JİNEKOLOJİDE ROBOTİK CERRAHİ

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2 JİNEKOLOJİDE ROBOTİK CERRAHİ
Prof. Dr. Fuat Demirci Kadıköyşifa Sağlık Grubu

3 1980 – Operatif laparoskopinin başlangıcı
Dr. Philippe Mouret ~ 1987 İlk laparoskopik kolesistektomi operasyonui Fransa 1987 At the same time that we were seeing significant development and advancement in robotics during the 1980s, technology was also developing in the medical arena. The first laparoscopic - or minimally invasive - surgery procedures were also being developed and conducted. Specifically, the development of endoscope-like devices were developed and the emergence of the Charge Coupled Device, better known as a CCD, video electronics and display technologies began to revolutionize the field of surgery and led to laparoscopic techniques for minimally invasive surgery. This culmination of technology advancements in surgery led to the first laparoscopic cholecystectomy on a female patient in 1987 by French physician Dr. Philippe Mouret. Soon after this landmark surgery, laparoscopic technology and techniques boomed in the late 1980s and continued to gain adoption into the 1990s for simple surgical procedures. However, the applications for laparoscopic surgery began to stall in the 1990s. The tools that were being employed for manual laparoscopy worked well for relatively simple surgical procedures that involved the excision of tissue and basic tissue closure… (next slide) Laparoskopik histerektomi 1989

4 da Vinci Standart da Vinci Sisyem - 1999 MIT – ilk dizayn
In the late 1980s DARPA (Defense Advanced Research Projects Agency) funded several of the previously mentioned institutions to research the possibility of a remote surgery program targeted toward battlefield triage. Similar to the robotic drones (planes) that are available today and are currently used in foreign conflicts, the idea was to replace human medics with robots and minimize human casualties. It turns out that the idea of a robotic medic on the battlefield was flawed in two key ways… The telecommunication transmissions required to control a robot at long distances essentially made the medic robot a “hotspot” on a battlefield that could be identified by the enemies tracking devices and would be neutralized. Therefore, it is likely that the medic robot and the soldier being treated would be “taken out” by the enemy before treatment could even occur. In the last twenty years, the primary policies and guidelines surrounding the emergency treatment of wounded soldiers has changed dramatically. Instead of performing a surgical procedure on the battlefield to treat a wounded soldier, standard practices now seek to stabilize the soldier and then transport him to a hospital for the surgical procedure. However, as a result of the funding from DARPA, there were significant advancements made toward telepresence at many institutions. For example, SRI was truly responsible for developing the “telepresence surgery system”. As you can see, the preliminary schematic drawing of this system that eventually influenced the da Vinci design can be seen in the lower left corner. Other notable achievements were the IBM-developed remote center technology and the MIT-developed cable-driven technology for low friction manipulators that is used in da Vinci today. In 1995, Intuitive Surgical was founded and secured licenses on the technologies developed by several institutions. Intuitive started the long process of turning good ideas and innovation into a true product. Not long after, da Vinci was born; the first da Vinci system, referred today as the “da Vinci Standard,” was taken to market in 1999. MIT – ilk dizayn SRI – ilk çizimler

5 Neden “da Vinci” ismi? Leonardo da Vinci kendi çizdiği
The name da Vinci stems for the 15th century inventor, painter, philosopher renaissance man: Leonardo da Vinci. da Vinci is widely renown for advancing the study of human anatomy. He participated in autopsies and produced many extremely detailed anatomical drawings, planning a comprehensive work of human and comparative anatomy. His study of human anatomy eventually led to the design of the first known robot in recorded history. The design, which has come to be called Leonardo's robot, was probably made around the year 1495 but was rediscovered only in the 1950s. da Vinci was intrigued by mechanics and automation, developing a number of mannequins including a mechanical knight shown in the picture shown here. Leonardo da Vinci kendi çizdiği Kendi portresi 1512 , 1515 Leonardo‘ da Vincinin robot tasarımı ve iç yapısı

