1. da Vinci Gynecologic Surgery
Wesley Harris, M. D.
da Vinci Gynecologic Surgery

2. Surgical Approaches to Gynecologic Conditions
Open (abdominal) surgery
Minimally invasive surgery (MIS)
Vaginal surgery
Conventional laparoscopic surgery
da Vinci® Hysterectomy (robotic-assisted surgery)

3. MIS – Laparoscopic Surgery
Minimally invasive surgery (MIS)
Ability to operate through small keyhole incisions
The camera and instruments fit through the keyhole incisions
Better visualization than open surgery

4. ACOG Committee Opinion Number 444 – November 2009
“Evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic and abdominal hysterectomy. When it is not feasible to perform a vaginal hysterectomy, the surgeon must choose between laparoscopic hysterectomy, robot-assisted hysterectomy or abdominal hysterectomy.”

5. Things that make vaginal hysterectomy easier:
Prior vaginal delivery
No adnexal pathology
Uterus <250 gm

6. Things that make vaginal hysterectomy more difficult:
Nulliparity
Prior cesarean section
Adnexal pathology
Severe pelvic adhesions
Morbid obesity

7. Program Gynecologic Conditions da Vinci® Surgical System
da Vinci Gynecologic Surgery
da Vinci Hysterectomy for Early Stage Gynecologic Cancer
da Vinci Hysterectomy for Benign Conditions
da Vinci Myomectomy
da Vinci Sacrocolpopexy
During the course of this seminar, I will discuss gynecologic problems, their symptoms and treatment options, including surgical options. I will provide an overview of da Vinci Gynecologic Surgery, which is your most effective, least invasive surgical option. This category of treatment includes da Vinci GYN Cancer Surgery, da Vinci Hysterectomy, da Vinci Myomectomy, and da Vinci Sacrocolpopexy.

8. Gynecologic Conditions
Pre-cancer
Cancer
Pelvic masses
Abnormal bleeding
Endometriosis
Fibroids
Pelvic floor disorders
Fallopian Tube
Uterus
Ovary
Bladder
Pubic Bone
Rectum
Urethra
Pre-cancer
Cancer
Fibroids, which appear in the wall of the uterus – the myometrium – or in the lining of the uterus – the endometrium
Pelvic masses, which may appear in the ovaries or fallopian tubes.
Abnormal bleeding
Endometriosis
Pelvic floor disorders, examples include: prolapsed uterus, vagina, bladder or rectum
Vagina

9. Benefits of Minimally Invasive Surgery (MIS)
Reduced blood loss
Fewer complications
Shorter LOS
Faster recovery
Less scarring
Less risk of infection
Significantly less pain
Improved cosmesis
Since the late 1980s, surgeons have been trained in MIS, leading to unprecedented patients benefits.
Circa. 1991

10. Drawbacks with Conventional Laparoscopic Surgery
Surgeon operates from a 2D image
Straight, rigid instruments (limited range of motion)
Instrument tips controlled at a distance
Reduced dexterity, precision and control
Unsteady camera controlled by assistant
Dependent on assistant for surgical support through an accessory port
Greater surgeon fatigue
Makes complex operations more difficult
Despite these advantages, there are still many drawbacks to a conventional laparoscopy.
The surgeon operates looking at a monitor that only shows a two dimensional image.
The rigid instruments the surgeon works with are controlled from a distance; they have no wrists, which decreases precision, dexterity and control.
As a result, the surgeon will also tire more quickly.
Due to the small incision, the participation of the assistant is limited. This makes complex gynecologic operations very difficult, resulting in a higher likelihood that you will receive a larger incision.

11. How to overcome these drawbacks?
Improve visualization
Improve instrument control
Enhance dexterity for technically challenging aspects of the procedure
Use superior ergonomics
The da Vinci System was designed to overcome the limitations of the traditional open and conventional laparoscopic (minimally invasive) approaches.
da Vinci is a state-of-the-art surgical robotic system that provides the extended capabilities necessary to complete your procedure using only a few small incisions.
With da Vinci Surgery, the surgeon is seated at a nearby console and is always in full control of the robotic instruments.
Since the assistant is next to the patient and has direct access to the surgical site, he or she can assist during complex steps of the procedure.
Of special note is the fact that all of these drawbacks are not only overcome for the average sized individual but also obese and morbidly obese patients.

12. da Vinci® Hysterectomy for Benign Gynecologic Conditions

14. da Vinci Hysterectomy
Dexterity for complex dissections (e.g endometriosis)
Vaginal cuff suture closure with ease
Improved visualization and access around the cervix for a colpotomy
The da Vinci System enables an improved hysterectomy technique by providing….
Video courtesy of Javier F. Magrina, M.D.

15. Benefits of da Vinci Hysterectomy
Enables GYNs to treat complex pathology endoscopically
Unsurpassed precision, dexterity and control offer potential for:
More precise and efficient dissections
Ureters, vesico-uterine reflection, colpotomy
Quicker, easier vaginal cuff closure
Greater ability to perform MIS on more patient types
Compromised anatomy and tissue planes, e.g., due to endometriosis and adhesive disease from prior pelvic surgeries
Larger pathology
Obese patients
So, let’s switch gears and review our value proposition for benign dVH. da Vinci enables GYNs to treat complex pathology endoscopically.
More precise and efficient dissections to isolate the ureters, create the vesico-uterine reflection and perform the colpotomy
Quicker, easier vaginal cuff closure
Greater ability to perform MIS on more patient types:
Greater ability to dissect compromised anatomy and tissue planes, e.g., due to endometriosis or prior pelvic surgery, using a minimally invasive approach.
Greater ability to operate on larger pathology, e.g., enlarged fibroid uterus, endoscopically.
Greater ability to treat more patients - including obese patients - minimally invasively.
Many GYNs choose or convert to laparotomy for these complex cases.
da Vinci enables these more complex cases, which can result in fewer conversions to laparotomy and a more endoscopic GYN surgical practice overall. And this is where value to the patient comes into play.

