monthly focus

surgical intervention video

In this educational video, authors present the case of a 58-year-old female patient. She presented with a symptomatic 10cm uterine fibroid and pelvic organ prolapse (POP) (C3H3R1 according to the Baden-Walker Halfway Scoring System/HWS), with deep venous insufficiency as her only comorbidity. The preoperative work-up consisted of a urinary tract and pelvic ultrasound, cervical cytology, and urodynamic evaluation. The large uterine fibroid was confirmed to be of 10cm in its largest diameter, attached to the posterior wall of the uterus. Vaginal bulge, pelvic pain, and dysuria were the main patient symptoms. 

The patient underwent sacral colpopexy and subtotal hysterectomy with bilateral salpingo-oophorectomy for pelvic organ prolapse using the Hugo™ RAS system (Medtronic). 

This surgical robotic platform is the newest alternative to traditional robotic systems, composed of 4 independent arm carts, a system tower, and an open console from which the surgeon can perform the procedure thanks to 3-dimensional glasses. 

A three-arm robotic configuration also known as “compact” for port placement and “bridge” for the arm cart positioning (https://www.frontiersin.org/articles/10.3389/fonc.2022.898060/full), as described by Gueli Alletti et al. was used (1). One robotic arm was used for the endoscope and the other two robotic arms for three different instruments, namely a bipolar Maryland forceps in the left arm, monopolar curved scissors in the right arm, and, during the reconstructive phase, a double needle driver was used in both arms after the removal of curved scissors. 

The patient was placed in a dorsal lithotomy position with both legs in Allen® stirrups. A Trendelenburg tilt was also used. 

The surgical procedure was performed using a standardized technique already published in the literature by the authors (2). 

No intraoperative complication was observed. The patient was discharged on postoperative day 2 with no postoperative complications. 

Final pathological findings confirmed the presence of a benign single uterine leiomyoma. 



Bibliography:

(1) Gueli Alletti S, Chiantera V, Arcuri G, Gioè A, Oliva R, Monterossi G, Fanfani F, Fagotti A, Scambia G. Introducing the New Surgical Robot HUGO™ RAS: System Description and Docking Settings for Gynecological Surgery. Front Oncol. 2022 Jun 9;12:898060. doi: 10.3389/fonc.2022.898060. PMID: 35756633; PMCID: PMC9218341.

(2) Campagna, G., Panico, G., Caramazza, D. et al. Laparoscopic sacrocolpopexy plus ventral rectopexy as combined treatment for multicompartment pelvic organ prolapse. Tech Coloproctol 24, 573–584 (2020). https://doi.org/10.1007/s10151-020-02199-5.

Robot-assisted sacral colpopexy and subtotal hysterectomy for pelvic organ prolapse (POP) and large uterine fibroid with the new Hugo™ RAS system

Sacrocolpopexie assistée par robot et hystérectomie subtotale pour prolapsus pelvien et gros fibrome utérin avec le nouveau système robotique  Hugo™ RAS 

Création d'un néovagin par la technique de Davydov pour syndrome de Mayer-Rokitansky-Küster-Hauser (MRKH) ou agénésie utérovaginale

Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is characterized by a uterovaginal agenesis or underdeveloped uterus (hypoplasia), although external genitalia are normal. It is a congenital anomaly impacting one in 4,000 women worldwide. Passive vaginal dilatation is the first treatment, but when this has no result, surgical correction is indicated to create a neovagina. There are many techniques to create a neovagina or vaginoplasty; including vaginal procedures with various grafts, laparoscopic procedures using peritoneum (Davydov procedure) or using a sigmoid segment. We present the case of a patient undergoing the Davydov procedure which, from our standpoint, has excellent anatomical and functional results, combining the advantages of minimally invasive surgery with those derived from the use of peritoneum as covering tissue for the neovagina. However, there is a lack of interdisciplinary consensus about the best option to restore physical and sexual quality of life. 

