Abstracts. Gynaecological Endoscopy and Robotic Surgery. E-Posters

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1 DOI: / Abstracts E-Posters Gynaecological Endoscopy and Robotic Surgery EP5.01 Case study: total laparoscopic resection of a large primary retroperitoneal mature teratoma in a patient with a suspected ovarian dermoid Simpson, P; See, ATA; Morris, E Norfolk & Norwich University Hospital, UK Background The majority of mature cystic teratomata in female adult patients are found arising from the ovary. However they can also be found in other midline structures such as anterior mediastinum, pineal gland and the retroperitoneum. Primary retroperitoneal teratomata are extremely rare in adults but when they do occur they tend to be localised to the gonadal and sacrococcygeal regions. Case A 29-year-old patient presented with dysmenorrhoea, dyspareunia and peri-menstrual symptoms of bloating and breast tenderness. Her symptoms were progressive but simple analgesia had been ineffective and she was unwilling to consider hormonal treatment. An ultrasound scan revealed a right adnexal mass containing homogeneous internal echoes and some hyperechoic areas, as well as mild dilatation of the proximal collecting system of the right kidney. These findings were thought to be as a result of either an endometriotic cyst or dermoid cyst arising from the right ovary. Her tumour markers and hormone profile were all normal but her prolactin was elevated at 919 miu/l. An MRI scan demonstrated a 9.5 cm complex right adnexal mass, containing fat and several soft tissue nodules, which was reported as a right adnexal dermoid cyst. As a result a decision was taken to proceed with a laparoscopic oophorectomy. At surgery a large dermoid cyst was found attached to the peritoneum anterior to the rectum, with a normal appearance to both the fallopian tubes and ovaries. Dissection of the mass was commenced but due to concerns about whether the mass was arising from the rectum an intraoperative review, by a colorectal surgeon, was requested. Following this review a decision was taken to proceed with an excision. The pararectal space was opened and the cyst was dissected with monopolar scissors and minimal diathermy. There was no rectal injury and the patient made full recovery. Conclusion Primary retroperitoneal mature teratomata are rare but should be considered in the differentials of a woman presenting with a pelvic mass. This case highlights the limitations of preoperative imaging and the need to adapt to unexpected operative findings. It also shows that surgical management of such tumours can be approached laparoscopically and a good outcome achieved. EP5.02 Is Africa lagging behind the rest of the world in advances in gynaecological surgery? Muteshi, C Aga Khan University, Nairobi, Kenya Introduction The surgical art is a rapidly evolving field with innovations happening in advanced countries in response to the technological pace, stringent need for evidence based practice and patient demand for convenient treatment that is least disruptive to their everyday life. These innovations do not always reach the developing world as soon as they are adopted in developed countries. A survey was conducted among Kenyan gynaecologists to determine access to and competence in minimal access surgery as well as the practice of alternatives to the traditional approaches of surgery. Methods A questionnaire was administered to gynaecologists attending a 3 day annual scientific meeting of the Kenya Obstetrical and Gynaecological Society in February 2013 at registration and collected back during the conference up to the last day. The responses were coded and analysed using SPSS 17.0, with results reported as proportions, mean or median as appropriate in descriptive terms. Results A total of 150 questionnaires were issued out of which 64 were returned, a response rate of 43.6%. There were 74.4% practising gynaecologists and 26.6% trainees in the specialty. Half of the respondents practised in a university teaching hospital, 21.9% in private hospital while the rest were either in a government or faith based institution. Only 60.9% had access to laparoscopic surgery with a majority 25 out of 32 (78.1%) based in a teaching hospital. None of those in government or faith based hospitals had access to laparoscopy. There were only 65.6% respondents who had