1. da Vinci® Sacrocolpopexy for Vaginal Vault or Uterine Prolapse: Lessons Learned
Oz Harmanli, MD
Chief, Urogynecology and Pelvic Surgery
Baystate Medical Center
Professor of OB/GYN
Tufts University School of Medicine
Massachusetts 1

2. Apical Prolapse Vaginal apex is the keystone Any surgical correction
of the anterior and posterior walls will fail if the apex is not adequately supported

3. Procedures for Apical Support
Sacral colpopexy
Sacrospinous ligament fixation
Utero-sacral ligament suspension
Ilio-coccygeus suspension
Vaginal mesh systems such as Prolift, Avaulta, Perigee/Apogee and etc.

4. Apical Prolapse Surgery
Cochrane Database Analysis for abdominal sacral colpopexy versus vaginal sacrospinous colpopexy
3 trials (Benson 1996; Lo 1998; Maher 2004)
Abdominal sacral colpopexy was better than vaginal colpopexy in terms of
Lower rate of apical recurrence (3/84 vs 13/85; RR 0.23, 95% CI 0.07 to 0.77)
Higher success rate (The number of women failing to improve to Stage 2 or better) (3/52 vs 13/66; RR 0.29, 95% CI 0.09 to 0.97)
Lower postoperative dyspareunia (7/45 vs 22/61; RR 0.39, 95% CI 0.18 to 0.86)
No significant difference in reoperation rate for prolapse (6/84 vs 14/85, RR 1.46, 95% CI 0.19 to 1.11)
Sacrospinous colpopexy was
Quicker
Cheaper
Faster return to normal activities
The data were too few to assess other clinical outcomes and complications
Maher et al. Neurourology and Urodynamics 2008

5. Sacral Colpopexy

6. Abdominal Sacral Colpopexy
Elevation of vaginal vault to Sacral 2 utilizing a mesh bridge
Abdominal, laparoscopic, or robotic approach
May change the vaginal axis (if sacral promontory is used)
85-90% success rate
May be done with cervical preservation as a cervicopexy
Mesh erosion around 3-5 %, higher with concomitant hysterectomy
Nygaard, Obstet Gynecol 2004, Kohli , Obstet Gynecol 1998

7. da Vinci Robotic Surgery Benefits
All the benefits of standard laparoscopy
Tremor filtration
Motion scaling
3D vision
EndoWrist® instruments with 7 degrees of freedom
4th arm to perform traction and retraction tasks
Net result: Improved technical capabilities
5 cm
1 cm 7

8. Patient Benefits Same as Standard Laparoscopy
Less post-operative pain
Less blood loss
Fewer transfusions
Less risk of infection
Less scarring
Improved cosmesis
Shorter hospital stay
Faster recovery time
Equivalent urogynecologic outcomes 8

9. Surgeon Benefits Improved access to the pelvis
Easier, more precise dissections
Improved handling of suture and mesh
Easier, quicker and more precise intracorporeal suturing
Control of camera and 3rd instrument arm adds precision, autonomy and efficiency
No short cuts just because it is minimally invasive surgery
Easier to learn, perform and teach 9

10. Surgeon Benefits Precise dissection Intracorporeal suturing
Mesh handling
Graft attachment 10

11. da Vinci Sacrocolpopexy: Proven Results
When compared with open techniques, robotic abdominal sacrocolpopexy is associated with less blood loss, shorter lengths of stay, and longer operative times
Geller Obstet Gynecol 2008
McDermott Obstet Gynecol Clin North Am 2009

12. da Vinci Sacrocolpopexy: Proven Results
E.J. Geller et al. Short-Term Outcomes of Robotic Sacrocolpopexy Compared With
Abdominal Sacrocolpopexy. Obstetrics & Gynecology ;112:1201–6
Robotic
Sacrocolpopexy
N=73
Open (Abdominal)
Sacrocolpopexy
N=105
P Value
Pre-op POP-Q Exam: C point* +3 +1
0.002
Concomitant Hysterectomy
47.9%
29.5%
0.02
Total Operative Time (min)
328
225
<0.001
Post-op POP-Q Exam: C point* -9 -8
0.008
EBL (ml)
103
255
<0.001
Length of Stay (days)
1.3
2.7
<0.001
73 v 105 patients
Higher POPQ values and more concomitant hysterectomies in the robotic group
 Blood loss and length of stay in the robotic group
C point suspension superior to open cohort results 12

13. Obstet Gynecol 2014
Costs of robotic sacrocolpopexy are higher than laparoscopic
Short-term outcomes and complications are similar
Primary cost differences resulted from robot maintenance and purchase costs.