Neovagina with Davydov procedure in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Hystérectomie totale extrafasciale et salpingo-ovariectomie bilatérale assistées par robot pour un utérus volumineux atteint de fibromatose diffuse avec le nouveau système de chirurgie robotique Hugo™

In this educational video, the authors present the case of a 60-year-old female patient. She presented with a symptomatic uterine diffuse fibromatosis, particularly due to an intramural fibroid of the uterus. The patients reported a strong familial history of breast cancer, but without any active comorbidity. The preoperative workup consisted of a gynecologic examination, pelvic ultrasound, and cervical cytology. Transvaginal ultrasound performed at the Gemelli CLASS Ultrasound OMIC center confirmed the largest uterine fibroid to be 7 cm in its largest diameter. Abnormal uterine bleeding, abdominal pain, and dysuria were the main patient symptoms. 

The patient underwent total extrafascial hysterectomy with bilateral salpingo-oophorectomy for a bulky uterus using the Hugo™ RAS system (Medtronic) at the Division of Gynecologic Oncology, Fondazione Policlinico Gemelli in Rome, Italy. 

This surgical robotic platform is the newest alternative to conventional robotic systems, composed of 4 independent arm carts, a system tower, and an open console from which the surgeon can perform the procedure thanks to tridimensional glasses. 

A four-arm robotic configuration also known as “compact” for port placement and “bridge” for the arm cart positioning (https://www.frontiersin.org/articles/10.3389/fonc.2022.898060/full), as described by Gueli Alletti et al. was used (1). One robotic arm was used for the endoscope and the other two robotic arms for three different instruments, namely bipolar forceps in the left arm, monopolar curved scissors in the right arm, Cadiere forceps in the fourth right arm and, during the vaginal cuff closure, a needle driver was used in the right arm after the removal of curved scissors. 

The patient was placed in a dorsal lithotomy position with both legs in Allen® stirrups. A Trendelenburg 30-degree tilt was also used. 

The surgical procedure was performed using a standardized technique already published in the literature by the authors (2). 

No intraoperative complication was observed. The patient was discharged on postoperative day 2 with no postoperative complications. 

Final pathological findings confirmed the presence of benign uterine leiomyomas and endometriotic foci on the left tubal tissues. 



Bibliography:

(1) Gueli Alletti S, Chiantera V, Arcuri G, Gioè A, Oliva R, Monterossi G, Fanfani F, Fagotti A, Scambia G. Introducing the New Surgical Robot HUGO™ RAS: System Description and Docking Settings for Gynecological Surgery. Front Oncol. 2022 Jun 9;12:898060. doi: 10.3389/fonc.2022.898060. PMID: 35756633; PMCID: PMC9218341.

(2) Gueli Alletti S, Restaino S, Finelli A, Ronsini C, Lucidi A, Scambia G, Fanfani F. Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin. J Minim Invasive Gynecol. 2020 Jan;27(1):22-23. doi: 10.1016/j.jmig.2019.06.001. Epub 2019 Jun 12. PMID: 31201941.

Robot-assisted total extrafascial hysterectomy and bilateral salpingo-oophorectomy for bulky uterus affected by diffuse fibromatosis with the new Hugo™ RAS system

The aim of cytoreduction in advanced ovarian cancer is to completely remove the gross disease. A retroperitoneal approach is crucial in radical surgery for advanced ovarian cancer. Hudson-Delle Piane is a radical procedure, which allows for an ‘en bloc’ removal of the uterus, ovaries, peritoneal pouch of Douglas, rectosigmoid colon with a retrograde approach in cases where rectosigmoid colon sparing is not an option. The authors demonstrate a retroperitoneal ‘en bloc’ posterior pelvic exenteration in advanced ovarian cancer in a stepwise fashion. The patient was a 52-year-old woman, with a body mass index of 21.1 who presented with abdominal pain and distension; the CT-scan showed peritoneal carcinomatosis. The different phases of the Fagotti score performed at diagnostic laparoscopy to triage for operability, are demonstrated. Vizzielli’s score was used to determine the risk of postoperative complications in case of primary debulking surgery. Immediately after diagnostic laparoscopy, a conversion to laparotomy with a cytoreductive surgery was performed. The Hudson-Delle Piane technique is demonstrated in 10 steps. The surgery lasted 360 minutes and the estimated blood loss was 400mL. No perioperative complication was noted. The histology revealed a FIGO stage IIIC high-grade serous ovarian cancer. The present video demonstrates that the retroperitoneal approach to advanced ovarian cancer with high volume pelvic disease, allows for an ‘en bloc’ tumor debulking with safe handling of key anatomical structures. 



