Background: Since the Da Vinci system was introduced in the gynaecological profession, for benign and most malignant procedures, it appeared that using 5 incisions for trocar insertion could jeopardize the system’s mini-invasiveness. To protect this important characteristic, robotic laparoendoscopic single-site surgery was developed and authorized for gynaecological use in 2013. Using a single small incision for the entire treatment appears to be a promising attempt to improve cosmetic results while lowering wound infections, postoperative pain, and recovery time. After nearly ten years of use, several limitations of this technique became apparent, such as a limited set of non-articulating instruments and electrical possibilities compared to multiport surgery, smoke evacuation and visual impairment. By examining the most relevant research, the goal of this review was to emphasize the indications, risks, and benefits of R-LESS in gynaecological surgery. Methods: A scoping review was conducted on Pubmed, Scopus, Web of Science, and Embase. Publications in English or Italian in the previous 10 years on the use of single-site robotic surgery in gynaecology for benign disorders were included. Results: This review includes 37 of the 297 papers that were retrieved. Myomectomy, hysterectomy, pelvic floor surgery, and endometriosis were the most common indications for single-site surgery. Several studies have reported R-LESS usage in cancer patients. According to the data analysis, the R-LESS approach is comparable to robotic multi-port surgery as regards feasibility and safety, with faster operative and postoperative durations, reduced pain, and a superior cosmetic outcome. Conclusions: The single-port robotic technique is gaining popularity. Our findings provide preliminary evidence of the global experience of surgical teams. Standardizing operative durations and conducting comparative research on the R-LESS learning curve represent one of the most significant future difficulties, as do surgical outcomes, costs, and patient satisfaction in the long run.
A pseudoaneurysm is an extraluminal collection of arterial blood, with turbulent flow, that results from blood flowing through a defect in an arterial wall. Uterine artery pseudoaneurysm (UAP) is a rare but life-threatening complication of uterine surgery such as Cesarean section1. It may be asymptomatic, may thrombose or may rupture, resulting in secondary postpartum hemorrhage (PPH)1-4. The incidence of ruptured UAP has been estimated to be about 3% of all patients presenting with PPH5. Diagnosis of UAP generally involves color Doppler sonography and confirmation by angiography1, 2. It can be treated with arterial embolization or hysterectomy, depending on clinical status2. We describe here our findings in a case of a giant UAP treated with a conservative approach. A 31-year-old woman delivered a 2750-g fetus by Cesarean section at 38 weeks' gestation. Uterine exteriorization, suturing and repositioning were sufficient to obtain adequate hemostasis. Before discharge from hospital, the woman underwent a pelvic ultrasound examination which revealed in the left lateral isthmic region a 49 × 39-mm hypoechoic cystic structure, consistent with a fluid collection. Color flow and spectral Doppler imaging revealed marked aliasing and bidirectional flow representing systolic and diastolic blood flow connected with the uterine artery of the ipsilateral side, which led to suspicion of pseudoaneurysm. Computed tomography was performed. Three-dimensional reconstruction of the resulting images revealed a large vascular neoformation, 42 × 35 mm in diameter, in the left iliac fossa at the level of the uterine cervix, vascularized by the ipsilateral uterine artery (Figure 1a). One hour later, angiographic evaluation of the left hypogastric artery confirmed the presence of a UAP and showed that it had increased in size to 65 × 55 mm (Figure 1b). Selective catheterization of the uterine artery was performed. Given the patient's age and her desire to preserve her fertility, and despite the large size of the UAP, we opted for conservative treatment by arterial embolization. When embolization is the treatment of choice, performing the procedure in the efferent as well as in the afferent vessel should be considered, in order to avoid recurrence of the lesion through the efferent vessel by reversed flow. In our case, however, because of the large volume of the lesion, such an approach was not possible and arterial embolization was therefore performed only on the afferent artery. This was done by positioning three microcoils within the tract proximal to the UAP. Release of microcoils within the pseudoaneurysm itself should be avoided as the absence of an arterial wall combined with the high pressure conferred by the coils can cause the pseudoaneurysm to rupture, with catastrophic consequences. The procedure in our case resulted in complete devascularization of the lesion. Color Doppler sonography and computed tomography (Figure 2a), performed 2 days after surgery, confirmed complete occlusion and thrombosis of the pseudoaneurysm. Angiographic examination of the left hypogastric artery also showed the UAP to have been completely thrombosed (Figure 2b). The patient was discharged from hospital 5 days after the procedure. UAPs are usually approximately 10 mm in diameter; rarely do they reach 30 mm5. In this case, early postpartum diagnosis of UAP and the clinically stable condition of the patient enabled us to plan conservative treatment despite the unusually large size of the UAP. According to the literature, embolization is the treatment of choice in visceral artery pseudoaneurysms generally, including UAPs6-9. Considering that hemorrhage of ruptured UAP may occur as long as 40 days after surgery10, ultrasound, particularly in cases of non-standard Cesarean section with uterine exteriorization and repositioning, adjunctive hemostatic sutures, uterine laceration or large uterine incision, may be a useful tool both for the early diagnosis of UAP and for follow-up to avoid the consequences of possible rupture.