ever performed a laparoscopy in their career, 9/17 (52.9%) trainees and 13/14 (92.9%) in private hospitals. Of those who had performed a laparoscopic procedure in the preceding 6 months 40.6% and 71.4% were in teaching and private hospitals respectively. When asked about vaginal hysterectomy 43.8% of the respondents had performed the surgery in the preceding 6 months, those who had not 16/36 (44.4%) lacked the surgical skill while 47.2% did not have the appropriate case loads. Regarding uterine fibroids 69.0% of respondents stated an alternative to surgical therapy. Conclusion Africa is seriously under-represented in the utility of advances in surgical innovations and best practice. Training of specialists should be well structured and funded in order that qualifying surgeons have the flexibility to offer a range of options for treatment to their patients. 68 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG

2 EP5.03 Laparoscopic sacrocolpopexy for vault prolapse Soman, U Federation of Obstetrics and Gynaecological Societies of India Introduction The aim of the study was to evaluate the clinical and functional outcomes of laparoscopic sacrocolpopexy. Methods A retrospective observational study of women undergoing laparoscopic sacrocolpopexy between April 2007 and March 2012 was undertaken. Pelvic organ support was assessed objectively using the pelvic organ prolapse quantification scale (POP-Q). Functional outcomes were assessed using the International Consultation on Incontinence questionnaire for vaginal symptoms (ICIQ-VS), both preoperatively and at 6 36 months postoperatively. Results Eighteen women with a mean age of 65 years (range, years) were studied. Five women (28%) had a stage 2 vault prolapse, 9 women (50%) had a stage 3 prolapse and the remaining four (22%) had a stage 4 prolapse. The mean duration of the sacrocolpopexy operation was 64 min (range, min), measuring from the first knife incision and excluding the time required to perform any concomitant procedures. All 18 procedures were completed laparoscopically. In all women a mesh was placed over the upper half of the anterior vaginal wall to correct the cystocele as well as posteriorly. Fourteen women (77%) had concomitant procedures performed at the same time as the laparoscopic sacrocolpopexy. There were two intraoperative bladder injuries that occurred during dissection of the bladder from the vaginal vault. These were repaired laparoscopically and the sacrocolpopexy procedure was then completed. The mean estimated blood loss was 75 ml (range, ml). The mean duration of postoperative inpatient stay was 2.5 nights (range, one to five nights). At follow-up, all women had good vault support (mean point C, 8.9; range, 10 to 8). Subjective improvements in prolapse symptoms and sexual well-being were observed with significant reductions in the respective questionnaire scores. Four women presented with mesh erosion at upper third of vagina out of which 2 required trimming of exposed mesh and were asymptomatic after 3 months. Conclusion Results confirm previous findings that laparoscopic sacrocolpopexy is a safe and efficacious surgical treatment for post-hysterectomy vaginal vault prolapse. It provides excellent apical support and good functional outcome with overall improvement in sexual function. EP5.04 A hundred cases of laparoscopic myomectomy over a 10 year period in a private clinic Desai, G; Desai, S Department of Obstetrics and Gynecology, Division of Endoscopic Surgery, Mothercare Nursing Home, Mumbai, India Introduction Myomectomy is an often carried out procedure in today s gynaecological practice. Two main methods of doing a myomectomy are by laparoscopy and open surgery. In the long term there can be drawbacks following the laparoscopic procedure such as rupture of uterus in a subsequent pregnancy. Technical skill is also important is carrying out a laparoscopic procedure. The pros and cons of carrying out a laparoscopic myomectomy will be discussed. Methods A 100 cases of laparoscopic myomectomy are compared to a 100 cases of open myokmectomy over a 10 year period at a private clinic. The duration of surgery, complications during surgery, blood loss and immediate and delayed postoperative complications were documented. Additionally subsequent fertility will also be discussed. Results Mean duration of open myomectomy was shorter in the first 