Kiyoshi Kanno

Short‐term outcomes of robot‐assisted versus conventional laparoscopic surgery for early‐stage endometrial cancer: A retrospective, single‐center study

AbstractAimWe compared the short‐term outcomes between conventional laparoscopic surgery (CLS) and robot‐assisted surgery (RAS) to assess the technical feasibility of the latter for early‐stage endometrial cancer.MethodsWe retrospectively compared the perioperative outcomes between two groups of 223 patients (CLS group, n = 102; RAS group, n = 121) with early‐stage endometrial cancer. Surgical procedures included hysterectomy, bilateral salpingo‐oophorectomy and retroperitoneal lymphadenectomy. We analyzed the data from intrapelvic surgery alone because para‐aortic lymphadenectomy was performed via conventional endoscopic extraperitoneal approach without robot for both groups.ResultsNo differences were identified in patients' age and body mass index. The mean operative time was 133 ± 28 versus 178 ± 41 min (P < 0.01), mean blood loss was 196 ± 153 versus 237 ± 146 mL (P = 0.047), mean length of postoperative hospital stay was 9 ± 4 versus 8 ± 3 days (P = 0.01) and mean rate of perioperative complications of Clavien‐Dindo grade III or higher was 2.0 versus 3.4% (P = 0.53) for the CLS versus RAS groups, respectively. There was no significant difference in the number of resected lymph nodes.ConclusionThe operative time was significantly longer and blood loss was significantly greater in the RAS group than in the CLS group, without a significant difference in the number of resected lymph nodes. These differences are within an acceptable clinical range, showing that RAS is feasible and safe for early‐stage endometrial cancer, providing short‐term outcomes comparable to those of conventional surgery. Future studies are warranted to compare the long‐term oncological outcomes by extending the observation period and including para‐aortic lymphadenectomy data.

Vaginal-Assisted Natural Orifice Translumenal Endoscopic Surgery Hysterectomy for Large Uterus Using the da Vinci SP

Recent advancements of minimally invasive gynecologic surgery have led to the development of transvaginal natural orifice translumenal endoscopic surgery (vNOTES) [1,2]. Robot-assisted vNOTES has also been explored as a method providing accurate and fine surgical procedures with improved ergonomics, visualization, wristed instruments, elimination of the hand tremor [3,4]. The objective of this video is to demonstrate the technical and anatomical highlights of a vaginal-assisted NOTES hysterectomy (VANH) using the da Vinci SP (SP). An urban general hospital. Stepwise demonstration of the technique with narrated video footage. A 51-year-old woman, para 2 with no previous history of abdominal surgery, who presented with dysmenorrhea and urinary frequency. Magnetic resonance imaging revealed a large uterus with multiple fibroids. The surgical steps are completely identical to conventional laparoscopic or robotic VANH [2,3]. This suggests that conventional laparoscopic skills are highly transferrable to SP. SP offer several advantages, including high-resolution three-dimensional visualization, articulating instruments, and improved dexterity and range of motion. In addition, conventional multi-arm robotic platforms have difficulty docking and adjusting the arm angle for vNOTES, but SP allows easy docking due to its single-arm design [5]. A Gelpoint V-Path is used as the vNOTES platform to hold the SP metal cannula. This cannula contains four channels, allowing the use of three instruments and a camera. The double bipolar method is used since this facilitates precise dissection with minimal thermal spread. The total operative time was 102 minutes. The estimated blood loss was 50ml without any complications. The uterus weighed 970 g. The postoperative course was uneventful. VANH using SP is technically safe and feasible for benign uterine diseases in selected patients. Maneuverability of articulating instruments used in SP may allow broad expansion of the indication for vNOTES to more challenging cases. VIDEO ABSTRACT.

Robot-assisted extraperitoneal para-aortic lymphadenectomy (RAePAL) performed with the bipolar cutting method

In comparison with laparoscopic transperitoneal para-aortic lymphadenectomy, the advantages of laparoscopic extraperitoneal para-aortic lymphadenectomy (ePAL) are that the operative field is not obstructed by bowel and the Trendelenburg position is not required [1]. The ePAL technique has been adopted to the robotic surgery with the da Vinci Xi. There are only a few reports demonstrating the technical feasibility of robot-assisted ePAL (RAePAL) [2 3]. This report describes the new surgical technique of RAePAL with the bipolar cutting method. The patient was a 53-year-old woman diagnosed as ovarian clear cell carcinoma (CCC) after left salpingo-oophorectomy. As the re-staging surgery, robot-assisted right salpingo-oophorectomy, hysterectomy, omentectomy, and pelvic lymphadenectomy were planned following ePAL. The patient was placed in the supine position and tilted 5 degrees to the right. Three da Vinci arms were docked at the patient's left side (Fig. 1). The bipolar cutting method was performed by with the surgeon's right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the para-aortic space was expanded, lymphadenectomy was performed up to the renal veins with the bipolar cutting method. The PAL operative time was 155 minutes, estimated blood loss was 25 mL. The patient developed no perioperative complications, and the postoperative diagnosis was stage IC1 ovarian CCC with no pelvic (n=0/42) and para-aortic lymph nodes (n=0/59) metastasis. RAePAL with the bipolar cutting method was technically feasible. Performing lymphadenectomy between the aorta and the vena cava was facilitated by the articulated robotic arm.