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Robotic Surgery in Gynaecological Oncology

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1 Robotic Surgery in Gynaecological Oncology
The 2nd International Meeting of the ERC and ELG-RCOG, Cairo, Egypt, 3rd&4th March 2012 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

2

3 Rossum's Universal Robots
Karel Capek Rossum's Universal Robots 1921

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

5 Laws of Robotics..!! Asimov, 1950s
Law 2: A robot must obey orders given to it by human beings, except where such orders would conflict with a higher order law. Law 3: A robot must protect its own existence as long as such protection does not conflict with a higher order law.

6 1980s; The era of industrial Robots

7 Development of Tele-surgery Technology
1990s; USA Stanford Research Institute Department of Defence NASA Development of Tele-surgery Technology

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

9 self-portrait (circa 1512 to 1515)
Da Vinci…… Leonardo da Vinci self-portrait (circa 1512 to 1515)

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

11 da Vinci® European Installed Base 1999 – 2010
2006 2008 2009 2005 2007 2001 2004 2000 2003 2002 1999 Courtesy of Intuitive

12 da Vinci® Middle Eastern Installed Base 1999 – 2010
2009 2008 2010 2003 2004 2006 2007 Courtesy of Intuitive

13 da Vinci Robot

14 The Console

15 The Console Filtered tremors 7-df Multi-task 3-D Vision

16 Robotic surgical arms: Patient’s cart
Console unit

17 Endo-Wrist Instruments & telescope

18 Advantages Disadvantages
Robotic Surgery Advantages Disadvantages 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 Open surgery techniques
Laparoscopic (Keyhole) Surgery Robotic Surgery

20 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 No undisclosed interests

21 Robotic Surgery in Endometrial cancer

22 Robotic Surgery in Endometrial cancer
Study Pt N. Proced Op Time EBL (ml) HS (d) IOC Remarks Diaz-Arrastia et al 2002 (R) 4 (all: 11) RAH+BSO 4.5 (hrs) 300 ( *) 2 (1/11*) 1st series (Recr.: 2001) BMI: 28 Side Dock. (Redocked) Set-up T: 45m8m Reynolds et al 2005 (P) (all: 7) ECS 257 (m) 50 Recr.: BMI: 27 LNC: 15 (Redocked) Marchal et al 2005 (P) 5 (all: 30) 181 (m) (CT: 120) 83 8 Recr.: LNC: 11 POC: 5 (17%) Robotic Surgery is: feasible; safe; ergonomic Reynolds 2005: FU 4-24m No Recurrence Marchal 2005: FU 2-23m No recurrence

23 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. BMI Op Time (m) EBL (ml) HS (d) POC % Conv Remarks DeNardis et al 2008 Robotic 56 29 177 105 1 3.6 5.4 Bl Tr.: 0 v 8.5% Open 106 34 79 241 3.2 20.8 Seamon et al 2009 242 100 12 ORT(m): 305 v 336 Bl. Tr.: 3 v 18% Laparosc. 76 287 250 2 26 Superior compared with Open or Laparoscopic Robotic Surgery is:

24 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. BMI Op Time (m) EBL (ml) HS (d) POC % Remarks Bogess et al 2008 Robotic 103 33 191 75 1 4.9* LNC: 33 vs 23 vs 15 *Post-Op C.: -PE:1 -Port site hernia:1 -Vaginal leak:1 -Lymphoecyst:1 -Lymphoedema:1 Laparosc. 81 29 213 146 1.2 9.9 Open 138 266 4.4 28.9 P <0.001

25 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. IOC % Conversion Bl. Transfusion Remarks Bogess et al 2008 Robotic 103 1* 2.9* 1 *Conversion RO: Adhesions: 1 Extra-uterine D: 2 *IOC: Sm. bowel injury: 1 Laparosc. 81 3.7 4.9 2.5 Open 138 0.7 NA 1.5 Laparoscopic IOC: Sm Bowel injury x 1; Bladder injury x 1; IVC injury x 1

26 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 Bogess et al 2008

27 Robotic Surgery in Endometrial cancer
Study N BMI OT EBL Conv LNC IOC POC LHS Veljovich et al 2008 25 26.3 283 67 - 17.5 1.7 Bell et al 2008 40 33 184 166 17 7.5 2.3 Hoekstra et al 2009 32 29 195 50 3.1 6.2 12.5 1

