New Approaches to Hysterectomy by Minimal Invasive Surgery (MIS)

Many variations of the procedures of laparoscopic assisted hysterectomy have been described, that vary principally by the extent of surgery performed via the laparoscopic route. The training and skill of the surgeon and equipment available may influence the extent of surgery performed via the laparoscope. This in turn has the potential impact on the clinical outcomes, such as perioperative complication rate and resource utilization outcomes such as readmission rate and post-surgical care.


Introduction
The most significant advancement in in reducing surgical morbidity in gynaecology over the last two decades has been an increased application of minimal invasive surgical techniques for both benign and malignant gynaecological disease requiring a subtotal, simple, or radical hysterectomy. 1,2,3,4,5,6.
Many variations of the procedures of laparoscopic assisted hysterectomy have been described, that vary principally by the extent of surgery performed via the laparoscopic route.The training and skill of the surgeon and equipment available may influence the extent of surgery performed via the laparoscope.This in turn has the potential impact on the clinical outcomes, such as perioperative complication rate and resource utilization outcomes such as readmission rate and post-surgical care.
Several attempts have been made to standardize the extent of surgery by minimal access approach by using a system of classification 7,8 .Unfortunately the clinical results published on this topic, in the literature seldom adhere to these classifications when describing their outcomes.The reluctance to adhere to these classifications may be due to the complexity of the classifications, with numerous subgroups in each type of the main four Types described by AAGL.Besides, this classification does not extend to more radical hysterectomies required for malignant conditions such as endometrial and cervical cancers.
Simplifying the classification described by AAGL for both subtotal and total hysterectomies by MIS and extending the classification to include pelvic and Para aortic lymphadenectomy and Piver's 9 classification of radical hysterectomy may be more useful to standardize and compare surgical outcomes by MIS in future.It is essential that surgeons have advanced laparoscopic skill recognised by their national or international governing body for training, before undertaking these procedures in the interest of their patients.The National Institute for Health and Clinical Excellence (NICE) of U.K. has recently issued the guidance on laparoscopic radical hysterectomy for early cervical cancer and emphasised the importance of adequate higher training in MIS for surgeons undertaking these procedures.(2010) 10 .

Laparoscopic radical hysterectomy with pelvic lymphadenectomy
Over a thousand laparoscopic radical hysterectomies have been performed to-date, 21,22,23,24 .However, laparoscopic surgery has not gained popularity amongst gynaecological oncologists.Many gynaecologists have been slow to adopt laparoscopic approach to radical hysterectomy largely due to prolonged learning curve, complexity of the procedure, technical challenges leading to prolonged operating time and surgeon's fatigue.The disadvantages of the laparoscopic approach which includes, two dimensional view, decreased range of movements, reduced degree of freedom of instruments and dependents on the skill of assistants.Wattiez et al 25 in a series of 1,647 cases showed the learning curve for total laparoscopic hysterectomy is prolonged and the technique requires a high level of expertise and training as recommended by NICE 10 .The complications with laparoscopic hysterectomy have been reported to be higher when performed by less experienced surgeons.Although patients treated with laparoscopic approach have been shown to experience less intraoperative blood loss, less post-operative pain and ileus, and short hospital stay than those who had conventional open hysterectomy 26 , minimal invasive surgery (MIS) is still an exception and not the rule in most gynaecologist practice.

Surgical robot -de Vinci surgical system (intuitive surgical inc.) (Fig 1.)
This robotic system was introduced in 1999 which is comprised of three components, the patient side surgical cart, the vision system, and the surgical console (fig 2).The surgeon's console is located remotely from the patient.The surgeon is seated at the console to control the robotic arms which hold the instruments within the patient's abdomen.With the aid of stereoscopic viewer, hand manipulators and foot pedals, the surgeon is able to conduct the surgery with greater precision and ease.The second component is the de Vinci 3D optics which consists of a sophisticated stereoscopic digital camera through a 12 mm endoscope (fig 3).The camera consists of two high definition units which recreate a true 3D colour image which is viewed by the surgeon at the con s o l e .T h e c a m e r a a l l o w s f o r u p t o 1 2 x magnification of the operating field, opening up the possibility of performing microsurgical procedures as well as spotting and managing small blood vessels to reduce bleeding and performing nerve sparing surgical dissection (fig 4).Three cameras are available for use on the de Vinci system, one straight and two angled cameras (up and down pointed), which allows the surgeon the options of viewing all nooks and corners of the pelvis and abdomen.The third component is the surgical cart which is composed of three to four arms for controlling the 3D camera and two to three surgical instruments.The robotic instruments are "wristed", thereby providing 7 degrees of freedom (df) compared with 4 df with traditional laparoscopy (fig 5).The robotic instruments are controlled by the principal surgeon who sits away from the patient at the surgical console via two "masters".The movements of the surgeon's arms and legs are translating in real time to the robotic instruments inside the patient's abdomen and are processed and scaled to reduce any tremor and thus enhance precision of movements and avoid tissue trauma.The surgical instruments and a stereoscopic video camera all work in unison during surgery.The hand-like surgical instruments move with 7 (df) and two degrees of axial rotation (fig 5).The surgical masters are placed in line with the surgeon's field of vision in order to restore a more intuitive eye-hand coordination than that experienced with traditional laparoscopy.The foot controlled pedals on the surgical console enable the surgeon to control and zoom the camera which gives complete control over the surgical field, unlike the traditional laparoscopy where the surgeon relies on the assistant to control the camera.

