Gynecology

Gynecologic surgery is recommended for women facing cervical and uterine cancer, uterine fibroids, endometriosis, pelvic prolapse and excessive bleeding (menorrhagia). Patients benefit by the use of robot-assisted minimally invasive surgery by:

  • Reduced pain
  • Reduced blood loss
  • Reduced hospital pain
  • Early return to normal activities

Uterine prolapse can occur when the ligaments supporting the uterus weaken, providing inadequate support. The uterus then descends into the vaginal canal. This can cause symptoms because the uterus begins to press on other organs in the area causing pressure and pain. There are several forms of treatment for uterine prolapse. If your gynecologist recommends surgery, minimally invasive repair of this condition has many benefits. Your doctor will discuss removing your uterus if the prolapse is severe, but this will depend on many individual factors.

A hysterectomy is the surgical removal of the uterus. Hysterectomies are performed for a wide variety of reasons. A hysterectomy is major surgery, but with new technological advances, the discomfort, risk of infection and recovery time has all been decreased. da Vinci Hysterectomy offers a number of benefits compared to traditional approaches to vaginal, laparoscopic or open abdominal hysterectomy, particularly when performing more challenging procedures like radical hysterectomy for gynecologic cancer. Benefits include fewer complications, shorter hospital stay, decreased risk of infection, and significantly less pain.

When a malignant tumor is discovered a team of doctors will determine whether you should proceed with surgery or not. In case they decide that this is the best option, the da Vinci platform will help to reduce the risks of surgery through the laparoscopic removal of malignant gynecological tumors. Uterine (endometrial) cancer can be treated by removing the uterus and examining the remaining tissues for the spread of cancer. Cervical cancer can be treated by removing the uterus and cervix and examining the remaining tissues for the spread of cancer.

Uterine fibroids (also known as myomas) affect thirty percent of women and are abnormal, non-cancerous growths on the inside and outside of the uterus. Many fibroids do not usually need treatment, but some may cause abnormal uterine bleeding, pressure, pain or other symptoms. Myomectomy is a procedure in which uterine fibroids are surgically removed. Surgical treatment of uterine fibroids used to involve a radical hysterectomy; the removal of the entire uterus and ovaries. However, with recent advances in surgical treatment options, surgeons may now perform surgical removal of uterine fibroids while still preserving the functionality of the uterus.

Athens Medical Center

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Dr. Petros Hirides, MD, PhD

  • Member of Minimmaly Invasive Robotic Association – MIRA

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31.01.15
Robotic Gynecological Surgery

Dr. Petros Hirides,MD, PhD Colleague of GAIA.

Robotic surgery is the development of minimally traumatic surgery in which the operation is performed through very small skin incisions.

The value of conventional laparoscopic surgery is recognized. Despite its advantages, its usefulness is limited by the high degree of necessary skill, the limited movements, the two-dimensional and mirror-image projected movements, and biotechnological parameters, such as physiological tremor of the hands of the surgeon which is augmented through the long, rigid instruments, particularly when they have to be kept steady for long periods of time.

Robotic surgery is the spearhead of endoscopy, which is to bridge the gap between the laparoscopic and open surgery. The tele-surgery provides technical features such as three-dimensional vision, great maneuverability of robotic instruments and filtering of physiological tremor of the surgeon’s hands. These factors provide an ergonomic environment for the surgeon that allows performing complex laparoscopic procedures.

Some of the advantages of the daVinci robotic system include precise movements, extended range of motion, greater dexterity, improved vision and the possibility for intervention in small, inaccessible areas. Overall ergonomics of the system, makes the surgeon feel safer during surgery. Patients on the other hand, enjoy shorter hospital stay, less pain, less blood loss, minimized risk of infection, improved cosmetic results, quicker recovery and faster return to daily activities.

Nowadays there is a considerable number of publications in literature with respect to the use of robotic systems in gynecologic surgery. More specifically, more than 280 publications refer to daVinci gynecologic operations, while some compare its effectiveness with conventional laparoscopy. Currently, the entire spectrum of gynecologic surgery can be conducted robotically, including both benign indications such as fibroid enucleation, total and subtotal hysterectomy, endometriosis, as well as malignancies such as pelvic tumors and lymph node dissections.

FIBROID ENUCLEATION

Surgical treatment of fibroids includes, apart from hysterectomy, alternative surgical methods such as the enucleation, i.e. removal of fibroids while maintaining the uterine body. This method is recommended for women who wish to preserve fertility and those who refuse to have their uterus removed. Robotic myomectomy is performed with unparalleled accuracy, increased movement flexibility and incredible three-dimensional image within the body. Even for large fibroids, the operation is completed through four minimal skin incisions, each less than 1cm in length. The HD (High Definition) image allows optimal recognition of the separation plane during enucleation. The uterus is sutured in multiple layers with sutures of equal strength compared to open surgery. The fibroid is removed from the abdomen into pieces without the need of an additional incision.

HYSTERECTOMY

The removal of the uterus (hysterectomy) is the most popular robotic operation in the US today. Although hysterectomy is carried out with conventional laparoscopy over the past 20 years, increased safety, was what prompted gynecologists to turn to the robotic approach. In recent reports, it seems that injuries to the ureters during hysterectomy occur much less frequently during robotic surgery in in comparison to open surgery or conventional laparoscopy. Also with robotic surgery, the large size of uterus ceases to be a limiting factor for minimally invasive surgery, since hysterectomies of large uteri over 1kg in weight are carried out with great success.

ENDOMETRIOSIS

Endometriosis is a benign disease affecting 7% of women of childbearing age, especially younger ones between 25-40 years. The foci of endometriosis usually involve the pelvic organs however, sometimes they occur in remote locations such as the lungs, the kidneys, even the upper extremities. Emerging lesions resemble small "bumps" on the surface of organs. Ovarian cysts can be formed around the endometrial tissue (i.e. endometriomas) which can grow to the size of an orange. Endometriosis is a progressive disease but progression is slow, causing inflammation and pain leading in scarring and formation of adhesions. Recent studies from SERGS (Society of European Robotic Gynecologic Surgery) recommend that robotic surgery is the safest method for the management of advanced endometriosis. Also robotic surgery is valuable in cases where fertility is desired, because it allows a thorough cleaning of the abdomen while maintaining the normal ovarian epithelial tissue.

GYNECOLOGIC ONCOLOGY

Radical hysterectomy is a classic and effective method for the treatment of early cervical cancer. Robotic assisted surgery allows a minimally invasive radical hysterectomy, with satisfactory results in terms of blood loss, duration of surgery, lymphadenectomy (removal of lymph vessels and nodes) and reduced hospitalization. In the treatment of endometrial cancer, the effectiveness of robotic method has already been recognized.

Regarding ovarian cancer, there is insufficient evidence regarding the robotic approach. However, experienced surgeons in certified oncology center introduce robotic surgery to both staging as well as treatment (debulking) of the disease. Minimally traumatic surgery not only ensures fewer complications, but also reduces morbidity therefore allowing a quicker onset of postoperative chemotherapy. The newer technology, "Firefly", which is available for the robotic system, facilitates recognition of lymph nodes, making it safer and more efficient in the processes of lymph node dissection.

Finally, it should be mentioned that for patients with morbid obesity, robotic surgery is superior compared to other approaches, both in reducing complications and in minimizing duration of surgery.

Single incision robotic surgery (Single-Site Robotic Surgery)is a recent innovation in the field of Laparoscopic Surgery. The surgeon is operating again using the robotic system, however now, all instruments enter the abdomen through a single, small incision of 15mm instead of four incisions. The insertion of surgical instruments through the same port, is technically very demanding, especially because all instruments lie on the same axis.With the evolution of technology, thinner, more flexible instruments are available and adapt on the Da Vinci system’s specially designed platform for single-site. The instruments cross each other at the point of entry and the system, electronically reverses the robotic arms (the right becomes left and vice versa) so that the movements of the surgeon are aligned, comfortable and natural.

Single Site robotic surgery is the least traumatic surgery available and ensures excellent cosmetic results.

Since 2006, when the daVinci surgical program initiated in Athens Medical Center, by the pioneer surgeon Dr. Konstantinos Konstantinidis and his team, more than 1,200 operations of various indications have been successfully completed and now, they are planned on a daily basis.

The vast experience of Dr. Konstantinidis in laparoscopy, served as the perfect background for the development of minimally invasive robotic surgery in challenging and demanding operations. These include operations for restoration of GERD (gastro - esophageal reflux disease), repair of hiatal hernias and esophageal achalasia, repair of ventral hernias of the abdominal wall, cholecystectomies and biliary operations, adrenalectomies, splenectomies, gastrectomies, colectomies, operations for morbid obesity such as the gastric bypass or the gastric 'sleeve' and removal of gastric bands. Also gynecologic operations discussed earlier, urologic operations such as prostatectomies and nephrectomies and even total cystectomies. Naturally, the spectrum of operations and the potentials are widening continuously.

20.05.14
Robotic Myomectomy

Dr. Petros Hirides,MD, PhD Colleague of GAIA.

Fibroids (or leiomyomas) of the uterus are benign tumors developed on the uterine wall that are usually discovered by chance during a regular check. They are the main reason of hysterectomy (33%), thus removal of the uterus in women of the USA.

Almost 20-40% of the women of reproductive age have uterine fibroids, which grow either alone or as groups under the influence of female hormones, i.e. estrogens. Usually they increase their number and size with age, while after menopause their growth is reverses and depending on their size they may disappear. Despite the fact that in most cases they do not produce clinical symptoms, the main manifestations of fibroids include acute bleeding during menstruation, pain or pressure to the lower abdomen and difficulties in conceiving

Conservative treatment of fibroids, which includes non steroid anti-inflammatory medicine, hormones and GnRH agonists , could reduce symptoms, however only surgery can achieve their definite treatment. Surgical treatment of fibroids, in addition to hysterectomy, includes alternative surgical methods, such as enucleation, thus the removal of fibroids while keeping the uterus in place. This method is suggested to women wishing to have a baby, as well as those refusing to remove their uterus. Traditionally, myomectomy (removal of a myoma) is done through large surgical incisions, similar or a little smaller than those of the C-section, via which the myoma is removed and the uterus is sutured to contain bleeding and infections.

Also, the proper suturing of the uterine walls reduces the risk of rupture in case of future pregnancy.

A new method of treating fibroids is the embolization of their blood vessels, which causes them to shrink. However, the very small number of studies regarding the long-term success of the method limits significantly its application. Another approach is the laparoscopic removal of fibroids, which offers the advantages of minimally invasive method, but needs an excellent surgical ability, while the quality of suturing and post-surgical fertility are doubted by many scientists.

Even today the majority of myomectomies are realized via the open method, due to the limitations of the conventional laparoscopic method. The limitations include the difficulty to discern the right plane between the myoma and the myometrium and the restoration of the wall in many layers for better mounting and haemostasis. Moreover, the laparoscopic enucleation of a myoma is a surgical challenge for the gynecologist, having as a result that operations are limited to those with one or at the most two fibroids, of a size up to 5 cm and preferably of subserosal position and located to the front part or the bottom of the uterus.

An evolution of the laparoscopic approach is the use of the da Vinci robotic system, which uses the most advanced available technology in order to surpass the challenges of laparoscopic removal of fibroids. Robotic myomectomy allows the realization of the surgery with incomparable accuracy, ease of moves and unbelievable 3D image from the inside of the body.

The operation is minimally invasive, because it is realized through 4 incisions smaller than 1 cm in length. The application of modern technology by the experienced hands of the gynecologist allows the enucleation of fibroids and the salvage of the uterus, even after previous c-sections or other uterine surgeries. The High Definition mage allows the identification of anatomy, vessels and the plan of detachments of the myoma during enucleation. The uterus is sutured in multiple layers same as open surgery. The myoma is removed through the abdomen in pieces of tissue, without the need of an extra surgical incision.

For women wishing to keep their uterus robotic myomectomy offers many advantages in comparison to the open method, such as:

  • Less post-surgical pain,
  • Less blood loss and need for transfusion,
  • Shorter hospitalization,
  • Faster recovery and return to daily life and family,
  • Less complications and post-surgical infections,
  • Less post-surgical symphyses,
  • Accurate and strong suturing of the uterine wall in multiple layers,
  • Minimally invasive surgery to women with large, intra-mural and anatomically difficult positioned fibroids,
  • Optimal cosmetic result with small surgical incisions. 

Petros Chiridis is a member of the General, Laparoscopic, Robotic and & Obesity Surgery Team of Κ.Μ. Konstandinidis, of the Athens Medical Center.

The Athens Medical Center has been equipped with the most advanced 4th generation robotic system da Vinci SI HD (High Definition), with magnified 3D high definition image that gives the impression to the surgeon of being inside the body he/she operates. The robotic team of the Athens Medical Center, under the direction of Dr. Κ. Μ. Konstandinidis, with the participation of experienced gynecologists, has realized robotic myomectomies very successfully leaving patients absolutely satisfied. Even after the removal of large fibroids of 10-12 cm, women were discharged in 24 hours.

By Petros Chiridis MD, PhD Obstetrician, Gynecologist Endoscopist, Colleague of GAIA.

20.05.14
Robotic Surgery in Gynecology

Dr. Petros Hirides,MD, PhD Colleague of GAIA.

Gynecologists were pioneers of laparoscopic surgery, from the early 70s, because the reduction of wall trauma not only simplified post surgical course, but also reduced post surgical symphyses. The subsequent fertility percentages were significantly improved. The maintenance and restoration of fertility were the basic motive for gynecologists to prefer laparoscopic surgery.

The value of conventional laparoscopy, as a minimally invasive surgery is fully recognized.

Despite its advantages, its use is limited by the its high difficulty, the limited ease of moves, 2D images, reverse display of moves and biotechnological parameters, such as the normal trembling of the surgeon’s hand, which is multiplied via the long, rigid tools, especially if those must be kept immobile for a large period of time.

Robotic surgery

Robotic surgery is a renewed special category of the minimally traumatic surgery, aiming to deal with technical difficulties of laparoscopy and to allow to major and demanding gynecological operations to realized via very small incisions on the skin of the patient. The advantages of the robotic system da Vinci, used by the Medical Center of Athens, are its greater accuracy and stability of moves, the ability for complex moves of the tools, greater agility, better magnification and 3D image and the ability to operate in small and difficult to access points. In its total, robotic surgery creates an ergonomic environment for the surgeon, while in parallel increases its surgical ability and safety. Each woman for its part enjoys the advantages of the minimally traumatic surgery in even higher degree than that of conventional laparoscopy.

The post-operational pain is even weaker, because there is not any extensive wound and surgical incisions, as well as because less air is used (CO2) for the required stretching of the abdomen. Recovery is fast and return to daily life is achieved in a few days.

Application field

Robotic gynecology is one of the faster advancing fields of robotic surgery and is applied for the treatment of benign gynecological surgeries, as well as for gynecological oncology. Up to today robotic systems have been used mainly for benign gynecological conditions, such as uterine fibroids, menstruation disorders, endometriosis, subfertility, ectopic pregnancy, pelvic prolapse, urine incontinence and benign tumors of the ovary.

Robotic technology simplifies many of the laparoscopic handlings, such as the preparation of tissues and suturing. Robotic myomectomy and hysterectomy are done with incomparable accuracy, ease of moves and unbelievable 3D image from the inside of the body.

Indications and abilities are multiplied along with the technological progress and the gradual training and experience of the surgeons. Extended hysterectomy and biopsy of lymph nodes are some of the operations realized by using the robot for the treatment of endometrial and uterine cervical cancer. Nowadays one can find a few publications mentioning the use of robotic systems to gynecological oncology. However, many research programs are being realized and pilot operations with a huge progress, a fact giving many promises for the direct future.

Single-Site Robotic Hysterectomy

Single Site Robotic Surgery is one more recent innovation of the field of laparoscopic surgery. The surgeon operates once more with the help of the robotic system, but all tools are inserted to the abdomen only through a small incision of 2 cm, instead of four incisions.

Robotic gynecology is one of the faster advancing fields of robotic surgery and is applied for the treatment of benign gynecological surgeries, as well as for gynecological oncology.

The avoidance of large incisions of open surgery does not only reduce post-surgical pain and speeds up recovery, but also eliminates the possibility for serious post-surgical troubles, such a dangerous infection of the wound, large painful hernias, even breaking and the need of additional operation. Of course it always aims for the optimal visual result without leaving scars.

Robotic System da Vinci Si HD

The first, in an international level, Single-Site Robotic Subtotal Hysterectomy was realized by Surgeon Dr. Κ. Μ. Konstandinidis and his colleagues (Dr  Π. Chiridis, gynecologist and surgeons Dr. S. Chiridis, Dr.. P. Chrisoheris and Dr. Μ. Georgiou) in November 2011. The patient was 53 old with uterine myomas. The operation took 3 hours and was completed bloodlessly, leaving a scar of 2 cm above the belly button. The patient was discharged in 15 hours after the operation, without painkillers or any other medicine.

The Athens Medical Center has been equipped with the most advanced 4th generation robotic system da Vinci SI HD (High Definition), with magnified 3D high definition image.

The robotic team of the Athens Medical Center, under the direction of Dr. Κ. Μ. Konstandinidis, with the participation of experienced gynecologists, realizes robotic operations in the regular operational schedule.

By Petros Chiridis MD, Obstetrician, Gynecologist- Laparoscopic surgeon, Colleague of the Athens Medical Center, Member of the team of General, Laparoscopic & Robotic Surgery of Dr. Κ. Μ. Konstantinidis.