Robot%chirurgie%in%de%Gynaecologische%Oncologie Verpleegkundigen%in%de%oncologie:%update 11%februari%2017%> Oostkamp

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1 Robot%chirurgie%in%de%Gynaecologische%Oncologie Verpleegkundigen%in%de%oncologie:%update 11%februari%2017%> Oostkamp Philippe'Van'Trappen,'MD'PhD'MRCOG(Gyn Onc) Head'Gynaecology/Oncology Bruges AZ'St.'Jan'Hospital'Bruges BELGIUM

2 Evolutie%gynaecologische%chirurgie

3 ROBOTIC%SURGERY

4 Robot%console 3D%View Ergonomic positionsurgeon Telesurgery Endowristed instruments Controle%of%Camera%and all instruments

5 Plaatsen%trocars%+% docking%aan%robot

6 Plaatsen trocars + docking aan Robot

7 Robotic%Surgery%in Gynaecological%oncology! Welke%patienten:! Endometrium%carcinoom%(FIGO>stadium%I)! Cervix%carcinoom%(FIGO>stadium%IA2>IB1)! Ovarium%carcinoom%(FIGO>stadium%IA)

8 Robotic%Surgery%in Gynaecological%oncology! Welke%operaties:! Robot%hysterectomie%+/> pelviene%klieren! Robot%radicale%hysterectomie%(Wertheim>Meigs)! Robot%para>aortale%klierdissectie! Robot%radicale%cervixamputatie/trachelectomie%met%pelviene% klierdissectie

9 Robotic'Assisted'vs'Straight'Stick'(Laparoscopy)! No'haptic'feedback! Three'dimensions! More'degrees'of'freedom! No'tremor! Telesurgery! Telementoring! Easier! Quicker'to'learn!?cost!?'More'breakdown! Haptic'Feedback! Two'dimensions! Less'degrees'of'freedom! Max'tremor! No'telesurgery! No'telementoring! Less'easy! Slower'to'learn! Less'cost! Less'risk'of'op'breakdown

10 Robotic'Assisted'vs'Straight'Stick! Endometrial'cancer! Overweight! Cervix'Cancer! Complex'Surgery! Ovarian'Cancer! Complex'Surgery

11 Obesity

12 Obesity 12

13

14 Endometrial Cancer

15 Endometrial Cancer

16 Endometrial Cancer

17 Endometrial Cancer

18 Endometrial Cancer 1995$% 13.9$/$100,000 x'2 2015$% 27.8$/$100,000$ 18

19 Risico%factoren%voor% endometrium%carcinoom

20 Laparoscopic vs Open Hysterectomy for Endometrial Cancer COMPLICATIONS Just RCTs 20

21 Laparoscopic Vs Open Surgery Endometrial Cancer Kalogiannidis et al Recurrence % Overall Survival % Disease-free survival % LH AH Zullo et al LH NR AH NR Nezhat et al LH NR AH NR Malzioni et al LH AH

22 Laparoscopic Vs Open Surgery Endometrial Cancer Level%1%evidence Longer%operating%time Shorter%hospital%stay Less%blood%loss Less%post7operative%complications 22

23 National%statistics%for%endometrial%cancer Approaches to hysterectomy for endometrial ca Open Vaginal Laparoscopic Unclassified Acknowledgment%to%Osama%Abughazza 23

24 Robotic Surgery Endometrial Cancer 24

25 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Boggess$2008 Pats ORT$ (min) LOS$ (days) EBL$(ml) LN ALN PLN Conv$ (%) RH LH AH Veljovich 2008 RH LH AH Bell$2008 RH LH AH DeNardis$2008 RH AH Comps$ (%) 25

26 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Gaia$2010 Pats ORT$ (min) LOS$ (days) EBL$(ml) LN ALN PLN Conv$ (%) RH LH RH AH Seamon$2009 RH LH RH AH Coronado$2012 RH LH AH Comps$ (%) 26

