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The Christie NHS Foundation Trust Robotic Surgery in Gynaecological Oncology Ahmed Sekotory Ahmed MD MRCOG Lead Consultant & Director of Gynaecological.

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Presentation on theme: "The Christie NHS Foundation Trust Robotic Surgery in Gynaecological Oncology Ahmed Sekotory Ahmed MD MRCOG Lead Consultant & Director of Gynaecological."— Presentation transcript:

1 The Christie NHS Foundation Trust Robotic Surgery in Gynaecological Oncology Ahmed Sekotory Ahmed MD MRCOG Lead Consultant & Director of Gynaecological Oncology University Hospital of South Manchester The Christie NHS FT Manchester-UK The 2 nd International Meeting of the ERC and ELG-RCOG, Cairo, Egypt, 3 rd &4 th March 2012

2 The Christie NHS Foundation Trust

3 The Christie NHS Foundation Trust Karel Capek Rossum's Universal Robots 1921

4 The Christie NHS Foundation Trust “..Waldo, 1942….a science fiction story” 1942; Waldo published in the Astounding Science fiction Magazine Robert A. Heinlein – Science Fiction Author

5 The Christie NHS Foundation Trust Laws of Robotics..!! Asimov, 1950s

6 The Christie NHS Foundation Trust 1980s; The era of industrial Robots

7 The Christie NHS Foundation Trust 1990s; USA Development of Tele-surgery Technology

8 The Christie NHS Foundation Trust Important timelines: 1985BUMA system: placing a needle for brain biopsy 1988PROBOT: TURP 1992ROBODOC: assistance with hip replacement 1997da Vinci Robot: Tubal re-anastmosis 1999Robotic Assisted Coronary Bypass 2001 Tele-Surgery: Cholecystectomy, Surgeon in New York; Patient at Strasburg 2002da Vinci Robotic Assisted Hysterectomy

9 The Christie NHS Foundation Trust Da Vinci…… Leonardo da Vinci self-portrait (circa 1512 to 1515)

10 The Christie NHS Foundation Trust The “da Vinci” Robot? Mechanical Night (Robotic Knight); 1495

11 The Christie NHS Foundation Trust da Vinci ® European Installed Base 1999 – Courtesy of Intuitive

12 The Christie NHS Foundation Trust da Vinci ® Middle Eastern Installed Base 1999 – Courtesy of Intuitive

13 The Christie NHS Foundation Trust da Vinci Robot

14 The Christie NHS Foundation Trust The Console

15 The Christie NHS Foundation Trust The Console 3-D Vision  Filtered tremors  7-df  Multi-task  Filtered tremors  7-df  Multi-task

16 The Christie NHS Foundation Trust Robotic surgical arms: Patient’s cart Console unit

17 The Christie NHS Foundation Trust Endo-Wrist Instruments & telescope

18 The Christie NHS Foundation Trust Robotic Surgery AdvantagesDisadvantages  Ergonomic  3-D Vision  Filtered tremors  Improved dexterity; 7 degrees of freedom  Less fatigue  Allows performing complex procedure  Lack of tactile feedback  Can’t change operating table position once arms are docked to patient  Set up time  Cost  Capital cost  Maintenance  Disposables

19 The Christie NHS Foundation Trust Open surgery techniques Laparoscopic (Keyhole) Surgery Robotic Surgery

20 The Christie NHS Foundation Trust Robotics in Gynaecological Oncology Endometrial cancer staging – Special conditions: e.g. obesity Cervical cancer treatment – Radical surgery – Radical fertility sparing surgery (i.e. Trachelectomy) Cost-effectiveness evaluation Other uses: ovarian cancer…etc. Future directions Endometrial cancer staging – Special conditions: e.g. obesity Cervical cancer treatment – Radical surgery – Radical fertility sparing surgery (i.e. Trachelectomy) Cost-effectiveness evaluation Other uses: ovarian cancer…etc. Future directions No undisclosed interests

