Saving the Uterus in Complex Fibroid Cases: Combined Robotic and Hysteroscopic Myomectomy

I recall a case from early in my training, at a government referral centre with a very high patient volume, where an abdominal pregnancy went undetected until around eight and a half months. We were fortunate to save both mother and baby, but there was significant bleeding because the placenta had implanted within the abdomen — we removed as much as we could safely, she spent 10 to 12 days in intensive care, and we used methotrexate afterward to help the residual placental tissue resorb. Abdominal pregnancy at a late gestational age is one of the most challenging obstetric emergencies you can face.

In more than five years and over 500 robotic procedures, I've had to convert to open surgery once. That patient had multiple fibroids and two previous midline Caesarean sections, and an unexpected mass was found near the umbilicus, right where our robotic entry point usually is. When we tried to remove it for histology, she started bleeding and we couldn't control it because we weren't certain of the nature of the mass — so she was converted to open surgery. That's one conversion in five years, out of more than 500 cases.

We welcome fellowships for robotic and minimal access training at Artemis — candidates can come and work with us for three to six months. How quickly someone masters the robot depends heavily on the laparoscopic experience they already bring; learning it from scratch is a much bigger challenge. There's also a structured simulator programme, roughly 100 hours, before formal certification on a cadaver, though the real prerequisite for anyone wanting to become a robotic surgeon is solid expertise in minimal access surgery first.

It depends on the case. For a straightforward third-degree prolapse, vaginal hysterectomy alone works well without robotic assistance. But if the patient also needs her ovaries removed, reaching them vaginally is technically difficult and risks bleeding — in those cases robotic or laparoscopic hysterectomy is the better option. There's also an advantage for recurrence: women with prolapse usually have lax pelvic ligaments, so we want to add a vault suspension at the same time. The traditional vaginal approach for that was a bloody technique with weeks of pain afterward; with the robot we can do the vault suspension from above with far greater precision and much less blood loss.

Yes, absolutely. We accept fellows at Artemis for different durations — three months or six months. The fellowship can accommodate gynaecologists and general surgeons who perform gynaecological procedures, starting from the basic level of minimal access surgery.

A 31-year-old patient from Iraq had two large uterine fibroids, one measuring 7 centimetres and prolapsing through the vagina, causing complete obstruction, and had already been told at other centres that her uterus would need to be removed.

Given her age, removing the uterus was not an option Dr. Aggarwal would accept, so the goal was to preserve fertility while resolving both fibroids.

Dr. Aggarwal combined two techniques in a single case, robotic myomectomy to remove the upper fibroid, and hysteroscopic myomectomy, approaching from below, to remove the fibroid prolapsing at the cervix.

The patient was discharged the very next day.

Patients who undergo this kind of surgery can typically plan a pregnancy around three months afterwards.