Laparoscopy: Basic Principles, Equipment, and Instrumentation

Advancements in conventional laparoscopy have allowed surgeons to treat more surgical pathology in a minimally invasive fashion. However, many procedures are still performed predominantly by laparotomy. Conventional laparoscopic instrumentation and the steep learning curve are often cited as possible obstacles to minimally invasive surgery. The advent and evolution of robotic technology may provide means to overcome the limitations seen with conventional laparoscopy through the use of three-dimensional imaging and more dexterous and precise instruments.

Abdominal sacrocolpopexy has been considered the gold-standard surgical procedure for repair of apical vaginal support defects. While it is feasible to perform this operation using conventional laparoscopic techniques, a limited number of surgeons have mastered the advanced minimally-invasive skills that are required. Introduction of the da Vinci® robotic system with instruments that have improved dexterity and precision and a camera system with three-dimensional imaging presents an opportunity for more surgeons treating women with pelvic organ prolapse to perform the procedure laparoscopically. This chapter will outline a technique that is exactly modeled after the open procedure for completion of a robotic-assisted colpo- and cervicosacropexy using the da Vinci® surgical system.

The use of robotics, or computer enhanced technology in laparoscopic myomectomy facilitates suturing and uterine reconstruction similar to laparotomy and LAM. It provides a 3-D view, eliminates tremor by downscaling movements, and superior range of motion. This makes laparoscopic suturing more intuitive in contrast to the counter-intuitive environment of LM, allowing proper reconstruction of uterine wall defects and minimizing risk of complications.

Hysterectomy is the most common major gynecologic surgery performed in the United States, second only to cesarean section. Over 500,000 of these procedures are performed each year using a variety of treatment modalities. The abdominal approach is by far the most common comprising of up to 64%. Laparoscopic hysterectomies make up only 14 % [1]. When one examines the different approaches to hysterectomy in the United States, the number of vaginal hysterectomies over the past 10 years has not changed significantly.

In April 2005, the FDA approved the use of the da Vinci Surgical System™ for surgery in Gynecology. This provided another option for surgeons other than the previously described methods. Recent data shows that the number of hysterectomies performed by the laparoscopic technique has the potential to increase by using computer enhanced telemanipulation otherwise known as Robotic Surgery [2].

Robotic assisted surgery is an emerging technology that has expanded the armamentarium of minimally invasive surgeons including the reproductive surgeons. Tubal anastomosis is among the procedures that have been done with robotic assistance. Robotic technology bridges the benefits of open microsurgery through a laparoscopic approach. This review will describe the evolution of robotic technology, the instrumentation and the essential components in the system. The technique of a robotic assisted tubal anastomosis is discussed.

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with gynecologic cancer including early, advanced, and recurrent endometrial, cervical and to a less extent ovarian cancer. Numerous gynecologic oncologists have published their experience using this new technology. Most case series of robotic assisted hysterectomy and lymphadenectomy, as well as radical hysterectomy for cervical cancer show that the procedure is feasible and comparable or superior to laparoscopic surgery. Less common procedures such as robotic radical trachelectomy, radical parametrectomy, and retroperitoneal aortic lymphadenectomy have also been described. Little information is available addressing a robotic approach for the treatment of advanced or recurrent ovarian cancer patients.

Clearly, robotic technology facilitates the surgical approach for endometrial and cervical malignancies as compared to the conventional laparoscopy. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for the surgeons.

Robotic technology represents a significant advancement in the field of minimal invasive surgery. Robotic procedures are increasingly used to perform various gynecological operations. While the robot addresses the limitations of the laparoscope and provides three-dimensional vision and precise movements, it has its some limitations including increased cost, bulky instrument with limited vaginal access, and lack of tactile feedback. Although the literature has shown that robotic surgery leads to early recovery and less blood loss, it is associated with increased operative time, which is associated with potential increase of anesthetic and perioperative complications. This article reviews the recent peer-reviewed literature concerning the complications of robotic technology in hysterectomy, myomectomy, tubal anastomosis, and sacrocolpopexy. Most of the literature consists of retrospective studies and authors' early experiences with this technique. Well designed prospective studies are necessary to determine the long-term outcomes including complications.

p>Robotics surgery differs from conventional laparoscopy in the absence of tactile feedback, need to perform procedure remotely and presence of fixed and rigid robotic arms. These factors bring a unique set of considerations that need to be recognized in order to avoid complications.