21 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer

22 The Christie NHS Foundation Trust Robotic Surgery is: feasible; safe; ergonomic Robotic Surgery is: feasible; safe; ergonomic Robotic Surgery in Endometrial cancer Reynolds 2005: FU 4-24m  No Recurrence Marchal 2005: FU 2-23m  No recurrence Reynolds 2005: FU 4-24m  No Recurrence Marchal 2005: FU 2-23m  No recurrence

23 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Robotic Surgery is: Superior compared with Open or Laparoscopic Robotic Surgery is: Superior compared with Open or Laparoscopic

24 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer

25 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Laparoscopic IOC: Sm Bowel injury x 1; Bladder injury x 1; IVC injury x 1

26 The Christie NHS Foundation Trust Bogess et al 2008 Robotic Surgery is: Safe and Effective alternative compared with Open or Laparoscopic Robotic Surgery is: Safe and Effective alternative compared with Open or Laparoscopic For Robotics:  > 50% Reduction in morbidity compared with laparoscopic route  5 times reduced morbidity compared with standard abdominal route Bogess et al 2008 For Robotics:  > 50% Reduction in morbidity compared with laparoscopic route  5 times reduced morbidity compared with standard abdominal route Bogess et al 2008

27 The Christie NHS Foundation Trust Robotic Robotic Surgery in Endometrial cancer

28 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Robotic staging for endometrial cancer was feasible and safe

29 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72%

30 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72%

31 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Mortality: 2 Cases 0.4% Case 1: Delayed vascular thermal injury -Presented 3 days post surgery (2/ post discharge): abdo pain; haemoperitonium -Leaking EIA  Stented -Condition deteriorated within 24 hrs Case 2: Cardiac event (MI) -Post-op shortness of breath, dizziness -Abnormal ECG -Sudden loss of consciousness -Cardiac arrest Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72%

32 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer

33 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer *Operative Time (Robotic), m: 183  153  149

34 The Christie NHS Foundation Trust dVH Learning Curve TLH Learning Curve TAH Learning Curve Reference: Lim PC, Kang E, PA-C, and Park DH. Learning curve and surgical outcome for robotic-assisted hysterectomy with lymphadenectomy: case-matched controlled comparison with laparoscopy and laparotomy for treatment of endometrial cancer. Journal of Minimally Invasive Gynecology, 2010;17(6): Robotic Surgery in Endometrial cancer Lim et al 2010; Pt N. 56(R); 56(L); 36(O)

35 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Comparable LNC 22 vs 23

36 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer *Operative Time (Robotic), m: 304  207

37 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Proportion of patients treated with MAS compared with Open technique: Increased from 6.4% to 80.5% over a 4-year period Paley et al; Am J Obstet Gynecol 2011 Proportion of patients treated with MAS compared with Open technique: Increased from 6.4% to 80.5% over a 4-year period Paley et al; Am J Obstet Gynecol 2011

38 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications

39 The Christie NHS Foundation Trust OT in T1, T2 and T3 for robotic ECS with pelvic and peri-aortic lymphadenectomy (n = 109) OT in T1, T2, T3 for robotic ECS with pelvic lymphadenectomy +/- periaortic LNS (n = 138) Robotic Surgery in Endometrial cancer Paley et al 2011: Full Endometrial Cancer Staging

40 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Comparison of complications in robotic and open surgery obese endometrial cancer cohorts (body mass index ≥30 and <40) Paley et al 2011 Comparison of complications in robotic and open surgery obese endometrial cancer cohorts (body mass index ≥30 and <40) Paley et al 2011

41 The Christie NHS Foundation Trust Comparison of major complications in robotic and open morbidly obese cohorts (body mass index >40) Robotic Surgery in Endometrial cancer Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications

42 The Christie NHS Foundation Trust Conversion to laparotomy in robotic endometrial cancer cohort by body mass index category Robotic Surgery in Endometrial cancer Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications

43 The Christie NHS Foundation Trust Robotic Surgery in Endometrial cancer Robotic staging in Obese patients (TRH+BSO+BPLND+/-PALND/Omentectomy)

