Robotic-assisted Laparoscopic Myomectomy for Uterine Fibroids

Proprietary Names: da Vinci Surgical System; da Vinci S Surgical System; da Vinci S High-Definition (HD) Surgical System; da Vinci Si HD Surgical System; EndoWrist instrumentation; Intuitive motion

Generic Device Names: remote surgical manipulator; robotic surgical platform; robotic surgical system; robotic telemanipulator system; surgical robot; telesurgical system

The da Vinci S robotic-assisted surgery system (Intuitive Surgical, Inc., Sunnyvale, CA, USA) includes a surgeon console, a computerized control system, a patient side cart containing three integrated instrument arms, and a fourth arm that has a binocular endoscope with a fiberoptic camera. The da Vinci Si HD Surgical System, the newest system model, features an enhanced three-dimensional (3-D), HD vision system that provides 10X magnification; an updated user interface, improved ergonomics, and operating room (OR) integration controls; digital zoom; adjusted aspect ratios that provide more viewing area; a motorized patient cart; and an optional second surgeon console with intercom that can be used for dual-surgeon procedures or for training during a procedure. One of the da Vinci system arms holds the laparoscope while the other arms hold various surgical implements. These proprietary laparoscopic instruments have grasping or cutting end-effectors that attach to the robotic instrument arms. The surgeon sits at a computer console in the OR and views the operative field that shows the view from a video camera mounted on one of the robotic arms. While watching the monitor in real time at the console, the primary surgeon uses master controls to operate the robotic arms. A second surgeon may assist directly at the operating table several feet away or at the second console.

A trained surgeon may use any of the da Vinci systems to surgically remove uterine fibroids during a procedure known as robotic-assisted laparoscopic myomectomy (RALM). According to Intuitive, the potential benefits of RALM compared to traditional procedures performed for this indication (i.e., open hysterectomy, open myomectomy) include the following:

Advantages of laparoscopic robotic-assisted surgery cited by surgeons include magnification in the 3-D visual field; greater surgical precision and dexterity due to wristed robotic-arm instruments, which have seven degrees of freedom; improved surgical access in the pelvic cavity; hand-tremor filtration; autonomy; and ergonomic comfort. Surgeons state that these technical features offer superior visualization, enhanced depth perception, and better dexterity. Also, some clinical experts feel that robotics may allow a surgeon to offer a minimally invasive approach to more patients, stating that standard laparoscopic techniques are more difficult to learn than robotic-assisted techniques and often require a skilled first assistant. Robotics may also allow a surgeon to offer minimally invasive surgery to patients who are obese or have significant adhesive disease. According to Intuitive, RALM offers the following three specific benefits for the surgeon: superior viewing of tissue planes, enhanced capability for dissecting and removing large fibroids (> 5 cm), and precise layered suturing of the uterus

Possible disadvantages of RALM are the initial and recurring costs, the initial marked learning curve for the operative team, and increased system setup time. Initially, RALM may require more intraoperative time than traditional open surgery. However, intraoperative time typically improves as surgeons gain experience and OR staff becomes more...