6 da Vinci® Sistemin ilerlemesi
3D HD Vision (720p) Görüntü Girişi – TilePro Multi-quadrant akses Kolay set-up Operasyon spesifik ve farklı enerji enstrumanları da Vinci® Si™ Çift Konsol Opsiyonu Gelişmiş HD Vision (1080i) Gelişmiş Ergonomi Arttırlımış cerrah kontrolü Küçülebilir yapı Geliştirilmiş enstrumanlar Geleneksel Laparaskopi The next generation da Vinci System was the da Vinci S System, introduced in 2006. The ‘S’ offered the surgeon HD vision for the first time in robotic surgery. Furthermore, many of the information sources - such as patient vitals - that a surgeon was accustomed to seeing in open or laparoscopic surgery on a monitor, were integrated into the surgeon console viewer through the advent of our TilePro feature. In addition, by increasing the instrument reach and arm movement, the da Vinci S offered the surgeon the ability to have multi-quadrant access. Previously, with the standard system, the device would have to be undocked, moved, and then re-docked. Finally, the da Vinci S system significantly streamlined the OR set-up and turnover process by offering a simplified set-up and fewer pieces to coordinate. The da Vinci Si System is the latest generation da Vinci System and was released in April of 2009. With the Standard and S systems, the surgeon worked in an independent fashion, even on complex cases where two surgeons would normally collaborate in open or even laparoscopic surgery. Now, with the dual console capability of da Vinci Si, two surgeons can work collaboratively in a robotic MIS fashion. In addition, the second console enables more efficient training of new surgeons and the ability for established surgeons to easily learn and share tips, tricks, and new advanced procedures and techniques. The Si also has significantly enhanced vision, refined master controllers, a simplified energy control footswitch panel, additional ergonomic settings, and several enhancements to increase the surgeons control of the operative field and the OR. Enhanced HD Vision (1080i) – Essentially doubles the resolution and clarity of the da Vinci S System. Refined masters – including a tactile feedback “bumper,” allow for light tissue grasping as well as independent hand clutching through the fingertip clutch. Superior ergonomics – Multiple ergonomic adjustments allow customization and comfort, for even the smallest or tallest surgeon. Increased surgeon control – Through a touchpad control center, the surgeon has comprehensive control of video, audio, and system settings. Scalable architecture – The da Vinci Si was specifically designed to allow for seamless integration into the OR of the 21st century and the ability to accommodate future applications and instruments. Like an iPhone with applications, it was designed to allow for add-ons of future technologies such as high-speed networking, image guidance, simulation, etc. da Vinci® Lap kıstlamaları ortadan kaldırdı 4.Kol (2003) Basit enstrumanlar 6

7 Nisan 2009 da Vinci Si HD

8 Dünyada da Vinci® ASYA 220 ORTADOĞU 26 AVRUPA 43 KANADA 22 ABD 2,001
Norveç 10 Yunanistan 8 Çek Cumhuriyeti 8 Romanya 7 Fransa 63 Finlandiya 5 Portekiz 2 Almanya 61 Avusturya 4 Bulgaristan 1 İngiltere 31 İrlanda 3 Slovakya 1 Belçika 30 İtalya 66 Polonya 1 İsviçre 20 İspanya 24 Slovenya 1 Hollanda 17 Türkiye 19 Güney Kıbrıs 1 İsveç 16 Rusya 15 Monako 1 Danimarka 15 ABD 2,001 KANADA 22 ASYA 220 Japonya 105 Güney Kore 36 Çin 23 Hindistan 22 Tayvan 16 Tayland 6 Singapur 6 Malezya 4 Endonezya 1 Filipinler 1 ABD 2,001 ORTADOĞU 26 Suudi Arabistan 11 İsrail 6 Katar 4 Pakistan 2 Mısır 1 Kuveyt 1 Lübnan 1 GÜNEY AMERİKA 29 Arjantin 4 Şili 4 Venezüela 3 Meksika 3 Kolombiya 2 Panama 1 Uruguay 1 Avustralya/Yeni Zelanda 32

