Exploring the feasibility of indocyanine green fluorescence for intraoperative ureteral visualisation in robotic transvaginal natural orifice transluminal endoscopy surgery during endometriosis resection.

BACKGROUND: To assess the feasibility of use of indocyanine green (ICG) in identifying and minimising urinary tract injury during surgical resection of endometriosis through robotic transvaginal natural orifice transluminal endoscopy surgery (RvNOTES). METHODS: We conducted a retrospective case series in two academic tertiary care hospitals. We examined 53 patients who underwent RvNOTES hysterectomy with planned endometriosis resection. RESULTS: The study involved 53 patients undergoing RvNOTES with ICG fluorescence for endometriosis resection. Mean patient age was 37.98 ± 6.65 years. Operative time averaged 181.32 ± 53.94 min, with estimated blood loss at 45.57 ± 33.62 mL. Postoperative stay averaged 0.23 ± 0.47 days. No ICG-related complications occurred. CONCLUSION: No complications occurred with ICG fluorescence in RvNOTES. It appears to be a safe option for ureteral localisation and preservation. ICG fluorescence is widely used in diverse medical specialities for identifying ureters during complex surgeries. Larger studies are needed to firmly establish its advantages in intraoperative ureteral visualisation during RvNOTES for deep infiltrative endometriosis.

Robotic-assisted vaginal natural orifice transluminal endoscopic surgery versus robotic-assisted single-site port for benign hysterectomy: a comparison of surgical outcomes.

The objective of this study is to evaluate the surgical outcomes for robotic-assisted vaginal natural orifice transluminal endoscopic surgery (R-VNOTES) hysterectomy versus robotic-assisted single-site port (RSSP) hysterectomy when performed for benign indications. This is a retrospective chart review in an academic tertiary setting. 404 patients underwent hysterectomy for benign indications. R-VNOTES hysterectomy and RSSP hysterectomy were performed by a single minimally invasive gynecologic surgeon from January 2015 to August 2022. The primary outcome of our study was total operative time (minutes). Secondary outcomes included estimated blood loss (mL), length of hospital stay (days), and postoperative pain score. Other intraoperative and postoperative surgical complications were also compared. 159 patients underwent R-VNOTES hysterectomy, and 269 patients underwent RSSP hysterectomy. Median length of surgery (minutes) demonstrated a statistically significant shorter operative time in the R-VNOTES hysterectomy group when compared to the RSSP hysterectomy group, (132 min versus 146 min, respectively, p = 0.0001). Additionally, patients in the R-VNOTES hysterectomy group experienced decreased postoperative pain levels at week 1 (6 versus 7, respectively, p = 0.01) and week 3 (1.5 versus 2.5, respectively, p = 0.01) after surgery. There were no statistically significant differences between the two groups when comparing length of hospital stay, estimated blood loss, and weight of the uterus. There was no difference in rates of urinary tract infection, blood transfusion, bowel injury, readmission, reoperation, conversion, deep surgical site infection, and venous thromboembolism between both groups. However, there was a higher rate of superficial SSI in the RSSP hysterectomy group (0.6% versus 4.5%, respectively, p = 0.03). When compared to RSSP hysterectomy, R-VNOTES hysterectomy is safe and feasible, as both approaches have comparable surgical outcomes. Patients undergoing R-VNOTES hysterectomy had shorter length of surgery, decreased postoperative pain, and lower rates of superficial surgical site infections.

Evaluation of the learning curve and safety outcomes in robotic assisted vaginal natural orifice transluminal endoscopic hysterectomy: A case series of 84 patients.

BACKGROUND: To explore the learning curve and safety outcomes of robotic assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) for hysterectomy in benign gynaecological diseases. METHODS: A retrospective chart review of all patients undergoing R-vNOTES hysterectomy for benign gynaecological disease from 2019 to 2021. SETTING: An academic tertiary care university hospital in Houston, TX, USA. RESULTS: 84 patients were identified that met the study requirements. The mean hysterectomy time was 77.27 ± 2.89 min. The median additional operation time was 63 (8-206) min. There were two conversions to robotic assisted single incision laparoscopy. Thirteen (15.48%) patients had an associated complication. Analysis of the learning curve suggests plateauing of hysterectomy time at approximately 10 cases and time for robot docking and port placement after 10-20 cases. CONCLUSION: R-vNOTES is a safe and effective route for hysterectomy. For a surgeon with experience in laparoscopic single site surgery and abdominal robotic surgery, they need to perform 10 cases of R-vNOTES hysterectomy and 10-20 cases in port placement and robotic docking to achieve proficiency.

