Robotic myomectomy – tips & tricks

Fibroid is a common problem in women of reproductive age group. Myomectomy remains the gold standard method in treating fibroids where uterine conservation is desired. With advent of minimally invasive techniques, laparoscopic myomectomy becomes the obvious method of choice. However it is not a very popular surgery because of technical challenges especially the need for extensive suturing. Introduction of robotic technology helps the surgeon to follow open surgical steps and addresses the technical challenges of conventional laparoscopic suturing and knot tying. Myomectomy is a suture-intensive surgery and assistance with robotic arms makes suturing simple and easy. This article discusses some of the tips and tricks of performing robotic myomectomy in the areas of pre operative assessment & MRI, port placement & docking, hybrid procedure, dealing with associated sub mucous fibroids and variations in suturing techniques. Pre operative MRI of the pelvis is helps in identifying the number and location of all the fibroids. The primary port is placed in the midline. The rest of the ports are placed 10 cms apart in an inverted “W” fashion. Hybrid technique is a variation in robotic myomectomy where a conventional laparoscopic enucleation of the myoma is followed by reconstruction with the da Vinci robot. Assosciated submucous fibroids can be removed by hysteroscopy myomectomy, however large type 2-sub mucous fibroid has been removed with robotic approach. Use of unidirectional knotless barbed suture substantially facilitates closure of uterine defects during minimally invasive myomectomy and may offer additional advantages such as minimizing operative time.