Role of Robotics in Benign Gynaecology

Robotic surgery in benign gynaecology uses a robotic system to operate through small incisions on non-cancerous conditions of the uterus and ovaries, such as fibroids, endometriosis, ovarian cysts and abnormal uterine bleeding. Its role began in gynaecological cancer surgery. For Dr. Deepika Aggarwal, Chief-Laparoscopic Gynae & Robotic Surgery, Artemis Hospitals, Gurugram, India, it now offers benign patients what laparoscopy does, with less blood loss, shorter stays and fewer conversions.

What robotic surgery in benign gynaecology covers

Benign gynaecology covers the conditions that are not cancer but that drive most gynaecological operations: fibroids (non-cancerous growths of the muscle of the uterus), endometriosis (tissue similar to the lining of the uterus growing outside it, often binding organs together with scar tissue), ovarian cysts and dysfunctional uterine bleeding. For many years the robot's established role in gynaecology was cancer surgery. With advances in the technology, Dr. Aggarwal argues, it has now taken on an excellent role in these everyday benign operations.

Her rule of thumb is simple: whatever can be done laparoscopically can also be done robotically. In practice that includes:

• Myomectomy, the removal of fibroids with the uterus left in place
• Hysterectomy, the removal of the uterus, with or without the tubes
• Ovarian cystectomy, the removal of a cyst while preserving the ovary, and removal of the ovaries where needed
• Endometriosis resection, cutting away endometriotic deposits and the adhesions they create
• Sacrocolpopexy, a prolapse repair in which the top of the vagina is lifted and fixed to the sacrum

Benign robotic surgery is her particular interest. She is also an advanced laparoscopic surgeon, a specialist in cervical cancer screening and an expert in colposcopy, the magnified examination of the cervix used to investigate abnormal screening results.

Three surgical eras in one career

Dr. Aggarwal's judgement about when to use the robot rests on having practised all three methods. She began her training in 1992. Around 2000, when she started practising as a gynaecologist, most operations were still open, performed through a large abdominal incision. Within three to five years she was doing a large share of her work laparoscopically. For the past three to four years, since certifying as a da Vinci surgeon, she has performed a large volume of robotic surgery, more than 400 to 500 robotic operations by the time of this masterclass.

That sequence matters because her comparisons are first-hand. When she states that robotic surgery outperforms open surgery, or that it handles a case laparoscopy would struggle with, she is comparing operations she has performed herself by each method.

The robotic system: console, vision cart and patient cart

A robotic surgical system has three parts:

1. The surgeon console, where the surgeon sits, which Dr. Aggarwal likens to the driver's seat of a car. Hand controls and foot pedals translate the movement of the surgeon's fingers into movements of the instruments inside the patient.
2. The vision cart, a screen on which the rest of the theatre team follows the operation.
3. The patient cart, carrying the robotic arms. Three or four arms are used, depending on the operation.

The surgeon is never replaced. The robotic arms reproduce exactly what the surgeon's hands do at the console, through a three-dimensional camera that can be rotated through 360 degrees, so the surgeon can move the view rather than the hands. Dr. Aggarwal noted that the system also alerts the surgeon if anything is going wrong.

Two features carry most of the clinical advantage in benign surgery. The first is magnification and precision: in a demonstration she showed, a robotic instrument peels the skin off a grape, and the three-dimensional view gives, in her words, about 15 times the precision of a laparoscope. That precision lets dense adhesions be separated with very little chance of complications. The second is the instrument set. A vessel sealer, an energy instrument that closes blood vessels before they are cut, seals vessels quickly in operations where heavy bleeding is expected, and in her experience blood transfusion is then hardly ever needed. A full description of the platform appears in Dr. Aggarwal's separate masterclass on how the da Vinci robot works in gynaecological surgery.

Benefits of robotic surgery: recovery, hospital stay and blood loss

Dr. Aggarwal summarises the advantages over laparoscopy in five points: less pain after surgery, faster recovery, greater safety, less blood loss, and a lower rate of conversion to open surgery (when an operation started through small incisions has to be completed through a large one). Complication and readmission rates fall with them.

