Download Robotic-assisted Surgery

SAMPLE REPORT OF ROBOTIC-ASSISTED SURGERY
OPERATIVE REPORT
DATE OF SURGERY
PREOPERATIVE DIAGNOSIS
1. Ovarian granulosa cell tumor.
2. Status post vaginal hysterectomy and right salpingo-oophorectomy.
POSTOPERATIVE DIAGNOSIS
1. Ovarian granulosa cell tumor.
2. Status post vaginal hysterectomy and right salpingo-oophorectomy.
3. Intraperitoneal adhesions.
PROCEDURE
1. Laparoscopy with lysis of adhesions.
2. Robotic-assisted laparoscopic left salpingo-oophorectomy.
3. Intraperitoneal biopsies.
4. Omentectomy. (Staging for ovarian cancer.)
5. Extensive lysis of adhesions.
SURGEON
FIRST ASSISTANT
ANESTHESIA
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS
100 mL.
URINE OUTPUT
750 mL.
IV FLUIDS
2000 mL.
HISTORY
This is a 53-year-old female who underwent a vaginal hysterectomy and left salpingo-oophorectomy.
An incidental finding on histology of the left ovary was that of a seemingly well circumscribed
granulosa cell tumor, adult type, with no capsular extension or obvious disruption of the capsule. The
right ovary was not removed at the time of that surgery due to adhesions and technical difficulty
reaching that ovary.
The patient was seen in gynecologic oncology where she was counseled regarding options. She is
interested in completing surgical staging with the pelvis and abdomen to evaluate whether there is any
overt evidence of metastatic disease. It was also noted that she has PET-avid lymph nodes in the
mediastinum for which she is being evaluated by the thoracic surgery team.
FINDINGS
There are adhesions. The liver is adherent to the anterior abdominal wall consistent with her prior
gastric bypass surgery. In the pelvis there are dense adhesions. The colon is adherent to the left pelvic
sidewall, and the left ovary is retroperitoneal and scarred into place. The right tube and ovary are
surgically absent. There are adhesions between the loop of colon and the right pelvic side wall. The
colon is extremely redundant with multiple folds of large bowel located within the pelvis.
There is no obvious tumor within the peritoneum. The liver diaphragm edges are smooth. The small and
large bowel grossly appear normal as do the adjacent mesentery. The omentum grossly appears normal.
The left tube and ovary appear normal such that there is no grossly visible evidence of metastatic
disease within the peritoneal cavity.
Inspection of the pelvic and para-aortic lymph node regions showed no appreciably enlarged lymph
nodes. This finding is also consistent with a negative PET/CT scan for adenopathy in the pelvis or
abdomen.
PROCEDURE
The patient was taken to the operating room and placed in the dorsal lithotomy position. After general
endotracheal anesthesia was administered, the patient was prepped and draped in the usual sterile
fashion. A timeout had been undertaken where the patient was identified by sight recognition and
hospital ID bracelet and the proposed procedure was reviewed and confirmed. A Foley catheter was
placed in the bladder. An orogastric airway was placed in the stomach on suction. Prepping and draping
were completed in anticipation of laparoscopy.
A 5 mm incision was made in the left upper abdomen with manual elevation of the abdominal wall and
direct visualization with insertion of a 5 mm trocar which was safely introduced into the peritoneal
cavity. Carbon dioxide gas was insufflated.
A 12 mm incision and trocar were placed in the midline approximately 7 cm above the umbilicus. An
8 mm trocar was placed in the right upper abdomen, left lower abdomen, and the original 5 mm trocar
exchanged for an 8 mm trocar.
Peritoneal washings were obtained for cytology. A long cup biopsy instrument was used to obtain
random peritoneal biopsies and to take down adhesions and to biopsy adhesions in the abdomen
including peritoneum overlying the diaphragm. These specimens were collected as part of peritoneal
biopsies. The sites were rendered hemostatic with monopolar cautery. The patient was placed in steep
Trendelenburg position. Blunt graspers were used to relocate the loops of small bowel from the pelvis to
the abdomen. The anatomy was surveyed with findings as described above.
The robotic system was brought into the operative field. The camera arm was attached to the midline
supraumbilical port. Robotic arms #1, 2, and 3 were attached to the right upper abdomen, left upper
abdomen, and left lower abdomen ports, respectively. Monopolar scissors, fenestrated bipolar forceps,
and ProGrasp manipulator were placed in arms #1, 2, and 3, respectively.
