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Robot-Assisted Laparoscopy, Natural Orifice Transluminal Endoscopy

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Robot-Assisted Laparoscopy, Natural Orifice Transluminal Endoscopy Robot-Assisted Laparoscopy, Natural Orifice Transluminal Endoscopy, and Single-Site Laparoscopy in Reproductive Surgery Antonio R. Gargiulo, M.D.,1 and Ceana Nezhat, M.D.2 ABSTRACT Minimally invasive gynecologic surgery is continuously pushing its limits by embracing ever more sophisticated technology. This is also true for reproductive surgery, arguably the birthplace of gynecologic endoscopy, where minimally invasive treatment of uterine, tubal, ovarian, and peritoneal pathology has long become the gold standard. This article describes in some detail three novel minimally invasive surgery approaches that have seen the light during the past decade: robot-assisted laparoscopic surgery, natural orifice transluminal endoscopic surgery, and single-incision laparoscopic surgery. These fascinat- ing technologies, far from being widely adopted, are sure to generate scientific controversy for years to come. Nonetheless, they follow in the footsteps of the tradition of innovation that is a defining aspect of our specialty and hold the promise to potentially revolutionize the field of reproductive surgery. KEYWORDS: Robotic surgery, robotics, natural orifice transluminal endoscopic surgery, NOTES, single-incision laparoscopic surgery, SILS, laparoscopic single-site surgery, LESS, reproductive surgery Just when advanced laparoscopic technique has two push the limits of minimal invasiveness at the cost of become more standardized and the laparoscopic ap- further raising the bar of the technical skills required. proach is finally being embraced even outside of the Together or separately, sooner or later, these techniques minimally invasive ‘‘sanctuary’’ of reproductive surgery, are likely to impact the way we will perform reproductive radically new techniques are being introduced that spark surgery in the future. familiar controversies and shatter surgical dogmas all over again. Robot-assisted surgery brings stereoscopic vision and intuitive instrument control back to laparo- ROBOT-ASSISTED REPRODUCTIVE SURGERY scopy, natural orifice transluminal endoscopy eliminates This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. incisions of the skin and fascia, and single-incision Reproductive surgeons abide by the principles of micro- laparoscopy aims at limiting these points of entry. The surgery. Laparoscopy represents the natural evolution of first technique proposes to bridge the technical gap classic microsurgery: its closed approach limits peritoneal between open surgery and laparoscopy, and the other trauma and promotes hemostasis. It also provides tissue 1Center for Infertility and Reproductive Surgery, Brigham and The Role of Modern Reproductive Surgery for the Evaluation, Ther- Women’s Hospital, and Department of Gynecology and Reproductive apy, and Preservation of Fertility; Guest Editor, Keith Isaacson, M.D. Biology, Harvard Medical School, at Boston, Massachusetts; 2Depart- Semin Reprod Med 2011;29:155–168. Copyright # 2011 by ment of Obstetrics and Gynecology at Northside Hospital, Emory Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, University School of Medicine, and Stanford University School of NY 10001, USA. Tel: +1(212) 584-4662. Medicine, Atlanta, Georgia. DOI: http://dx.doi.org/10.1055/s-0031-1272478. Address for correspondence and reprint requests: Antonio R. ISSN 1526-8004. Gargiulo, M.D., 75 Francis Street, Boston, MA 02115 (e-mail: [email protected]). 155 156 SEMINARS IN REPRODUCTIVE MEDICINE/VOLUME 29, NUMBER 2 2011 magnification and lighting conditions comparable with operations where they can best contribute their knowl- those achieved in microsurgery. Thanks to improved edge and understanding of the field have become too patient acceptability and a lower rate of complications, complex to be mastered within an already demanding laparoscopy has replaced almost all open procedures in assisted reproductive technology (ART) practice. This the reproductive specialist’s armamentarium.1,2 pattern of referral represents, in our view, a concerning This has come at a price. Laparoscopy has inher- disconnection from subspecialty care. ent sensory and mechanical limitations compared with It is in this environment that robotic surgical open surgery. Sensory limitations include loss of stereo- platforms are coming of age, with a potential to induce scopic vision and partial loss of tactile sensation. Me- a paradigm shift in reproductive surgery. chanical limitations are caused by operating through a fulcrum (the anterior abdominal wall) with levers (the shafts of the laparoscopic instruments). In open surgery, SURGICAL ROBOTS: A TECHNOLOGY IN the surgeon’s upper limbs handle