Magrina slides reformatted for printing
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Transcript of Magrina slides reformatted for printing
Robotic Surgery in Gynecologic Oncology and Advanced Benign
Gynecology
Javier F. Magrina, MD
Professor of Gynecology
Mayo Clinic Scottsdale
Scottsdale, Arizona
JFM101603
Objectives
• Robotic results • Ovarian cancer• Advanced endometriosis
Robotic Surgery at Mayo Clinic Arizona 2003-2011
• Hysterectomy Kho RM, Hilger WS, Hentz JG, Magtibay PM, Magrina JF. Robotic hysterectomy: technique and initial outcomes. Am J Obstet Gynecol 2007 Jul; 197(1):113
• Adnexectomy**Magrina JF, Espada M, Munoz R, Noble BN, Kho RM. Robotic adnexectomy compared with laparoscopy for adnexal mass. Obstet Gynecol 2009 Sep; 114(3):581-4
• Myomectomy**Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol 2009 Dec; 201(6):566
• Presacral neurectomy. Int J Med Robot. 2011 Oct 07 • Appendectomy Akl MN, Magrina JF, Kho RM, Magtibay PM.
Robotic appendectomy in gynaecological surgery: technique and pathological findings. Int J Med Robot 2008 Sep; 4(3):210-3
Robotic Surgery at Mayo Clinic Arizona 2003-2011
• Cervical cancer**Magrina JF, Kho RM, Weaver AL, Montero RP, Magtibay PM. Robotic radical hysterectomy: comparison with laparoscopy and laparotomy. Gynecol Oncol 2008 Apr; 109(1):86-91
• Ovarian cancer** Magrina JF, Zanagnolo V, Noble BN, Kho RM, Magtibay P. Robotic approach for ovarian cancer: Perioperative and survival results and comparison with laparoscopy and laparotomy. Gynecol Oncol. 2011 Apr; 121(1):100-5
• Endometrial cancer**Magrina JF, Zanagnolo V, Giles D, Kho RM, Noble B, Magtibay PM. Robotic surgery for endometrial cancer: comparison with laparoscopy, vaginal/laparoscopy, laparotomy. Eur J Gynaecol Oncol. 2011; 32(5):476-80
Robotic Surgery at Mayo Clinic Arizona 2003-2011
• Robotic transperitoneal aortic lymphadenectomy Int J Gynecol Cancer. 2010 Jan; 20(1):184-7
• Robotic extraperitoneal aortic lymphadenectomy Gynecol Oncol. 2009 Apr; 113(1):32-5
• Robotic radical hysterectomy: Technical aspects. Gynecol Oncol. 2009 Apr; 113(1):28-31
• Robotic radical parametrectomy Acta Obstet Gynecol Scand. 2010 Aug; 89(8):1108-10
• Robotic transperitoneal infrarenal aortic lymphadenectomy for gynecologic malignancy: a left lateral approach. J Laparoendosc Adv Surg Tech A. 2011 Oct; 21(8):733-6
Robotic Surgery at Mayo Clinic Arizona 2003-2011
• Robotic extraperitoneal aortic lymphadenectomy: Development of a technique. Gynecol Oncol. 2009 Apr; 113(1):32-5
• Robotic nerve-sparing radical hysterectomy: feasibility and technique. Gynecol Oncol. 2011 Jun 1; 121(3):605-9
• Robotic nerve-sparing radical parametrectomy. Int J Med Robotics Computer-assisted Surg 2012
Robotics vs. Laparoscopy PRT Total Hysterectomy
Laparoscopy Robotics p
n=36 n=39
Uterus, gm 158.3 157.3 NS
OR, min 160.5 130.3 NS
EBL, ml 73.3 73.8 NS
LOS, hr 24.3 21.2 NS
Robotics vs. LaparoscopyHysterectomy
Complications, %
Robotics Laparoscopy p
Intraop 0 0 NS
Postop 5.1 0 NS
Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass
Robotic Laparoscopy p n=85 n=91
OR, min 83 71 0.01 EBL, ml 39 41 NS Hospital, >2 d, % 0 3 NS
Obstet Gynecol 2009, 114:581-4
Robotic vs. Laparoscopic Adnexectomy for the Adnexal Mass
Complications,%
Robotic Laparoscopy P
Intraop 1 2 NS
Postop ≤ 6 wk 12 11 NS
Obstet Gynecol 2009, 114:581-4
Robotic vs. Laparoscopic MyomectomyMayo Clinic Arizona
Robotic Laparoscopy p
OR, min 141 166 NS
EBL, ml 100 250 0.02
Hospital > 2d,% 5 9 NS
Am J Obstet Gynecol 2009, 201:566