28 Robotic Surgery in Endometrial cancer
Study ECS Pt N. BMI Op Time (m) Conversion % HS (d) Remarks Peiretti et al 2009 80 25 181 3.7 2.5 Docking time: 4.5 minutes Holloway et al 2009 100 203160 4 - LNC: 25 V. Cuff dehiscence: 16%0 Robotic staging for endometrial cancer was feasible and safe

29 Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% BMI IOC Conversion Op Time EBL (ml) LNC POC HS (d) 32.4 3.5 % 6.7 % 171 (m) 88 16 14 % 1.8 Conversion to Laparotomy 6.7% Intra-Op Complications 3.5% Extra-Uterine D. 6 (1.5%) Vascular injury (V) 5 (1.2%) Large Uterus 10 ( 2.5%) Bowel injury 4 (1%) Ventilation Risk Bladder injury 3 (0.7%) Adhesions 7 (1.7%) Trocar injury 1 (0.2%)

30 Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% Post-Operative Complications Pyrexia 10 (2.5%) UTI 7 (1.7%) VTE Seroma Abscess 6 (1.5%) Lymphoedema/Cyst 5 (1.2%) Vault bleeding 3 (0.7%) Vault dehiscence Post-Operative Complications Ileus 3 (0.7%) Vesico-Vaginal Fistula 2 (0.4%) Delayed vascular injury* 1 (0.2%) Acute Renal F. Retro-peritoneal Haematoma Superficial Thrombophlebitis Total 57 (14%)

31 Robotic Surgery in Endometrial cancer
Lowe et al 2009: Multi-institutional Experience; 405 patients Full Endometrial Cancer Staging (Pelvic & PALND): 72% 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

32 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. BMI Op Time (m) EBL (ml) HS (d) POC Conv % Remarks Gocmen et al 2010 Robotic 10 33 235 95 2.8 - LNC: 42 vs 47 Open 12 30 169 255 8.8 Lee et al 2010 6 26 200 180 Small number: ? Learning phase

33 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N 148 BMI Op Time* (m) EBL (ml) IOC % POC % LNC HS Conversion Lim et al 2010 Robotic 56 30 163 89 14 27 1.6 1.7 Laparosc 28 193 209 13 21 45 2.6 7.1 Open 36 29 137 266 19 4.9 - P Sig. NS *Operative Time (Robotic), m: 183153149

34 Robotic Surgery in Endometrial cancer
Lim et al 2010; Pt N. 56(R); 56(L); 36(O) 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):

35 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. BMI Op Time (m) EBL (ml) IOC % Ret. To Theat. % HS Conver. % Cardenas-Goicoechea et al 2010 Robotic 102 32.3 237 109 2 1.9 1.8 1 Laparoscopic 173 32.7 178 187 3.5 1.2 2.3 5.2 P NS S Comparable LNC 22 vs 23

36 Robotic Surgery in Endometrial cancer
Study ECS Proced Pt N. BMI Op Time (m) EBL (ml) POC % LNC HS Conver. % Paley et al 2011 Robotic 377 27-33 247 47 6.4 18 1.4 3.45 Open (P&PALND: 55%) 131 - 198 20.6 13 5.3 *Operative Time (Robotic), m: 304207

37 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

38 Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications Complication Robotic, n = 377 Open, n = 131 P value Cardiac 1 (0.26%) 5 (3.8%) Pulmonary 3 (0.79%) 1 (0.76%) DVT/PE Infections 4 (1.1%) 6 (4.6%) ARF/ureteral injury 4 (3.0%) Wound dehiscence/separation 9 (6.9%) Major vessel injury Anemia requiring transfusion 2 (0.53%) Labile blood sugar Ileus/SBO Cystotomy Chylous ascites Cuff dehiscence Total 24/377 (6.4%) 27/131 (20.6%) < .0001 Category Robotic, n=377 Open, n=131 Admission to ITU 0.5 3.8 Mortality 0.27 1.5

