Preoperative considerations
Patient history and physical exam
• Thorough assessment of tolerance of abdominal insufflation/Trendelenberg positioning
– Smoking history, exercise tolerance, obesity
– Cardiopulmonary/renal disease
– Increased ICP
– Hypovolemic state
• Abdominal survey for scars, hernias, and understanding of prior pelvic surgeries, anatomical variants
• Uterine mobility, adnexal mass
– Lateral mobility ≥2 cm for uterine vessel access
• Gentle preoperative bowel prep only when deemed necessary (surgeon preference)
– Mg Citrate, Miralax
Patient positioning and surgical setup
• Proper use of corporeal padding
• Joint flexion at maximum angle of 30°
• Anti-skid materials to decrease risk of nerve injury
– Pink pad, egg crate, surgical beanbag
• Facial padding, eye taping to reduce facial injury
– Direct facial trauma responsible for 20% of corneal abrasions
• Be mindful of degree of Trendelenberg positioning absolutely necessary
– Less steep degree may decrease morbidity without negative effects on surgical time, visibility (Ghomi et al.)
• 30° camera for optimal sacral visualization
– If distance from umbilicus to pubic symphysis <15 cm, camera port should be supra-umbilical
• Direct visualization and abdominal survey during trocar insertion
– Port site bleeding most commonly from perforation of inferior epigastric artery
– 55% of bowel perforations occur during intra-abdominal access
• Use of 8-mm or 5-mm accessory port to decrease hernia risk
Intraoperative complications
• Port site bleeding
– Attempt to cauterize injured vessel with offending trocar in place
– Tamponade can be attempted using a 12-Fr foley catheter through trocar
– Sutures can be placed at each side of trocar site and tied externally with removal after 24–48 h
• Bowel injury
– Use of fan retractors, accessory stitch, Endoloop to retract bowel effectively
– If injury detected vicryl or barbed suture can be used for repair
– Repair should be performed in two layers with sutures placed on the long axis of intestine to prevent stricture
• Presacral hemorrhage
– Middle and lateral sacral vessels should be well delineated
– Assess for variability of sacral/iliac vessels, particularly on the left side of anterior longitudinal ligament
– Apply direct pressure with a RAYTEK or cottonoid as first line treatment
– Hemostatic agents (Floseal, Surgicel) and laparoscopic vessel fasteners should be readily available
• Urinary tract injury/vaginotomy
– Use of EEA sizers or vaginal stents to allow for proper visualization of vesicovaginal junction
– Dissection of this junction should be bloodless if correct plane has been identified
– 25 mg ICG in 10 mL sterile h20 can be injected into ureters prior to RASC for ureteral identification
– Bladder/vaginal injury should be repaired in a double, imbricating layer using vicryl or barbed suture
– Mesh should not be placed directly over vaginotomy site, should one occur
Postoperative issues
• Surgical site infection
– Cephalosporins should be redosed intraoperatively after 4 h or with >1500 mL blood loss
– Patients >120 kg should receive a 3 g initial dose instead of standard 2 g dosing
– Postoperative antibiotics for wound infection should be targeted at Gram-positive bacteria
• VTE
– LMWH should be considered in patients >60 yo, as they are deemed “high risk” with VTE risk 20–40%
• Bowel complications
– Dyschezia, obstructed defecation, and outlet constipation are the most common types of post-op bowel dysfunction and patients should not expect a bowel movement within the first 3 days after surgery
– Extensive dissection of rectovaginal septum should be avoided to reduce bowel denervation
• Mesh complications
– Mesh should be placed as flat as possible and against sacral promontory to decrease anorectal dysfunction
– Supracervical hysterectomy is preferred to reduce mesh extrusion rates
– Use of lightweight type I mesh to reduce risk of graft infection
• De novo SUI
– Vaginal examination should be performed intraoperatively to assess for anterior/apical overcorrection which could lead to new onset stress urinary incontinence
References
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Oliphant SS, Jones KA, Wang L, Bunker CH, Lowder JL. Trends over time with commonly performed obstetric and gynecologic inpatient procedures. Obstet Gynecol. 2010;116(4):926.CrossRefPubMedPubMedCentral
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ACOG Committee Opinion No. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114:1156–8.
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AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL position statement: robotic-assisted laparoscopic surgery in benign gynecology. J Minim Invasive Gynecol. 2013;20(1):2–9.CrossRef
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Appledorn SC, Costello AJ. Complications of robotic surgery and how to prevent them. In: Patel VR, editor. Robotic urologic surgery. London: Springer; 2007. p. 69–178.
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Graybill WS et al. Impact of smoking on perioperative pulmonary and upper respiratory complications after laparoscopic gynecologic surgery. Gynecol Oncol. 2012;125(3):556–60.CrossRefPubMedPubMedCentral
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