Question 1

For a young woman with heavy, very painful periods who has been on many hormonal medicines, where does Mirena insertion fit as an option?

Dr. Deepika Aggarwal · Accepted Answer

Bleeding problems are not confined to later life; they occur in young women too, and fertility sparing becomes paramount. In the case I reviewed, the young woman also has an element of adenomyosis. There are medical treatments for that, and in young women we would certainly try medical treatment first; one of them is Mirena. Mirena is a hormonal T-shaped device, similar to the copper T used for contraception in some countries. It is inserted inside the uterus in a very simple procedure. Sometimes it can be done in the outpatient department, but a woman who is not sexually active may find that painful, and then it can be done as a simple procedure under sedation, taking only five minutes. It releases hormone locally inside the uterus and thins the lining of the womb, so the woman bleeds less. If she has adenomyosis, which is technically endometriosis of the uterus, it counteracts that as well. The success rate is 80 to 85%, and we usually expect results within three to four months. If it works, it can stay for five years and be changed; if she plans a family within those five years, any gynaecologist anywhere in the world can easily remove it. In her case I felt it was the best proposition, because giving hormones orally or intramuscularly causes more side effects. That is acceptable as an interim measure for a few months, but not as long-term treatment.

Question 2

In your experience with robotic surgery, have you had to convert a robotic procedure to open surgery? If so, how often does it happen, and what clinical conditions or intraoperative challenges led to the conversion?

Dr. Deepika Aggarwal · Accepted Answer

I have been performing robotic surgery for over five years. Because robotic surgery is expensive and patients are paying a lot for it, whenever I have a doubt I first insert a laparoscopic camera to assess the situation before starting. Even so, I have had to convert to open surgery once in those five years. The patient was a woman in her thirties with multiple fibroids who had had two Caesarean sections, both through midline incisions. An unexpected mass was found around her umbilicus, and the robotic incision is usually placed 3 to 4 cm above the umbilicus. When I tried to remove the mass to send it for examination, she started to bleed from it, and the bleeding could not be controlled because we did not know what the mass was. At that point she had to be converted to an open procedure.

Question 3

Roughly how many robotic procedures have you performed in those five years?

Dr. Deepika Aggarwal · Accepted Answer

More than 500. At the moment I am performing around 12 to 15 robotic cases a month. One conversion in that number is a very, very small figure.

Question 4

How long do I need to train for robotic surgery at your hospital?

Dr. Deepika Aggarwal · Accepted Answer

We encourage fellowships for robotic and minimal access training at Artemis: trainees can come, observe and work with us for three months or six months. The training certificate depends on the minimal access experience the trainee brings. Learning the robot de novo can be a huge challenge, but someone already doing a lot of laparoscopic surgery will get to know the robot much faster. The second challenge is simulator training. When we became robotic surgeons, the da Vinci programme was very stringent: about 100 hours of simulator sessions, acknowledged by the da Vinci team, followed by certification on a cadaver, which is effectively an examination. It is not essential for everyone who wants to become a robotic surgeon to go through that simulator pathway, but the paramount requirement is expertise in minimal access surgery.

Question 5

For basic minimal access surgery training, does the trainee need to be a surgeon, or can a gynaecologist also come and train?

Dr. Deepika Aggarwal · Accepted Answer

Of course a gynaecologist can come: I am a gynaecologist, and gynaecology is surgery in itself. Trainees do not have to be general surgeons, although in many countries, including India, general surgeons also perform gynaecological surgery, and in Africa general surgeons also perform hysterectomies. Either can come, even those who want to start from the basics. There are three levels of minimal access training, basic, intermediate and advanced, and the fellowship depends on where the surgeon or gynaecologist wants to start. Basic laparoscopic training is about understanding the system, placing the ports and starting with small cases such as laparoscopic salpingectomy, ovarian cystectomy and adhesiolysis. There is a structure to basic, intermediate and advanced training.

Question 6

How can you operate on a patient with uterine prolapse robotically?

