JİNEKOLOJİK ONKOLOJİDE ROBOTİK CERRAHİYE GÜNCEL YAKLAŞIM

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1 JİNEKOLOJİK ONKOLOJİDE ROBOTİK CERRAHİYE GÜNCEL YAKLAŞIM JİNEKOLOJİK ONKOLOJİ DOĞU KARADENİZ ÇALIȘTAY VE SEMPOZYUMU 2-3 MAYIS 2015 ÇORUM Prof Dr Ahmet Göçmen İstanbul Medeniyet Üniversitesi Kadın Hast ve Doğum ABD İSTANBUL

2 JİNEKOLOJİK ENDOSKOPİK CERRAHİ ( Laparoskopik/Robotik) Histerektomi/SO Myomektomi DIEndometriosiz Sakroserviko-kolpopeksi Over cerrahisi Tubal cerrahi Abdominal serviko-istmik serklaj Presakral nörektomi Radikal Histerektomi Pelvik Lenfadenektomi Paraaortik Lenfadenektomi Endometrial kanser staging Erken evre over kanser staging Radikal Trakelektomi Pelvik Exenterasyon İnguinofemoral LND (Vulva Testis)

3 Endoskopik cerrahi 1. Laparoskopi Konvensiyonel/mikro laparoskopi Laparolift/İsobarik 2. Robotik LESS (Laparoendoskopik single site surgery) OASIS (Orifice-assisted small incision surgery)

4 Minimal invazif cerrahi Daha az post-operatif ağrı Kısa hastanede kalış Daha az kan kaybı Daha erken normal aktiviteye dönüş Daha küçük insizyon Görüntüleme yöntemlerine göre daha güvenilir (MRI / CT scan) Gereksiz eksploratif laparotomiyi önler

5 Endoskopik Onkolojik Cerrahide sorular Lapatomiye göre operatif onkolojik prensiplerde fark Kısa dönem sonuçlar Uzun dönem sonuçlar Komplikasyon/maliyet

6 Konversiyon %27 En sık seb kötü görüntü %15ozukluğu

7 2009 results of LAP2 study : Laparoscopically treated patients had ; A superior QOL through the first 6 postoperative weeks. Fewer complications Less pain Faster recovery Reduced length of hospital stay

8 Konversiyon %27 En sık seb kötü görüntü %15ozukluğu

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10 Robotic Surgery Benefits Improved visual fields Less dependence on surgical assistance Surgeon comfort Increased instrument mobility Drawbacks Cost Loss of tactile feedback Availability Bulky machine Trochar size

11 da Vinci Sistemin ilerlemesi da Vinci Si da Vinci Xi Four quadrant access Geleneksel Laparoskopi da Vinci Lap kıstlamaları ortadan kaldırdı 4.Kol (2003) Basit enstrumanlar da Vinci S 3D HD Vision (720p) Görüntü Girişi TilePro Multi-quadrant akses Kolay set-up Operasyon spesifik ve farklı enerji enstrumanları Tek Port Cerrahi Çift Konsol Opsiyonu Gelişmiş HD Vision (1080i) Gelişmiş Ergonomi Arttırılmış cerrah kontrolü Küçülebilir yapı Geliştirilmiş enstrumanlar

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20 Endometrial Cancer (LT-LS) Systematic review and Meta-analysis of randomised controlled trials 8 studies, 3666 patients, Zullo F et al, 2012 Endometrial kanser evrelemesinde L/T vs L/S; İntraoperatif komplikasyon bakımından fark yok Post op komplikasyon oranı L/S grubunda daha az

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22 NO difference for intraoperative complications Fewer postoperative complications in laparoscopy

23 Endometrial Cancer Robotic vs Laparoscopy vs Laparotomy Prospective randomized trial yok En geniş sistematik review 8 comparative studies, 1591 hasta Robotik: 589, laparoskopik: 396, laparotomi: 606 Gaia G et al, 2010

