Minimally Invasive Surgery in Gynaecology

Minimally invasive surgery in gynaecology means operating through a few small incisions, by laparoscopy or with a robotic system such as da Vinci, instead of opening the abdomen. Dr. Deepika Aggarwal, Chief-Laparoscopic Gynae & Robotic Surgery, Artemis Hospitals, Gurugram, India, can now perform with the da Vinci robot all the gynaecological operations once done open, yet chooses conventional laparoscopy where the robot's gain does not justify its cost.

How minimally invasive gynaecological surgery evolved: open, laparoscopic, robotic

Gynaecological surgery has changed its operating method twice within a single career. Dr. Aggarwal began her training in 1992, when gynaecological operations of all kinds were performed by opening the abdomen. By the end of the 1990s she and her colleagues were moving those cases to laparoscopy, in which the surgeon operates with long instruments and a camera (the laparoscope) passed through small cuts. Today she can perform all of them with the da Vinci robotic system. Her view of minimally invasive surgery is shaped by having practised all three methods, and by knowing where each still belongs.

Dr. Aggarwal brings 26 years of experience to the specialty. Her undergraduate and postgraduate training took place at medical colleges in Delhi. She then spent 14 years in London, from 2003 to 2017, where she obtained her MRCOG and FRCOG (membership and fellowship of the Royal College of Obstetricians and Gynaecologists), earned accreditation in advanced laparoscopy, and qualified as a colposcopy specialist through the British Society for Colposcopy and Cervical Pathology (BSCCP). That last credential is relevant to the oncology side of her practice, where early disease of the cervix is part of the case mix.

She returned to India in 2017 and certified as a da Vinci robotic surgeon. She spent eight years as a director at CK Birla Hospital, Gurgaon, before joining Artemis, where she now leads minimal access and robotic gynaecology. Over the five years before this masterclass she had performed more than 500 robotic procedures, and her current volume runs at around 12 to 15 robotic cases a month.

Her practice spans three areas of obstetrics and gynaecology:

• Benign gynaecology: fibroids, endometriosis, adenomyosis, ovarian cysts and prolapse.
• Gynaecological oncology: early cancers of the uterus, tubes, ovaries and cervix, managed together with the oncology team.
• Complex obstetrics and vaginoplasty, which she describes as her other forte.

Robotic or laparoscopic surgery: when is the robot worth the cost?

The choice is made case by case. Dr. Aggarwal is explicit that the arrival of the robot does not mean laparoscopy should stop. In her view, robotic surgery offers clear advantages in precision, vision and recovery, and it also costs more. In some cases she still chooses conventional laparoscopy because the clinical gain does not justify the cost of the robot.

Conversion to open surgery, in which an operation begun through small incisions has to be completed by opening the abdomen, has been almost unknown in her robotic practice: one case in more than 500. The mechanics of the system, the evidence behind its outcomes and that single conversion are examined in how the da Vinci robot works in gynaecological surgery.

Which gynaecological operations can be done robotically?

The list of operations Dr. Aggarwal now performs robotically shows how far the method has moved beyond simple hysterectomy (removal of the uterus):

• Hysterectomy, for benign disease and for cancer
• Lymphadenectomy (removal of lymph nodes) and removal of the omentum, the fatty apron of tissue inside the abdomen, in cancer surgery
• Removal of the tubes and ovaries, and of tumours in the adnexa, the area of the tubes and ovaries beside the uterus
• Myomectomy (removal of fibroids with the uterus left in place), including multiple myomectomy, for women who want to keep the uterus
• Cystectomy for complex cysts, such as dermoid cysts and large mucinous cysts, and for endometriomas (ovarian cysts formed by endometriosis) in young women who want to conceive
• Surgery for endometriosis where the bowel, bladder and ureter are stuck together
• Uterus-sparing prolapse repair (sacrohysteropexy) in young women, in which the uterus is lifted and fixed to the sacrum with a mesh
• Hysterectomy with vault suspension, which supports the top of the vagina, for older women whose prolapse comes with lax ligaments

These operations fall into two clinical families, each with its own logic.