39 Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging OT in T1, T2 and T3 for robotic ECS with pelvic and peri-aortic lymphadenectomy (n = 109) Year Mean OT (range), min Mean node count , n = 20 304(189–443) 19.6 , n = 29 230(105–314) 15.0 , n = 60 207(100–364) 18.8 OT in T1, T2, T3 for robotic ECS with pelvic lymphadenectomy +/- periaortic LNS (n = 138) Year Mean OT (range), min Mean node count (T1), n = 10 228 ( ) 13.1 (2–25) (T2), n = 28 190 (93–296) 14.4 (2–45) (T3), n = 100 171 (78–296) 12 (5–39)

40 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 Complication (BMI≥30 and <40) Robotic n = 136 Open n = 47 P Infection 1 (0.7%) 4 (8.5%) Wound dehiscence/separation 5 (10.6%) Anemia requiring transfusion 1 (2.1%) Pulmonary 2 Cystotomy Cardiac (MI, AF) 2 (4.2%) ARF Ureteral injury Total 5 (3.7%) 15 (31%) < .0001

41 Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications Comparison of major complications in robotic and open morbidly obese cohorts (body mass index >40) Complication Robotic, n = 53 Open, n = 23 P value Wound dehiscence/separation 6 (26%) Infection 3 (5.7%) 2 (8.7%) ARF Pulmonary 1 (1.9%) DVT/PE Labile BP Total 6 (11.3%) 10 (43.5%) .0006

42 Robotic Surgery in Endometrial cancer
Paley et al 2011: Full Endometrial Cancer Staging; Peri-operative Complications Conversion to laparotomy in robotic endometrial cancer cohort by body mass index category BMI category N=377 Total % of EC patients Conversions Normal weight 93 24.7% 2.1% Overweight 94 24.9% 4.2% Obese 138 36.6% 2.9% Morbidly obese 52 13.8% 5.8%

43 Robotic Surgery in Endometrial cancer
Robotic staging in Obese patients (TRH+BSO+BPLND+/-PALND/Omentectomy) Lau S et al 2011 Pt N.=108 BMI < 30 n=52 BMI 30 – 39.9 n=33 BMI ≥ 40 n=23 P % Radical Hysterectomy 7.7 2 NS N. Pelvic LNC 10.4 10.8 10.5 % PALND 42.3 27.3 4.4 S N. PA LNC 7 6.2 5 % Partial/Infracolic Oment. 15.4 9.1 4.3 % Lap. Adhesolysis 50 57.6 34.8 Uterine Wt. (g) 138.5 149.8 204 EBL 64.1 95.9 94 Post-Op Hb 116.4 118 115.9 OT, skin to skin (min) 237 255 257 OT, console time (min) 168 174 183 % Mini-Lap 6 3 LHS 1

44 Robotic Surgery in Cervical Cancer

45 Surgery for Cervical Cancer
1652 Pares & Talipius Osiander 1813 Langenbeck 1878 Freund 1895 Ries & Clark Cervical Amputation Cervical Amputation x 8 Vaginal Hysterectomy Abdominal Hysterectomy Radical Hyst and LND 1900 Wertheim 1902 Suhauta 1907 Bonney 1943 Taussig 1944 Meigs Radical Abdo Hysterectomy Radical Vag Hysterectomy Large series of Radical Hyst Surgery & Radiation Rad Hyst & LND

46 Radical Vag. Trachelectomy Robotic Radical Hysterectomy
Surgery for Cervical Cancer 1987 Dargent 1988 Sakamoto 1990 Canis 1991 Querleu 1992 Nezhat Coelio-Schauta Extraperit. LND Nerve Sparing Rad. Hyst Laparoscopic Rad Hyst Coelio-Schauta Transperit LND Laparoscopic Rad Hyst 1994 Dargent 1997 Smith 1998 Shepherd 1998 Maas 2006 Sert Radical Vag. Trachelectomy Radical Abdo Trachelectomy Modified RVT Nerve Sparing Rad. Hyst Robotic Radical Hysterectomy

47 Robotic Surgery in Cervical Cancer
Study Pt N. LNC Op Time EBL (ml) HS (d) *POC % Remarks Marchal et al 2005 7 (all: 30) 11 185 83 8 17 All complications Sert & Abeler 2007 RRH 13 241 71 4 4/8 *POC UTI: 1 each Lymphocyst: 2R vs 3L Bladder Inj: 1 each Compart. S.: 1L LRH 15 300 160 6/7 Kim et al 2008 10 27.6 207 355 - 1/10 *Pneumonia: 1 Robotic surgery in early cervical cancer is feasible and safe Sert et al 2007: FU months No recurrence

