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Update on Gynecologic Electrosurgery

M. Jonathan Solnik, MD

The latest electrosurgical equipment features a number of safeguards to minimize the potential for thermal injury, but this has also been accompanied by greater specialization of applications.

In the not-so-distant past, many physicians condemned the use of electrosurgery. Whether it was the delayed thermal injuries that occurred in the early stages of modern-day endos- copy,1 or the constituency who swore by the adage ñto operate, all one needs is a fork, knife, and spoon,î surgeons have since learned to embrace technologic advancements that truly facilitate gynecologic procedures.

A number of instruments have recently been introduced into the electrosurgical armamentarium that allow for surgical-ease precision, hemostasis, and efficiency. It is the responsibility of the surgeon to be cognizant of these innovations, and consider the utility, cost, and benefit to the patient. A fundamental understanding of electrosurgery will not only reduce the number of potential complications, but will also allow the surgeon to apply these energy-based systems more effectively.2

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MONOPOLAR ENERGY


The electrosurgical devices that revolutionized the surgical arena circa 1910 utilized monopolar energy. These versatile instruments are quite useful for dissecting, cutting, and coagulating tissue. Although many safety precautions have been implemented over the years, the inherent risks of monopolar electrosurgery still apply to laparoscopic procedures. Two such events which occur independent of surgeon action or skill are capacitive coupling (Figure 1) and insulation breaches. Both can result in a significant release of electrical energy to nontarget tissues and present as delayed thermal injury.

Figure not available online

FIGURE 1. Capacitive coupling. Courtesy of Valleylab.

Current Technologies

Active electrode monitoring (AEM) laparoscopic instruments utilize a protective mechanism conceived to avert both capacitive coupling and insulation failure. This line of 5-mm instruments has a secondary conductor within the shaft that provides coaxial shielding (Figure 2). Along with additional insulation, these instruments safely absorb coupled energy. The AEM system measures stray currents and shuts down the circuit when it detects only 2 W of stray energy. There is a nominal expense for the AEM monitor (which can be relayed to most generators) plus reusable handles and adaptors, but the long-term cost is comparable to that of disposable instruments that do not provide the same level of safety.

Since the advent of these early devices, the use of robotic technology to facilitate laparoscopic procedures in gynecology has increased rapidly over the past 5 years—particularly with the introduction of the latest and only US Food and Drug Administration-approved platform in surgical robotics, the da Vinci surgical system. Numerous studies across various surgical disciplines have reported that this is a safe, effective alternative to conventional laparoscopic surgery, especially when dealing with complex pathology. In the area of gynecology, there are multiple reports of robot- assisted laparoscopy with the da Vinci system for a wide range of pathologic conditions.

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THE DA VINCI SURGICAL SYSTEM

The da Vinci surgical system is a laparoscopic assistive device that is comprised of three components (Figure 1). The first component is the surgeon's console, which is located remotely from the patient's bedside. Seated at this console, the surgeon is able to control robot-assisted instruments in the surgical field with the aid of a stereoscopic viewer, hand manipulators, and foot pedals. The second component is the InSite vision system, which provides three-dimensional imaging through a 12-mm endoscope. Although a 5-mm endoscope is available, this only provides two-dimensional imaging. The third component is the patient-side cart with robotic arms and EndoWrist instruments. Currently, the da Vinci system is available with either three or four robotic arms. One of the arms holds the endoscope while the other two or three arms hold the various EndoWrist instruments, which come in 8-mm and 5-mm sizes. A newer model, the da Vinci S, functions on the same platform as its predecessor, but provides the surgeon with additional range of motion from longer instruments and increased pitch.

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FIGURE 1. The da Vinci robotic system. From left to right: surgeon’s console, patient-side surgical cart, and InSite vision tower. Courtesy of Intuitive Surgical, Inc.