9 Yıllara göre dünyada robotik operasyon sayıları

10 Yıllara göre pubmed’de indekslenen robotik cerrahi yayınlarının sayısı

11 da VinciTM robotik sistem özellikler
3 boyutlu HD görüntü üstünlüğü ve 10 kata kadar büyütebilme avantajı Cerrahi operasyon alanının içinde el ve göz birlikteliği Konforlu , ergonomik 3. kol avantajı ‘Açık’ cerrahi hissi, NavigatorTM kamera kontrol Kollar hareket yeteneği sayesinde cerraha 7 eksende hareket özgürlüğü sağlar Kollar İnsan bileğinin yapamayacağı hareketleri, kendi çevresinde 540 derece dönüş yaparak gerçekleştirebilir. Cerrahın becerilerini daha verimli kullanmasına olanak sağlar

12 EndoWristTM Enstrümantasyon
Üst Düzeyde Hassaslık ve Kontrol El bileği hareketlerini modelleyen hareket yeteneği Yüksek iletim hızlı kablo sistemi Parmak uçlarından enstrumana anlık ileti 7 düzlemde serbest enstruman kontrolü

13 EndoWristTM Enstrümantasyon
Üst Düzeyde Hassaslık ve Kontrol Hareket Ölçekleme 2:1 to 5:1 5 cm 1 cm Titreme Önleme İki eli aynı anda kullanma yeteneği

14 Robotik Jinekolojik Cerrahi
Domuz salpingo-ooferektomi ve Histerektomi Endometrial Kanser Evreleme Sakral kolpopeksi TLH 2002 2004 2006 1999 FDA onayı 2001 2007 2004 2005 Mart Miyomektomi Radikal Hist. & PLND Tubal Anastamoz Robotik LAVH

15 Robotik cerrahinin açık cerrahiye avantajları
Travma daha azdır. Enfeksiyon riski azalmıştır Kan kaybı azdır Ağrı daha azdır Hastanede kalış süresi azdır İyileşme süreci ve işe dönüş süresi kısadır Kozmetik görünüm daha iyidir

16 Robotik cerrahinin laparoskopiye üstünlükleri
3 boyutlu HD görüntü ve görüntüyü büyütebilme Eklemli aletlerle bilek hareketlerinden daha iyi hareket Sütür atma kolaylığı Daha kolay kanama kontrolü 3. kol avantajı Ayna görüntüsü olmaması, el ve göz birlikteliği Dar alanlarda rahat çalışabilme Cerrahın yorulmaması, konfor ve ergonomi El titremelerinin minimalize edilmesi Ameliyat süresinin kısa olması Sinir koruyucu cerrahi

17 Robotik cerrahinin açık ve laparoskopiye göre dezavantajları
Dokunma hissinin olmaması Hasta pozisyonunu değiştirememe Yatırım maliyetinin yüksek olması

18 Hasta avantajları Daha az postop ağrı Daha az kanama
Daha az transfüzyon Daha az enfeksiyon riski Daha az skar Artmış kozmetik görüntü Hızlı iyileşme İyi anatomik düzeltme ve başarı oranları

19 Genel jinekolojide robot kullanımı
Histerektomi Kistektomi Ooferektomi Salpingoooferektomi Salpenjektomi Presacral Neurectomy Tubal ligasyon

20 Histerektomi: Robotik vs. açık
Daha az kanama Hastanede daha kısa süre kalma Daha az komplikasyon Daha az ağrı kesici ve medikal bakım ihtiyacı Payne ve ark. J Minim Invasive Gynecol, 2008 Giep ve ark. J Robot Surg. 2010 Brudie ve ark. J of Robotic Surg. 2011 Shashoua ve ark. JSLS. 2009

