Senhance Robotic Platform System for Gynecological Surgery.

BACKGROUND AND OBJECTIVES: Laparoscopic hysterectomy provides patients and surgeons with benefits of less pain, quicker recovery, and better scar cosmesis. Previously, robotic surgical hysterectomy was reserved for patients with complicated disease issues. The objective of this case series was evaluating a new robotic surgical platform, Senhance Surgical System, as a surgical tool in common gynecological procedures. METHODS: The clinic routinely collects surgical and outcome data for all patients and procedures. Data on robotic surgery in hysterectomy, salpingectomy, endometriosis excision, and lysis of adhesions was evaluated. RESULTS: Fifteen consecutive patients that underwent gynecological surgery using the Senhance System were assessed. Average age was 47.27 years (31 - 63 years). Ten procedures were robotic total laparoscopic hysterectomy and 14 of 15 procedures had at least one salpingectomy. Average blood loss was 52.7 mL (10 - 100 mL). Pain scores at discharge averaged 1.42 and 2.73 at two weeks post-surgery. Minimal pain medication was used. Patient satisfaction with the surgery was 98% and satisfaction with scarring was 100%. Return to normal activities and to work averaged 7.93 and 11.1 days respectively. The haptic feedback and the platform visualization of the procedure was useful. The system provided more surgeon control over both camera and tools compared to previously used robotic systems and traditional laparoscopic surgery. CONCLUSION: This initial experience with Senhance Surgical System provided a stable, precise surgical technique with enhanced visualization within the confined space of the abdomen during gynecological surgery. The initial results suggest high patient satisfaction with gynecological surgery and resulting scars. Further study is needed to validate the findings.

Easy way to perform salpingectomy by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) (with video).

The transvaginal natural orifice transluminal endoscopic surgery (vNOTES) is a new minimally invasive and emerging technique. Feasibility and safety profiles of peritoneal access via transvaginal routes have been demonstrated especially for the adnexal surgery. In order to be reproducible and replicable with a standardized procedure, we propose the step-by-step video description of the vNOTES salpingectomy. The advantages of the vNOTES (low postoperative pain, faster postoperative recovery, scarless surgery) could lead to a promising alternative to conventional laparoscopic salpingectomy/adnexectomy.

Laparoscopy-assisted suprapubic salpingectomy 'Kaya technic' - a low-cost treatment of ectopic pregnancy.

We aimed to demonstrate the feasibility and total cost of laparoscopy-assisted suprapubic salpingectomy (LASS), which utilises conventional open surgery equipment without any sealing or coagulation devices and reduces port sites compared to conventional laparoscopy (CL). Fifty-seven consecutive, age-matched patients presenting with a tubal pregnancy were enrolled. In the LASS group, a 10 mm reusable umbilical optical trocar and a 10 mm suprapubic trocar was used. The other 30 patients were managed with multiport CL. All of the patients were asked to use the visual analogue scale and Patient and Observer Scar Assessment Scale to evaluate their cosmetic satisfaction. The duration of surgery was 21.19 ± 2.33 minutes for the LASS group and 36.9 ± 4.9 minutes for the CL group (p < .001). The postoperative 6th-hour VAS score was 2.44 ± 0.5 for the LASS group and 3.03 ± 0.8 for the CL group (p: .005). All of the PSAS and OSAS parameter scores were significantly lower in LASS group than CL group. In conclusion, the LASS procedure is a feasible method for treating ectopic pregnancies with a shorter surgical duration, lower VAS scores, and better cosmetic scores than CL. Impact statement What is already known on this subject? Laparoscopy or laparotomy may be performed for the surgical management of ectopic pregnancy. Conventional laparoscopy has some advantages such as shorter hospital stay and recovery time and the better cosmetic results. However, the equipment used in conventional laparoscopy and single incision laparoscopy are more expensive than conventional open surgery equipment. What the results of this study add? Laparoscopy-assisted suprapubic salpingectomy (LASS) method has shorter operation time, lower VAS scores, better cosmetic scores and cheaper than conventional laparoscopy. What the implications are of these findings for clinical practice and/or further research? The LASS procedure looks like a feasible method for treating ectopic pregnancies and the feasibility of this procedure should be confirmed by a larger series of patients and randomised trials.

