Multidirectional Traction Method Using SURGICEL NU-KNIT and Surgical Suture in Robot-assisted Laparoscopic Surgery for Endometrial Cancer

Objective To describe a novel approach to robot-assisted laparoscopic total hysterectomy (RH) for endometrial cancer that minimizes cancer sell spillage and develops a stable surgical field. Design Demonstration of the multidirectional traction method with narrated video footage. Setting Many reports have indicated that RH for endometrial cancer has the same or superior short-term results compared with conventional laparoscopic hysterectomy (LH), and the long-term prognosis is the same [ 1 Park DA Lee DH Kim SW Lee SH Comparative safety and effectiveness of robot-assisted laparoscopic hysterectomy versus conventional laparoscopy and laparotomy for endometrial cancer: A systematic review and meta-analysis. Eur J Surg Oncol. 2016; 42: 1303-1314 Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar , 2 Perrone E Capasso I Pasciuto T et al. Laparoscopic vs. robotic-assisted laparoscopy in endometrial cancer staging: large retrospective single-institution study. J Gynecol Oncol. 2021; 32: e45 Crossref PubMed Scopus (19) Google Scholar ]. However, there are no randomized controlled trials of RH versus LH, and some previous reports [ 3 Argenta PA Mattson J Rivard CL Luther E Schefter A Vogel RI Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer. Gynecol Oncol. 2022; 165: 347-352 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar ] have suggested that RH has a worse prognosis than LH, so the long-term prognosis should be considered with caution. Factors that may affect the long-term prognosis include the use of uterine manipulators [ 4 Padilla-Iserte P Lago V Tauste C et al. Impact of uterine manipulator on oncological outcome in endometrial cancer surgery. Am J Obstet Gynecol. 2021; 224: 65.e1-65.e11 Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar ] and compression of the uterine body with robotic forceps without tactile sensation [ 3 Argenta PA Mattson J Rivard CL Luther E Schefter A Vogel RI Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer. Gynecol Oncol. 2022; 165: 347-352 Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar ]. However, to the best of our knowledge, no surgical technique capable of avoiding these factors has been established yet. Herein, we report a multidirectional traction method using SURGICEL NU-KNIT (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan), a local hemostatic agent, and surgical sutures. Intervention Cut 2-0 Prolene (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan) with straight needles (ST-70) thread to 35 cm, stick a 1 × 2 cm piece of SURGICEL NU-KNIT, and make knots Fig. 1. This implement is used to puncture the incisional margins of the peritoneum and then the abdominal wall to bring the thread to the surface of the body, where it is grasped with forceps and fixed. By repeating this operation, multidirectional traction can be obtained Fig. 2. A manipulating suture is also attached to the uterus to minimize the compression of the uterine body with robotic forceps. Conclusion The multidirectional traction method allows for reproducible stable surgical field development and minimizes cancer cell spillage by reducing uterine grasping by robotic forceps without the use of uterine manipulators.