21 Histerektomi:Robotik vs. laparoskopik
Cerrahın hareket yeteneği sınırlıdır: 2 Boyutlu görüntü Rijid enstrumanlar Ayna görüntüsü Robotik Daha hassas, çok yönlü ve kontrollü hareket: 3 Boyutlu HD görüntü Eklemli enstrumanlar Gerçek görüntü ve hareket 3. kolu asistan gibi kullanma, etkili ve tam cuff kapatılması Objective Point out limitations of conventional laparoscopy; contrast these to the advantages of da Vinci. Note: Please mute the audio during the first video clip. The second clip contains no audio – turn your audio back on during the 2nd video clip. Script “This slide shows a side-by-side comparison of conventional laparoscopy and da Vinci Surgery for closing the vaginal cuff or cervical stump respectively.” “In the laparoscopic video, the surgeon’s movements are less precise and accurate. The task is more difficult to accomplish… and less efficient.” “In contrast, you can see how precise, accurate, and fluid the surgeon’s movements are with da Vinci. “In fact, with da Vinci, the surgeon controls the camera and 3 operative arms – providing greater surgical autonomy, precision, and efficiency compared to conventional laparoscopy. This is a significant advantage over conventional laparoscopy – especially in private practice where you may not have a skilled patient-side assistant.” Questions Can you see how da Vinci provides a higher level of reproducibility for complex dissections and reconstruction? How will da Vinci enable you to perform more complex surgical procedures?

22 Robotik histerektomi vs. LAVH ve LSTH
Operasyon süresi ve kanama miktarı RH ve LSTH de LAVH’den daha az Giep, B. N., H. N. Giep, et al. "Comparison of minimally invasive surgical approaches for hysterectomy at a community hospital: robotic-assisted laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy." Journal of Robotic Surgery: 1-9; 2010 .

23 Öğrenme sonrası kısa operasyon süresi
Laparoscopy pre-robotic (N=100) da Vinci® (N=100) Last 25 da Vinci P Value Age (years) 43.5 43.2 - BMI 28.8 Estimated blood loss (ml) 113 61 <.0001 Hospital stay (days) 1.6 1.1 <.007 Overall TAH rate 20% 4% 0% .0008 Intra-op conversions (subset of TAH) 9% .0003 Avg. uterine weight of conversions (g) 359.5 1387.5 .008 TAH due to adhesions 8% Not stated Operative times (skin-to-skin) 92.4 119 78.7 Roobotta daha az kanama, hastanede kalma ve operasyon süresi ve konversiyon Here is just one clinical study I find especially interesting because Dr. Payne and Dr. Dauterive began the study believing da Vinci Surgery didn’t have a place in their gynecology practice. This data is from the Ochsner Clinic in Baton Rouge, LA where they started a da Vinci® program for men’s health. With excess capacity on the da Vinci System, hospital executives approached Drs. Payne & Dauterive to gauge their interest. Drs. Payne & Dauterive were already accomplished laparoscopic surgeons and their initial impression was that they didn’t need da Vinci Surgery. However, they decided to get trained and conduct a study comparing their clinical results from their last 100 laparoscopic cases compared to their first 100 da Vinci Surgery cases, which included their learning curve. Retrospectively, Drs. Payne & Dauterive were surprised to learn that their overall laparotomy (TAH) rate was higher than they thought, 20 women out of 100 in their practice received a TAH. However, the da Vinci Surgery cohort reduced this to only 4 women, and there were 0 women in their last 25 cases that had a TAH. Conversions to laparotomy decreased significantly from 9 women to 4 women, and no women were converted intra-operatively in their last 25 cases The average uterine weight of the conversions was substantially higher in the da Vinci cohort compared to the laparoscopic cohort, 1388g vs 360g respectively 8 women in the laparoscopic cohort underwent TAH due to adhesions, compared to none in the da Vinci group With proficiency, da Vinci enables GYN surgeons to minimize and potentially eliminate TAH da Vinci enables GYNs to treat more complex pathology minimally invasively Operative times with da Vinci were comparable to laparoscopy after 50 cases and faster after 75 cases This data demonstrates that da Vinci minimizes total abdominal hysterectomy (TAH) and conversion rates compared to conventional laparoscopy. Reference: Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol May-Jun;15(3): Epub 2008 Mar 6. Öğrenme sonrası kısa operasyon süresi Reference: Payne TN, Dauterive FR. A comparison of total laparoscopic hysterectomy to robotically assisted hysterectomy: surgical outcomes in a community practice. J Minim Invasive Gynecol May-Jun;15(3): Epub 2008 Mar 6.