Two Surgical Techniques for Essure Device Ablation: The Hysteroscopic Way and the Laparoscopic Way by Salpingectomy with Tubal Interstitial Resection.

STUDY OBJECTIVE: To describe 2 different surgical techniques for Essure removal on the same patient: the hysteroscopic and laparoscopic techniques. DESIGN: An educational video approved by the local institutional review board (Canadian Task Force classification III). SETTING: A university hospital (University Hospital of Strasbourg, Strasbourg, France). PATIENT: A 46-year-old woman with many symptoms after Essure device implantation. An ultrasound found a right implant in the uterine cavity and a left intratubal implant. INTERVENTIONS: The first step was the hysteroscopic removal of the right implant. We viewed the 2 internal and external spirals, allowing the gripping of the whole device without risking any fragmentation or tubal lesion. The second step was bilateral salpingectomy with resection of the left interstitial tubal portion. We longitudinally incised the antimesial edge of the fallopian tube 2 to 3 cm from the tubal serous to the implant contact. A circumferential incision was performed at the uterine horn to circumscribe the interstitial tubal portion. The implant was released from the surrounding tissue. It was gently pulled to completely extract it and avoid spiral fragmentation. Then, we performed a bilateral total salpingectomy. An X-ray of the implants and pelvis was performed to ensure complete removal of the device. We made an X-stitch in the uterine horn to avoid the risk of fistula. CONCLUSION: More and more patients are asking for the removal of their implants. The surgical technique has to be adapted to the location of the implants and has to allow their complete removal to avoid leaving fragments that can cause the persistence of side effects.

Comparison of Three Different New Bipolar Energy Modalities and Classic Bipolar in Vivo for Tissue Thermal Spread.

OBJECTIVE: The aim of this study was to compare three different new bipolar energy modalities and classic bipolar in vivo for tissue thermal spread. MATERIAL AND METHOD: This prospective, randomized, single-blind study was conducted between Septemsber 2012 and July 2013. Eighteen patients aged 40-65 years undergoing hysterectomy and bilateral salpingectomy for benign etiology were included in the study. Before the hysterectomy operation began, it was marked nearly distal third cm started from uterine corn and proximal close third cm started from fimbrial bottoms by visualizing both fallopian tubes. The surgery was performed using one 5 mm applicator of PlasmaKinetics™, EnSeal®, LigaSure™ or classic bipolar energy modality. The time each device was used was standardized as the minimum time of the audible warning of the device for tissue impedance and as tissue vaporization on classic bipolar. Tissues were dyed by both H&E and Masson's Trichrome in the pathology laboratory. Thermal spread was compared. RESULTS: Evaluation of the damage on the uterine tubes by each device used revealed that LigaSure™ was associated with increased thermal injury compared to PlasmaKinetics™ (p=0.007). Apart from PlasmaKineticsTM (p=0.022), there was no statistically significant difference between the three devices in terms of thermal damage spread in the distal and proximal fallopian tubes. CONCLUSION: To reduce lateral thermal damage, Plasmakinetics™ may be preferable to Ligasure™ among the three different new bipolar energy modalities.

Bilateral Salpingectomy Using Percutaneous Minilaparoscopy.

STUDY OBJECTIVE: To show a new technique for bilateral salpingectomy using percutaneous minilaparoscopy. DESIGN: Step-by-step video demonstration and narration of the surgical procedure. SETTING: Minilaparoscopy was first described in the late 1980s and early 1990s. Since then, minilaparoscopic instruments have been successfully applied to several general surgery and gynecologic procedures, including hysterectomy. Potential benefits of minilaparoscopy compared with conventional laparoscopy include decreased tissue trauma, pain, and improved cosmesis. INTERVENTIONS: Percutaneous minilaparoscopic approach for bilateral salpingectomy. CONCLUSION: Percutaneous minilaparoscopy, in addition to conventional laparoscopy, is a feasible approach for bilateral salpingectomy.

