Teresa M. Walsh

Robotic-Assisted, Ultrasound-Guided Abdominal Cerclage During Pregnancy: Overcoming Minimally Invasive Surgery Limitations?

Herein, we report robotic abdominal cerclage placement under ultrasound guidance. The da Vinci Si system (Intuitive Surgical, Sunnyvale, CA) allows a simultaneous display of the operative field and transvaginal ultrasound images. Additionally, the vaginal ultrasound probe assisted in the manipulation of the uterus to improve visualization without placing excessive pressure on the gravid uterus. Ultrasound guidance improves needle placement accuracy and reduces potential for injuries.

Outcomes of robotic sacrocolpopexy using barbed delayed absorbable sutures.

STUDY OBJECTIVEnTo evaluate 1-year outcomes of robotic sacrocolpopexy (RSC) for pelvic organ prolapse using barbed delayed absorbable sutures.nnnDESIGNnRetrospective cohort study (Class II-3).nnnSETTINGSnUniversity-based hospital in Southeast Texas.nnnPATIENTSnPatients with symptomatic apical pelvic organ prolapse who underwent RSC using barbed delayed absorbable sutures between January 2011 and August 2012. Patients were examined postoperatively at least twice (after 6 weeks and 1 year).nnnINTERVENTIONSnRSC procedure.nnnMEASUREMENTS AND MAIN RESULTSnThe study included a total of 20 patients, of them 15 had grades 3 or 4 whereas 5 had grade 2 apical defects according to the Baden-Walker classification system. Fourteen patients (70%) underwent concomitant hysterectomy while 9 (45%) underwent concomitant anti-incontinence surgery. Mesh suturing times were 46.9 ± 12.6 and 20.5 ± 9.3 minutes in the first 10 versus the last 10 cases, respectively (p < .001). The mean follow-up duration was 17.3 months (range, 12-24 months). There were no recurrences of apical defects or mesh/suture exposure/erosion. However, 1 patient developed a grade 2 cystocele, and another developed new-onset urinary incontinence, both after 1 year. A third patients urine leakage did not improve postoperatively. Lastly, a fourth patient developed port site incisional hernia and underwent repair 5 months later.nnnCONCLUSIONnOur study suggests that barbed delayed absorbable sutures are safe and effective in RCS procedures over 1xa0year. Larger, comparative, and randomized trials are recommended for definitive conclusions.

Effect of residents' previous laparoscopic surgery experience on initial robotic suturing experience.

Objective. To assess the impact of gynecology residents previous laparoscopic experience on the learning curve of robotic suturing techniques and the value of initial structured teaching in dry lab prior to surgery. Methods. Thirteen gynecology residents with no previous robotic surgery experience were divided into Group 1, consisting of residents with 2 or fewer laparoscopic experiences, and Group 2, consisting of residents with 3 or more laparoscopic experiences. Group 1 had a dry-laboratory training in suturing prior to their initial experience in the operating room. Results. For all residents, it took on average 382 ± 159 seconds for laparoscopic suturing and 326 ± 196 seconds for robotic suturing (P = 0.12). Residents in Group 1 had a lower mean suture time than residents in Group 2 for laparoscopic suturing (P = 0.009). The residents in Group 2, however, had a lower mean suture time on the robot compared to Group 1 (P = 0.5). Conclusion. Residents with previous laparoscopic suturing experience may gain more from a robotic surgery experience than those with limited laparoscopic surgery experience. In addition, dry lab training is more efficient than hands-on training in the initial phase of teaching for both laparoscopic and robotic suturing skills.

Intraocular pressure and steep trendelenburg during minimally invasive gynecologic surgery: Is there a risk?

STUDY OBJECTIVEnSteep Trendelenburg position is frequently used during gynecologic minimally invasive surgery (MIS). However, little attention has been given to the potential impact of this nonphysiologic positioning on patients, specifically intraocular pressure (IOP). The purpose of our study was to evaluate IOP changes during laparoscopic or robotic hysterectomy conducted in the steep Trendelenburg position.nnnDESIGNnProspective cohort study (Canadian Task Force classification II-2).nnnSETTINGnJohn Sealy Hospital at the University of Texas Medical Branch, Galveston, TX.nnnPATIENTSnFemale patients with no history of ocular pathology who underwent elective robotic or laparoscopic hysterectomy.nnnINTERVENTIONSnThe anesthesia protocol was standardized for all study patients. IOP and mean arterial pressure (MAP) were obtained before anesthesia, after general anesthesia and intubation were achieved, after 1 hour of steep Trendelenburg positioning, after 2 hours of steep Trendelenburg positioning, and after the patient was returned to the supine position. Ocular perfusion pressure (OPP) was calculated using the following equation: OPP = MAP - IOP.nnnMAIN RESULTSnA total of 10 patients were included in this prospective study. A significant increase in IOP from baseline was observed after 1 hour and 2 hours of steep Trendelenburg positioning (p = .005 and .002, respectively). There was a statistically significant trend of increasing the IOP from baseline to the second hour of steep Trendelenburg positioning (p < .001). The IOP remained significantly elevated once the patient was returned to the supine position when compared with the baseline IOP (p = .006). OPP significantly decreased from baseline after 2 hours of steep Trendelenburg positioning (p = .03).nnnCONCLUSIONSnIOP increases significantly when patients are placed in the steep Trendelenburg position. Although further studies are needed to better characterize this process, given the aging population of our MIS patients in whom risk for glaucoma is significant, preoperative ocular health assessment should be considered in certain cases.

Trocar site hernia on an 8-mm port following robotic-assisted hysterectomy.

The increasing use of laparoscopy has resulted in added complications specific to the laparoscopic approach, such as trocar site hernia (TSH), which is an uncommon but well-recognized problem for both regular laparoscopic and robotic-assisted laparoscopic procedures. We describe an extremely rare case of TSH at an 8-mm port site occurring a relatively short time after surgery in a 53-year-old patient undergoing robotic-assisted laparoscopic hysterectomy for benign reasons. Additionally, this report attempts to explain the possible etiological factors relating to TSH following robotic-assisted surgery. According to our case report, a defect in the 8-mm port that may lead to hernia is one possible explanation, and closure of the 8-mm trocar sites fascia may be a safer approach during robotic-assisted surgery. Additional reports are needed to accurately determine the frequency of occurrence and importance of this complication.