24 Prognozu kötü hastalarda da düşük konversiyon oranı
Practice 1 (N=80) Practice 2 (N=79) Practice 3 (N=55) Practice 4 (N=25) Practice 5 (N=17) Total (N=256) Mean BMI 31.1 30.6 30.5 34.7 29.9 Mean Uterine Weight (g) 596.1 660.0 484.8 484.7 498.5 574.5 Prior Surgery -Pelvic/Abdominal (%) 56.3 55.7 69.1 48.0 17.7 55.5 Conversion (%) 2.5 0.0 3.6 1.6* Complications (%) 1.3 7.6 1.8 4.0 3.5 Length of Hospital Stay (days) 1.1 1.2 1.0 1.4 Est. Blood Loss (mL) 81.4 112.3 91.9 105.0 132.4 98.9 Mean skin-to-skin operative time (min) 123.7 193.4** 148.6 138.7 125.5 151.4 Prognozu kötü hastalarda da düşük konversiyon oranı (Yüksek BMI, büyük uterus ve sekonder cerrahi Here is another study on hysterectomy. This multicenter study shows da Vinci® Hysterectomy can be performed in women with large uteri with repeatable clinical outcomes, including very few conversions to abdominal hysterectomy, minimal blood loss, short hospital stay and a low rate of complications. The patient population presented with complex pathology, along with the following characteristics: High mean uterine weight of 575 g, including multiple uteri >1,000g High mean BMI of 31.1 Over 55% had prior pelvic surgery Patients experienced excellent, repeatable clinical outcomes: Short average length of stay, averaging 1.1 days Low estimated blood loss, averaging 98.9 mL with no transfusions Extremely low conversion rate of 1.6% on average, especially considering the complex nature of these patients Low overall complications, averaging 3.5% In summary, this study demonstrates that da Vinci Hysterectomy is an effective and repeatable procedure across institutions. Furthermore, large uteri are not a barrier to robotic-assisted MIS; surgeons can offer this procedure to a wide range of patients, including those presenting with obesity and prior pelvic surgery. * 3 of the 4 conversions due to lack of intraabdominal space because of the large size and shape of uteri. ** Practice 2’s operative time affected by high percentage of additional procedures, where all patients received a modified McCall’s culdoplasty during surgery. Reference: Payne TN, Dauterive FR, Pitter MC, et al. Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices. Obstet Gynecol Mar;115(3): * 3 of the 4 conversions were due to lack of intra-abdominal space because of the large size and shape of uteri. ** Practice 2’s operative time was affected by high percentage of additional procedures, where all patients received a modified McCall’s culdoplasty during surgery. Reference: Payne TN, Dauterive FR, Pitter MC, et al. Robotically assisted hysterectomy in patients with large uteri: outcomes in five community practices. Obstet Gynecol Mar;115(3):

25 Robotik histerektomi vs. laparoskopik histerektomi
arası 441 hastanede histerektomi incelenmiş Hastane kalma süresi <2 gün % vs. % 24.9 Transfüzyon %1.4 vs. %1.8 Maliyet robotik histerektomide 2189 dolar fazla Morbidite benzer bulunmuş. Wright ve ark. JAMA.2013