48 Robotic Surgery in Cervical Cancer
Study Pt N. LNC Op Time EBL (ml) HS (d) *POC % Remarks Fanning et al 2008 20 18 310 300 1 2/20 Bladder injury:1 Uretero-Vag. Fist: 1 Ko et al 2008 16 RRH 16 290 82 1.7 18.8* Vag. cuff abscess x 1 Uret.-Vag Fist x 1 (Temp) Lymphocyst x 1 32 ARH 17 219 665 4.9 21.9 Robotic surgery in early cervical cancer is feasible and safe..but took a long time! Fanning 2008: FU 7-36 m 90% alive without disease. Ko 2008: ARH Intraop. ureteric injury; wound inf. x 3; PE x 2

49 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. Op Time (m) EBL (ml) IOC* POC % LNC HS *Remarks Nezhat et al 2008 RRH 13 323 157 2/13 30 24.7 2.7 Cystotomy x 2 LRH 318 200 2/30 20 31 3.8 No conversion to laparotomy in either group F/U: No recurrence (R: 12m; L: 29m) RRH is comparable to LRH

50 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. BMI Op Time (m) EBL (ml) Bl Transf. POC % LNC HS Conver. % Bogess et al 2008 Robotic RH 51 29 211 97 7.8 34 1 Open RH 49 26 248 417 8% 16.3 23 3.2 Robotic Radical Hysterectomy is feasible and may offer better outcome compared with open; still need further studies

51 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. Op Time (m) EBL (ml) LNC HS Magrina et al 2008 RRH 27 190 133 26 1.7 LRH 31 220 208 2.4 Open RH 35 167 443 28 3.6 FU: monthsNo recurrence Robotic Radical Surgery was technically superior

52 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. BMI Op Time (m) EBL (ml) IOC % LNC HS POC Maggioni 2009 Robotic RH 40 24 272 78 5 20 3.7 20/40 Open RH 199 221 12.5 26 31/40 Recurrence: 12.5% in both cohorts Post-operative bladder function tend to be better in RRH

53 Robotic Surgery in Cervical Cancer
Early Post-Operative Complications RRH N=40 ARH SC Emphysema 4 Bl Transfusion 3 9 Pyrexia 12 Infection 1 PV discharge Ileus Obt. N. palsy 2 Pl. effusion Re-intervention Late Post-Operative Complications RRH N=40 ARH Mild Lymphoedema 2 Vaginal dehiscence 3 Incisional hernia 1 Lymphocyst 6 Re-admission 4 5 Re-intervention Robotic surgery in early cervical cancer is feasible and safe Rates of blood transfusion, re-admission and re-intervention are high..nevertheless; authors commented Robotic surgery is safe and feasible. Maggioni et al 2009

54 Robotic Surgery in Cervical Cancer
Persson et al 2009: Analysis of 64 patients with Cervical cancer Stages Op Time (m) EBL (ml) LNC Re-intervention IA1-IIA 262 475132 150 ( ) 26 (15-55) Re-suturing vaginal vault x 5 Repair port-site hernia x 2 Cystoscopy and stenting x 1 14% needed 60 days or more to resume spontaneous voiding

55 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. BMI Op Time (m) EBL (ml) IOC % LNC HS POC % Estape et al 2009 RRH 32 30 144 130 2.6 18.8 LRH 17 28 132 209 19 2.3 23.5 ARH 14 114 621 26 4 28.6 Positive margins: RRH: 16%; LRH: 18%; ARH: 21% RRH is feasible, safe and may be preferable to LRH & ARH

56 Robotic Surgery in Cervical Cancer
Study Procedure Pt N. BMI Op Time (m) EBL (ml) LNC HS Remarks Geisler et al 2010 RRH 30 34 154 165 25 1.4 Bladder took longer to recover in RRH ARH 32 166 323 26 2.8 RRH is feasible; recommended further prospective studies