Robotic-assisted total hysterectomy technique
The steps of surgical technique are similar to those in an open or laparoscopic surgical approach, which include careful preparation of the vascular pedicles prior to ligation by bipolar, mono-polar energy sources or other energy sources (Harmonic scalpel, En seal, Ligasure) for vessel sealing as described earlier 27 .There has been an increase in the use of robotic assisted technique over laparoscopic approach for minimal invasive surgery and hysterectomy in the past five years in the United states .This popularity of robotic approach may be attributed to greater degrees of freedom of movement, 3D viewing and ease of intracorporal suturing and less steep learning curve when compared to laparoscopic approach.Laparoscopic hysterectomy has been shown to have a longer operative time compared to robotic surgery, with comparable blood loss, length of hospital stay and post-operative complications 28 .Others have shown that robotic surgery has a lower operating time when compared to laparoscopic surgery and decreased hospital stay, less blood loss and lower conversion to open surgery 29 .

Robotic assisted hysterectomy & radical hysterectomy with pelvic +/-paraaortic lymphadenectomy in gynaecological oncology
Patients with endometrial cancer often are obese, elderly with increased incidents of medical comorbidities including diabetes and cardiovascular disease.The advantages of laparoscopic minimal invasive surgery in women with endometrial cancer have been shown by several studies, in the reduction of hospital stay, quicker recovery, lower incidents of thromboembolic complications and post-operative infections 5,30,31,32,33.Since 2005 the use of robotic assisted MIS has gained popularity in gynaecological oncology.Robotic assisted surgery offers 3D, high definition visualisation in a stable field, more intuitive instrument control, better ergonomics and increased dexterity 4,34,35 .
Unlike laparoscopic technique, once the patient is docked to the robot, the Trendelenburg position cannot be reversed without undocking the patient.At 30 degrees steep Trendelenburg position, there is a hypothetical risk of higher inspiratory pressure due to reduced ventilatory compliance which may compromise the advantages of MIS in obese and elderly women, which is frequently to co-morbidity in women with endometrial cancer.However, studies this far have not shown any increased risk using robotic assisted surgery in these high risk women with endometrial cancer, when compared to laparoscopic or open surgery.Table 1 shows comparison between open laparoscopic and robotic surgery in women with endometrial cancer 36,39,40,41 .The rate of conversion to laparotomy has been reported between 3% to 16%, 36,37,38 .Older women had lower risk of surgical complications with laparoscopic vaginal approach 43,44 yet implementation of laparoscopic surgery in these patients is low.In a prospective study Vakin et al showed that using robotic assisted technique in elderly patients with endometrial cancer had similar overall outcomes when compared with younger patients with endometrial cancer, despite having significantly more co-morbidities and more advanced disease 38 .Quality of life and patient satisfaction have shown to be superior with robotic assisted approach 38 , which could be due to lower postoperative pain hence reduce intake of narcotic analgesics.
In 2006 Sert et al 45 described the first robotic assisted radical hysterectomy for early stage cervical cancer (stage IB1).They performed type III robotic assisted radical hysterectomy with estimated blood loss of 200 ml with no intra-operative or post-operative complications.The patient was discharged home four days later.Over the past five years several reports have been published on the robotic assisted radical hysterectomy 46,47,48,49,50 2. Outcomes of Robotic Radical Hysterectomy some of the reported series with their outcomes.Although the recurrence rates seem to be equivalent to those after laparotomy and laparoscopic hysterectomies, long term follow up is still necessary.The intra-operative and post-operative morbidity of robotic assisted total hysterectomy are similar or sometimes less than those reported following open and laparoscopic hysterectomies.
To date, there are no randomised trials comparing the robotic assisted approach to radical hysterectomy, laparoscopy and laparotomy.There is an on-going phase III randomised clinical trial comparing the three techniques of radical hysterectomy in women with early stage cervical cancer, developed and designed by the Gynaecology Oncology Committee from American Association of Gynaecologic Laparoscopists 51 .The outcome of this trial may shed more light on the future approach to radical hysterectomy.
The potential for robotic assisted surgical devices to revolutionize complex surgery by reducing surgical morbidity, improving quality of life, minimising hospital stay which in turn reduced costs to the Health Service, is a high possibility in the near future.

Conclusions
Minimal invasive surgery ,both laparoscopic and roboticassissted surgery are alternative techniques to conventional open hysterectomy.However the training required to use these techniques, is an important factor to minimize complications during surgery.The reduced hospital stay., quicker recovery and increased patient satisfaction with these new approaches makes minimal invasive surgery certainly a viable challenge to conventional hysterectomy.

Table 1 .
. TableIIshows Outcomes of robotics hysterectomy and pelvic lymphadenectomy