Abstract Remote surgery provides opportunity for enhanced surgical capabilities, wider healthcare reach, and potentially improved patient outcomes. The network reliability is the foundation of successful implementation of telesurgery. It relies on a robust, high-speed communication network, with ultra-low latency. Significant lag has been shown to endanger precision and safety. Furthermore, the full-fledged adoption of telerobotics demands careful consideration of ethical challenges too. A deep insight into these issues has been investigated during the first Telesurgery Consensus Conference that took place in Orlando, Florida, USA, on the 3rd and 4th of February, 2024. During the Conference, the state of the art of remote surgery has been reported from robotic systems displaying telesurgery potential. The Hinotori, a robotic-assisted surgery platform developed by Medicaroid, experienced remote surgery as pre-clinical testing only; the Edge Medical Company, Shenzen, China, reported more than one hundred animal and 30 live human surgeries; the KanGuo reported human telesurgical cases performed with distances more than 3000 km; the Microport, China, collected more than 100 human operations at a distance up to 5000 km. Though, several issues—cybersecurity, data privacy, technical malfunctions — are yet to be addressed before a successful telesurgery implementation. Expanding the discussion to encompass ethical, financial, regulatory, and legal considerations is essential too. The Telesurgery collaborative community is working together to address and establish the best practices in the field.
Abstract We sought to create an Italian version of Mishel's Uncertainty in Illness Scale, dedicated to people undergoing conservative rehabilitation for urinary incontinence, for studying uncertainty as a determinant of therapeutic adherence. Urinary incontinence has a high prevalence worldwide, ranging from 25% to 45%. Incontinence is often treatable with conservative interventions but demands a long and intensive commitment from the patient. Results are not immediate, and relapses are possible. These patients can experience uncertainty and difficulty complying with rehabilitation programs, hence the importance of the therapeutic relationship with a healthcare professional. Mishel's theory of uncertainty can be used to measure uncertainty and the effects of such a relationship, but no instrument currently exists for this purpose. Prospective observational study enrolling all male and female adult patients admitted to a nurse‐led outpatient pelvic clinic for non‐neurogenic urinary incontinence, excluding puerpera. A scale named MUIS‐PF (pelvic floor) was created, based on previous versions of Mishel's scale, and administered during the first consultation and at the end of the rehabilitation program. Internal consistency was assessed, and exploratory factor analysis was conducted. A total of 109 patients enrolled (54 M, 55 F) aged 64 ± 5 years, medial initial leakage 245 grams/day, IQR [90; 370]. Seventy‐nine percent obtained continence; there were no dropouts during the study. Internal consistency of the MUIS‐PF was high (93%), and structure analysis yielded a clear separation of the factors. Patient uncertainty decreased significantly at the end of the program compared to the first consultation ( p < 0.001). The MUIS‐PF is valid and reliable. Utilizing the correct approach, the nurse could significantly reduce the uncertainty of persons with incontinence by listening, giving clear information and searching for the best solution for their continence issues.
To summarize comparative studies describing clinical outcomes of robotic-assisted surgeries compared with traditional laparoscopic or laparotomy techniques for the treatment of endometrial cancer.Using search words "robotic hysterectomy" and "endometrial cancer," 22 citations were identified from Medline and PubMed (2005 to February 2010).We selected English language studies reporting at least 25 robotic cases compared with laparoscopic or laparotomy cases that also addressed surgical technique, complications, and perioperative outcomes. Patients underwent total hysterectomy, bilateral salpingo-oophorectomy, and lymphadenectomy.Eight eligible comparative studies were identified that included 1,591 patients (robotic=589, laparoscopic=396, and laparotomy=606). Pooled means of the resected aortic lymph nodes for robotic hysterectomy and laparoscopy were 10.3 and 7.8 (P=.15), and robotic hysterectomy and laparotomy were 9.4 and 5.7 (P=.28). Pooled means of pelvic lymph nodes for robotic and laparoscopic hysterectomy were 18.5 and 17.8 (P=.95) and 18.0 compared with 14.5 (P=.11) for robotic hysterectomy compared with laparotomy. Estimated blood loss was reduced in robotic hysterectomy compared with laparotomy (P<.005) and laparoscopy (P=.001). Length of stay was shorter for both robotic and laparoscopic cases compared with laparotomy (P<.01). Operative time for robotic hysterectomy was similar to laparoscopic cases but was greater than laparotomy (P<.005). Conversion to laparotomy for laparoscopic hysterectomy was 9.9% compared with 4.9% for robotic cases (P=.06). Vascular, bowel, and bladder injuries; cuff dehiscence; and thromboembolic complications were similar for each surgical method. Transfusions for robotic hysterectomy compared with laparotomy was 1.7% and 7.2% (P=.06) and robotic hysterectomy compared were laparoscopy was 2.6% and 5.0% (P=.22).Perioperative clinical outcomes for robotic and laparoscopic hysterectomy appear similar with the exception of less blood loss for robotic cases and longer operative times for robotic and laparoscopy cases.
