Robot-Assisted Hysterectomy Using the Double-Bipolar Method.

OBJECTIVE: To demonstrate the efficacy of the double-bipolar method in a benign hysterectomy. DESIGN: Stepwise demonstration of the technique with a narrative video. SETTING: The double-bipolar method was first reported in 2011 [1] and is gaining popularity in Japan; however, its usefulness in robot-assisted hysterectomy is under-reported. When unexpected bleeding occurs during robot-assisted hysterectomy using a monopolar technique, corrective measures may be prolonged and often require changing forceps. The Maryland forceps have 4 functions, including incision, dissection, grasping, and coagulation, which enable rapid responses to bleeding and reduce forceps changes and cost. Previously, we reported the usefulness of the double-bipolar technique in other surgical procedures [2,3]. Herein, we present a case of robot-assisted hysterectomy using this technique at an urban general hospital, including detailed insights into its execution. INTERVENTIONS: A 45-year-old female patient presented to our hospital with painful menstrual bleeding. Magnetic resonance imaging revealed an 8-cm myoma in the posterior wall of the uterine cervix. Consequently, a robot-assisted hysterectomy was performed using right-handed Maryland forceps (Intuitive, Sunnyvale, CA) and the ForceTriadTM Energy Platform (Medtronic, Minneapolis, MN) in the macro mode, with an output of 60 W. This configuration ensured a consistent electronic output, regardless of the electrical resistivity of the target tissues, facilitating precise incisions using a momentary high voltage [4]. The surgical duration was 60 minutes, and the estimated blood loss was 5 mL. CONCLUSION: The highly versatile double-bipolar method uses one forceps for incision, dissection, coagulation, and grasping and is useful in gynecological surgery. VIDEO ABSTRACT.

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis.

PURPOSE: Drug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE. METHODS: We retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE. RESULTS: Between the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22 min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49 ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2 days, p = 0.45) and perioperative complications with Clavien-Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery. CONCLUSION: Compared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.

Short-term outcomes of robot-assisted versus conventional laparoscopic surgery for early-stage endometrial cancer: A retrospective, single-center study.

AIM: We compared the short-term outcomes between conventional laparoscopic surgery (CLS) and robot-assisted surgery (RAS) to assess the technical feasibility of the latter for early-stage endometrial cancer. METHODS: We retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early-stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo-oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para-aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups. RESULTS: No differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P < 0.01), mean blood loss was 196 ± 153 versus 237 ± 146 mL (P = 0.047), mean length of postoperative hospital stay was 9 ± 4 versus 8 ± 3 days (P = 0.01) and mean rate of perioperative complications of Clavien-Dindo grade III or higher was 2.0 versus 3.4% (P = 0.53) for the CLS versus RAS groups, respectively. There was no significant difference in the number of resected lymph nodes. CONCLUSION: The operative time was significantly longer and blood loss was significantly greater in the RAS group than in the CLS group, without a significant difference in the number of resected lymph nodes. These differences are within an acceptable clinical range, showing that RAS is feasible and safe for early-stage endometrial cancer, providing short-term outcomes comparable to those of conventional surgery. Future studies are warranted to compare the long-term oncological outcomes by extending the observation period and including para-aortic lymphadenectomy data.

[Comparison of the efficacy of ropivacaine and that of levobupivacaine for postoperative epidural analgesia in patients undergoing gynecological open abdominal surgery].

BACKGROUND: Postoperative analgesia is important in patients undergoing open abdominal surgery. We prospectively compared the efficacy of ropivacaine and that of levobupivacaine for postoperative epidural analgesia in patients undergoing gynecological open abdominal surgery. METHODS: Fifty-two ASA 1-2 patients scheduled for gynecological open abdominal surgery under combined general and epidural anesthesia were enrolled and randomized into two groups. In ropivacaine group (n = 26) the patients received 0.187% ropivacaine and fentanyl 3.2 microg x ml(-1) for postoperative epidural analgesia. In levobupivacaine group (n = 26) the patients received 0.187% levobupivacaine and fentanyl 3.2 microg ml(-1). Visual analogue scale (resting pain and pain on mobilization), the amount of rescue analgesics and epidural anesthesia related adverse events such as hypotension, nausea and vomiting were observed for 48 hours after surgery. RESULTS: There were no differences in visual analogue scale at all intervals between the two groups. In levobupivacaine group the patients used less amounts of rescue analgesics than ropivacaine group (P = 0.01). There were no differences in the incidences of postoperative hypotension, nausea and vomiting between the two groups. CONCLUSIONS: Both 0.187% ropivacaine and levobupivacaine similarly provide appropriate postoperative epidural analgesia for patients undergoing gynecological open abdominal surgery.

Feedback-based error monitoring processes during musical performance: an ERP study.

Auditory feedback is important in detecting and correcting errors during sound production when a current performance is compared to an intended performance. In the context of vocal production, a forward model, in which a prediction of action consequence (corollary discharge) is created, has been proposed to explain the dampened activity of the auditory cortex while producing self-generated vocal sounds. However, it is unclear how auditory feedback is processed and what neural mechanism underlies the process during other sound production behavior, such as musical performances. We investigated the neural correlates of human auditory feedback-based error detection using event-related potentials (ERPs) recorded during musical performances. Keyboard players of two different skill levels played simple melodies using a musical score. During the performance, the auditory feedback was occasionally altered. Subjects with early and extensive piano training produced a negative ERP component N210, which was absent in non-trained players. When subjects listened to music that deviated from a corresponding score without playing the piece, N210 did not emerge but the imaginary mismatch negativity (iMMN) did. Therefore, N210 may reflect a process of mismatch between the intended auditory image evoked by motor activity, and actual auditory feedback.