Oophorectomy, laparoscopic, robot-assisted laparoscopy (DaVinci)

DaVinci:

• Positioning is done in lithotomy position (or more securely on spreadable straight leg supports), ideally on a large vacuum cushion or non-slip mat
• It is recommended to adduct both arms (caution: cotton wrapping when positioning with a cloth sling), or to position one arm on the side of the robot
• For leg positioning, padded "boots" are recommended so that the legs can be moved separately and covered sterilely if necessary. Alternatively, the legs can be positioned in leg holders with fixation (Caution: Compartment syndrome).
• The legs should be adjustable via the OR table control during the procedure
• Shoulder supports bilaterally to prevent the patient from slipping on the OR table
• For longer procedures, application of pneumatic compression cuffs for the legs for thrombosis prophylaxis
• Attachment of a portio adapter

Note: It is important to be aware of the risk of injury to the patient from the instruments if the patient slips. With coupled tables in the Xi system, intraoperative position changes are possible without uncoupling. If the "Table-Motion" technique is not available, the surgical robot must always be undocked and removed from the OR table before any position change

Davinci: 

Creation of a pneumoperitoneum by inserting a Veress needle approximately 20 cm from the target anatomy (usually periumbilical). The three to four 8 mm robotic trocars are positioned in a straight, horizontal line (Xi) or a slightly curved line towards the surgical site (X, SI). Ideally, there is a distance of 8 cm between each trocar (minimum 7 cm to maximum 10 cm). The 10 or 12 mm assistant trocar can be placed in the lower abdomen, cranial to the trocars, or as an additional trocar along the straight line, depending on the assistant's positioning at the operating table and the surgeon's preference (see illustration). The patient is positioned at the end of the operating table and then placed in a steep Trendelenburg position (approximately 30°). The table tilt is adjusted as needed for anesthetic or surgical requirements. The laser marking is aligned so that the crosshair points directly at the camera trocar (Xi). The DaVinci system is then aligned. The arms are connected (docked) with the three to four 8 mm robotic trocars. Subsequently, the instruments are introduced under visual control and parked under the anterior abdominal wall. 

Caution: The trocars must be positioned with the wide black ring at the level of the muscular abdominal wall (so-called remote center) to avoid injury during movement.

Note:  Depending on the operating room and the surgeon's preference, the positioning of the Da Vinci "patient cart" and the trocars can vary.

During laparoscopy, the inspection of the abdomen is performed, including the upper abdominal area, the diaphragmatic domes, the liver, the gallbladder, the stomach, and the omentum. Additionally, an inspection of the intestines and peritoneum is conducted, and the pelvis is inspected, considering the uterus, both adnexa, the Douglas pouch, as well as the transperitoneal representation of both ureters. The ovarian cyst is assessed endomorphologically.

Note: If there is uncertainty regarding the benign nature of the ovarian cyst, it is recommended to perform a lavage cytology, and care should be taken to leave the cyst intact, meaning an adnexectomy should be performed or, if clarification is lacking, the operation should be aborted.

Precise depiction of the ovary. Luxating and grasping the ovary, the ligamentum ovarii proprium, or the ligamentum infundibulo pelvicum of the affected side to fix the ovary. Now, an antimesenteric ovariotomy is performed using a monopolar scissor. Care should be taken to avoid rupturing the cyst if possible. The ovarian tissue (tunica albuginea) is then separated from the cyst wall by undermining and spreading movements of the second instrument. Both layers are predominantly separated bluntly by traction, with occasional bipolar/monopolar coagulation of vessels for hemostasis.

Note: Hemostasis should be particularly performed in the area of the hilum ovarii or the ligamentum ovarii proprium (as there is a higher tendency for increased bleeding here).