The first is benign disease, where the dominant question is usually fertility. A young woman with fibroids, adenomyosis or endometriomas wants her uterus and her remaining eggs preserved. Sometimes that can be achieved without an operation; where surgery is needed, the precision of the robot matters most in difficult anatomy. Dr. Aggarwal's approach to these patients, including when she uses a hormonal coil rather than an operation, and her case of a woman who had been told elsewhere that her uterus had to come out, is covered in fertility-sparing gynaecological surgery and its limits.

The second is early gynaecological cancer, where the questions are case selection, safety under anaesthesia and the treatment that follows surgery. Here she is deliberately conservative about which patients go on the robot. Her criteria, and a case in which a frail older woman with a serious lung condition underwent robotic cancer surgery, are set out in the same article.

Recovery after robotic surgery for patients who travel

Dr. Aggarwal's international patients can usually return home within five days of a major robotic procedure, such as a robotic hysterectomy or a robotic multiple myomectomy, or six at most. For women who travel across borders for surgery, that speed changes the economics of the trip as well as the experience, because patients pay for their stay as well as for the operation. Typical fees for fibroid surgery are listed on the myomectomy cost page.

One of her cases illustrates the pattern. A woman in her late forties travelled to Gurgaon with very heavy menstrual bleeding and constant lower abdominal pain. Ultrasound showed multiple large fibroids, with the uterus enlarged to the size of a 16 to 18 week pregnancy. Dr. Aggarwal performed a robotic hysterectomy, removing the tubes at the same time, and the patient flew home five days after discharge.

Abdominal pregnancy: a case from complex obstetrics

An abdominal pregnancy is one that implants in the abdominal cavity rather than inside the uterus. Dr. Aggarwal's obstetric experience reaches back to her training as a postgraduate and senior resident at a government tertiary centre in India. Asked during the session how to approach an abdominal pregnancy, she described the one case she remembers from that period. The pregnancy had gone unrecognised until the woman presented at around eight and a half months, and the team realised it was abdominal only at the time of delivery.

Both mother and baby survived, but there was heavy bleeding, because the placenta lay within the abdomen. The team removed as much of it as they could while controlling the haemorrhage. The mother spent 10 to 12 days in intensive care and was given methotrexate afterwards so that the remaining placental tissue would be absorbed. The use of methotrexate for placenta left in place after an abdominal pregnancy is controversial, because rapid breakdown of placental tissue can lead to infection. She also developed postpartum psychosis, from which she recovered. The full exchange is on the masterclass Live Discussion page.

How to train in robotic gynaecological surgery

Expertise in minimal access surgery comes before the robot. Much of the discussion at the masterclass came from surgeons and gynaecologists who want to build these skills, and Dr. Aggarwal's answer starts with that prerequisite, for reasons explained in the article on the da Vinci system.

Three levels of laparoscopic training

Minimal access training at Artemis follows a structured progression through basic, intermediate and advanced levels, and a fellowship is built around the level at which the trainee starts. Basic training covers understanding the system and starting with smaller operations: laparoscopic salpingectomy (removal of a fallopian tube), ovarian cystectomy and adhesiolysis (the division of scar tissue). Trainees can come to observe and work with her team for three or six months, and the training certificate they receive depends on the minimal access experience they bring.

The training is open to gynaecologists as well as general surgeons. In Dr. Aggarwal's words, gynaecology is surgery in itself. She noted that in many countries, including India, general surgeons also perform gynaecological operations, and that in Africa general surgeons perform hysterectomies too. Either group can enter the pathway, including at the basic level.

da Vinci certification: simulator hours and a cadaver examination

When Dr. Aggarwal certified on the da Vinci system, the manufacturer's programme was stringent. Surgeons completed about 100 hours of simulator sessions, which were reviewed and acknowledged by the da Vinci team, and then sat a certification on a cadaver, effectively a practical examination. She does not regard the simulator pathway as essential for every surgeon who wants to operate robotically.