5 years of data collection as compared to laparoscopic myomectomy (45+\ 9.5 min vs. 1 h 1 h 36 min +\ 12.4 min, P < 0.5). However in the second 5 years, the mean duration was comparable (41.6+/ 10.5 min vs / 7.5 min, P = 0.2). laparoscopic myomectomy was associated with more intraoperative complications including haemorrhage (12 patients open vs. 18 in lap myomectomy, P = 0.2). But postoperative complications were more often seen with open myomectomy (5 vs. 2 had infection). No mortality was reported in either procedure. Total blood loss was significantly less with lap myomectomy (345+/ 213 ml, range: ml) as compared to open myomectomy (780+/ 457 ml, range: ml, P < 0.5). Laparoscopic and open myomectomy saw a comparable rates of return of fertility (76% vs. 68%, P = 0.4 respectively). Conclusion Laparoscopic myomectomy is an excellent substitute for open myomectomy particularly because of its similar duration of time, lower postoperative morbidity and shorter hospital stay. Additionally laparoscopic myomectomy has lower blood loss as compared to its open counterpart. Fertility rates were better with the endoscopic procedure. EP5.05 Gynaecologists current knowledge of electrosurgical equipment and power settings prior to the treatment of endometriosis Mannan, S 1 ; Jaiyesimi, R 1 ; Kalburgi, S 1 ; Anthony, R 2 ; Raja, M 3 1 Basildon University Hospital, Essex, UK; 2 Southend University Hospital, Essex, UK; 3 Broomfield Hospital, Essex, UK Introduction It is good practice for clinicians to be conversant with any equipment employed while treating patients. This can be attained by formal training. Medical devices vary from hospital to hospital and it is essential that each hospital ensures that new appointees have formal training in the use of their equipment. Failure to do so could result in serious injuries to patients. Methods A survey was conducted in 3 hospitals in England to determine what system is in place to ascertain the training, knowledge and competency of surgeons before utilising electrosurgical equipments. The participants were Consultants and Registrars in Obstetrics and Gynaecology. Results 10% of the doctors in Hospital A knew what model of equipment and probe available. 90% were aware of the correct ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 69

3 power settings for the treatment of endometriosis. However, only 30% were aware of the correct devise available to be used for endometriosis overlying the ureter. 55% had formal training in electrosurgery. Less than 5% had formal training during the current rotation. 22% of the doctors in Hospital B were aware of the model of equipment. 90% were aware of the probe and devises available in the hospital. Only 58% were aware of power settings while 15% were aware of the probe used for endometriosis overlying the ureter. 82% of the doctors had formal training; however only 1% had training during the current rotation. In Hospital C, only 5% of doctors were aware of the model of equipment used in the hospital. In contrast 90% were aware of the probes and devices available in the hospital. 70% of this group were aware of power setting used, while 15% were aware of the probes to be used for endometriosis overlying the ureter. 70% had previous formal training but only 1% had training during the current rotation. Conclusion Electrosurgery uses radiofrequency energy in the cutting or coagulation of tissue during surgery. There are potential risks associated with electrosurgery. In all three hospitals the number of doctors who had received formal training was very low. As doctors rotated to different hospitals no formal training was offered to orientate them with the type of electrosurgical equipment available. This is a major area of concern as diathermy burns are a never event and could have a debilitating impact on patients. It is pertinent that all surgeons receive instructions on how to use the electrosurgical stack available in hospital in which they practice. EP5.06 Hysteroscopic local anaesthetic intrauterine cornual block before endometrial ablation in an outpatient setting: A feasibility study Kumar, V; Sood, A; Gupta, JK Birmingham Women s NHS FoundationTrust, UK Introduction The optimal approach to provide complete uterine anaesthesia during office hysteroscopic endometrial ablation has yet to be determined. The aim of this study was to evaluate the