Dr. Deepika Aggarwal · Accepted Answer

It depends on the case. Uterine prolapse can easily be managed vaginally: with a third-degree prolapse there is no real need for a robotic hysterectomy, and it can be done from below. However, if a woman with prolapse also wants her ovaries removed, access to the ovaries vaginally is challenging and bleeding can occur. In those women I suggest a robotic or laparoscopic hysterectomy with removal of the ovaries. A manipulator pushes the uterus in, the surgery is done from above, and the uterus is taken out from below. There is a further advantage. Women with uterine prolapse have lax ligaments, usually after the age of 60 or 70, and to prevent recurrence of the prolapse we want to perform a vault suspension. Traditionally this was done vaginally as a sacrospinous fixation, which was a very bloody technique, and patients used to have pain for weeks. With the robot, the vault suspension can be done from above. The choice depends on the state of the woman's ligaments.

Question 7

In the third case study, the 76-year-old woman, what was the prognosis before the procedure?

Dr. Deepika Aggarwal · Accepted Answer

She had already had a hysteroscopy and D&C, so we knew she had a Grade 1 endometrial cancer, and imaging showed Stage 1, which meant it had not spread. All she needed was a total hysterectomy with removal of both tubes and ovaries, and that would very likely be curative. She was otherwise well: even at 76 and with sarcoidosis she was not bed-bound and had good lung function. The challenge with sarcoidosis was not for me as the surgeon but for the anaesthetist. Patients usually manage when lying flat, but in robotic and laparoscopic surgery the head is down and the legs are up at 30 degrees, which puts more pressure on the lungs. As a multispecialty team we felt she would benefit from robotic surgery despite this: the operating time would be shorter, bleeding would be less, and with three or four small incisions she would recover and mobilise faster. In frail women of her age the risk of DVT after surgery is very high, so on balance we decided to give her the benefit of robotic surgery.

Question 8

Across your years of robotic experience, how are the outcomes in malignant conditions like this?

Dr. Deepika Aggarwal · Accepted Answer

It comes down to very careful case selection. Not every malignant case can be done robotically. It is usually Stage 1 cancers that we manage robotically. Ovarian cancers are the main challenge: if the ovarian mass is big, we would not do it robotically. Generally speaking, Stage 1 endometrial cancer can be dealt with robotically. For early cervical cancer, open radical hysterectomy is now the standard, because the LACC trial showed poorer survival with minimally invasive surgery, and the robot is reserved for very small, low-risk tumours in selected cases.

Question 9

In these Stage 1 cases, do patients still need adjuvant therapy such as chemotherapy?

Dr. Deepika Aggarwal · Accepted Answer

Once we have the histopathology, we also run additional marker tests on the specimen. We hold a dedicated multidisciplinary meeting once a week at Artemis, attended by everyone from PET-CT to the chemotherapy team, radiation, and the surgical team. Depending on the marker results, some patients need three or four sessions of chemotherapy or radiotherapy, sometimes even in Stage 1 cancers, specifically to prevent recurrence. We have to look at the long-term recurrence rate even after cure. Not all patients need it.

Question 10

Is there a fellowship programme that can accommodate African doctors to train in India?

Accepted Answer

Dr. Isaya asked the same question earlier, and Dr. Deepika accepts fellows for different durations, such as three months or six months. Gynaecologists can also start with basic training: there are three levels of laparoscopic training, basic, intermediate and advanced, and laparoscopic experience is the prerequisite for robotic training. Jivo will obtain details of the programme and the application cycle from Artemis and will ask the hospital to waive any academic fee for Jivo doctor partners.

Question 11

If you encounter an abdominal pregnancy at close to 20 weeks, what advice can you give?

Dr. Deepika Aggarwal · Accepted Answer

I remember one case of abdominal pregnancy from my training, when I was a senior resident at a tertiary government centre in India, around 20 years ago. The abdominal pregnancy had been missed, and we only came to know when she presented at around eight and a half months. It was only at the time of delivery that we realised it was an abdominal pregnancy. We were able to save both the baby and the mother, but there was a lot of bleeding because the placenta was in the abdomen. We removed as much as we could while stopping the bleeding. She stayed in the ICU for 10 to 12 days, and we gave methotrexate afterwards for the remaining placenta to be absorbed. She also developed postpartum psychosis, but she recovered. The lesson for today: if the placenta is attached to the bowel or other organs, it is safer to leave it in place and monitor it as it is absorbed than to try to remove it, because partial removal causes heavy bleeding, and methotrexate is no longer favoured for the retained placenta.

Question 12

For robotic surgery, which anaesthesia is most commonly used, spinal or general?

Dr. Deepika Aggarwal · Accepted Answer

General anaesthesia.

Live Discussion with Dr. Deepika Aggarwal