Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

The development of a robotic gynaecological surgery training curriculum and results of a delphi study.

BACKGROUND: Technology for minimal access surgery is rapidly progressing in all surgical specialities including Gynaecology. As robotic surgery becomes established in increasing numbers of hospitals, there is no set curriculum for training in robotic gynaecological surgery or the assistant role in use in the UK. The purpose of this study was to determine a list of competencies that could be used as the basis of a core robotic gynaecological surgery curriculum, to explore its acceptability and the level of interest in undertaking training in robotics among obstetrics & gynaecology (O&G) trainees. METHODS: A four-round Delphi study was conducted using members and associates of British & Irish Association of Robotic Gynaecological Surgeons (BIARGS). In Round 1 respondents were asked to propose standards that could be used in the curriculum. In the following three rounds, the respondents were asked to score each of the standards according to their opinion as to the importance of the standard. Items that scored a mean of 80% or above were included in the final proposed curriculum. Following this, a national survey was conducted to explore the interest among O&G trainees in undertaking a formal robotic training for the first assistant and console surgeon roles. RESULTS: The items proposed were divided into three separate sections: competencies for a medical first assistant; competencies for a console surgeon; continued professional development for trained console surgeons. From the national survey; 109 responses were received of which 60% were interested in undertaking a formal training for the first assistant role, and 68% are expressing interest in training for the console surgeon role. CONCLUSION: Undertaking a Delphi exercise to determine a core gynaecological robotic training curriculum has enabled consensus to be achieved from the opinions of BIARGS members/associates. There is interest among O&G trainees at all levels of training to gain experience and develop their skills in robotic surgery by undertaking a formal training in robotic surgery at both the first assistant and console surgeon level.

Anaesthetic management of robotic-assisted gynaecology surgery in the morbidly obese - A case series of 46 patients in a UK university teaching hospital.

BACKGROUND AND AIMS: The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position. METHODS: We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis. RESULTS: The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days. CONCLUSION: Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.

Prophylactic balloon occlusion of the common iliac arteries for the management of suspected placenta accreta/percreta: conclusions from a short case series.

PURPOSE: The management of women with abnormally invasive placenta remains one of the most challenging aspects of obstetric care. Various surgical and interventional radiological techniques have been developed to limit the risk of massive haemorrhage at caesarean section. Here we describe our experience with three such cases that required caesarean hysterectomy and were managed with prophylactic balloon catheterisation of the common iliac arteries. METHODS: The details of three cases that received prophylactic balloon catheterisation of the common iliac arteries for the surgical management of placenta accreta/percreta are presented. Observational conclusions from these cases as well as a review of the relevant literature are discussed. RESULTS: Our three cases required caesarean hysterectomy for suspected placenta accreta/percreta. The mean estimated blood loss was 3,333 ml. In one of the cases, we observed notable reduction in blood loss during occlusion of the common iliac arteries, as the balloons were deflated every 5 min to avoid lower limb ischemia. CONCLUSIONS: The cases presented here, and also our literature review, suggest that occlusion of the common iliac arteries appears to be more effective than, and as safe as the occlusion of the internal iliac arteries. Clinicians need to be aware of the potential risks and employ measures to prevent them. Further research is required to investigate the optimum length of occlusion and balance between reducing blood loss and risking ischemia of the limbs when occluding the common iliac arteries.

Characterizing T-cell response in low-grade and high-grade vulval intraepithelial neoplasia, study of CD3, CD4 and CD8 expressions.

OBJECTIVE: The objective of our study was to compare immunocyte infiltrates in vulval epithelium from low-grade and high-grade vulval intraepithelial neoplasia (VIN) lesions to determine if difference in T-cell presence reflected the grade of VIN. MATERIAL AND METHODS: Thirty-six vulval specimens were obtained from 24 patients who had previously undergone vulval biopsies for VIN, 14 high-grade diseases (VIN 3 with or without HPV) and 14 low-grade diseases (VIN 1 and VIN 2 with or without HPV). Eight samples of normal vulval tissue were selected from the excision margins of resected vulval biopsies. The lymphocyte surface markers included CD3 (Pan T-cell marker), CD4 (T helper cells), and CD8 (T cytotoxic cells). Each tissue section was visualized under high power magnification and cells were counted in 10 random areas at the dermo-epidermal junction. RESULTS: A significantly higher number of total mean T lymphocytes were detected in VIN specimens compared to normal vulval tissue (P = 0.002). In low-grade VIN, there were significantly more CD8 cells than CD4 when compared to high-grade VIN. This difference in CD4/CD8 ratio was significant (P = 0.001). CONCLUSIONS: This study suggests that increased CD8 response in VIN is a feature of low-grade disease and we speculate that this may be a protective mechanism. In high-grade disease, both CD4 cells and CD8 cells are equally present with preservation of normal CD4/CD8 ratio.