26 Hysterectomy in the U.S.1-3 (over 500,000 hysterectomies per year)
Histerektomi Hysterectomy in the U.S.1-3 (over 500,000 hysterectomies per year) Robotic-Assisted da Vinci® Surgery was introduced for GYN in 2005 10% 14% 24% 31% 23% 22% MIS 61% 16% 14% Now look at the dramatic change since Since the introduction of da Vinci Hysterectomy in 2005, the rate of open hysterectomy decreased from 64% to 39%. Vaginal surgery decreased and laparoscopy grew only 2%. With vaginal and laparoscopic hysterectomy remaining relatively steady, it’s clear that da Vinci provided women a minimally invasive approach who otherwise would have received an abdominal hysterectomy. References: Farquhar CM, Steiner CA. Hysterectomy rates in the United States Obstet Gynecol Feb;99(2): Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of laparoscopic hysterectomy vs. abdominal and vaginal approaches. Obstet Gynecol Nov;114(5): Thompson Healthcare’s Solucient Database (US, 2012) from reporting hospitals in Thompson Healthcare's dataset, on file at Intuitive Surgical, Inc. 76% 67% 64% 39% Open 39% References: 1. Farquhar CM, Steiner CA. Hysterectomy rates in the United States Obstet Gynecol Feb;99(2): Jacoby VL, Autry A, Jacobson G, et al. Nationwide use of laparoscopic hysterectomy vs. abdominal and vaginal approaches. Obstet Gynecol Nov;114(5): 3. Thompson Healthcare’s Solucient Database (US, 2012) from reporting hospitals in Thompson Healthcare's dataset, on file at Intuitive Surgical, Inc.

27 Reprodüktif Sistem Cerrahisi
Myomektomi Tubal Reanastomoz Ovarian Transpozisyon Endometriozis

28 Robotik grupta daha büyük myom çıkarabilme
Abdominal (N=393) Laparoscopy (N=93) Robotic (N=89) Overall P Value Surgical Time (min) 126 155 181 <.0011 Myoma Weight (g) 263.00 96.65 223.00 <.0012 Estimated Blood Loss (mL) 200 150 100 <.0013 Hemoglobin Drop (g/dL) 2.00 1.55 1.30 <.0014 Length of Hospital Stay (days) 3 1 <.0015 Robotik grupta daha büyük myom çıkarabilme Robotik grupta Daha az kanama ve hastanede kalma süresi, daha uzun operasyon süresi Let’s look at a study on myomectomy, published in 2011 Obstetrics & Gynecology, popularly known as “the Green Journal” – the official publication of ACOG (American Congress of Obstetricians and Gynecologists). This study was done by several Cleveland Clinic physicians, including Drs. Steve Zimberg and Tommaso Falcone. This study involves 575 patients and compares retrospective cohorts of abdominal and laparoscopic myomectomy with a prospective cohort of da Vinci® Myomectomy. They found significantly less estimated blood loss for da Vinci, versus both abdominal and lap cohorts. They also found a significantly lower drop in hemoglobin and shorter length of stay versus abdominal. This is important because 25 women in the open group needed blood transfusions versus only 2 in the robotic group (or 6% vs. 2%). As you know, this can be significant to your patients and shows one of the benefits of minimally-invasive surgery. Now, let’s go back to the top and talk about myoma weight. This is where it gets interesting. With da Vinci, the average weight of myomas removed was 223g vs only 97g with laparoscopy. So, they were able to remove significantly heavier myomas with da Vinci than with lap. What they concluded was that da Vinci allows a surgeon to replace more abdominal cases with minimally-invasive surgery than traditional laparoscopy. Essentially, as a surgeon, I will be able to successfully complete more cases withda Vinci than with standard lap. That means more patients can benefit from MIS. 1 Abdominal vs. laparoscopic, P=.142; abdominal vs. robotic, P=.003; laparoscopic vs. robotic, P=.083. 2 Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P=.360; laparoscopic vs. robotic, P=.021. 3 Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P=.818. 4 Abdominal vs. laparoscopic, P=.061; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P=.431. 5 Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P=.506. Reference: Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy: A Comparison of Surgical Outcomes. Obstet Gynecol Feb;117(2 Pt 1): 1 Abdominal vs. laparoscopic, P=.142; abdominal vs. robotic, P=.003; laparoscopic vs. robotic, P= Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P=.360; laparoscopic vs. robotic, P= Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P= Abdominal vs. laparoscopic, P=.061; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P= Abdominal vs. laparoscopic, P<.001; abdominal vs. robotic, P<.001; laparoscopic vs. robotic, P=.506. Reference: Barakat EE, Bedaiwy MA, Zimberg S, et al. Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy: A Comparison of Surgical Outcomes. Obstet Gynecol Feb;117(2 Pt 1):

