da Vinci Gynecology

Wesley Harris, M. D.

da Vinci Gynecologic Surgery

da Vinci Gynecology

Open (abdominal) surgery

Minimally invasive surgery (MIS) Vaginal surgery Conventional laparoscopic surgery da Vinci® Hysterectomy (robotic-assisted surgery)

Surgical Approaches to Gynecologic Conditions

da Vinci Gynecology

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

da Vinci Gynecology

ACOG Committee OpinionNumber 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.”

da Vinci Gynecology

Things that make vaginal hysterectomy easier:

1. Prior vaginal delivery

2. No adnexal pathology

3. Uterus <250 gm

da Vinci Gynecology

Things that make vaginal hysterectomy more difficult:

1. Nulliparity

2. Prior cesarean section

3. Adnexal pathology

4. Severe pelvic adhesions

5. Morbid obesity

da Vinci Gynecology

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

da Vinci Gynecology

Gynecologic Conditions

•Pre-cancer•Cancer•Pelvic masses•Abnormal bleeding•Endometriosis•Fibroids •Pelvic floor disorders

Uterus

Fallopian

TubeOvary

Bladder

Urethra

Pubic Bone

Vagina

Rectum

da Vinci Gynecology

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

Circa. 1991

da Vinci Gynecology

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

da Vinci Gynecology

How to overcome these drawbacks?

Improve visualization Improve instrument

control Enhance dexterity for

technically challenging aspects of the procedure

Use superior ergonomics

da Vinci Gynecology

da Vinci® Hysterectomy for Benign Gynecologic Conditions

13

da Vinci Gynecology

Dexterity for complex dissections (e.g endometriosis)

Vaginal cuff suture closure with ease

Improved visualization and access around the cervix for a colpotomy

Video courtesy of Javier F. Magrina, M.D.

da Vinci Hysterectomy

da Vinci Gynecology

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

Benefits of da Vinci Hysterectomy

da Vinci Gynecology

da Vinci® Sacrocolpopexy

da Vinci Gynecology

Easier, quicker and more precise suturing

Complete control of the camera and all three operative arms

A reproducible approach

Video courtesy of Anthony Visco, M.D.

Double-click to view video

da Vinci Sacrocolpopexy

da Vinci Gynecology

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 approachfor 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

Benefits of da Vinci Sacrocolpopexy

da Vinci Gynecology

da Vinci® Gynecology

Improving the Quality of Life for

WomenAs 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 Gynecology

da Vinci Hysterectomy Minimizes TAH and Conversion Rates

Data from Drs. Thomas Payne and Ralph DauteriveOchsner Clinic, Baton Rouge, LA

Source: Oral presentation by Dr. Thomas Payne at AAGL 2007.

Pre-robotic (n=100) da Vinci (n=100)Last 25da Vinci

Age (years) 43.5 43.2

BMI 28.8 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% 4% 0%

Avg uterine weight of conversions 359.5 1387.5

TAH due to adhesions 8% 0%

Operative times (skin-to-skin) 92.4 119 78.7

Retrospective Review of Hysterectomy: Pre-Robotic versus da Vinci

da Vinci Gynecology

Robotic

Surgery

Conventional

Laparoscopy

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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

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Complication Rates

AH LH RH VH

Matthews 23% 7.0% 4.3% 11.1%

Sarlos EQUAL EQUAL

Landeen 14.0% 8.8% 8.4% 8.0%

da Vinci Gynecology

Complication Rates

• Complication Rates for the minimally invasive procedures are relatively equal

• Minimally invasive procedures have a lower complication rate than open procedures

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OR Time

AH VH LH RH

Pasic 169 193

Giep 90 90

Sarlos 83 109

Barnett 147 213 192

Landeen 84 99 118 117

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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

da Vinci Gynecology

Length of Stay

AH VH LH RH

Matthews 3.34 1.8 1.7 1.6

Landeen 2.7 1.9 1.8 1.3

Pasic 1.4 1.4

Giep 1.2 1.0

Sarlos 3.9 3.3

Payne 1.6 1.0

da Vinci Gynecology

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

da Vinci Gynecology

Direct Cost

• Equipment• Capital

• Non Capital

• Operative Time

• Post Operative Time

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Sarlos

LH RH

Personnel Costs 1824 2434

Material Costs 1128 3152

Total Costs 2952 5583

da Vinci Gynecology

Surgical Supplies

AH VH LH RH

Landeen 156 283 890 1859

Barnett 198 1138 2210

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Total Cost – NO Depreciation

AH LH RH

Barnett 7009 6581 7478

Landeen 4025 4475 6129

da Vinci Gynecology

Societal Perspective Modelof Barnett

Conventional

Laparoscopic10,128

Robotic 11,476

Laparotomy 12,847