Robotic-assisted Laparoscopic Ureterolysis for Deep Infiltrating Endometriosis using Indocyanine Green Under Near-Infrared Fluorescence.

STUDY OBJECTIVE: To demonstrate safe identification of ureters in patients with deep infiltrating endometriosis or severe adhesive disease using indocyanine green (ICG) under near-infrared fluorescence (NIRF) on the robotic platform. DESIGN: Stepwise demonstration using narrated video footage. SETTING: An academic tertiary care hospital. A 43 year old G0 with stage IV endometriosis presented with chronic pelvic pain. Her surgical history is notable for 2 aborted hysterectomies due to severe adhesive disease, despite extensive lysis of adhesions. She desired surgical intervention. INTERVENTIONS: In cases of stage IV endometriosis, localizing the ureters can be challenging due to severe adhesive disease, surrounding fibrotic tissue, and distorted anatomy. Intravenous ICG has previously been described to assist with resection of endometriosis [1-3]. Alternatively, we describe a technique that allows for easier identification of ureters using ICG injection retrogradely in ureteral stents while visualized under NIRF [4,5]. IN SUMMARY: The patient underwent robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral ureterolysis, low anterior bowel resection with primary anastomosis, and resection of endometriosis without intraoperative complications or ureteral injury. Her postoperative course was unremarkable. At her 3 week postoperative visit, pelvic pain had completely resolved. CONCLUSIONS: This case demonstrates the use of intraureteral ICG and NIRF to identify the ureters and perform ureterolysis in cases of deep infiltrative endometriosis.

Postoperative opioid use for patients with chronic pelvic pain undergoing robotic surgery for resection of endometriosis.

We aimed to identify the amount of opioids used in the postoperative setting for patients with a history of chronic pelvic pain undergoing robotic surgical excision of endometriosis and compare this to patients undergoing benign robotic gynecologic surgery for other indications. We conducted a retrospective cohort study in an urban academic university hospital from January 2019 to March 2020. Data regarding opioid use was collected via a patient-reported survey that was given at the 3 weeks follow-up visit. Data regarding opioid use was compared to patients undergoing robotic surgery for other benign gynecologic indications. Our study included 158 patients, 119 undergoing surgery for endometriosis and 39 patients undergoing robotic surgery for other benign gynecologic indications. Patients undergoing surgery for endometriosis used on average 105.9 morphine milligram equivalents (MME), equivalent to 14 tabs of oxycodone 5 mg. There was no statistically significant difference in the amount of opioids used postoperatively based on stage of endometriosis or need for hysterectomy. Patients undergoing surgery for other benign indications used on average 49.4 MME, equivalent to 6 tabs of oxycodone 5 mg. The difference in amount of opioids used between patients with and without endometriosis was statistically significant. In conclusion, patients undergoing robotic surgery for endometriosis used over two times as many opioids postoperatively as patients without endometriosis and have a higher perceived postoperative pain. Providers should be aware of this difference in order to provide better pain control for this patient population.

Application of robotic single-site surgery with optional additional port for endometriosis: a single institution's experience.

To evaluate the safety and feasibility of treating stage I-IV endometriosis patients with robotic single-site surgery (RSSS). A retrospective chart review was conducted on 334 patients with endometriosis treated by a single surgeon at a university hospital from January 2015 to November 2019. Surgeries were performed in a single institution between 2015 and 2019. All patients presented with pelvic pain and underwent surgical resection of the lesion. American Society of Reproductive Medicine (ASRM) standards were used to classify endometriosis. The primary goal of this study is to investigate the feasibility and safety of RSSS for surgical resection of stage I-IV endometriosis patients. We will compare patient characteristics and surgical parameters, such as blood loss, operating time, and postoperative complications, across different endometriosis stages to evaluate the effectiveness of this novel technique. RSSS was used for all cases, with no conversions to laparotomy or traditional laparoscopy. One to two additional ports were placed in 41 patients with deeply infiltrating endometriosis (DIE) involving the colorectal and urinary tract and/or extensive pelvic adhesions. Across patient groups, there were no significant differences in age, BMI, fertility history, abdominal surgery history, and hysterectomy ratio (P > 0.05). The median operation time was 140.25 min (range: 85.50-260.00 min, P < 0.05) and median blood loss was 31.25 mL (range: 15-100 mL, P < 0.05). Histopathology supported the diagnosis in 259/334 patients. The undiagnosed patients were associated with lower ASRM scores. For 83.3% of patients (295/334), the length of hospital stay was < 24 h. The postoperative complication rate was 6.0% (20/334), although only two cases were severe. Our results indicate that RSSS is an alternative, safe, and acceptable platform for the surgical treatment of all stages of endometriosis.