29 Myomektomi Daha büyük myomları çıkarabilme Daha az komplikasyon
Barakat ve ark. Obstet Gynecol. 2011 Bedient ve ark Am J Obstet Gynecol. 2009

30 Stage 4 , % 28 sekonder cerrahi, >%50 Douglas oblitere
Robotic (N=80) Operative time (min) 115 ± 46 Estimated blood loss (ml) 88 ± 67 Blood transfusions Length of hospital stay (days) 1.0 ± 0.37 Pain relief at 8 weeks post-op 79 (98.8%) Minimal kan kaybı, kısa operasyon süresi ve daha az ağrı This is the last clinical study for today – it’s on endometriosis. This is the largest published case series on da Vinci® Endometriosis Resection. Some of the key points of the study are that this series involves all complex cases of advanced stage (IV) disease. 28% of patients had prior pelvic surgeries, >50% had complete obliteration of the cul-de-sac, and endometriosis was found in many pelvic locations (ovaries, tubes, cul-de-sacs, bowel). There were few conversions, all within the 1st 15 cases. Despite the fact that all of the cases were performed during the learning curve, patients experienced minimal blood loss, short hospital stay, and the resolution of pain was excellent. This shows the value of da Vinci Surgery for endometriosis patients. Reference: Brudie LA, Gaia G, Ahmad S, et al. Peri-operative outcomes of patients with stage IV endometriosis undergoing robotic-assisted laparoscopic surgery. J of Robotic Surg Oct. DOI: /s Stage 4 , % 28 sekonder cerrahi, >%50 Douglas oblitere Reference: Brudie LA, Gaia G, Ahmad S, et al. Peri-operative outcomes of patients with stage IV endometriosis undergoing robotic-assisted laparoscopic surgery. J of Robotic Surg Oct. DOI: /s

31 Ürojinekolojide robot kullanımı
Sakrokolpopeksi Rektopeksi Vezikovajinal fistül onarımı

32 Robotik sakrokolpopeksi
Daha az kanama Benzer başarı Kısa kateter süresi Kısa operasyon süresi Payne ve ark.J Minim Invasive Gynecol, 2008

33 Robotik sakrokolpopeksi
arası yapılan 12 çalışma Toplam 350 hasta ay takip Op. süresi: 203 dakika Konversiyon oranı % 3.4 İntraop kompl: % 4.6, Periop. kompl.:% 7.1 Erozyon(exposure): % 2.5 Başarı: % 97 Selsen et al. Urol Prog. 2012

34 Robotik vs. abd. sakrokolpopeksi
Retrospektif karşılaştırma Daha iyi destek(C noktası) (-9 vs. -8) Mesane yaralanması (1 vs. 1) 1 konversiyon Geller et al. Obstet Gynecol 2008

35 Robotik vs. LS ve abdominal sakrokolpopeksi
Robotik Laparaskopik Abdominal Op. süresi (dakika) Konversiyon(%) Transfüzyon (%) Hast.kalma süresi(day) Maliyet (dolar) Judd et al. J Minim Invasive Gynecol. 2010

36 Jinekolojik onkolojide robot kullanımı
Over kanseri Servikal kanser Endometriyal kanser

37 Jinekolojik Onkolojide robot kullanımı
Daha az komplikasyon Daha az kanama Daha az açığa dönme Düşük postoperatif ağrı Daha az hastanede kalma Bell ve ark. Gynecologic Oncology III 2008. Lim ve ark ve ark.. J Robotic Surg .2012 Boggess ve ark . Am J Obstet Gynecol 2008. 26. Magrina ve ark.Eur J Gynaecol Oncol. 2011 Scandola ve ark.J Minim Invasive Gynecol. 2011

38 Robotik histerektomi vs. Açık histerektomi
Daha çok lenf nodu çıkarılması (1) Daha az komplikasyon (1,2,3) Daha az hastanede yatış süresi (1,2) Daha az kan kaybı (1,2). 1. Boggessand Schafer, University of North Carolina, presentation made atSociety of Gynecologic Oncology Conference, held in San Diego, CA March 2007 2.Rick Estape, University of Miami, presentation made at the 36th Global Congress of the AAGL, held in Washington DC November 2007. 3.J.M. Piquion-Joseph, A. Nayar, A. Ghazaryan, R. Papanna, W. Klimek, R. Laroia. Robot-assisted gynecological surgery in a community setting. J Robotic Surgery :61-64.