safety, feasibility and efficacy of a new method of transhysteroscopic intrauterine cornual block (ICOB) on women s perception of pain during outpatient Thermachoice endometrial ablation in combination with traditional direct cervical block (TEA). Methods Pre-menopausal women with dysfunctional uterine bleeding undergoing TEA were included in the study. The intervention used was a hysteroscopic injection of local anaesthetic into the myometrium just medial to both tubal ostia (ICOB). We measured the acceptability of ICOB and pain score (visual analogue score scale) immediately after the procedure. Results We treated 30 patients (mean age 41 years, SD 6; BMI 29 7) between January 2012 and December All patients had a successful ICOB block and found TEA with ICOB acceptable. The mean VAS score was which was two points lower compared to our other prospective cohort of patients undergoing EA with a traditional direct cervical block only (mean , n = 213). No serious complications occurred during the procedure or postoperatively. Three patients experienced a vasovagal response, which resolved spontaneously. Conclusion ICOB is a safe, feasible and efficacious method of pain control during TEA. There is however a need to evaluate efficacy of ICOB in a randomised placebo controlled trial. EP5.07 An audit of outpatient hysteroscopy in Royal Derby Hospital Shittu, SA 1 ; Petipiece, L 2 ; Kohle, S 2 1 Leicester General Hospital, Leicester; 2 Royal Derby Hospital, Derby Introduction Hysteroscopy offers an extension of the gynaecologists armamentarium as it improves the diagnostic accuracy and permits better treatment of abnormal intra-uterine conditions. All gynaecological units should provide dedicated outpatient hysteroscopy service as it is associated with clinical and economic benefits. The objective was to assess the compliance of our practice with the standards in the RCOG/BSGE guideline and to assess correlation between our hysteroscopic and histological findings. The auditable standards of the RCOG that were assessed include success rate and reasons for failures, rate of cervical dilatation, and percentage of women with written information leaflet and informed consent. Methods We retrospectively reviewed the medical notes of 114 patients who had hysteroscopy over 3 months period in Royal Derby Hospital. Data obtained were analysed using Microsoft excel software. Result The result showed that postmenopausal bleeding (48%) was the commonest indication for the referral to the outpatient clinic. Success rate was 90.4%. All the patients were given information leaflets prior to consent. Recommended vaginoscopy approach was used in 63.2%, cervical dilation was done in 15%. Success rate of outpatient polypectomy was 84.4%. Documentation was considered standard in 84.2% of patients. The correlation between histology and hysteroscopic findings was satisfactory with sensitivity of 100% and specificity of 75% for endometrial carcinoma. Hysteroscopy could not differentiate between endometrial hyperplasia and carcinoma. Where no sample was available for histology, hysteroscopy was significantly helpful. Conclusion We recommended expansion of the outpatient operative service to include endometrial ablation, sterilisation and removal of submucous fibroids and use of a standardised proforma for documentation of procedure in all patients. The audit revealed good compliance with guideline and that outpatient hysteroscopy service in the hospital was efficient. Hysteroscopy is invaluable where sample is not available for histology. 70 ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG

4 EP5.08 Thunderbeat as the energy source for laparoscopic hysterectomy Ananthakrishnan, M; Sundaram, M APOLLO Hospitals, Chennai, India Introduction To analyse the feasibility, technique, blood loss and duration of surgery in patients who underwent total laparoscopic hysterectomy with Thunderbeat as an energy source. Thunderbeat is an energy modality that uses bipolar energy and ultrasonic energy designed in the same handpiece. This combined energy modality reduces the lateral thermal spread decreases the duration of surgery, minimises instrument exchange and reduces the blood loss intraoperatively. Methods Retrospective review. Setting: Dedicated high volume gynaecological laparoscopic center Patients: 50 women who underwent total laparoscopic hysterectomy at