27 COSTS'??? Robotic%Surgery%For%Endometrial%Cancer 27

28 Costs Before & After Pre-Robot Median (Range) Post-Robot Median (Range) All Cases Median (Range) Comparison Mann-Whitney P (Med. Dif.: 95%CI) Ward/Clinic Costs ( ) 3,391 (641 14,303) 1,585 (380 4,410) 2,631 (380 14,303) P < (1,528: 1,070 2,021) Medical Staffing Costs ( ) 2,153 (143 7,936) 2,322 (73 5,811) 2,182 (73 7,936) NS (11: -304 to 349) Theatre Costs ( ) 2,325 (917 5,264) 2,476 (599 4,722) 2,355 (599 5,264) NS (118: -45 to 279) Drugs / Pharmacy Costs ( ) 150 (16 5,178) 139 (7 579) 147 (7 5,178) NS (18: -12 to 49) Blood Products Costs ( ) 0 (0 490) 0 (0 588) 0 (0 588) NS (0: 0 to 0) Imaging Costs ( ) 54 (0 893) 133 (0 602) 71 (0 893) NS (0: 0 to 55) Pathology Costs ( ) 614 (35 1,804) 585 (35 1,134) 605 (35 1,804) NS (41: -23 to 105) Rehab Therapy Costs ( ) 198 (0 3,582) 0 (0 8,174) 153 (0 8,714) P < (84: 41 to 158) High Dependency Care Costs ( ) 2,830 (0 9,639) 2,560 (0 5,222) 2,830 (0 9,639) NS (270: -128 to 270) Total Cost ( ) 11,463 (3,062 34,276) 10,048 (4,192 17,306) 11,115 (3,062 34,276) P = 0021 (1,707: 638 to 2,745) Cost Including Depreciation ( ) 11,476 (3,088 34,276) 10,274 (4,402 17,306) 11,124 (3,088 34,276) P = (1,470: 441 to 2,478)!

29 29 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% l-tomy Robotics l- scopy Acknowledgement Slide provided by Walter Gotlieb, Canada.

30 30 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al Apr$2003% Nov$2007 L%tomy+L%scopy (n=160) Dec$2007$ May$2010 Robotic (n=143) pivalue BMI$(mean) Obese%(30)39.9) Morbidly%Obese%(>40) Age$(mean) <56 56I65 66I75 > % 8.8% % 16% Complications$> gr2 41.9% 13.3% < Wound$complications 15.6% 3.5% < Acknowledgement Slide provided by Walter Gotlieb, Canada.

31 31 Laparoscopic Vs Open Surgery Vs Robotic Endometrial Cancer Lau et al Apr$2003% Nov$2007 L%tomy+L%scopy Mean$(P25%P75) (n=160) Dec$2007$ May$2010 Robotic Mean$(P25%P75) (n=143) pivalue Time$(skin$to$skin,$min.) 207(159I 244) 241'(205I272) < EBL$(ml) 266''(100I300) 73'(20I100) < Hospital$stay$(days) 5'(4I6) 1'(1I2) < Overall$Cost$per$surgery Including$amortization (8236%12500) 8370$ (7090%9651) Acknowledgement Slide provided by Walter Gotlieb, Canada.

32 Summary for Robotic! Less complications! Shorter hospital stay! Longer time in theatre! Cheaper

33 Robotic%surgery%with%staging%for%endometrial%cancer:% multi>institutional%experience Lowe et al, Obstet Gynecol 2009 n patients Oper.'time Blood'loss n'lns Hosp.'stay Intraoper.' compl Postoper.' compl 'min 87.5'ml 'days 3.5% 14.6%

34 Robotic%hysterectomy%+%LND%versus%Laparoscopic% hysterectomy%+%lnd: case>matched%controlled%study%on% surgical%outcome Lim et al, Gynecol Oncol 2011 Robot N%=%122 Laparoscopy N%=%122 Oper.%Time 147.2%min LN N%=%19.2 Blood%loss 81.1%ml Hosp. 1.5%days Oper.%Time 186.8%min LN N%=%24.7 Blood%loss 207.4%ml Hosp. 3.2%days

35 Robotic hysterectomy +%LND%versus%Laparoscopic hysterectomy +%LND: surgical outcomes at%a% minimally invasive surgical center Cardenas et al, Gynecol Oncol 2010 Robot N=%102 Laparoscopy N%=%173 Oper.%Time 237%min Oper.%Time 178%min Blood%loss 109%ml Blood%loss 187%ml n LNs and complications equal