Mini-Laparoscopy for Removal (Partial) of Adnexae at the Time of Hysterectomy.

STUDY OBJECTIVE: To demonstrate our technique of mini-laparoscopic adnexectomy or salpingectomy at the time of total laparoscopic hysterectomy (TLH). DESIGN: Step-by-step video demonstration of our technique. SETTING: The advantages of laparoscopic surgery have been widely recognized, including improved visualization and exposure, reduced operative trauma owing to smaller incisions and gentler tissue handling, and faster postoperative recovery. Continuing technological developments have allowed the use of smaller-caliber instruments while maintaining a high standard of surgical performance. Mini-laparoscopy requires the use of 3-mm or smaller ports. The main advantage of mini-laparoscopy is the reduced incision size, which can translate into a lower incidence of incision-related complications such as postoperative pain, infection, and trocar site herniation, along with superior cosmetic results. Today, in younger patients, prophylactic salpingectomy can be considered instead of adnexectomy, taking into account the well-known benefits of ovarian conservation. Prophylactic salpingectomy involves Fallopian tube removal for primary prevention of epithelial carcinoma of the fallopian tubes, ovaries, and peritoneum in women undergoing pelvic surgery for another indication. Other advantages of this intervention are the avoidance of hydrosalpinx (which affects ∼30% women after hysterectomy), the 7.8% lifetime risk of revision surgery [1], tubal infection, and benign and malignant Fallopian tube tumors. Finally, salpingectomy has no known physiological side effects, is safe and feasible, does not worsen surgical outcomes, does not significantly increase the operative time, and is not related to increased rates of intraoperative and postoperative complications or readmission. INTERVENTIONS: The patient is a 44-year-old woman with a history of 2 previous cesarean sections with adenomyosis and endometriosis infiltration of the uterosacral ligaments. After discussion about the risks and benefits of ovarian conservation with prophylactic salpingectomy versus adnexectomy, the patient opted to preserve her ovaries. A TLH with partial removal of the uterosacral ligaments nodules and prophylactic bilateral salpingectomy was performed. To begin, the patient was placed in lithotomy position with Allen stirrups at an angle of approximately 100 degrees. Standard trocar placement was used. A 5- or 10-mm 0° scope was placed at the level of the umbilicus and three 3-mm skin incisions were made for accessory lower quadrant trocar placement: 2 lateral, approximately 3 cm medial to the anterior superior iliac spine, and 1 suprapubic, slightly higher than the line made by the lateral trocars, ensuring that the distance between this port and the camera trocar exceeded 8 cm. This triangulation of the accessory ports allowed for good ergonomics for the surgeon. The procedure continued with abdominopelvic cavity inspection and bilateral transperitoneal ureter identification and eventual adhesiolysis, and then the following steps: The instruments used were a 10-mm scope, a 3-mm bipolar forceps, 3-mm cold scissors, a 3-mm suction-irrigation device and 3-mm grasping forceps. CONCLUSION: Mini-laparoscopy is an alternative to classic laparoscopy associated with greater patient satisfaction. Prophylactic salpingectomy has proven to reduce the risk of ovary, peritoneal, and tubal epithelial carcinomas as well as benign tubal diseases, and does not significantly increase the operative time or the incidence of postoperative complications.

Total laparoscopic hysterectomy using a percutaneous surgical system: a pilot study towards scarless surgery.

OBJECTIVE: The evolution of minimally invasive surgery has moved beyond reduction of surgical trauma while maintaining adequate efficacy and safety standards. Percuvance™ Percutaneous Surgical System (PSS) instruments represents the last novelty in this panorama. Consisting of less than 3mm laparoscopic shaft introduced percutaneously with an interchangeable 5mm tool installed in place of the needle tip, they combine micro-invasiveness and operative performance. STUDY DESIGN: We prospectively collected and retrospectively analyzed data of 10 cases of laparoscopic total hysterectomy with Percuvance™ PSS for benign or early malignant gynecological diseases in order to assess the capability and safety of this new device. Data were recorded in a prospectively designed clinical database including patient demographics characteristics, operative data, intra- and postoperative complications, conversion rate, length of hospital stay and cosmetic outcome. RESULTS: The reported series consisted of 10 patients undergoing total laparoscopic hysterectomy with a median age of 51.5 years (range 44-72 years) and a median BMI (body mass index) of 25.3 (range 19.7-30.4). All patients had bilateral salpingo-oophorectomy or bilateral salpingectomy and two of them underwent pelvic lymphadenectomy. A median operative time of 67min (range 45-180min) and a median estimated blood loss (EBL) of 50ml (range 10-100ml) were registered. Median PSS introduction time was 5min (range 3-10min). No conversions to standard laparoscopy or laparotomy were required and no intraoperative complications occurred. Discharge was on day 1 in 4 cases, on day 2 in the other 6 cases. All patients conveyed complete satisfaction with the cosmetic result and postoperative pain control. No complications were registered within 30 days after surgery. CONCLUSIONS: PSS total laparoscopic hysterectomy is safe and feasible with good results in terms of operative time, cosmesis, postoperative pain, recovery and short hospitalization. Further studies are needed to compare PSS total hysterectomy to conventional multi-access laparoscopic and other mini-invasive approaches.

Natural orifice transluminal endoscopic surgery in humans: feasibility and safety of transgastric closure using the OTSC system.

BACKGROUND: NOTES is a technique in which an operation is performed within the body without a skin incision by using a natural body orifice to provide access. The principal challenge of transgastric NOTES procedures is still the feasibility and safety of access closure. Currently, there are very limited data regarding the closure of transgastric NOTES in humans, and the standard method and device for closure has not been defined. Herein, we evaluate the feasibility and safety of gastric closure after NOTES procedures in humans with the over-the-scope clip (OTSC). METHODS: Review of collected data of patients underwent transgastric NOTES in prospective clinical studies between April 2010 and March 2014 focused on the gastric closure with the OTSC. RESULTS: A total of 43 patients underwent transgastric NOTES: 36 patients with an acute appendicitis, six patients with a prophylactic bilateral salpingo-oophorectomy, and one patient with uterus myomatosus. In all 43 cases, the incision of the gastric wall and the endoscopic access to the abdominal cavity succeeded without any difficulty. After performing transgastric procedures, it was possible to close the access by OTSC in all cases. There were all in all three adverse events: one major (Clavien-Dindo Grade III) and two minor (Clavien-Dindo Grades I and II). CONCLUSION: Even if we could show for the first time in more than 40 consecutive patients that there is a safe approach for closing the transgastric access, it is absolutely necessary that further investigation in clinical settings has to be done to establish clear indications and guidelines for the use of transgastric NOTES.

LAPAROSCOPIC SALPINGECTOMY IN TWO CAPTIVE LEOPARDS (PANTHERA PARDUS) USING A SINGLE PORTAL ACCESS SYSTEM.

Laparoscopic salpingectomy was performed in two adult leopards (Panthera pardus) using a single portal access system, with a multicannulated single-incision laparoscopic surgery port, without any complications. The poorly developed ovarian bursa provided easy access to the uterine tube for salpingectomy. Laparoscopic salpingectomy can be safely performed in the leopard using a single portal access system.

Imaging System for Vaginal Surgery.

BACKGROUND: The vaginal surgeon is challenged with performing complex procedures within a surgical field of limited light and exposure. INSTRUMENT: The video telescopic operating microscope is an illumination and imaging system that provides visualization during open surgical procedures with a limited field of view. The imaging system is positioned within the surgical field and then secured to the operating room table with a maneuverable holding arm. A high-definition camera and Xenon light source allow transmission of the magnified image to a high-definition monitor in the operating room. The monitor screen is positioned above the patient for the surgeon and assistants to view real time throughout the operation. EXPERIENCE: The video telescopic operating microscope system was used to provide surgical illumination and magnification during total vaginal hysterectomy and salpingectomy, midurethral sling, and release of vaginal scar procedures. All procedures were completed without complications. The video telescopic operating microscope provided illumination of the vaginal operative field and display of the magnified image onto high-definition monitors in the operating room for the surgeon and staff to simultaneously view the procedures. CONCLUSION: The video telescopic operating microscope provides high-definition display, magnification, and illumination during vaginal surgery.