our center from There were no exclusion criteria based on the size of the uterus or the number of previous surgeries. Intervention: Total laparoscopic hysterectomy was done in all patients and Thunderbeat was used as the energy source for tackling all the pedicles. Results 77% of patients had normal vaginal delivery and 23% had previous caesarean section. The median clinical size of the uterus was 10 weeks (6,20). The median weight of the specimen was 220 g (60 960). The median duration of surgery was 60 min (20 180) and the median blood loss was 40 ml (10 200). Conclusion Total laparoscopic hysterectomy with Thunderbeat considerably reduces the time of surgery and blood loss with added advantage of minimal lateral thermal spread. It can be used by experienced surgeons in all cases of total laparoscopic hysterectomy for all pedicles irrespective of the size of the uterus. EP5.09 Impact of virtual simulation training in gynaecological endoscopic surgery: a prospective study Desai, G 1 ; Desai, S 2 1 University Of Mumbai, India; 2 PD Hinduja Hospital and Research Center, India Introduction To assess the role of virtual simulation on an actual laparoscopic operation in surgeons of varying experience. Methods This ongoing prospective study was undertaken at a tertiary medical and research gynaecological department. A total of 14 gynaecological surgeons were recruited to the study, and were divided into novice (n = 5, <10 laparoscopic procedures), intermediate (n = 6, 20 50) and experienced (n = 4, >100) groups. User performance was evaluated by two independent observers blinded to trainee and training status using a previously validated general and task specific rating scale. The secondary outcome measure was operation time in minutes. Operative performance was assessed by the time taken to perform surgery, blood loss and total instrument path length, complications if any. Results Inter observer agreement was Conclusion Virtual simulation in laparoscopy improves user performance of novice surgeons significantly. The performance level of intermediate and well experienced laparoscopists improved minimally. Simulator training should be considered before trainees carry out laparoscopic procedures. EP5.10 Outcomes of total laparoscopic and laparoscopic assisted myomectomy Mehra, S 1 ; Verma, M 2 ; Khatri, IB 2 ; Hotchandani, M 2 ; Mehra, G 2 1 Kings College, London, UK; 2 Moolchand Medcity, India Introduction In recent years, there has been an increase in the uptake of laparoscopic surgery due to its inherent advantages. The size of large fibroids can be a limiting factor for a total laparoscopic myomectomy (LM). Laparoscopic assisted myomectomy (LAM) offers an alternative by offering laparoscopic assistance to minimize the morbidity of a large incision with an open procedure. We present our outcomes in women undergoing LM or LAM and evaluate both techniques. Methods We included women who underwent LM or LAM between January 1990 to December 2010 at Moolchand Medcity. Case records were reviewed and a telephone interview conducted. Inclusion criteria included women with symptomatic fibroids scheduled for myomectomy. Exclusion criteria included failure of medical fitness for surgery, submucous fibroids, perimenopausal women and very large uterus (fundus reaching >3 cm above umbilicus). Initial laparoscopic inspection decided either to perform LM or LAM. LAM was reserved for cases with large fibroids that would otherwise require an open procedure. Entire procedure for LM was performed through laparoscopic route. LAM required a small 3.5 cm suprapubic incision. Laparoscopic route identified large myomas and these were removed by morcellation from the suprapubic incision. Data were recorded on maximum size of fibroid, operating time, blood loss, hospital stay and reproductive outcomes. Results 1872 women underwent LM (n = 687) or LAM (n = 1185). The median age was 39 years (LM) and 30 years (LAM) was 39 years. The mean size of largest fibroid removed was (5.8 cm 4) cm by LM and (9.1 4) cm by LAM. The mean operating time for LAM ( ) minutes was significantly shorter than LM (105 25) minutes (P-Value = ). Blood loss was significantly more in LM group ( ) ml than LAM group ( )ml (P = ). The mean hospital stay was similar in LAM ( days) and LM ( days). One case was converted to laparotomy in LM group. The pregnancy rates were similar (LM = 55%; LAM = 56%). There was no significant difference in early pregnancy loss (LM = 20%; LAM = 22%). Two women had uterine rupture during pregnancy. Conclusion Both LM and LAM are safe procedures to perform for women undergoing myomectomy with similar good reproductive outcomes. LAM has a shorter operating time and less blood loss compared to LM. It offers a less invasive alternative for excising ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 71

