Vaginal Robotic Supracervical Hysterectomy in an Ovine Animal Model: The Proof of Concept

Abstract

Objective: To gain insight into the feasibility and safety of a novel vaginal robot for performing supracervical hysterectomy in an ovine model. Introduction: The clinical application of transvaginal natural or fice transluminal endoscopic surgery (vNOTES) has broadened significantly. vNOTES reduces wound complications such as infection, hematoma formation, or herniation and is currently utilized for hysterectomy, adnexal surgery, myomectomy, and staging surgery for endometrial cancer. Robotic assistance has been proposed to overcome the current vNOTES mechanical obstacles. The implementation of the current robots has limited utility due to their bulk and inflexibility. Robotic Natural Orifice Transluminal Surgery (rNOTES) is the new frontier in advancement of surgical robots. In developing new task specific robots, it is important to utilize an accurate model for testing. A novel vaginal robot introduced through the posterior cul-de-sac to perform a complete retrograde hysterectomy is the subject of this study. Methods: The study was conducted at the animal lab, Asaf-Harofe hospital, Israel. The ovine model was preferred since the anatomical landmarks and vascular anatomy are comparable to the human except for a bicornuate uterus in sheep. A vaginal robotic supra-cervical hysterectomy was performed in a sheep. Results: A vaginal robotic supracervical hysterectomy was performed successfully in an ovine model. The uterus was extracted via the entry point in the pouch of Douglas. 20 cc of blood loss was reported and no complications were observed. Conclusions: Vaginal supracervical hysterectomy via a vaginal approach using a novel robotic system was found to be feasible.

The Fresh Frozen Cadaveric Study of Direct Pouch of Douglas Laparoscopic and Robotic Trocar Insertion for Vaginal Natural Orifice Transluminal Endoscopic Surgery

“…vNOTES surgeries have gained wide acceptance among gynecologists; the use of POD for peritoneal cavity inspection was described by Decker et al [14] in 1944. This concept is important as the use of the POD as a surgical port access has gained popularity for both vNOTES surgeries [15] and robotic vaginal surgery (robotic attempts at vNOTES) [9]. In vNOTES surgeries, the POD is grasped and cut into blindly using cold scissors.…”

“…Robotic attempts at vNOTES are ongoing. This concept has been previously tested in an ovine model [9]. Advantages to vNOTES technique compared with open and conventional abdominal laparoscopic/robotic surgery include avoidance of abdominal incision−related complications (wound infections, adhesions, and hernias), less postoperative pain, improved esthetics, and a diminished immunologic impact [10].…”

Robotic Natural Orifice Transluminal Endoscopic Surgery Hysterectomy and Salpingo-Oophorectomy in a Porcine Model

“…Recently, a novel surgical system Hominis™ (Memic Innovation Surgery, Israel) that uses 2 articulated humanoid arms that can retroflex and allow 360° maneuvers have been developed and evaluated in a transvaginal supravesical hysterectomy procedure. 18 However, at the time of report, an external laparoscopic camera was utilized in the study. Although NISImagine is designed as a NOTES capable surgical robotic system, to simplify the evaluation in its feasibility to perform gynecological surgical procedures, a pure NOTES setting was not assessed at this time; however, the reversal of the robotic arms can provide a view to the surgeons as in an abdominal procedure unlike in vaginal robotic NOTES where the view is in the opposite orientation, greatly eliminating the surgeons need to adapt to a different anatomical view of the pelvic organs.…”

“…17 This study further explored the possibility of NOTES with a robotic system, adding the advantages of robotic surgery to NOTES procedures. Some studies 18,19 have suggested an ovine model is a more preferred animal model for undertaking gynecological experimental evaluation due to its similarity of the pelvic anatomy to a human female. However, for the purpose of our study, a porcine model was used as it was more representative to conduct an evaluation on the dissection field and assessment of the workspace availability in particular the maneuverability and ability of the robotic arms to reach the left and right extremities of the pelvic cavity and to form adequate triangulation.…”

Pelvic Organ Prolapse Reconstruction with the Chitosan-Based Novel Haemostatic Agent in Ovine Model—Preliminary Report

“…Of these, pigs stand out due to their pronounced anatomical and physiological resemblances to humans, rendering them a favored choice. Notably, the resemblance between the pelvic floor and genital hiatus anatomy prompted researchers to focus on sheep as a prospective model for urogenital surgery [14]. Analogous similarities extend to the urogenital realm, where organ prolapse can manifest [15].…”