Patient takes clear liquids a day prior to surgery. Proctoclysis enema and two Dulcolax (bisacodyl) tablets are given per oral a night before the surgery. We do not administer Peglec which causes dilatation of the bowel.

Port placement (Figs. 7.3 and 7.4) and instrumentation (Fig. 7.8)

Vaginal-Cervical Ahluwalia Retractor-Elevator (VCARE) uterine manipulator is fixed to the cervix after placing patient in lithotomy position. Intraoperatively, it helps in manipulating the uterus. A 12 mm camera port is placed 3 cm above the umbilicus in the midline with optical trocar. The rest of the ports are placed after insufflating the abdomen with gas and marking the port measurements. Arm-one (8 mm) port is placed on patient’s right side, 3–5 cm below and at least 8 cm lateral to the camera port. Arm-two (8 mm) port is placed on patient’s left side, 8 cm lateral and 3–5 cm below the level of the camera port. Arm-three (8 mm) port is placed on patient’s right side, 2 cm above the anterior superior iliac spine and 8 cm away from the first port. Assistant port (12 mm) is placed on patient’s left side, slightly cephalad to the camera port on an arc at the midpoint between the camera port and the instrument arm-two port.

Zero-degree scope is used for all the steps, except for para-aortic lymph node dissection where 30° down scope is used. In arm-one hot shears (monopolar curved scissors), in arm-two fenestrated bipolar forceps, and in arm-three prograsp forceps is used (Figs. 7.5 and 7.6, 7.7).

After placing all the ports, the patient is positioned before docking the robot. Head end side is lowered completely, and all the bowel loops are taken toward the upper abdomen. Pelvic wash is given and fluid is taken for cytological examination (Fig. 7.8).

Dissection is done in a circular fashion from one round ligament to the other.

Step 6: Bilateral pelvic lymphadenectomy (Figs. 7.11 and 7.12) is done by exposing the pararectal and paravesical spaces. Separate specimen bag is used for each side of the lymph nodes, and specimen is delivered through the vagina. Para-aortic lymph node dissection is done when indicated. The vaginal cuff is closed with a 15 cm long self-retaining polydioxanone (monofilament, violet) barb suture, and uterosacral ligaments are included laterally.

The role of systematic pelvic lymphadenectomy is an issue of current debate. Excision of suspicious or enlarged nodes is important to exclude metastasis. A more selective and tailored lymphadenectomy approach is now recommended to avoid systematic overtreatment [6]. No randomized trial data support full lymphadenectomy [7] although some retrospective studies have suggested that it is beneficial [8]. A subset of patients may not benefit from lymphadenectomy, but it is difficult to preoperatively identify these patients because of the uncontrollable variable of change in grade and depth of invasion in final histopathology.

As the grade of the tumor increases, accuracy of intraoperative evaluation of myometrial invasion by gross examination decreases. Therefore, frozen section examination for evaluation of the histology, size of primary, grade, and depth of invasion is important. Pending further trials, pelvic lymphadenectomy is done in all patients. Para-aortic lymphadenectomy is indicated in high-risk patients.

Anatomical spaces in pelvic dissection:

Anatomical boundaries:

The Gynecologic Oncology Group (GOG) has completed a phase III randomized study (lamina-associated polypeptide 2 (LAP2)) comparing laparoscopy vs. laparotomy in endometrial cancer [9]. Patients with clinical stage I–IIA uterine cancer were randomly assigned to laparoscopy (n = 1696) or open laparotomy (n = 920), including hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. Laparoscopy was initiated in 1,682 patients and completed without conversion in 1,248 patients (74.2 %). Conversion from laparoscopy to laparotomy was secondary to poor visibility in 14.6 %, metastatic cancer in 4.1 %, bleeding in 2.9 %, and other causes in 4.2 %. Laparoscopy had fewer moderate to severe postoperative adverse events than laparotomy (14 % v 21 %, respectively; P = .0001) but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 204 v 130 min, respectively; P = .001). Hospitalization of more than 2 days was significantly lower in laparoscopy vs. laparotomy patients (52 % v 94 %, respectively; P = .0001). They concluded that laparoscopic surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Time to recurrence was the primary end point, with non-inferiority defined as a difference in recurrence rate of less than 5.3 % between the two groups at 3 years. The recurrence rate at 3 years was 10.24 % for patients in the laparotomy arm, compared with 11.39 % for patients in the laparoscopy arm, with an estimated difference between groups of 1.14 % (90 % lower bound, −1.278; 95 % upper bound, 3.996) [10]. Although this difference was lower than the pre-specified limit, the statistical requirements for non-inferiority were not met because of a lower-than-expected number of recurrences in both groups. The estimated 5-year overall survival was almost identical in both arms at 89.8 %. These results, combined with previous findings from this study of improved QOL and decreased complications associated with laparoscopy, are reassuring to patients and allow surgeons to reasonably suggest this method as a means to surgically treat and stage patients with presumed early-stage endometrial cancers.