39 Endometrium Kanseri

40

41

42 Hihg grade endometrium kanserinde MIS vs. laparatomi
191 laparotomi, 192 MIS(% 65 robotic, %35 LS) Operasyon süresi MIS’de daha fazla(191 vs 135 dak) MIS grubunda daha fazla lenf nodu(39 vs. 34) Daha kısa hastanede kalış(1 vs. 4 gün) Daha az komplikasyon(%8.4 vs. %31.3) Fader ve ark. Gynecol Oncol 2012

43 Robotik Histerektomi+LND vs. laparoskopik histerektomi+ LND
Retrospective Review of Staging Endometrial Cancer Boggess J, 2008 Lap (n=101) Robotic (n=43) p-value Age (years) 61 NS BMI 29.2 32.2 0.008 Estimated blood loss (ml) 142 63 0.0001 OR time (min) 213 163 0.002 Lymph nodes 23.2 29.8 0.004 Left para-aortic lymph nodes 7 Hospital stay (days) 1.2 1.0 0.04 % complications 12.8% 4.6% % conversion to laparotomy 3% 0% In the Fall of 2006, at the American College of Surgeons meeting, Dr. Boggess compared his data on staging endometrial cancer using da Vinci (n = 43) versus laparoscopic staging (n = 101). Dr. Boggess also presented this data during the Live Surgery Webcast of a da Vinci Hysterectomy for Endometrial Cancer with Staging on February 21st: Compared to his laparoscopic cohort: Significantly more nodes were retrieved (30 vs. 23) Significantly less blood was lost (63 vs. 142 ml) with no blood transfusions Operative time was substantially less (163 vs. 213 minutes); da Vinci provides improved OR efficiency compared to laparoscopy & comparable operative times to open surgery. Complications were minimized (13% down to < 5%) compared to laparoscopy. Complications in the robotic group consisted of port site hernias in very obese women early in their experience. These complications have been eliminated by switching to blunt trocars using a 2mm endoscope to facilitate direct to trocar placement. Patients were sent home more quickly (1 vs. 1.2 days) compared to his laparoscopic cohort. The short hospital stay & rapid recovery afford GYN Oncologists the advantage of beginning adjuvant therapy more quickly following surgery (in those patients who require it). No need for IV analegsics. Finally, there were no conversions to laparotomy for the robotic group compared to 3% for the laparoscopic group.

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45 Serviks kanseri Robotik radikal histerektomi+PLND vs açık rad. Hist.
51 robotik rad.hist. 48 açık rad.hist. Robotik kolda Kanama daha az Operasyon süresi daha kısa Lenf nod sayısı daha yüksek Komplikasyon daha az(% 7.8 vs. 16.3) Hastanede kalış daha kısa( 1 vs. 3.2 gün) Bogges ve ark. Am J Obstet Gynecol 2008

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47 Sonuçlar Robotik cerrahinin bütün jinekolojik operasyonlarda uygulanabileceği önerilmesine karşın günümüzde konvansiyonel laparoskopi yapılan merkezlerde fizibıl kullanım alanları Myomektomi Sakrokolpopeksi Kanser cerrahisi(Serviks ve endometrium) dir. Öğrenme körvünün kısa olması nedeniyle laparoskopi yapılamıyorsa diğer operasyonlarda da kullanılabilir. Maliyetin düşmesi ve ekipmanların her gün gelişen modifikasyonları gelecekte jinekolojik operasyonların tamamına yakınında robot kullanımını getirecektir.

48 Teşekkürler