Bibliographic references:



•	Berretta R, Marchesi F, Volpi L, Ricotta G, Monica M, Sozzi G, Di Serio M, Mautone D. Posterior pelvic exenteration and retrograde total hysterectomy in patients with locally advanced ovarian cancer: Clinical and functional outcome. Taiwan J Obstet Gynecol. 2016 Jun;55(3):346-50. doi: 10.1016/j.tjog.2016.04.010. PMID: 27343313.

•	Petrillo M, Vizzielli G, Fanfani F, Gallotta V, Cosentino F, Chiantera V, Legge F, Carbone V, Scambia G, Fagotti A. Definition of a dynamic laparoscopic model for the prediction of incomplete cytoreduction in advanced epithelial ovarian cancer: proof of a concept. Gynecol Oncol. 2015 Oct;139(1):5-9. doi: 10.1016/j.ygyno.2015.07.095. Epub 2015 Jul 18. PMID: 26196319.

•	Marchetti C, Giannarelli D, Vizzielli G, Ferrandina G, Tortorella L, Fanfani F, Costantini B, Pasciuto T, Scambia G, Fagotti A. Quality of life in patients with advanced ovarian cancer after primary debulking surgery versus neoadjuvant chemotherapy: results from the randomised SCORPION trial (NCT01461850). BJOG. 2023 Jun 19. doi: 10.1111/1471-0528.17558. Epub ahead of print. PMID: 37334772.

•	Ghirardi V, Fagotti A, Scambia G. Laparoscopic selection for surgery in epithelial ovarian cancer. A short review. Facts Views Vis Obgyn. 2023 Mar;15(1):25-28. doi: 10.52054/FVVO.15.1.060. PMID: 37010331; PMCID: PMC10392116.

Anatomical description of the retroperitoneal space to perform an ‘en bloc’ posterior pelvic exenteration in advanced ovarian cancer: Hudson-Delle Piane procedure in 10 steps

Description anatomique de l'espace rétropéritonéal afin de réaliser une exentération pelvienne postérieure "en bloc" dans le cas d'un cancer de l'ovaire avancé : Procédure de Hudson-Dellepiane en 10 étapes

This video shows the laparoscopic management of an isolated tubal torsion of the right uterine tube with a tube-sparing ovarian plication using the ‘hot dog in a bun’ technique.



Bibliographic references:



1. Adnexal torsion in adolescents. ACOG Committee Opinion No. 783. Obstet Gynecol 2019;134(2):e56–e63. DOI: 10.1097/ AOG.0000000000003373.

2. Shah NH, Joshi AV, Belekar G. Hotdog in bun: A recent technique for oophoropexy. Int J Reprod Contracept Obstet and Gynecol 2019;8(5):2100–2102. DOI: 10.18203/2320-1770.ijrcog20191975.

3. Pappachan C, Minna UR, Presanna Kumari B, et al. Minimally invasive conservative management of ovarian torsion by hotdog in a bun technique: A case series. Int J Clin Obstet Gynaecol 2020;4(4):293–296. DOI: 10.33545/gynae.2020.v4.i4e.661.

Focus on gynecologic surgery

Robot-assisted sacral colpopexy and subtotal hysterectomy for pelvic organ prolapse (POP) and large uterine fibroid with the new Hugo™ RAS system

Robot-assisted total extrafascial hysterectomy and bilateral salpingo-oophorectomy for bulky uterus affected by diffuse fibromatosis with the new Hugo™ RAS system

Anatomical description of the retroperitoneal space to perform an ‘en bloc’ posterior pelvic exenteration in advanced ovarian cancer: Hudson-Delle Piane procedure in 10 steps

Right-sided isolated tubal torsion with tube-sparing ovarian plication performed bilaterally

Neovagina with Davydov procedure in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome