SUMMARY OBJECTIVE: Robotic surgery is currently on the rise and has been widely applied all over the world. Gynecology offers great opportunities for the development of innovative techniques due to the magnitude of surgical needs. The aim of this study was to correlate perioperative complications, surgical time, and length of hospital stay with surgical diagnosis, procedure performed, and surgeon experience in robot-assisted gynecological surgeries in a 10-year period. METHODS: This was a retrospective, transversal, cross-sectional study involving 632 patients who underwent robotic gynecological surgery from January 2008 to December 2017 in a community hospital in Sao Paulo, Brazil. Medical records of robot-assisted gynecological operations were searched for perioperative complications, operative time, and length of hospital stay, correlating these outcomes with surgical diagnosis, procedure performed, and surgeon experience, considering those with 20 or less robotic procedures and surgeons with more than 20 cases in their career as in-training or qualified surgeons, respectively. RESULTS: Endometriosis (381 cases) was the most common surgical indication, followed by uterine myoma (171 patients). Qualified surgeons had 64% less complications than in-training surgeons (p=0.03) and achieved 20% lower surgical time and 15% shorter length of hospital stay. CONCLUSION: In this study, qualified surgeons with more than 20 robotic procedures had better perioperative outcomes and less complications than in-training surgeons during their first 20 robotic surgeries.

Resumo Objetivo Analisar a aplicabilidade e eficiência de um treinamento em laparoscopia com múltiplas abordagens, em melhorar as habilidades laparoscópicas básicas de residentes de ginecologia e obstetrícia (GO). Métodos Estudo transversal, observacional e descritivo, desenvolvido no Centro de Treinamento em Experimentação e Cirurgia (CETEC) do Instituto de Pesquisa do Hospital Albert Einstein com residentes de GO. Foram aplicadas avaliações teóricas e práticas a 24 residentes de GO com o objetivo de avaliar suas habilidades laparoscópicas antes e após sua participação em um curso de 8 semanas. O curso envolveu palestras teóricas e exercícios práticos de cirurgia laparoscópica através de modelos de borracha, caixas pretas, simuladores virtuais e modelos animais (porcos). Resultados Houve uma melhora geral na habilidade dos residentes, comaumento do número de respostas corretas na avaliação teórica e diminuição do tempo na execução dos testes práticos (montagem do porta-agulha e realização de nó laparoscópico). O curso foi avaliado pelos alunos como altamente relevante por melhorar suas habilidades cirúrgicas e motivá-los a continuar praticando. Conclusão O treinamento laparoscópico utilizando múltiplas abordagens resultou em melhora significativa das habilidades cirúrgicas atrelado a alto nível de satisfação dos participantes. Novos estudos ainda são necessários para mensurar a retenção destas habilidades adquiridas a longo prazo.

Abstract Objective To analyze the applicability and efficiency of amulti-approach laparoscopic training in improving basic laparoscopic skills of obstetrics and gynecology (OBGYN) residents. Methods Cross-sectional, observational and descriptive study, developed at the Experimentation and Surgery Training Center (CETEC, in the Portuguese acronym) of the Hospital Israelita Albert Einstein with OBGYN residents. Theoretical and practical tests were applied to 24 OBGYN residents to assess their laparoscopic skills before and after their participation in an 8-week course. The course involved theoretical lectures and practical laparoscopic surgery exercises developed using rubber models, black boxes, virtual simulators and animal models (pigs). Results There was an overall improvement in the ability of the residents, with an increase in the number of correct answers in the theoretical evaluation and decrease in the time needed to perform practical tests (needle holder assembly and laparoscopic node). The course was evaluated by the students as highly relevant for both improving their surgical skills and motivating them to continue practicing. Conclusion Laparoscopic training using multiple approaches resulted in significant improvement of surgical skills with a high satisfaction level of the participants. Further studies are still needed to measure the long-term retention of these acquired skills.

