The Giep needle pass: a simple technique for the passage of needles for vaginal cuff closure in robotically assisted laparoscopic hysterectomy.

The passage of needles and suture to close the vaginal cuff during a robotically assisted laparoscopic hysterectomy typically necessitates the use of a 10-12 mm accessory port to allow for the passage of a CT-1 sized needle. This results in a relatively large incision, which may lead to increased patient discomfort and dissatisfaction with cosmetic results compared to a smaller incision. Our technique of passing the needle and suture through the vagina allows us to use a smaller caliber accessory port while maintaining our ability to use a larger CT-1 needle easily and safely, with a reduced risk of losing the needle within the patient's abdomen.

Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital: robotic-assisted laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy.

The study reported here compares outcomes of three approaches to minimally invasive hysterectomy for benign indications, namely, robotic-assisted laparoscopic (RALH), laparoscopic-assisted vaginal (LAVH) and laparoscopic supracervical (LSH) hysterectomy. The total patient cohort comprised the first 237 patients undergoing robotic surgeries at our hospital between August 2007 and June 2009; the last 100 patients undergoing LAVH by the same surgeons between July 2006 and February 2008 and 165 patients undergoing LAVHs performed by nine surgeons between January 2008 and June 2009; 87 patients undergoing LSH by the same nine surgeons between January 2008 and June 2009. Among the RALH patients were cases of greater complexity: (1) higher prevalence of prior abdominopelvic surgery than that found among LAVH patients; (2) an increased number of procedures for endometriosis and pelvic reconstruction. Uterine weights also were greater in RALH patients [207.4 vs. 149.6 (LAVH; P < 0.001) and 141.1 g (LSH; P = 0.005)]. Despite case complexity, operative time was significantly lower in RALH than in LAVH (89.9 vs. 124.8 min, P < 0.001) and similar to that in LSH (89.6 min). Estimated blood loss was greater in LAVH (167.9 ml) than in RALH (59.0 ml, P < 0.001) or LSH (65.7 ml, P < 0.001). Length of hospital stay was shorter for RALH than for LAVH or LSH. Conversion and complication rates were low and similar across procedures. Multivariable regression indicated that LAVH, obesity, uterine weight ≥250 g and older age predicted significantly longer operative time. The learning curve for RALH demonstrated improved operative time over the case series. Our findings show the benefits of RALH over LAVH. Outcomes in RALH can be as good as or better than those in LSH, suggesting the latter should be the choice primarily for women desiring cervix-sparing surgery.

Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices.

OBJECTIVE: To examine outcomes of robotically assisted laparoscopic hysterectomy in patients with benign conditions involving high uterine weight and complex pathology. METHODS: A multicenter study was undertaken in five community practice settings across the United States. All patients who had minimally invasive laparoscopic hysterectomy with robotic assistance March 2006 through July 2009 and uterine weights of at least 250 g were included. Retrospective chart review identified outcomes including skin-to-skin operative time, conversion to an exploratory laparotomy, blood loss, complications, and hospital duration of stay. The effect of uterine weight on skin-to-skin time and blood loss also was examined. RESULTS: Data were analyzed for 256 patients with uteri weighing 250 to 3,020 g (median 453 g). Most patients were obese or had a history of pelvic or abdominal surgery. Median operative time was 145 minutes. Duration of surgery in patients with uteri 500 g or greater was significantly longer than in patients with uteri less than 500 g (167 compared with 126 minutes, P<.001). Median estimated blood loss also was greater in women with uteri weighing 500 g or more (100 compared with 50 mL, P<.001). Multivariable linear regression analysis confirmed the independent effect of uterine weight on operative time and blood loss. Median duration of hospital stay was 1 day. The conversion rate was 1.6%, the minor complication rate was 1.6%, and major complications occurred in 2.0% of patients. CONCLUSION: Women with large uteri may successfully undergo robotically assisted hysterectomy with low morbidity, low blood loss, and minimal risk of conversion to laparotomy. Results were reproducible among general gynecologists from geographically diverse community settings.