Robotic Surgery in Benign Gynecologic Indications Technique

Updated: Mar 05, 2015
  • Author: Kimberly S Gecsi, MD, FACOG; Chief Editor: Michel E Rivlin, MD  more...
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Technique

Approach Considerations

Trocar Placement

Similarly to conventional laparoscopy, robotic surgery begins with trocar placement followed by gas insufflation.

Placement of trocar sites depends on the procedure planned and the size and type of pathology. In addition, the number of robotic arms to be used determines the number of ports. The camera port can be placed 8-10 cm cephalad to the uterine fundus or in the umbilicus. In 3-arm placement, the trocar for arm 1 should be inserted on the patient’s right side slightly caudad to the camera port along an arc centered at the pubic symphysis, with 2- to 3-cm clearances from the anterior superior iliac spine. Arm 2 is placed on the patient’s left side in a similar fashion. The assistant port can be placed at the patient's right or left side cephalad to the camera port at an arc midway between the camera port and arm 1 at a size of 8-15 mm.

If a fourth arm will be used, it should be placed on the patient's left or right side cephalad to the camera port on an arc midway between the camera port and the instrument arm. Benefits of using a fourth arm include intraoperative uterine manipulation, bowel retraction for increased BMI, and a minimized need for a skilled side assistant. [19]

Docking the Robot

The robot is docked between the patient's legs or, side docked at a 30° angle to the patient. The advantage of an angled dock is the ability to have access to the vagina and uterine manipulator. Once the robot is moved into the desired position, the camera arm is attached first. The remaining instrument arms are then attached with maximized spacing between all instrument arms for good range of motion. [19]