suture available, it’s quite feasible to do most myomectomies with straight sticks, and
closing the cuff after laparscopic hysterectomy is quite easy. (Our second year residents learn it in about 2-3 cases.)
3) Speed?: Size of uterus, complexity of the sidewalls, and teaching time are the real rate-limiting steps, not the robot or lack thereof.
4) Less pain after surgery?: Hinted at in the marketing, but no data.
5) Less scarring after surgery?: Same as #4.
For the larger uterus (over about 16 weeks), I now use two 5 mm ports on each side, and find this allows a very rapid and low blood loss procedure, even
with a relatively less experienced resident assisting. Choice of tissue-dividing instrument matters little, as there are no data to support a clinically
meaningful difference in healing or safety.
The current pressure to get labeled as a “robotic surgeon” worries me. I think we will see surgeons attempting difficult surgeries they are really not qualified to do, thinking that the robot will make it easier. In fact, the lack of tactile feedback will make it more difficult to successfully deal with advanced
endometriosis, difficult pelvic sidewalls, and the like. More, not fewer, complications are the likely result.
So far, the fact remains that there is nothing special that the robot does for the gyn surgeon with a modicum of experience, who is doing benign
gynecology. I would leave the discussion of gyn cancer surgery and urologic surgery to others, although the issues are far from settled in those areas as
We need to be fair and honest in the information we advance to the public. We need to not let competition among providers distort the data. Advantage
of the robot? The emperor has no clothes.

John Steege, MD

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