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35 Recurrence & Survival Analysis GOG LAP2 Prospective randomized trial Stage I - IIA 1696 laparoskopi vs 920 laparotomi Pelvik ve paraaortik LND Median follow-up 59.3 ay Walker JL et al, 2012

36 Estimated 5 year overall survival : 89.8% in the laparoscopy group 89.8% in the laparotomy group A total of 350 deaths 224 of which resulted from disease 1 52 in the laparoscopy group 72 in the laparotomy group

37 Endometrial Cancer PFS and OS For Robotic Surgery Kilgore JE et al, 2013 Retrospective study, 499 cases Median follow-up: 23 months.

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43 Cost Analysis Direkt cost : Robotik sistem millyon $ İndirekt cost: ( Hekim ücreti, robotik sarflar, operasyon odası ücreti,llaboratuvar-radyoloji ve ilaç ücretleri, komplikasyonlara ait ücretler, iş gücü kaybına bağlı ücret, robotik bakım ücreti)

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45 Cost Analysis Barnett JC et all, decision models to compare the cost associated with robotic, laparoscopic, and open hysterectomy for the treatment of endometrial cancer. 1) Societal perspective model: inpatient hospital costs, robotic expenses, lost wages and caregiver costs 2) Hospital perspective and robot cost model: İdentical to model 1 but excluded lost wages and caregiver costs. 3) Hospital perspective without robot cost model: Identical to model 2 except that it excludes initial cost of robot.

46 Cost Analysis Model 1: Laparoscopy $ Robotic $ Open $ Model 2: Laparoscopy $6581 Open $7009 Robotic $8770 Model 3: Laparoscopy is the least expensive

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50 1000$ 1400$ Monopolar makas 5000$/10 kul Robotik enstruman/kul Bipolar Maryland Forceps 4000$ / 10 kul 3-4 kol drape $ Bipolar Fenestrated forceps 4000$/ 10 kul 2 robotik enstruman 1 makas+1 Bipolar Prograsper Sütür kesici iğne tutucu Rob enst kolu drape Rob kamera kolu drape 3500 / 10 kul 3800/ 10 kul 75 $/ kul (x3) 50$/ kul 3 robotik enstruman 1 makas +1 Bipol + 1 sutur cut portegu 4 robotik enstruman makas+bipolar+ prograsp +iğne tutucu 5 robotik enstruman =1600$ Rob kamera head drape 40$/ kul Makas+bipolar+ prograsp+ iğne t(2)

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54 Endoskopik cerrahiye bağlı endişeler 1. Uterin manipulatör-tümör yayılımı 2. Port site rekürrens 3. Cuff evisserasyonu 4. Port site herni

55 HOHL Uterine Manipulator CLERMONT-FERRAND KONINCKX RUMI

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65 Benign Four RCTs compared robot-assisted surgery for benign gynecologic disease with laparoscopy, and none showed any benefit from using the robotic approach. These and other studies show that robot-assisted gynecologic surgery can be performed safely in centers with experienced surgeons and that this minimally invasive approach could be considered for procedures that might otherwise require laparotomy. Sarlos D Obstet Gynecol 2012 Paraiso MF Am J Obstet Gynecol 2013 Anger JT Obstet Gynecol 2014

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72 Gynecologic Malignancies Endometrial cancer Although randomized prospective trials currently do not exist for the robotic assisted surgical management of endometrial cancer, there are 13 retrospective trials comparing robotassisted hysterectomy with either conventional laparoscopic or abdominal hysterectomy. Hastanede kalma süresi ve kan kaybı robotik grupta daha az Lenf nodu sayısı bakımından fark yok

73 Cervical cancer Robot-assisted surgery is increasingly used for treatment of, but outcome data are limited to retrospective reviews. One study that compared robot assisted hysterectomy with laparoscopic radical hysterectomy found no advantages to the robotic approach. Additional studies are necessary to help validate whether robot-assisted and laparoscopic radical hysterectomy have similar outcomes.

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