36 Robotic surgeryfor patients with low%andhigh%bmi%in%a German Gynecological Cancer%Center Kannisto et)al,)archgynecol Obstet,)2014)July Retrospective study N=116%patients Operations:%Robot%(radical)%hysterectomy,%Adnexectomy,%LN%dissection,%etc Complications overall:%15/116%(12.9%) Perioperative complications:%normal BMI'='high'BMI > vascular injury (2) > intestinal injury (2) > not well%exposedparaaortic field%(1) > bladder%injury (1) Late%complications:%vaginaldehiscence (2),%vaginalhemorrhage (1),%cuff hematoma (4), Lymphocyst (1),%urinary tract injuries,%ureter%(2)%

37 Robot%versus%Laparoscopicnerve>sparing%radical hysterectomy for early>stage%cervical cancer Chong et)al,)int)j)gynecol Cancer,)2013)July 50)Robot Robot N%=%50 Oper.%Time 230.1%min Laparoscopy N%=%50 Oper.%Time 211.2%min LN N%=%25 LN N%=%23.1 Blood%loss 54.9%ml Normal%res.% urine 9.6%days Blood%loss 201.9%ml Normal%res.% urine. 11%days P<0.001

38 Robot%versus%Laparoscopicnerve>sparing%radical hysterectomy for early>stage%cervical cancer Chong et)al,)int)j)gynecol Cancer,)2013)July Complication rate!!: > ROBOT:%0% > LAPAROSCOPIC:%8%

39 Robotic vs Laparoscopic Surgery Endometrial Cancer Operative$Time 39

40 Robotic vs Laparoscopic Surgery Endometrial Cancer Days$Stay 40

41 Robotic vs Laparoscopic Surgery Endometrial Cancer EBL 41

42 Robotic vs Laparoscopic Surgery Endometrial Cancer Complications 42

43 Robotic vs Laparoscopic Surgery Endometrial Cancer Conversions 43

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45 ROBOTIC PROCEDURES IN GYNAECOLOGY/ONCOLOGY in AZ St. Jan BRUGES CONSOLE OPERATIVE TIMES (average): -Robot Hysterectomy (large/myomatous uteri): 60 min -Robot Hysterectomy (endometrial cancer): 45min -Robot Hysterectomy + Pelvic Lymph Node Dissection (endometrial cancer): 90min -Robot Radical Hysterectomy + Pelvic Lymph Node Dissection: 150min -Robot Pelvic and Para-aortic Lymph Node Dissection: 60-90min

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49 Vessel Sealer for lateralising ureter

50 Vessel Sealer for dissecting Para>Vesical and%para>rectal space in% Robot%Radical Hysterectomy ParaQVesical Space BLADDER UTERUS LEFT OVARY

51 Vessel Sealer for opening%space between bladder%and cervix/vagina Left uterine'artery Left ureter

52 Vessel Sealer for opening%para> rectal space Identification of% splanchnic (Hypogastric)% nerves in%meso> ureter%during Radical Hyterectomy. Splanchnicnerves in%meso>ureter

53 Vessel Sealer for Pelvic Lymph Node%Dissection (iliac vessels) LYMPH%NODE%TISSUE Right%External Iliac Artery/Vene

54 Vessel Sealer for dissecting lymph node%tissue% (obturator fossa)

55 Vessel Sealer for lymph node%dissection at Para>aortic region (here left side) Lymph node'tissue Left Coimmon Iliac Artery Aorta

56 Left Para>aortic region

57 Left Ureter' Inferior Mesenteric Artery Left'ParaQaortic'Region' after'removal'ln Aorta

58 Right'Ureter Aorta Vena'Cava Lymph nodes

59 Right%Common%Iliac Artery AortaQVena'CavaQUreter'Right

60 Radical Hysterectomy (end%of% procedure) BLADDER Ureters

61 BLADDER PUBIC%BONE after PLND%and Radical Hysterectomy Obliterated Hypogastric Artery VAGINA open Vaginal swab OBTURATOR' NERVE EXT'ILIAC' VESSELS RIGHT'URETER

62 BLADDER PUBIC'BONE Obliterated Hypogastric Artery VAGINA closed OBTURATOR NERVE EXT'ILIAC' VESSELS RIGHT%URETER

63 Fibrin/collagen patch%on%iliac vessels after lymph node% dissection

64 4>arm%da%Vinci%Xi Single%arm da%vinci%sp