The EndoWrist instruments are unique in that they possess a wrist-like mechanism that allows seven degrees of movement, thereby replicating the full range of motion of the surgeon's hand and eliminating the "fulcrum" effect seen with conventional laparoscopy. Although these instruments exhibit significant dexterity compared with those used in traditional laparoscopy, they lack haptic or tactile feedback, which may be a limitation for some surgeons. A series of EndoWrist instruments—eg, needle drivers, scissors, graspers—can be interchanged on either of the lateral robotic arms (Figure 2). Although dispos-able, these instruments typically last for 10 uses and cost approximately $2,500 each. The da Vinci surgical system retails for around $1,300,000 to $1,500,000.

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FIGURE 2. Example of EndoWrist instrument (tenaculum). Courtesy of Intuitive Surgical, Inc.

Prior to incorporating robotics into their surgical armamentarium, surgeons must first undergo device training, case observations, and proctoring of early cases. Much of the credentialing and privileging requirements for any robotics platform will depend largely on individual hospital policies. Critical to the success of a robotics program is a team-oriented approach, in addition to a willingness to undergo the learning curve associated with a new technical approach. Appropriate case selection is critical; the criteria utilized to determine safe candidacy for conventional laparoscopy should also be applied to any robotic case, including variables such as body habitus, surgical history, and anticipated size of the pathology.

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GYNECOLOGIC APPLICATIONS

Robotic applications in gyne- cologic surgery are quite varied. The majority of experience thus far has been in the area of hysterectomy. Specifically, the da Vinci surgical system has facilitated the completion of totally endoscopic hysterectomy (uterus/cervix or supracervical) as described by the American Association of Gynecologic LaparoscopistsÍ classification system.6 A broad range of benign indications have been addressed (Table 1). Although variables such as operative time were not improved, the overall safety and feasibility of the approach was confirmed.7-12 This experience was carried over into oncologic applications, an approach that holds promise for endometrial and possibly cervical cancer staging (Table 2).7,10,13

Table not available online

TABLE 1. Robot-assisted Laparoscopic Hysterectomy CIN = cervical intraepithelial neoplasia; CA = cancer; UTI = urinary tract infection.

Table not available online

TABLE 2. Robot-assisted Laparoscopic Cancer Staging CIN = cervical intraepithelial neoplasia; CA = cancer; UTI = urinary tract infection.

Although much of the early experience with robotics in gynecology has involved hysterectomy, more suture-based procedures have been investigated as well. Robot-assisted laparoscopic myomectomy holds great promise, given that most conservative surgery for leiomyomata in this country depends on laparotomy. In one study, Advincula et al14 were able to demonstrate both feasibility and an ability to adhere to open surgical techniques such as multilayer, sutured closure of a myometrial defect. Other, more complex suture-based applications have been in the areas of tubal reanastomosis and sacrocolpopexy.15,16 In an early study,16 20 patients undergoing robot-assisted laparoscopic sacrocolpopexy were found to have shorter hospital stays, low complication and conversion-to-laparotomy rates, and high rates of patient satisfaction despite a mean follow-up of 5.1 months (range 1 to 12 months).

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CONCLUSION

The use of robot-assisted technology may provide a means to overcome both advanced pathology and the surgical limitations of conventional laparoscopy by providing surgeons with improved dexterity and precision coupled with advanced imaging that allows for the completion of complex MIS procedures. The feasibility of approaching gynecologic surgery with robotics has been demonstrated clearly. Although prospective, randomized studies comparing this technology with traditional approaches have yet to be performed, the application of robotics to gynecologic surgery represents a promising advancement in MIS. Despite the expense and learning curve associated with such technology, as well as the absence of haptic instrument feedback, the potential long-term benefits to both patients and surgeons may still outweigh the initial investment and technical limitations.

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Arnold P. Advincula, MD, is associate professor and director, Minimally Invasive Surgery Program and Fellowship, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor.

Disclosure
Dr Advincula reports that he has received grant research support from Intuitive Surgical, Inc.

References

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