Robotic Assisted Hysterectomy S Kapurubandara12 Y Nikam234 1 Westmead Hospital 2 University of Sydney 3 Sydney West Area Pelvic Surgery (SWAPS) 4 University of Western Sydney

Case Preparation Largest OT room Dorsal lithotomy position and trendelenburg buttock just off the table. Securely positioned The arms padded in neutral position OGT IDC EUA + Uterine manipulator Once the robot is docked Cannot change the setup Securely positioned to avoid slippage/rhabdomyolysis

Port placement & Docking Two ways of docking – end of the bed. On the side. Left lateral is more popular allows concommitent vaginal and abdominal access and the scrub and assisstent placed on the right. The docked robot/should be in a straight line with umbi and opposite shoulder.

Case 38 yr old G3 P3 – 3 NVD Background – severe dysmenorrhea and menorrhagia OCP 6/12 Mirena 8/12 Declined endometrial ablation Clinically BMI 22 12/40 bulky uterus Minimal prolapse and no significant vaginal decent Normal US Option of Robotic vs Total laparoscopic hysterectomy (financial incentive was the same) No additional risks compared to laparoscopy. There are some case reports of modified trenedelenburg casuing cerebral odema (however this risk is the same fro TLH)

Step 3. The ovaries If the ovaries are to be conserved then the utero-ovarian ligament is cauterized and cut Step 4. The contra lateral side In a similar fashion the contra lateral side is secured. See the ease at which the contralateral side is secured. Step 2. Opening of the broad ligament. The round ligament is identified, cauterized using the fenestrated bipolar and cut using the monopolar Hot shears. The anterior leaf of the broad ligament is then incised towards the bladder and the vesicouterine reflection (bladder flap) is started. Step 5. The Vesico-uterine reflection The anterior leaf of the broad ligament is completely incised creating the vesicouterine reflection anteriorly. The vesicouterine reflection is tented up using the fenestrated bipolar and the bladder is gently dissected off the uterus and cervix using mostly sharp dissection with the shears. This will ensure adequate visualization of the colpotomy ring . Can approach this centrally or laterally (especially if previous surgeries eg LSCS) Step 6. Uterine Vessels the uterine arteries can be skeletonized adequately. This will ensure that the ureters are sufficiently lateral and out of harms way. The uterine arteries can then be coagulated using the bipolar and cut with the shears. I want to point out the contralateral ligation of UA here. I know most surgeons do not like to show their mistakes but this is a useful one to learn from. You can see we are using the instrument here like a straight stick - > this is where the learning curve comes from. After a few attempts, you realise the wrist action to simulate what you would do in open surgery an appropriately ligate Artery at 90 degrees to uterine artery It is advisable to begin coagulation at the ascending branch of the uterine artery and move caudal along the cardinal ligaments (Fig. 7). Step 7. Colpotomy The colpotomy is performed using the monopolar Hot Shears and taken all around. At one point the uterine manipulator will no longer suffice for retraction as the colpotomy progresses. The assisstent may help to hold the uterus to provide tension to coplete the colpotomy Specimen is then removed vaginaly. Vaginal cuff closure Irrigation is performed and any significant bleeding is controlled. Minimal oozing from the vaginal cuff can be controlled with the closure. Excessive cautery should be avoided to prevent cuff dehiscence The vaginal cuff can then be closed with interrupted figure of eight stitches using 2-0 Vicryl incorporating the uterosacral ligaments. The needle is passed in and out of the abdomen by the surgeon assistant. Alternatively, the vaginal cuff can be closed with a running stitch and the use of V lock.

Which one would you choose? Id like to leave you with an analogy used by Dr. monolistas at the AGES recently. Would you prefer the robot which is like a magnificent A380 designed to enhance your piloting skills, comfort at probably no extra safety or cost benefit Or would you prefer to persevere to the conventional way which is counterintuitive almost like flying upside down if you want to go look up Which one would you choose

Thank you