Robotic Hysterectomy for Large Fibroids: A Case From Uzbekistan

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.

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.

A 49-year-old patient presented with very heavy menstrual bleeding and constant lower abdominal pain, which an ultrasound traced to multiple large uterine fibroids.

The fibroids had enlarged her uterus to the size expected at 16 to 18 weeks of pregnancy.

Dr. Deepika Aggarwal performed a robotic hysterectomy, removing the uterus along with the fallopian tubes.

She was discharged within 24 hours of the operation and was able to fly home just five days after surgery.

It shows the kind of fast turnaround, diagnosis to discharge to travel home within days, that makes robotic surgery a practical option for patients travelling from abroad.