57 Robotic Surgery in Cervical Cancer
Lowe et al: Multi-Institutional study; Retrospective analysis of 42 Patients with cervical cancer who underwent Type II-III RRH Stages BMI Op Time (m) EBL (ml) Bl Trans. LNC IOC % POC % Con % HS Remarks IA1-IB2 25 215 50 4.8 12 2.4 1 Uret. Injury: 2.4% DVT: 2.4% Postoperative adjuvant treatment was required for 14% of patients RRH offers low morbidity rates and may be an alternative to Open procedures

58 Radical Abdominal Hysterectomy: Intraoperative morbidity profile Roy et al 1996

59 Radical Abdominal Hysterectomy: Functional outcome
Kenter et al 1989; Bergmark et al 1999; Perrille & Jensen 2003

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

61 Nerve Sparing Radical Hysterectomy
Maas et al 2003

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

63 Nerve Sparing Radical Hysterectomy
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 Kenter 2007

64 Nerve Sparing Radical Hysterectomy
Kenter; data compiled from ESGO 2007

65 Robotic Surgery in Cervical Cancer
Magrina et al 2011: Nerve sparing RRH; prospective evaluation of 6 patients who underwent NS RRH (3 Pt has had Pelvic and PA LND) Stages BMI Op Time (m) EBL (ml) LNC IOC POC* CTL HS Remarks Ib1-Ib2 27.8 (23-35) 238.6 ( ) 135 ( ) 23.6 (19-29) 1/6 2 (1-4) *POC: Ileus x 1 Void. Dysf x 1 NS RRH is feasible and safe; urinary dysfunction may occur (transient) 17% Transient voiding dysfunction

66 Robotic Surgery in Cervical Cancer Fertility preservation options: Robotic Radical Trachelectomy
Study N Stage Op Time (m) EBL (ml) LNC POC Persson 2008 2 IA2,IB1 387359 1835 Geisler et al 2008 1 IB1 172 100 26 Chuang et al 2008 IA2 345 200 43 Burnett et al 2009 6 360 ( ) 108 (50-250) - 2/6 Ramirez et al 2010 4 IA1-IA2 340 ( ) 63 (50-75) 20 (18-27) 1/4 Complications (all studies): Bleeding from abdominal wall x 1 Incisional hernia x 1 LL sensory neuropathy x 1 NB: one patient required hysterectomy based on final histology Robotic Radical Trachelectomy is feasible; technique needs refinement Larger collaborative work is needed Medium and long term outcome is still awaited Yim et al 2011

67 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 Iglesias 2011

68 Robotic surgery in Gynaecology/Gynaeoncology
Vaginal cuff dehiscence Paley et al 2010: Evaluation of 832 Robotic Gynae/GO procedure involving vault closure Year N Cuff dehiscence % Mean BMI (range) T1 113 3 2.6% 26.5 (17.4–49.4) T2 277 2 0.72% 29.5 (14.6–69.2) T3 442 1 0.22% 30.1 (15.9–70.1) Zapardiel et al 2010: No dehiscence in 42 cases after technique refinement; FU: 4 months (0 vs 7% control group)

69 Robotic Hysterectomy: Comparative cost
Cost in USD* (average total) Robotic (n=40) Laparoscopic (n=30) Open (n=40) P Direct Cost $ $ $ >0.05 Indirect Cost $ $ $ <0.05 Total Cost $ $ $ 12,943.60 Days to return to normal activity 24.1 ± 6.9 31.6 ± 11.2 52.0 ± 71.8 <0.0001 <0.005 Estimated lost wages/productivity $ $ $ *DaVinci Surgical System cost is included as well as depreciation and maintenance Bell et al 2008

70 Robotic surgery in Gynaecological Oncology
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

71 Robotic surgery in Gynaecological Oncology
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!

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

73 Robotics; Future directions
Reduced bulk of equipment Ceiling Mounted Robotic arms Robotic Integrated OR Courtesy of intuitive

74 Robotics; Future directions
Augmented Reality Real time data fusion Courtesy: CBYON Courtesy of Intuitive

75 Robotics; Future directions
Courtesy of intuitive

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

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

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

79 Fluorescence Imaging - Vasculature
Robotics; Future directions Fluorescence Imaging - Vasculature Courtesy of intuitive

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

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

82

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

84 Ahmed Sekotory Ahmed ahmedsekotory@hotmail.com
Thank you Ahmed Sekotory Ahmed


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