5 larger fibroids that would otherwise be unsuitable for laparoscopic approach. EP5.11 Hysteroscopy a diagnostic and therapeutic tool 500 case series Banu, LF Fehmicare Hosptal, India Introduction 550 patients who had hysteroscopy both diagnostic and therapeutic over a period of 5 years were analysed. Methods Patients data were retrieved from electronic medical recording system and case papers from 2009 to All patients had detailed history, clinical and gynaecological examination. Relevant blood investigations and USG pelvis were performed. Hysteroscopy was performed mostly under short general anaesthesia with high definition optic system. Operative findings were recorded in mediscope software. Patient age, parity, co-morbid conditions, indication, operative findings, HPE were analysed. Results Women who underwent hysteroscopy were of age between 20 and 70 years. Mean age was % were married and 2% were unmarried. Diabetes was found in 10% and HTN in 14%. Indications were infertility in 58.78%, 33.64% were primary and 25.23% secondary, menorrhagia in 17%, polyp excision in 15.88%, septal resection in 2.8%. Other indications were myoma resection, endometrium resection, tubal cannulation, foreign body removal and adheshiolysis. On USG uterus size was normal in 57.94%, and bulky in 42.05%. The endometrium thickness was measured. In 49% it was up to 10 mm, in 34.58% between 11 and 15 mm, 12.15% it was 16 to 19 mm, and above 20 mm in 3.73%. In total procedures 74.76% were diagnostic and 25.23% were therapeutic. The mean age for diagnostic hysteroscopy was and mean age for operative hysteroscopy was In 53.50% cases only hysteroscopy was performed, in 46.50% laparoscopy was performed in addition for reasons like infertility, endometriosis etc. All patients had risk assessment and consent prior to the procedure. Operative findings were video recorded. The entire uterine cavity and both ostea were visualised. Evidence of polyps and other pathology were recorded. Distension medium was normal saline and energy source was bipolar underwater cautery in operative procedures. Diagnostic cases were day care procedures. Complications like bleeding, perforation, fluid overload, bronchospasm were occurred in 1.09%. Histopathology was obtained in 90.67% of cases. The results revealed proliferative phase in 35%, Secretory phase in 14%, Simple hyperplasia in 13.8%, polyps in 13%, Leiomyoma in 18%, and malignancy in 2.8%. Others were inflammatory and granulomatous infections. Conclusions Hysteroscopy is a very invaluable tool in gynaecologists armamentarium for various diagnostic and therapeutic procedures with least complications. It makes diagnosis more accurate and treatment with least morbidity. EP5.12 Carbon dioxide tolerance pattern in obese women undergoing gynaecological laparoscopic surgery Desai, G 1 ; Desai, S 2 1 University of Mumbai, India; 2 PD Hinduja Hospital and Research Center, India Introduction A possible drawback of creating a pneumoperitioneum in gynecological endoscopic surgery is the likelihood of creating a state of hypercapnia. This can adversely affect the postoperative period, particularly in morbidly obese women. The purpose of the study was to examine carbon dioxide homeostasis using a metabolic monitor in obese (BMI >30 kg/m 2 ) and normal/control individuals during gynecological laparoscopic procedures at a teritiary medical center in urban India. Methods Twenty obese women (Grp I, mean age: 38+/ 2.5 year, mean BMI kg/m 2 ) were compared with 20 non obese women (Grp II, mean age: 32+/ 3.4 years, BMI kg/ m 2 ) undergoing gynaecological laparoscopic intervention. Minute ventilation was adjusted to maintain a normal arterial partial pressure and normal end-tidal partial pressure of carbon dioxide throughout the surgery. The arterial partial pressure of carbon dioxide, end-tidal partial pressure of carbon dioxide, total exhaled carbon dioxide per minute, and arterial