Another prospective randomized trial is ongoing at Australian and the UK institutions, the Laparoscopic Approach to Cancer of the Endometrium (LACE) trial anticipated to randomize 590 patients to total laparoscopic hysterectomy and lymph nodal staging vs. standard, open surgery [11].

Disadvantages of laparoscopy:

An analysis of robotic-assisted hysterectomy with lymphadenectomy vs. total laparoscopic hysterectomy with lymphadenectomy and laparotomy with total abdominal hysterectomy with lymphadenectomy was done by Lim PC et al. [14]. Data were categorized by chronologic order of cases into groups of 20 patients each. The learning curve of the surgical procedure was estimated by measuring operative time with respect to chronologic order of each patient who had undergone the respective procedure. Analysis of operative time for robotic-assisted hysterectomy with bilateral lymph node dissection with respect to chronologic order of each group of 20 cases demonstrated a decrease in operative time: 183.2 (69) min (95 % CI, 153.0–213.4) for cases 1–20, 152.7 (39.8) min (95 % CI, 135.3–170.1) for cases 21–40, and 148.8 (36.7) min (95 % CI, 130.8–166.8) for cases 41–56. For the groups with laparoscopic hysterectomy with lymphadenectomy and traditional total abdominal hysterectomy with lymphadenectomy, there was no difference in operative time with respect to chronologic group order of cases. It was concluded that the learning curve for robotic-assisted hysterectomy with lymph node dissection seems to be easier compared with that for laparoscopic hysterectomy with lymph node dissection for surgical management of endometrial cancer.

Retrospective study was conducted at two academic centers to compare the survival of women with endometrial cancer managed by robotic- and laparoscopic-assisted surgery [15]. A total of 183 women had robotic-assisted surgery and 232 women had laparoscopic-assisted surgery. With a median follow-up of 38 months (range 4–61 months) for the robotic and 58 months (range 4–118 months) for the traditional laparoscopic group, there were no significant differences in survival (3-year survival 93.3 and 93.6 %), DFS (3-year DFS 83.3 and 88.4 %), and tumor recurrence (14.8 and 12.1 %) for robotic and laparoscopic groups, respectively. Univariate and multivariate analysis showed that surgery is not an independent prognostic factor of survival. Robotic-assisted surgery yields equivalent oncological outcomes when compared to traditional laparoscopic surgery for endometrial adenocarcinoma.

A retrospective chart review was performed for all consecutive endometrial adenocarcinoma patients surgically staged with robotic-assisted laparoscopy at the University of North Carolina Hospital from 2005 to 2010 [16]. Demographic data, 5-year survival, and recurrence-free intervals were analyzed. Surgical staging was 85.2 % for stage IA, 80.2 % for stage IB, 69.8 % for stage II, and 69 % for stage III. Projected 5-year survival was 88.7 % for all patients included in the study. Nearly 82 % of cases were endometrioid adenocarcinoma, with papillary serous, clear cell, or mixed histology comprising 17.4 % of cases. Median follow-up time was 23 months, with a range of 0–80 months. Among stage IA, IB, II, and III patients, projected overall survival was 94.2 %, 85.9 %, 77.4 %, and 68.6 %, respectively. The results from this study demonstrate that robotic-assisted surgical staging for endometrial cancer does not adversely affect rates of recurrence or survival. These findings provide further evidence that robotic-assisted laparoscopic surgical staging is not associated with inferior results when compared to laparotomy or traditional laparoscopy.