Ensuring Adequate Traction and Avoiding Uterine Manipulator Use During Robotic Hysterectomy for Uterine Cancer Surgery

Abstract

OBJECTIVE Laparoscopic or robotic surgery is generally considered an option for treating endometrial cancer.[1-3] However, some reports have suggested that robotic surgeries may be linked to poor oncological outcomes.[4] The major debate in this context revolves around the use of uterine manipulators. A Japanese nationwide analysis suggested that intrauterine manipulator use may increase the risk of lymphovascular space invasion and malignant peritoneal cytology.[5] Therefore, we aimed to develop a robotic hysterectomy technique without relying on a uterine manipulator, ensuring optimal visualization and minimizing the need for assistance. DESIGN A detailed explanation of the procedure is presented in a surgical video footage [Video]. PATIENT A Japanese woman was diagnosed with early-stage endometrial cancer. INTERVENTIONS In conventional laparoscopic surgery, the assistant often provides uterine traction.[6] In robotic surgery, excessive traction from the robotic arm can cause tears in the uterus or fallopian tubes, resulting in bleeding. We developed a robotic hysterectomy technique that eliminates the use of a uterine manipulator while ensuring optimal visualization and minimizing the need for assistance. The standardized procedure for achieving effective surgical traction was as follows: Step 1: Development of the retroperitoneum, identification of the ureter, and bladder dissection prior to transection of the round and infundibulopelvic ligaments Gross uterine traction was abandoned, allowing the uterus to remain mobile. An assistant arm was used for round ligament retraction, providing sufficient tension during bladder dissection and lateral peritoneal reflection. The round and infundibulopelvic ligaments are important for traction and should not be transected until bladder dissection and ureter identification are achieved. Step 2: Using a bowel spatula for bladder dissection and cervical elevation A bowel spatula was inserted into the anterior vaginal fornix to apply traction to the vesicouterine pouch, facilitating bladder dissection [Figure 1]. The boundary between the bladder and cervix or vagina was widened to identify the dissectible layers. A bowel spatula was inserted into the posterior vaginal fornix for cervical elevation.Figure 1: A bowel spatula is inserted into the anterior vaginal fornix to apply traction to the vesicouterine pouch, facilitating bladder dissection.http://www.apagemit.com/page/video/show.aspx?num= 1395&kind=2&page=1Step 3: Hooking the uterus to the assistant arm to provide traction on the broad ligament Notably, traction on the broad ligament was achieved by hooking the uterus to an assistant arm, facilitating medial dissection and ureter identification, whereas traction on the uterosacral ligament ensured accurate transection. RESULTS This standardized technique enabled robotic hysterectomy dissection. CONCLUSION This standardized technique enables robotic hysterectomies without requiring a uterine manipulator and assistant forceps while maintaining excellent visualization. It may be adopted by other facilities as a cost-effective and valuable approach and is well-suited for presentation as a video article. Ethics statement The study was conducted in accordance with the Declaration of Helsinki and was approved by Jichi Medical University, Saitam Medical Center with (approval number: S23-107; approval date: 11/30/2023). The patient consent was waived by the IRB. Author contributions Conceptualization, K. Chikazawa; Methodology and Writing – Original Draft, K. Chikazawa; Data Curation, Formal Analysis, and Writing – Original Draft, S. Hayashi; Writing – Review and Editing, S. Miyamoto; Investigation and Supervision, T. Kuwata. All authors have read and agreed to the final version of the manuscript. Data availability statement The data that support the findings of this study are available from Jichi Medical University but restrictions apply to the availability of these data, which were used un