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.

Effect of Uterine Weight on the Surgical Outcomes of Robot-Assisted Hysterectomy in Benign Indications.

Background Uterine weight is an important factor in determining the complexity of a hysterectomy. Although greater uterine weight increases operative time and blood loss in open or laparoscopic surgery, it remains uncertain whether this applies to robot-assisted hysterectomy. This study aimed to investigate the effect of uterine weight on the surgical outcomes of robot-assisted hysterectomy. Methods We conducted a retrospective cohort study involving 872 patients who underwent robot-assisted hysterectomies at our institution between January 2019 and June 2022. Of these, 724 cases were analyzed and classified into four groups based on uterine weight: <250 g (377 patients), 250-500 g (253 patients), 500-750 g (69 patients), and ≥750 g (25 patients). We performed univariate analysis with the following endpoints: operation time, blood loss, postoperative hospital stay, complication rate, conversion to laparotomy rate, and blood transfusion rate. Results Operating time and blood loss increased significantly with greater uterine weight in the four groups (both p-values <0.01), but postoperative hospital stay and complication rate did not increase (p = 0.448, p = 0.679, respectively). None of the patients underwent conversion to laparotomy or blood transfusion. Conclusion Although the operating time for robot-assisted hysterectomy and blood loss increased with greater uterine weight, the complications and length of postoperative hospital stay were similar between groups. Robot-assisted hysterectomy is safe in cases of much uterine weight.

Recombinant thrombomodulin prevents heatstroke by inhibition of high-mobility group box 1 protein in sera of rats.

Heatstroke, a severe inflammatory response disease, is a medical emergency characterized by high body temperature. The protein C anticoagulant system inhibits inflammation resulting from various causes. Thrombomodulin (TM), a widely expressed glycoprotein originally identified in vascular endothelium, is an important cofactor in the protein C anticoagulant system. We tested the hypothesis that TM could prevent acute inflammation induced by heat stress in a rodent model. Male Wistar rats received a bolus of 1 mg x kg of body weight of TM or saline injected into the tail vein, followed by heat-stress treatment (exposure to 42°C for 30 min). Serum concentrations of cytokines (IL-1ß, IL-6, and TNF-α), NO, and high-mobility group box 1 (HMGB1) protein were measured at various time points after treatment. We observed a decrease in the levels of cytokines and HMGB1 protein in sera of TM-treated animals over time. Inhibition of NO overproduction by recombinant TM was observed during heat stress-induced inflammation. Because of the decline in inflammatory marker levels, TM ameliorated injury to various organs in the rat model of heat stress-induced acute inflammation. As TM exhibited a strong anti-inflammatory effect in a rat model of acute inflammation induced by heat stress, TM represents a potential therapeutic for heatstroke prevention or management in patients.