44 The Christie NHS Foundation Trust ROBOTIC SURGERY IN CERVICAL CANCER

45 The Christie NHS Foundation Trust Surgery & Radiation Rad Hyst & LND 1652 Pares & Talipius Osiander Osiander1813Langenbeck1813Langenbeck1878Freund1878Freund1895 Ries & Clark 1895 Cervical Amputation Cervical Amputation x 8 Vaginal Hysterectomy Abdominal Hysterectomy Radical Hyst and LND Radical Abdo Hysterectomy Radical Vag Hysterectomy Hysterectomy Large series of Radical Hyst 1900Wertheim1900Wertheim1902Suhauta1902Suhauta1907Bonney1907Bonney1943Taussig1943Taussig1944Meigs1944Meigs Surgery for Cervical Cancer

46 The Christie NHS Foundation Trust1987Dargent1987Dargent1991Querleu1991Querleu1992Nezhat1992Nezhat 1994Dargent1994Dargent1997Smith1997Smith Coelio-Schauta Extraperit. LND Coelio-Schauta Coelio-Schauta Transperit LND Coelio-Schauta Laparoscopic Rad Hyst Radical Vag. Trachelectomy Radical Abdo Trachelectomy TrachelectomyModifiedRVTModifiedRVT Nerve Sparing Rad. Hyst 1998Shepherd1998Shepherd1998Maas1998Maas 1990Canis1990Canis Laparoscopic Rad Hyst Robotic Radical Hysterectomy 2006Sert2006Sert 1988Sakamoto1988Sakamoto Nerve Sparing Rad. Hyst Surgery for Cervical Cancer

47 The Christie NHS Foundation Trust Sert et al 2007: FU months  No recurrence Robotic surgery in early cervical cancer is feasible and safe Robotic Surgery in Cervical Cancer

48 The Christie NHS Foundation Trust Fanning 2008: FU 7-36 m  90% alive without disease. Ko 2008: ARH  Intraop. ureteric injury; wound inf. x 3; PE x 2 Fanning 2008: FU 7-36 m  90% alive without disease. Ko 2008: ARH  Intraop. ureteric injury; wound inf. x 3; PE x 2 Robotic surgery in early cervical cancer is feasible and safe..but took a long time! Robotic Surgery in Cervical Cancer

49 The Christie NHS Foundation Trust Robotic Surgery in Cervical Cancer No conversion to laparotomy in either group F/U: No recurrence (R: 12m; L: 29m) RRH is comparable to LRH No conversion to laparotomy in either group F/U: No recurrence (R: 12m; L: 29m) RRH is comparable to LRH

50 The Christie NHS Foundation Trust Robotic Radical Hysterectomy is feasible and may offer better outcome compared with open; still need further studies Robotic Surgery in Cervical Cancer

51 The Christie NHS Foundation Trust FU: months  No recurrence Robotic Radical Surgery was technically superior FU: months  No recurrence Robotic Radical Surgery was technically superior Robotic Surgery in Cervical Cancer

52 The Christie NHS Foundation Trust Recurrence: 12.5% in both cohorts Post-operative bladder function tend to be better in RRH Recurrence: 12.5% in both cohorts Post-operative bladder function tend to be better in RRH Robotic Surgery in Cervical Cancer

53 The Christie NHS Foundation Trust Maggioni et al 2009 Robotic surgery in early cervical cancer is feasible and safe Robotic Surgery in Cervical Cancer

54 The Christie NHS Foundation Trust 14% needed 60 days or more to resume spontaneous voiding Persson et al 2009: Analysis of 64 patients with Cervical cancer Robotic Surgery in Cervical Cancer

55 The Christie NHS Foundation Trust Robotic Surgery in Cervical Cancer Positive margins: RRH: 16%; LRH: 18%; ARH: 21% RRH is feasible, safe and may be preferable to LRH & ARH Positive margins: RRH: 16%; LRH: 18%; ARH: 21% RRH is feasible, safe and may be preferable to LRH & ARH

56 The Christie NHS Foundation Trust RRH is feasible; recommended further prospective studies Robotic Surgery in Cervical Cancer

