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

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

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

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.”

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

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

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.

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

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

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.

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.

da Vinci® Hysterectomy for Benign Gynecologic Conditions

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.

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.

da Vinci® Sacrocolpopexy

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.

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.

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 871180 Rev. A 6/08

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.

Robotic Surgery Conventional Laparoscopy

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

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%

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

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

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

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

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

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

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

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

Total Cost – NO Depreciation AH LH RH Barnett 7009 6581 7478 Landeen 4025 4475 6129

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