Robotic Cancer Surgery in Elderly, High-Risk Patients: Case Selection and a Case With Sarcoidosis

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.

She'd already had a hysteroscopy and D&C confirming Stage 1, Grade 1 endometrial cancer — meaning it hadn't spread — so a radical hysterectomy alone would be curative. The real challenge wasn't the surgery itself, it was the anaesthesia, because the head-down position adds pressure to lungs already compromised by her sarcoidosis. More broadly, outcomes in malignant conditions depend heavily on careful case selection — Stage 1 endometrial cancer and very early cervical cancers can generally be managed robotically, but larger ovarian masses usually can't. We also run a weekly multidisciplinary team meeting with oncology, radiation oncology and the surgical team to decide on adjuvant therapy once histopathology comes back, since even some Stage 1 cancers benefit from a few sessions of chemotherapy or radiotherapy to prevent recurrence.

She was 76 years old with Stage 1 Grade 1 endometrial cancer complicated by sarcoidosis, a lung condition that had significantly reduced her lung capacity, further strained by the head-down position robotic and laparoscopic surgery both require.

The anaesthesia team maintained pneumoperitoneum at a bare minimum of 8 mmHg instead of the standard 15 mmHg, and the surgeon undocked the robot every 20 minutes to let her lungs recover.

Its precision allowed a faster operation, smaller 5 mm ports, less blood loss, and faster mobilisation, all of which reduce the risk of DVT and other complications that are especially dangerous in major open surgery at advanced age.

No. Stage 1 endometrial cancer and very early Stage 1A cervical cancers can generally be managed robotically, while larger ovarian masses usually cannot.

Every case goes through a weekly multidisciplinary team meeting involving PET-CT, oncology, radiation oncology and the surgical team, which reviews histopathology and tumour markers to decide whether adjuvant chemotherapy or radiotherapy is needed.