Minimally invasive surgical management of a cornual ectopic pregnancy, with and without a concurrent intrauterine pregnancy.

OBJECTIVE: To describe techniques for resection of a cornual heterotopic pregnancy. DESIGN: This video demonstrates a surgical technique for excision of a cornual heterotopic pregnancy with narrative video footage using two case examples. SETTING: The incidence of cornual heterotopic pregnancy is unknown; however, the incidence of heterotopic pregnancy itself has increased through the use of assisted reproductive technologies and the majority of cornual heterotopic pregnancies occur after assisted reproductive technologies use. These cases have been treated traditionally using exploratory laparotomy and cornual wedge resection with good outcomes. With advancements in minimally-invasive surgical techniques, laparoscopic resection of cornual heterotopic pregnancies has been demonstrated to be safe and feasible. PATIENT(S): A patient with an 8-week cornual heterotopic pregnancy and a patient with a 10-week cornual ectopic pregnancy. INTERVENTIONS: Laparoscopic resection of the cornual ectopic pregnancy. MAIN OUTCOME MEASURE(S): Feasibility of a "purse-string" technique for the resection of a heterotopic cornual pregnancy. RESULT(S): Robotic-assisted laparoscopic resection of a cornual heterotopic pregnancy can be performed with minimal blood loss with the use of the "purse-string" technique in settings where vasopressin cannot be used for hemostasis. This technique includes the use of a 2-0 V-Loc suture in a circumferential fashion around the ectopic pregnancy, which allows for faster suturing and immediate tension at the myometrium. The same suture is then used to close the defect, which allows for a simpler and efficient closure with minimal entry into the myometrium. CONCLUSION(S): In this video, we demonstrate the successful resection of cornual heterotopic pregnancy using a "purse-string" surgical technique. This technique allows for minimal blood loss in cases where additional techniques for hemostasis cannot be used, such as injection of vasopressin and uterine artery ligation.

Surgical Outcomes of Hysterectomy via Robot-assisted versus Traditional Transvaginal Natural Orifice Transluminal Endoscopic Surgery.

STUDY OBJECTIVE: To evaluate the safety and feasibility of robot-assisted transvaginal natural orifice transluminal endoscopic surgery (R-vNOTES) hysterectomy when compared with traditional vNOTES (T-vNOTES) hysterectomy. DESIGN: Retrospective chart review. SETTING: Academic tertiary setting. PATIENTS: Total of 114 patients with benign gynecologic indication for hysterectomy. INTERVENTIONS: T-vNOTES or R-vNOTES hysterectomy performed by a single minimally invasive gynecologic surgeon in the study period. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study was surgical equivalence, measured principally by total operative time between T-vNOTES and R-vNOTES hysterectomy. Secondary operative outcomes that were measured included estimated blood loss, length of hospital stay, reported postoperative pain levels, and number of conversions. A total of 79 women underwent T-vNOTES hysterectomy, and 35 women underwent R-vNOTES hysterectomy without differences in operative time (p = .37), estimated blood loss (p = .27), length of hospital stay (p = .06), or reported postoperative pain levels at weeks 1, 2, and 3 after surgery (p = .78, p = .36, p = .38, respectively). A total of 6 patients underwent conversion in the T-vNOTES hysterectomy group compared with 0 in the R-vNOTES hysterectomy group; however, this was not statistically significantly different, and there were no conversions to laparotomy. CONCLUSION: R-vNOTES hysterectomy is a feasible approach to surgery when compared with T-vNOTES hysterectomy and warrants further consideration as a skill set in a gynecologic surgeon's toolbox. Wristed instruments may allow surgeons who are inexperienced in single-site laparoscopy to adopt vNOTES more quickly as a new technique when performing hysterectomy through a comparable minimally invasive approach.

Laparoscopic Single-site "In-bag" Ovarian Dermoid Cystectomy in a 16-week- pregnant Patient.