Robotic vs. Laparoscopic MyomectomyMayo Clinic Arizona
Complications,% Robotic Laparoscopy p
n=40 n=41
Intraop 2 15 NS
Postop 12 10 NS
Conversion 0 5 NS
Readmissions 5 3 NS
Am J Obstet Gynecol 2009, 201:566
Robotics vs. Laparoscopy for Endometriosis
Robotics Laparoscopy p
OR time, min 159 179 NS
EBL, ml l88 103 NS
Hospital, d 1 1.1 NS
Robotics vs. Laparoscopy for Endometriosis
Robotics Laparoscopy p
Complications
Intraop 0.1 0 NS
Postop 6 8 NS
Conversion 2 0 NS
Mayo Clinic Arizona
Robotics vs. Laparoscopy
No major differences in perioperative results
Conclusion
Robotics is preferable to laparoscopy for:• Areas of difficult access• Extensive suturing• Complex dissection • Precision• Bleeding• Obesity
Robotics for Ovarian Cancer
• Primary debulking• Interval debulking • Recurrent cancer
Disease localized to pelvis and one or two other areas
Patient Selection for Robotics in Ovarian Cancer
Primary tumor excision (Hyst + BSO + omentectomy + lymphadenectomy) + 1 or 2 major procedures
• Modified posterior pelvic exenteration • Diaphragm resection• Small bowel resection • Other
Types of Debulking
Type
I Hyst + staging + 1 major
procedure
II Hyst + staging + 2 major
procedures
III Hyst + staging + 3 or more
major procedures
Type I Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparoscopy Laparotomy p n=15 n=20 n=41
OR, min 282 249 230 NS
EBL, ml 152 222 1005 <0.001
Hosp, d 3 3 7 <0.001Gynecol Oncol; 121:100, 2011
Type I Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparoscopy Laparotomy p
Complications,%
Intraop 20 10 10 NS
Postop 20 5 17 NS
Type II Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparoscopy Laparotomy p n=8 n=7 n=46
OR,min 345 267 259 0.02
EBL,ml 191 389 1261 <0.001
Hosp,d 5 5 11 <0.001Gynecol Oncol; 121:100, 2011
Type II Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparoscopy Laparotomy p
Complications,%
Intraop 0 14 11 NS
Postop 25 0 54 0.01
Type III Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparotomy n=2 n=32
OR, min 443 305
EBL, ml 150 1775
Hosp, d 11 10 Gynecol Oncol; 121:100, 2011
Type III Debulking in Ovarian CancerMayo Clinic Arizona
Robotics Laparotomy
Complications,%
Intraop 0 22
Postop 100 56
Survival in Ovarian CancerMayo Clinic Arizona
Robotics Laparoscopy Laparotomy p n=25 n=27 n=119
OS 3-yr,% 67 76 66 NS OS vs. debulking Complete 71 78 82 NS Incomplete 50 50 45 NS Gynecol Oncol; 121:100, 2011
Robotic Disadvantages for Ovarian Cancer
• OR table rotation • Additional trocars• Increased OR time with increased number of procedures
• Incision for anastomosis or removal of large specimens
Turning OR Table 180
Head Docking
Head Docking
R Upper Docking
R Upper Docking
assistantassistant
Pubis
camera
Cameraumbilicus
assistant
Infrahepatic and Anterior Diaphragm
Right ribs
Right ribs
AssistantAssistant
AssistantAssistant
22ndnd assistant assistant
Posterior Diaphragm
xyphoidxyphoid
Need for Incision
Neoadjuvant Chemotherapy
Increases % MIS for debulking
Sigmoid and Left Ovary
Before After
Infracolic OmentumBefore After
OmentumBefore After
StomachBefore After
Right DiaphragmBefore After
Splenic OmentumBefore After
PelvisBefore After
Right PelvisBefore After
Ascending ColonBefore After
Hepatic OmentumBefore After
Right Diaphragm and LiverBefore After
Liver After
Left Diaphragm and LiverAfter After
Robotic Excision Liver Metastasis
Excision Diaphragm Peritoneum
Robotic Full-thickness Diaphragm Resection
Robotic Excision Diaphragm Endometriosis
Robotic Resection L Diaphragm Recurrence
Infracolonic Omentectomy
Thank you