TELELAP ALF-X Robotic-assisted Laparoscopic Hysterectomy: Feasibility and Perioperative Outcomes.

STUDY OBJECTIVE: To show the safety, feasibility, and perioperative outcomes of total TELELAP ALF-X hysterectomy (SOFAR S.p.A., ALF-X Surgical Robotics Department, Trezzano Rosa, Milan, Italy). DESIGN: Phase II study (Canadian Task Force II-2). SETTING: Catholic University of the Sacred Heart, Rome, Italy. PATIENTS: From October 2013 to May 2014, 80 women underwent total TELELAP ALF-X hysterectomy. The study population was divided into 2 groups according to surgical procedures: total hysterectomy ± bilateral salpingo-oophorectomy (group 1) and endometrial cancer patients staged with pelvic lymphadenectomy (group 2). INTERVENTIONS: Total TELELAP ALF-X hysterectomy ± bilateral salpingo-oophorectomy with or without pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: The median age was 51 years (range, 48-79), and the median body mass index was 24 kg/m(2) (range, 17.3-34.2). Forty-five patients (56.2%) had previous surgery. The median operative time was 140 minutes (range, 58-320) in group 1 and 197 minutes (range, 129-290) in group 2 (p < .001). The median docking time was 8 minutes (range, 3-25). During the study period, a significant trend in operative time reduction was observed. Procedures were successfully performed without conversion in 93.7% of cases. We observed 2 (2.5%) intraoperative complications, 3 (3.7%) conversions to standard laparoscopy, and 2 (2.5%) to laparotomy. The median time to discharge was 2 days (range, 1-5). One patient (1.2%) was readmitted in the early postoperative period. CONCLUSION: As new technology evolves, critical appraisal of patient-related outcomes, use, cost, and access to minimally invasive hysterectomy must remain a priority. Despite the relative small number of our series, we showed the feasibility and safety of total TELELAP ALF-X hysterectomy for benign and malignant disease.

Laparoscopic sterilization of the African Lioness (Panthera leo).

OBJECTIVE: To describe laparoscopic ovariectomy and salpingectomy in the African lioness (Panthera leo). STUDY DESIGN: Descriptive clinical study. ANIMALS: Female lions (n = 16). METHODS: Lionesses were randomly divided into 2 groups: O = ovariectomy (n = 8) and S = salpingectomy (n = 8) for laparoscopic surgery. Two Veress needle placement techniques were used. RESULTS: Laparoscopic ovariectomy and salpingectomy were performed without complications. The poorly developed mesosalpinx and ovarian bursa rendered the uterine tube more accessible for salpingectomy compared to the dog making the procedure easier in the lioness. Similarly, salpingectomy is a relatively easier procedure compared with ovariectomy especially when the modified Hasson technique for Veress needle placement is used. CONCLUSIONS: Laparoscopic ovariectomy and salpingectomy can be safely performed in the African lioness.

Comparative efficacy of postpartum sterilisation with the titanium clip versus partial salpingectomy: a randomised controlled trial.

A multicentre trial was conducted to compare efficacy of postpartum sterilisation with clip and partial salpingectomy. Life-table estimates of pregnancy probabilities were compared through 2 years of follow up. A significantly different risk of pregnancy between the clip and partial salpingectomy groups was observed. Nine pregnancies were observed in the clip group versus two in the partial salpingectomy group. Cumulative probability of pregnancy through 2 years was 0.017 with the clip and 0.004 [correction added after online publication 25 September 2012; 0.044 has been replaced with 0.004] for partial salpingectomy (P < 0.04). Equivalent efficacy of the clip compared with partial salpingectomy has not been demonstrated in postpartum women.