57 The Christie NHS Foundation Trust RRH offers low morbidity rates and may be an alternative to Open procedures Lowe et al: Multi-Institutional study; Retrospective analysis of 42 Patients with cervical cancer who underwent Type II-III RRH Robotic Surgery in Cervical Cancer

58 The Christie NHS Foundation Trust Radical Abdominal Hysterectomy: Intraoperative morbidity profile Roy et al 1996

59 The Christie NHS Foundation Trust Radical Abdominal Hysterectomy: Functional outcome Kenter et al 1989; Bergmark et al 1999; Perrille & Jensen 2003

60 The Christie NHS Foundation Trust Radical Abdominal Hysterectomy: Functional outcome Maas et al 2006 Loss of labial sensation: 3%; 74%; 81%; 79% at above intervals

61 The Christie NHS Foundation Trust Nerve Sparing Radical Hysterectomy Maas et al 2003

62 The Christie NHS Foundation Trust Advantages: – Preserve bladder compliance – Less bladder over-activity – Less incontinence – Preserve rectal function – Preserve vaginal lubrication: Less dyspareunia Better libido Advantages: – Preserve bladder compliance – Less bladder over-activity – Less incontinence – Preserve rectal function – Preserve vaginal lubrication: Less dyspareunia Better libido Nerve Sparing Radical Hysterectomy Kenter 2007

63 The Christie NHS Foundation Trust Feasible in approx. 80% of surgical cases: – No extra Blood loss – Little extra time – No increased complication rate – Relatively difficult cases: High BMI Barrel shaped tumours Feasible in approx. 80% of surgical cases: – No extra Blood loss – Little extra time – No increased complication rate – Relatively difficult cases: High BMI Barrel shaped tumours Nerve Sparing Radical Hysterectomy Kenter 2007

64 The Christie NHS Foundation Trust Nerve Sparing Radical Hysterectomy Kenter; data compiled from ESGO 2007

65 The Christie NHS Foundation Trust Robotic Surgery in Cervical Cancer NS RRH is feasible and safe; urinary dysfunction may occur (transient) 17% Transient voiding dysfunction NS RRH is feasible and safe; urinary dysfunction may occur (transient) 17% Transient voiding dysfunction Magrina et al 2011: Nerve sparing RRH ; prospective evaluation of 6 patients who underwent NS RRH (3 Pt has had Pelvic and PA LND)

66 The Christie NHS Foundation Trust Robotic Surgery in Cervical Cancer Fertility preservation options: Robotic Radical Trachelectomy Complications (all studies):  Bleeding from abdominal wallx1  Incisional herniax1  LL sensory neuropathy x1 NB: one patient required hysterectomy based on final histology Complications (all studies):  Bleeding from abdominal wallx1  Incisional herniax1  LL sensory neuropathy x1 NB: one patient required hysterectomy based on final histology Yim et al 2011 Robotic Radical Trachelectomy is feasible; technique needs refinement Larger collaborative work is needed Medium and long term outcome is still awaited Robotic Radical Trachelectomy is feasible; technique needs refinement Larger collaborative work is needed Medium and long term outcome is still awaited

67 The Christie NHS Foundation Trust Robotic surgery in Ovarian cancer staging MAS is safe and effective in borderline ovarian tumours and early ovarian cancer No sufficient evidence to support its use in advanced disease Concern remains regarding: – Adequate abdominal exploration & staging – Cyst/Tumour rupture – Port site metastasis MAS is safe and effective in borderline ovarian tumours and early ovarian cancer No sufficient evidence to support its use in advanced disease Concern remains regarding: – Adequate abdominal exploration & staging – Cyst/Tumour rupture – Port site metastasis Iglesias 2011

68 The Christie NHS Foundation Trust Robotic surgery in Gynaecology/Gynaeoncology Vaginal cuff dehiscence Zapardiel et al 2010: No dehiscence in 42 cases after technique refinement; FU: 4 months (0 vs 7% control group) Paley et al 2010: Evaluation of 832 Robotic Gynae/GO procedure involving vault closure