The difference in hospital stay is the most tangible. In her practice, about 90% of patients go home one day after robotic surgery, even after removal of the uterus or of fibroids. The same operation done laparoscopically needs a stay of at least two to three days, and done open, three to five days.

Operating time also falls. Because the planes between tissues can be dissected cleanly, without disturbing the fatty tissue that tends to bleed during laparoscopy, a robotic hysterectomy takes less time than a laparoscopic one, in her account, and the patient spends less time under anaesthesia. Suturing, in her experience, becomes precise and easy because the instrument wrist moves through 360 degrees.

The evidence behind these claims, the complication rates she cited and the one conversion in her robotic practice are examined in robotic vs laparoscopic surgery in benign gynaecology.

Who should have robotic gynaecological surgery: three clear indications

Asked to state plainly when robotic surgery should be preferred to laparoscopy, Dr. Aggarwal named three groups of women who should seriously consider it:

1. Severe endometriosis, where the bowel, uterus and ovaries are stuck together and precision protects the organs.
2. A uterus with multiple fibroids, where each fibroid has to be removed and the uterus rebuilt.
3. Obese women with a body mass index (BMI) above 30, for whom a shorter anaesthetic is safer.

She adds a fourth consideration within the fibroid group: a young woman who wants children in the future, because the strength of the uterine wall after robotic suturing is, in her experience, far better than after laparoscopy. How fibroid patients are selected for myomectomy or hysterectomy, and how size and number of fibroids change the choice of approach, is the subject of robotic surgery for fibroids.

Robotic hysterectomy in practice: three cases

A large fibroid, refused laparoscopy elsewhere. A woman in her early fifties with a 10 cm fibroid had spent two to three months moving between centres, all of which declined to operate laparoscopically. With a uterus that size, Dr. Aggarwal explained, a laparoscopic surgeon sometimes has to quote a 5% risk of conversion to open surgery. She was confident the robot would avoid that, performed a robotic hysterectomy, and discharged the patient after one day, with no blood transfusion.

Postmenopausal bleeding. A woman of about 60 with bleeding after the menopause and a thickened endometrium (the lining of the uterus) chose hysterectomy after discussion. The recording Dr. Aggarwal showed demonstrates a dissection with almost no bleeding: monopolar scissors that both cut and coagulate, a bipolar instrument that grasps and coagulates, and precise robotic closure of the top of the vagina.

Early cancer in a frail older woman. A woman in her seventies with early endometrial cancer also had sarcoidosis, an inflammatory disease that had compromised her lungs. Open surgery would have carried high morbidity, and laparoscopy would have taken longer than the robot, a real problem with poor lung function. After discussion, the team performed a robotic hysterectomy. She did not need intensive care or a transfusion, and she went home after two days.

Beyond benign disease: robotics in gynaecological cancer

Robotic surgery has a large role in gynaecological cancer, and that is where it began in gynaecology. Cancer operations are long and intricate: removing lymph nodes means extensive dissection around the ureter (the tube draining each kidney) and around the pelvic and para-aortic blood vessels, in a region crowded with nerves. Robotic precision is most valuable there. Dr. Aggarwal performs hysterectomy for early endometrial cancer robotically, and describes robotic lymph node dissection as excellent, with stays of one to two days even after these major operations. Open surgery is still required in certain ovarian cancers and in a very large fibroid uterus.

Referral and training in robotic gynaecology

For referring doctors, the question is less whether robotic surgery is better than whether the local team can manage a given case. Dr. Aggarwal's guidance on when to refer, and what the robotic option costs relative to laparoscopy, is set out in the comparison article linked above. Indicative fees for two of the operations listed earlier are on the myomectomy cost page and the ovarian cystectomy cost page. The full set of questions put to her by doctors from Nigeria, Cameroon, DR Congo and Ethiopia, including the outlook for training gynaecologists in robotic and laparoscopic surgery, is on the Live Discussion page. Her wider work in obstetrics and gynaecology, including complex obstetrics and fertility-sparing surgery, is covered in her later masterclass on minimally invasive surgery in gynaecology.