[Feasibility of laparoendoscopic single-site surgery in gynecology with conventional laparoscopic instruments]. / Faisabilité de la cœliochirurgie gynécologique par mono-trocart avec instruments droits standards.

OBJECTIVES: To describe the safety and efficacy of single-port access for laparoscopic surgery in gynecology with conventional laparoscopic instruments. PATIENTS AND METHODS: In this prospective study, we report our experience with 90 patients who underwent Single Port Access (SPA) laparoscopic surgery for gynecologic pathology with the use of the SILS(®) Port Multiple Instrument Access Port (Covidien(®), Mansfield, MA). RESULTS: We realised 15 ovarian cystectomies, 30 salpingo-oophrectomies with 14 one side, 9 lysis of adhesions, 7 distal tubal repairs, 6 salpingectomy, 8 other procedures. The mean surgical time is 47 min (25-120). One conversion to conventional laparoscopy and one in laparotomy were performed. The mean duration stay is 2 days [1-3]. DISCUSSION AND CONCLUSION: SPA in gynecology is feasible with conventional laparoscopic instruments. SPA surgery represents the newest frontier in minimally invasive surgery.

The "Ruston Stretch": a simple way to get a large specimen out through a small hole.

The balance between port-site size and ease of specimen removal is often a challenge in laparoscopic surgery. Herein we describe a simple technique that circumvents this dilemma by means of port-site dilation using Hegar dilators.

Electrocautery-associated vascular injury during robotic-assisted surgery.

BACKGROUND: The robotic surgical platform is increasingly used in gynecology and, similar to laparoscopy, it has risks of electrocautery-associated injury. CASE: We present three cases of injury caused by failures of the monopolar scissors' insulating sheath while coagulation and cutting currents were set at 35 W. In case 1, an external iliac vein injury required blood transfusion and emergent laparotomy. In case 2, a full-thickness external iliac artery injury was repaired robotically. In case 3, a partial-thickness external iliac artery injury also was repaired robotically. CONCLUSION: Unintended electrosurgical arcs can occur from monopolar instruments. Insulation failure is a common finding in this type of injury. Surgeons should avoid excessive instrument collisions and should change the monopolar scissors' insulating sheath if there are any concerns of a defect in its integrity.

Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial.

BACKGROUND: The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial. METHODS: In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used. RESULTS: There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers. CONCLUSION: There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.

Single-port versus conventional laparoscopic salpingectomy in tubal pregnancy: a comparison of surgical outcomes.

OBJECTIVE: To compare the surgical outcomes of single-port laparoscopic salpingectomy (SPLS) and conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy. STUDY DESIGN: From January to June 2009, patients with tubal pregnancy were assigned to two surgical groups: SPLS and conventional laparoscopic salpingectomy. Surgical outcomes, including operative time, postoperative haemoglobin drop, hospital stay and complications, were compared prospectively. For SPLS, a novel multichannel port was made using a wound retractor and a surgical glove. RESULTS: In total, 60 patients were enrolled in the study (30 in the SPLS group and 30 in the conventional group). All operations were completed successfully. No significant difference was observed between the two groups in terms of mean operative time (52.6 ± 16.1 min vs 46.8 ± 16.2 min; p=0.174), mean difference between pre- and postoperative haemoglobin (1.7 ± 0.8 g/dl vs 1.8 ± 1.0 g/dl; p=0.636), or mean postoperative hospital stay (2.4 ± 0.5 days vs 2.4 ± 0.9 days; p=1.000). No complications were encountered in either group, and there was no conversion to conventional laparoscopy in the SPLS group. CONCLUSION: SPLS has comparable surgical outcomes to conventional laparoscopic salpingectomy for the surgical treatment of tubal pregnancy in terms of operative time, hospital stay and complication rates. However, further studies are needed to evaluate the merits expected of single-port laparoscopic surgery, such as cosmetic advantage and decreased pain in patients.