blood gas analysis were obtained at 10-min intervals, along with other cardiorespiratory parameters. Results Total exhaled carbon dioxide per minute increased by the same percentage in both groups (Grp I: 23% vs. Grp 2: 22.6%, P > 0.01). In non obese patients, the total exhaled carbon dioxide per minute plateaued within 15 min from creating the pneumoperitoneum but not in the obese group of patients. After desufflation, the total exhaled carbon dioxide per minute returned more rapidly to baseline in the non obese women than in obese women ( and min). Conclusion The study shows that with adequate intraoperative ventilation adjustments, the load of carbon dioxide is well tolerated in both normal as well as obese patients. However, after pneumoperitoneum removal, the return to a normal total exhaled carbon dioxide per minute took longer in obese women. Prolonged mechanical ventilation is therefore advisable in obese women undergoing gynecological laparoscopic procedures. EP5.13 Initial experience with robotic hysterectomy Naragony, K KIMS Hospital, India Introduction Ever since the introduction of robotic surgery, it is being widely adopted by majority of surgeons due to its perceived advantages over laparoscopy. This study is done to assess the outcome and feasibility of robotic hysterectomy by a surgeon who was well experienced in laparoscopic surgery. Methods Robotic hysterectomy was performed in 12 patients in the age group 47 to 58 years at Krishna institute of medical sciences, Hyderabad, A.P, India from January 2011 to July, ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG

6 The indications were abnormal uterine bleeding, fibroids, high grade CIN lesions. Few of these patients had multiple previous surgeries such as three of them had 2, two had 3 previous cesarean sections and the uterine size varied from 10 to 20 weeks. One 12 mm port for camera, two 8 mm operating ports and one 10 mm assistant ports are placed, docking done and all ligaments and bilateral uterine arteries are cauterized and cut. Bipolar and monopolar energy sources and scissors were used and vault is cut. Uterus is removed either vaginally or morcellated and vault sutured robotically with delayed absorbable suture. Result Hospital stay was 3 days. Docking time was 20 min and the operating time was 120 min to 210 min with a blood loss of ml. Injuries and conversion to laparotomy was nil. Duration of surgery and pain was more as compared to laparoscopy. Cost was 3 times that of laparoscopic hysterectomy. Numbers of ports used are more and the port size is also big. Conclusion Laparoscopic skills have definitely aided in easy adaptation to robotic surgery. Robotic surgery is more precise, has excellent 109 magnification, enhanced dexterity, more manoeuverability of the instruments and excellent ease of suturing makes it definitely a promising technology. At present; cost is the main limiting factor. More teamwork is required. Increased duration of surgery, loss of tactile sensation, more dependence on the patient side assistant appears to be the initial limiting factors. More expertise is required to overcome these factors. EP5.14 Robotic surgery in benign gynaecological conditions Panda, A; Reddy, P Apollo Hospital, Hyderabad, India Introduction Robotic surgery is the latest development in minimal invasive surgery. It provides superior visualisation and dexterity and so allows surgeons to perform complex tasks better than laparoscopy. To assess the effectiveness, safety and learning curve in robotic assisted surgery in benign gynaecology. Methods 15 cases were done robotically in 15 months at Apollo Hospital Hyderabad, included hystrectomies, overian cystectomies, chronic pelvic pain, myomectomies and adhesiolysis. Results In hysterectomy the operating time was 3 h for TLH with suturing. Blood loss was minimal. Suturing was far superior in robotic myomectomy. Chronic pelvic pain was a case of atypical endometrosis which was missed on prior laproscopy. The overian cysts were dermoid and endometrosis. Adhesiolysis was superior and easy. Conclusions Robotic surgery provides 3D view for simpler dissection with less blood loss. Hospital stay was same as laparoscopy. It enables a laparoscopic approach in difficult surgeries. The learning curve is shorter compared to laparoscopy. ª 2014 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2014 RCOG 73