69 The Christie NHS Foundation Trust Robotic Hysterectomy: Comparative cost Bell et al 2008*DaVinci Surgical System cost is included as well as depreciation and maintenance

70 The Christie NHS Foundation Trust May be superior to either Open or ordinary MAS Offers clear advantage in technically difficult cases (e.g. morbidly obese; endometrial cancer patients) Potentially improved outcome in Cervical cancer patients (e.g. Nerve sparing surgery) Role in Trachelectomy needs further evaluation May be superior to either Open or ordinary MAS Offers clear advantage in technically difficult cases (e.g. morbidly obese; endometrial cancer patients) Potentially improved outcome in Cervical cancer patients (e.g. Nerve sparing surgery) Role in Trachelectomy needs further evaluation Robotic surgery in Gynaecological Oncology

71 The Christie NHS Foundation Trust Still awaiting:  Larger multi-centre & prospective studies  Evaluation of long term Outcome & Prognosis  Evaluation of Self-reported patients’ Outcome  New innovations to enhance performance & reduce cost! Still awaiting:  Larger multi-centre & prospective studies  Evaluation of long term Outcome & Prognosis  Evaluation of Self-reported patients’ Outcome  New innovations to enhance performance & reduce cost! Robotic surgery in Gynaecological Oncology

72 The Christie NHS Foundation Trust Robotics; Future directions Courtesy: Karlsruhe Courtesy: Surgical Science  Central register for training  Objective and uniform assessment  Easy access to training  Tele-Mentoring  Tele-Surgery  Central register for training  Objective and uniform assessment  Easy access to training  Tele-Mentoring  Tele-Surgery Teaching and Training

73 The Christie NHS Foundation Trust Reduced bulk of equipment Ceiling Mounted Robotic arms Robotic Integrated OR Reduced bulk of equipment Ceiling Mounted Robotic arms Robotic Integrated OR Courtesy of intuitive Robotics; Future directions

74 The Christie NHS Foundation Trust Augmented Reality Real time data fusion Courtesy: CBYON Robotics; Future directions Courtesy of Intuitive

75 The Christie NHS Foundation Trust Robotics; Future directions Courtesy of intuitive

76 The Christie NHS Foundation Trust Instruments Additional types of instruments Reusable instruments Use of the CO2 laser Robotic Needle holder Courtesy of intuitive Robotics; Future directions Courtesy of Intuitive

77 The Christie NHS Foundation Trust Future Tissue Interaction Concepts* – Linear Cutters – Seal and Cut – Suction/Irrigation Integrated Energy Instruments (current) –Monopolar Energy –Bipolar Energy –Advanced Bipolar –Harmonic –Advanced Graspers –Laser * Research only. Not FDA approved. * Robotics; Future directions Courtesy of intuitive

78 The Christie NHS Foundation Trust Image Guidance - Fluorescence ICG Central venous Interstitial Specific antibodies plus fluorescing markers Vasculature Lymph Node Mapping Robotics; Future directions Courtesy of intuitive

79 The Christie NHS Foundation Trust Fluorescence Imaging - Vasculature Robotics; Future directions Courtesy of intuitive

80 The Christie NHS Foundation Trust In Vivo Microscopy Sub-micron in vivo histology Real-time functional and molecular imaging and diagnosis Tissue information (cancer, endometriosis, etc) Robotics; Future directions Courtesy of intuitive

81 The Christie NHS Foundation Trust Advanced Single Port or NOTES Flexible Systems Natural orifice / trans-umbilical da Vinci-like capability Large range of motion (multi- quadrant capability) Instruments and accessories shown have not been approved by the FDA Single Port Robotics; Future directions Courtesy of intuitive

82 The Christie NHS Foundation Trust

83 The Christie NHS Foundation Trust 6 th – 7 th September 2012 Manchester-UK 6 th – 7 th September 2012 Manchester-UK The 3 rd Annual Conference of the British & Irish Association of Robotic Gynaecological Surgeons

84 The Christie NHS Foundation Trust Thank you Ahmed Sekotory Ahmed


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