16. da Vinci® Sacrocolpopexy

17. da Vinci Sacrocolpopexy
Easier, quicker and more precise suturing
Complete control of the camera and all three operative arms
A reproducible approach
The da Vinci System enables the myomectomy procedure by….
Double-click to view video
Video courtesy of Anthony Visco, M.D.

18. Benefits of da Vinci Sacrocolpopexy
da Vinci Sacrocolpopexy is considered the gold standard for vaginal vault prolapse
<5% are performed with laparoscopy
This procedure typically requires difficult dissections and extensive suturing
da Vinci enables an endoscopic approach for sacrocolpopexy
The unsurpassed visualization, depth perception, dexterity and control offered by the da Vinci System provide:
Improved access to the pelvis compared to open and conventional laparoscopic approaches
Easier, more precise rectovaginal and presacral dissections
Improved handling of suture and mesh for more accurate graft placement and attachment
And because they can perform the same surgery with the da Vinci System that they perform open, robotic urogyns believe that dVSC could become the new surgical gold standard for sacrocolpopexy.
In terms of clinical value, da Vinci provides a greater ability to visualize and dissect the vaginal vault and the sacrum for precise graft attachment.
More precise and fast suturing of the graft to the anterior-posterior vaginal wall and to the anterior surface of the sacrum…and to retroperitonealize the graft following graft attachment.
Most importantly, it will allow urogyns to offer the potential benefits of MIS to their pelvic floor prolapse patients.

19. da Vinci® Gynecology Improving the Quality of Life for Women
As with any surgery, these benefits cannot be guaranteed, as surgery is patient- and procedure-specific. This program presents the opinions of and techniques used by an independent surgeon and not those of Intuitive Surgical. Intuitive Surgical does not provide clinical training nor does it provide or evaluate surgical credentialing or train in surgical procedures or techniques. While clinical studies support the effectiveness of the da Vinci® System when used in minimally invasive surgery, individual results may vary. Surgery with the da Vinci Surgical System may not be appropriate for every individual. Always ask your doctor about all treatment options, as well as their risks and benefits. © 2006 Intuitive Surgical. All rights reserved. Intuitive, Intuitive Surgical, da Vinci, da Vinci S, TilePro and EndoWrist are trademarks or registered trademarks of Intuitive Surgical. All other product names are trademarks or registered trademarks of their respective holders. PN Rev. A 6/08

20. da Vinci Hysterectomy Minimizes TAH and Conversion Rates
Data from Drs. Thomas Payne and Ralph Dauterive
Ochsner Clinic, Baton Rouge, LA
Retrospective Review of Hysterectomy: Pre-Robotic versus da Vinci
Pre-robotic (n=100)
da Vinci (n=100)
Last 25 da Vinci
Age (years)
43.5
43.2
BMI
28.8
Estimated blood loss (ml)
113 61
Hospital stay (days)
1.6
1.1
TAH rate
20% 4% 0%
Conversions (subset of TAH) 9%
Avg uterine weight of conversions
359.5
1387.5
TAH due to adhesions 8%
Operative times (skin-to-skin)
92.4
119
78.7
The Ochsner Clinic data demonstrates that da Vinci Minimizes Total Abdominal Hysterectomy (TAH) and Conversion Rates Compared to Conventional Laparoscopy
Highlight key endpoints in bold.
IMPORTANT: The Ochsner Clinic data has been submitted for publication. DO NOT distribute (leave behind) this information! Doing so could jeopardize their pending publication.
Source: Oral presentation by Dr. Thomas Payne at AAGL 2007.

21. Robotic
Surgery
Conventional
Laparoscopy

22. Less Conversions for Robot as compared to conventional laparoscopy
Matthews LH
12%
57 cases RH 0%
70 cases
Payne LH 9% RH 4%
Sarlos – review
Mixed Reports

23. Complication Rates AH LH RH VH Matthews 23% 7.0% 4.3% 11.1% Sarlos
EQUAL
Landeen
14.0%
8.8%
8.4%
8.0%

24. Complication Rates
Complication Rates for the minimally invasive procedures are relatively equal
Minimally invasive procedures have a lower complication rate than open procedures

25. OR Time AH VH LH RH Pasic 169 193 Giep 90 Sarlos 83 109 Barnett 147
213
192
Landeen 84 99
118
117

26. OR Time
Operating times are fairly equal between laparoscopic and robotic hysterectomy
Open laparotomy does lead to a decrease in OR time compared to laparoscopic and robotic procedures

27. Length of Stay AH VH LH RH Matthews 3.34 1.8 1.7 1.6 Landeen 2.7 1.9
1.3
Pasic
1.4
Giep
1.2
1.0
Sarlos
3.9
3.3
Payne

28. Length of Stay
Length of stay NOT significantly different among minimally invasive procedures
Length of stay for all minimally invasive procedures is significantly less than for open surgery

29. Direct Cost Equipment Operative Time Post Operative Time Capital
Non Capital
Operative Time
Post Operative Time

30. Sarlos LH RH Personnel Costs 1824 2434 Material Costs 1128 3152
Total Costs
2952
5583

31. Surgical Supplies AH VH LH RH Landeen 156 283 890 1859 Barnett 198
1138
2210

32. Total Cost – NO DepreciationAH LH RH
Barnett
7009
6581
7478
Landeen
4025
4475
6129

33. Societal Perspective Model of Barnett
Conventional
Laparoscopic
10,128
Robotic
11,476
Laparotomy
12,847