14. Robotic vs Standard Laparoscopic Sacrocolpopexy Anger et al.

16. Systematic Review of Robotic Sacrocolpopexy Hudson et al FPMRS 2014
13 studies were selected for the systematic review.
Meta-analysis yielded a combined estimated success rate of 98.6% (95%CI 97.0–100%)
The combined estimated rate of mesh exposure/erosion was 4.1% (95%CI 1.4–6.9%)
The rate of reoperation for mesh revision was 1.7%

17. Systematic Review of Robotic Sacrocolpopexy Hudson et al FPMRS 2014
The rates of reoperation for recurrent apical and non-apical prolapse were 0.8% and 2.5%
The most common surgical complication (excluding mesh erosion) was cystotomy
(2.8%), followed by wound infection (2.4%).

18. Optimizing Operating Room Efficiency in Robotic Surgery
Baystate Medical Center
Tufts University School of Medicine
Massachusetts
Oz Harmanli, MD
Keisha Jones, MD
Beril Yuksel, MD
Faisal ElJehani, MD
University of Massachusetts
Isenberg School of Management
Massachusetts
Senay Solak, PhD
Armagan Bayram, PhD
This research was funded by an unrestricted educational grant from Intuitive Surgical Inc.

19. Optimizing Operating Room Efficiency in Robotic Surgery Objectives
To assess the critical threshold to optimize operating room time for each surgical team member in robotic sacrocolpopexy.
Evaluate the peak and plateau of the performances for each surgical team member
Determine the most optimal team configurations

20. Optimizing Operating Room Efficiency in Robotic Surgery Optimal Experience Level
Doctor
First Assistant
Anesthesia Provider 46
Scrub Technician 66
Circulating Nurse 56

21. Console Time for Surgeon by Experience
The Console Time of an inexperienced surgeon can be up to 1 hour longer

22. First Assistant’s Experience Level and Console Time
While some difference (up to around 25 minutes) in average Console Times exists for FA with different experience levels, these time differences are not sufficient to claim a statistically significant distinction

23. Does the Time of the Robotic Procedure Matter?
Specifically, the impact of the shift change in the afternoon
Cases which start before 11am were significantly shorter than those that start after 11am
The average difference was 12 minutes

24. The Role of a Dedicated Anesthesia Provider
Effect of a highly experienced Anesthesia Provider on OR time and specifically surgery prep time was studied
No significant difference in total OR times (which may be due to the effects of other factors)
However, prep times was significantly different

25. The Most Optimal Team Configurations Based on the Stochastic Model
The optimization tool can be used at a hospital to determine the `best’ surgical team assignments for any set of available team members with known experience levels

26. Practical Implications of the Stochastic Model
If a Surgeon has low experience, it is better to match him with more experienced First Assistant
If a Surgeon has high experience, it is fine to match him with less experienced First Assistant and Scrub Technician
If both the Surgeon and First Assistant are not as experienced it is better to match them with an experienced Scrub Technician

27. Practical Implications of the Stochastic Model
A low-experienced Scrub Tech should be matched with either a more-experienced Surgeon or First Assistant
We do not recommend to team up a low-experienced Surgeon, First Assistant, and Scrub Tech
If the anesthesia provider has more experience, it is fine to have a less experienced Circulating Nurse, however if anesthesia provider has less experience, it is best to match with a more experienced Circulating Nurse
Low-experienced Circulating Nurse should be teamed with an experienced Surgeon or vice versa