Lysis of adhesions was carried out to gain access to the pelvis and complete surgical objectives. It is
estimated that an hour was spent in total time lysing extensive adhesions and to allow completion of
surgical objectives. Multiple adhesive bands were collected as peritoneal biopsies. Additional biopsies
from the pelvis and lower abdomen were obtained and collected as peritoneal biopsies. Retroperitoneal
dissection was carried out on the right side. The right tube and ovary were surgically absent, but an
effort was made to ensure that there is no remnant. The right infundibulopelvic ligament was dissected
and isolated to the level of the pelvic brim. The right ureter was identified. The intervening peritoneum
was opened. The infundibulopelvic ligament was isolated and cauterized at the level of the pelvic brim
and transected. The residual right utero-ovarian ligament remained as a point of attachment in the pelvis
which was isolated, cauterized, and transected, thereby removing the right gonadal vessels which were
placed in the right paracolic gutter for later retrieval.
After lysis of adhesions was carried out, the bowel was freed from its dense adherence to the left pelvic
side wall, and the third robotic arm was used to assist in traction on the bowel medially. This allowed
retroperitoneal dissection on the left side. The residual round ligament on the left was isolated,
cauterized, transected. The anterior and posterior leaflets of the broad ligament were opened. The left
ureter was identified. The left infundibulopelvic ligament was isolated and the intervening peritoneum
was opened. The infundibulopelvic ligament was isolated to the level of the pelvic brim where it was
cauterized and transected.
Dissection distally allowed removal of the ovary and the tube from the retroperitoneal positions. The
distal point of attachment at the residual utero-ovarian ligament was isolated, cauterized, and transected.
There were surgical staples noted in this region. It is unclear if these were used with a recent
gynecologic surgery or if the patient had had surgery in the more distant past with a small cluster of
staples located in what appeared to be the residual left utero-ovarian ligament. Two loose staples were
removed and withdrawn through a laparoscopic port. The site was hemostatic and the left tube and
ovary were placed in the right pericolic gutter for later retrieval. At this point the instrument was
removed from the fourth robotic arm, and all of the peritoneal biopsies were handed to the surgical
assistant where they were removed through this port. A small piece of distal omentum which had been
taken down with lysis of adhesions was also removed through this port.
Lymph node beds were inspected and noted to be without enlargement. It was felt that the morbidity of
lymph node dissection exceeded the benefit. Lymphadenectomy was not performed.
The distal edge of the infracolic omentum was grasped with the third robotic arm instrument and pulled
on traction towards the pelvis. The transverse colon was identified. Nonvascular attachments were taken
down with sharp dissection and bipolar cautery. Vascular attachments were cauterized with bipolar
cautery and transected. This was carried out starting near the hepatic flexure and continued toward the
splenic flexure, removing a large portion of the infracolic omentum which again grossly appeared
normal. All sites were hemostatic. The omentum was placed in the pelvis for later retrieval.
The dissection bed was carefully inspected. Small bleeders were rendered hemostatic with bipolar
cautery. Sites were irrigated and noted to be hemostatic. It was felt all reasonable surgical objectives in
this patient had been completed. The robotic instruments were withdrawn. The system was withdrawn
from the operative field. I reentered the bedside under sterile conditions. Two Raytec sponges that had
been placed in the peritoneal cavity were withdrawn. Visual inspection confirmed there were no
remaining foreign objects in the peritoneal cavity, and preliminary counts were correct.
A 12 mm trocar was exchanged for a 15 mm trocar and an Endo Catch bag used to capture the left tube
and ovary, the right infundibulopelvic ligament, and the omental specimens. The bag was brought up to
the abdominal wall. Ring forceps were used to help deliver the specimens through the supraumbilical
port.
After delivery of all specimens, the peritoneal cavity was again inspected, irrigated, noted to be
hemostatic. Surgicel was placed in the pelvic dissection bed, and again all sites were noted to be
hemostatic.
The 12 mm fascial defect was closed with 2 interrupted 0 Vicryl sutures using a Gore needle passer
under direct laparoscopic visualization. This rendered the fascia completely airtight and hemostatic. The
remaining trocars were withdrawn. Sites were hemostatic. Carbon dioxide gas was removed from the
peritoneal cavity.
Vicryl 3-0 subcutaneous followed 3-0 Vicryl subcuticular and Steri-Strips were used to close the skin
edges. The Foley catheter was discontinued. Pelvic exam confirmed there were no remaining foreign
objects in the vagina. Preliminary and final counts were correct. The patient was returned to the supine
position and was pending reversal of anesthesia as I left the operating room to precede the patient to the
postanesthesia care unit.