STUDY OBJECTIVE: To demonstrate a novel "in-bag" ovarian cystectomy technique for a large adnexal mass in pregnancy. DESIGN: Stepwise demonstration with narrated video. SETTING: An academic tertiary care hospital. The patient was a 26-year-old woman, gravida 1, para 0, at gestational age of 7 weeks and 3 days who presented to the emergency department with persistent left pelvic pain and was diagnosed with a 16 cm × 10 cm × 12 cm dermoid cyst. She re-presented at gestational age of 16 weeks and 3 days with worsening pelvic pain, and the decision was made to proceed with surgical intervention. INTERVENTIONS: Laparoscopic transumbilical single-site surgery for the surgical management of adnexal masses in pregnancy has been demonstrated to be feasible and safe [1-3]. However, single-site laparoscopic ovarian cystectomy can be very challenging in pregnancy, especially when the need for suturing arises. Exteriorizing the ovary and cyst after intraperitoneal drainage may allow for extracorporeal suturing that is faster and easier; however, it may increase the probability of spillage of cystic contents if it is not performed in a bag, which can then cause peritonitis in cases of dermoid cysts. A combination of in-bag and extracorporeal ovarian cystectomy is a novel alternative minimally invasive approach that is cosmetic, safe, and effective. Several helpful techniques in this novel combination technique include the following: • Creating an umbilical incision of at least 2 cm or one that is large enough for better manipulation of both the surgical bag and adnexal mass. • Tightening the bag appropriately around the infundibulopelvic ligament so that it is not too tight leading to compromised blood supply and tissue necrosis, yet not too loose resulting in leakage of cystic contents. • Ensuring that the infundibulopelvic ligament is stabilized within the surgical bag. • Inserting small-sized wound retractor into the bag for better exposure during cystectomy. • Having a double-suction irrigation setup for large adnexal masses, as demonstrated in this patient, to reduce the spillage of cystic contents. The procedure was successfully performed in approximately 110 minutes, and the fetal heart rate postprocedure was 128 bpm through bedside transabdominal ultrasound. Estimated blood loss was 5 mL, and the patient was discharged the same day with an uneventful 4-week postoperative follow-up. CONCLUSION: Laparoscopic single-site "in-bag" ovarian dermoid cystectomy is feasible, effective, and safe in pregnant patients with a large adnexal mass. This technique results in better stabilization of the ovarian cyst and reduction of cystic content spillage.

Integration of a Robotic Platform for Sacrocolpopexy in Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Novel Surgical Technique.

OBJECTIVE: To demonstrate the feasibility and the simplified surgical techniques of intraabdominal suturing and knot-tying in robotic transvaginal natural orifice transluminal endoscopic surgery (RV-NOTES) sacrocolpopexy. MATERIALS AND METHODS: We report on two patients with symptomatic stage II apical pelvic organ prolapse who underwent a new technique of RV-NOTES sacrocolpopexy. Case one: A 69-year-old G2P2002 with a history of two prior vaginal deliveries presented with a vaginal bulge and pressure symptoms. She was initially fitted for a pessary but was unsatisfied and elected to proceed with surgical intervention. Case two: A 50-year-old G2P0011 female with a history of one prior vacuum-assisted vaginal delivery presented with symptoms of vaginal mass and bleeding due to an endometrial polyp. She was noted to have stage 2 apical prolapse and opted for transvaginal sacrocolpopexy. RESULTS: Both patients were observed overnight and discharged home twelve hours after surgery on postoperative day 1, after completing a voiding trial. For both patients, the postoperative course was unremarkable, and they only required one day of pain medications. At the three-week follow-up visit, they endorsed no postoperative pain or complications, and the POP-Q stage was noted to be 0. Patients had telemedicine visits at eight weeks postoperatively, at which time they had returned to their regular activities and denied symptoms of vaginal bulge or pressure. CONCLUSION: Robotic assisted transvaginal NOTES sacrocolpopexy is a feasible and an alternative to traditional laparoscopic NOTES sacrocolpopexy.

Robot-assisted Transvaginal Single-site Sacrocolpopexy for Pelvic Organ Prolapse.

STUDY OBJECTIVE: To demonstrate stepwise techniques for the successful use of the laparoscopic single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. DESIGN: Stepwise demonstration with narrated video footage (Canadian Task Force classification III). SETTING: Academic tertiary care hospital. The patient, aged 69 years gravida 2 para 2-0-0-2 with a history of SVD × 2, presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. INTERVENTIONS: Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, the retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomic variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer, and effective. Several helpful techniques in robot-assisted transvaginal single-site include the following: (1)The use of a 30°-angled scope alternating between "facing up" and "facing down" depending on the need for dissection or suturing. (2) The use of 3-dimensional visualization with a robotic camera that can highlight the depth of the surgical anatomy, therefore facilitating easier identification in the dissection of a surgical pedicle. (3) The use of wristed instruments that permit increased articulation and triangulation that are lacking in traditional laparoscopic single-site surgery, allowing for much easier and proficient suturing and knot tying. (4) Integration of the robotic platform that stabilizes the fine motor movement in a surgeon's hands improving the precision of the suturing and knot tying. The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. CONCLUSION: Robot-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse. Patients experience improved cosmesis, decreased postoperative pain, and faster recovery compared with abdominal sacrocolpopexy.