RESUMO Objetivo: Apresentar a primeira série de casos de histerectomia usando sistema robótico de portal único (single-port) em hospital no Brasil. Métodos: No período de novembro de 2014 a outubro 2016, de modo inédito no Brasil, 11 pacientes tiveram indicação inicial e 9 delas foram submetidas à histerectomia por portal único, com a plataforma da Vinci Single-Site®. Em duas pacientes, devido a múltiplas cirurgias abdominais prévias, grande volume uterino e/ou útero sem mobilidade, optou-se pela instalação de pneumoperitônio com agulha de Verres e inspeção da cavidade pélvica com ótica de 5mm, constatando-se, nestes casos, não ser viável a cirurgia por single-port, levando-se, assim, à opção pela técnica robótica multiportal, sem intercorrências. Os nove casos single-port foram operados por um mesmo cirurgião, no Hospital Israelita Albert Einstein. Os dados analisados das pacientes foram idade, índice de massa corporal, cirurgias anteriores e diagnóstico clínico. Os dados relacionados à cirurgia foram tempo operatório, incisão da pele, registro de complicações intraoperatórias, necessidade de conversão para laparotomia, necessidade de transferência para unidade de terapia intensiva, necessidade de transfusão sanguínea, lesão inadivertida de outros órgãos, tempo de internação e óbito. Resultados: Todos os casos foram concluídos sem intercorrências com a plataforma da Vinci Single-Site®. Quatro pacientes apresentavam adenomiose como indicação cirúrgica, duas apresentavam mioma uterino, uma câncer de endométrio, um pólipo endometrial e uma hidrorreia. A média de idade das pacientes foi 44 anos (variando de 40 a 54 anos) e o índice de massa corporal variou entre 23,4 a 33,2kg/m2 (média de 26,4). Nenhum caso teve qualquer tipo de complicação, como lesão intestinal ou vesical, sangramento ou necessidade de reabordagem cirúrgica. Todos os nove procedimentos foram concluídos com o portal único robótico, e nenhuma paciente necessitou de transfusão sanguínea. Conclusão: Apesar deste trabalho apresentar apenas uma série inicial de pacientes operadas por portal único robótico, ele demonstra a factibilidade do método e indica a possibilidade futura de adotar esta técnica em histerectomias eletivas e em outros procedimentos ginecológicos, assim como descrito em grandes centros de referência em cirurgia avançada no mundo. Especificamente na prática ginecológica, a evidência existente sobre o uso de portal único robô-assistido parece ser promissora e, ainda que nem todos os casos tenham indicação, é necessário que exista esta opção no arsenal cirúrgico. No entanto, estudos clínicos aleatorizados e controlados são necessários, a fim de se estabelecer a superioridade da cirurgia robótica por portal único diante da cirurgia laparoscópica com incisão única e da cirurgia laparoscópica convencional.

ABSTRACT Objective: This article presents the first series of robotic single-port hysterectomy cases performed at a hospital in Brazil. Methods: From November 2014 to October 2016, 11 patients were indicated to undergo, and nine of them were submitted to single-port hysterectomy using da Vinci Single-Site® platform. However, in two patients, due to multiple previous abdominal surgeries, large uterine volume, and/or a uterus with no mobility, a pneumoperitoneum was performed with a Verres needle, and the pelvic cavity was assessed using a 5mm optics endoscope. In these cases, single-port surgery was not recommended; therefore, multiportal robotic access was chosen, and no intercurrent events were reported. Nine single-port cases were operated on by the same surgeon at Hospital Israelita Albert Einstein. Patient data analyzed included age, body mass index, previous surgeries, and clinical diagnosis. Surgical data included operative time, skin incision, report of intraoperative complications, need for conversion to laparotomy, need for transfer to intensive care unit, need for blood transfusion, inadvertent injury to other organs, length of hospital stay, and death. Results: All cases were completed with da Vinci Single-Site® system, with no intercurrent events. Four patients presented with adenomyosis as the surgical indication, two had uterine myoma, one endometrial cancer, one endometrial polyp, and one desquamative inflammatory vaginitis. The mean age of patients was 44 years (range, 40 to 54 years), and body mass index varied between 23.4 and 33.2kg/m2 (mean 26.4). No complications occurred in any of the cases, such as intestinal or bladder injury, bleeding, or the need for a second surgery. All nine procedures were completed with the robotic single-port access, and no patient required a blood transfusion. Conclusion: Although this study merely presented an initial series of patients submitted to robotic single-port surgery, it demonstrated that the method is feasible and safe, suggesting the possible use of this technique in elective hysterectomy and other gynecological procedures in the future, as described in large reference centers of advanced surgery worldwide. Specifically, in gynecological practice, existing evidence on the use of robot-assisted, single-port surgery seems promising, and although it is not indicated in all cases, it should be considered as a surgical option. Nonetheless, further randomized and controlled clinical studies are necessary to establish the preeminence of robot-assisted, single-port surgery versus single-incision and conventional laparoscopy.