instruments with seven RAPID DEVELOPMENT degrees of freedom: the elbow provides yaw (left-right At the time in which this article was written there is only movement about the transverse axis), pitch (up-down one robot being used in gynecologic surgery worldwide movement about the vertical axis) and insertion (in-out and approved for this specific use by the U.S. Food and movement), the wrist provides another level of yaw and Drug Administration (FDA): the da Vinci surgical pitch as well as providing roll (rotation around the system (Intuitive Surgical, Sunnyvale, CA). longitudinal axis); finally the hand provides grip (open- The setup of the da Vinci surgical system is based close movement). In laparoscopy we lose yaw and pitch on the principle of robotic telepresence: The main at the wrist. Lack of these movements is particularly surgeon is physically removed from the operating table taxing during microsurgical procedures because we are and guides the movements of a passive patient-side used to performing our fine yaw and pitch movements robotic device while sitting at a master console. The da with our wrists, rather than our elbows. Vinci Si model also supports an assistant surgeon’s Working through a fulcrum also establishes a console. The surgeon operates the master console counterintuitive working environment where every yaw through two hand controls and several foot pedals. and pitch of an instrument in the pelvis must correspond Each of the hand controls is designed to accommodate to a diametrically opposed movement outside of the the surgeon’s thumb and opposing finger and allows body. Finally, operating through long instruments allows complete freedom of upper limb movement in three an amplification of natural muscle tremors that is not dimensions. These movements are translated and down- ideal for microsurgical applications. scaled into movements of the robotic arms at the patient- Many excellent gynecologic surgeons who cannot side cart, and into fine movements of the interchange- afford the time and effort required to become proficient able ‘‘wristed’’ robotic instruments that the surgeon elects laparoscopists are faced with a professional dilemma: to to connect to the robotic arms during each step of any persevere in offering conventional surgery or to start a given case (Fig. 1). pattern of referral to gynecologists trained in minimally The robotic three-dimensional (3D) endoscope invasive surgery. What has happened to the field of enters the abdominal cavity through an 8.5- or 12-mm reproductive surgery during the past 2 decades follows cannula placed at or above the umbilicus (a dedicated the same practice-shift pattern, but the ramifications of camera port has been designed for the new-generation such a shift are more complex. Gynecologic surgery in 8.5-mm 3D endoscope). Robotic instruments enter women facing reproductive challenges should be ap- through dedicated 5- or 8-mm steel cannulas. Although proached with a comprehensive plan fostering their 5-mm robotic instruments do exist, their use in gyneco- reproductive endeavor. In this perspective, reproductive logic surgery is limited at this time, mostly due to the This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. surgery encompasses virtually every conservative gyne- lack of electrosurgical instrumentation. cologic operation during the reproductive years. At a The transposition of the elbows’ movements in very minimum, it includes all those techniques aimed at the transverse axis (yaw) and vertical axis (pitch) is the restoration of reproductive structures (tubal, uterine, automatically inverted at the level of the robotic arms and ovarian surgery) and at the conservative manage- so the surgeon can perform intuitive movements at the ment of pelvic endometriosis. console just as if he or she was operating in a conven- It would seem that indications for reproductive tional open case. Moreover, the accuracy of movement of surgery abound. Yet a contraction of the field of proper the robotic arms and instruments can be scaled down to reproductive surgery is more apparent than general the surgeon’s preference. The surgeon’s hand move- statistics seem to suggest.3 This is due to the fact that ments at the console occur in a fluid and unrestricted many reproductive endocrinology and infertility (REI) environment. This comes at the expense of tactile subspecialists refer their surgical patients to gynecolo- sensation (haptic feedback). Simulated haptic feedback gists trained in minimally invasive surgery because the is one of the expected improvements of future robotic MINIMALLY INVASIVE REPRODUCTIVE SURGERY/GARGIULO, NEZHAT 157 Figure 1 Current version of the da Vinci Si robotic surgical platform by Intuitive Surgical. (A) Surgeon’s console. (B) Optional second surgeon’s console. (C) Patient-side
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