Question 1

What is the cost implication of robotic surgery compared with laparoscopic or open surgery?

Dr. Deepika Aggarwal · Accepted Answer

Robotic surgery is a little more expensive than laparoscopic surgery. Depending on the type of surgery, it is somewhere around $1,000 to $1,200 more than a conventional laparoscopic surgery.

Question 2

Given the resources, the cost and the need, how do you decide which patient is suited to open surgery, which to laparoscopy and where robotic surgery should be preferred?

Dr. Deepika Aggarwal · Accepted Answer

Some cases are straightforward. With a fibroid uterus where the fibroids are massive, extending 4 to 5 cm above the belly button, there is no space to place the camera or to manoeuvre, so it has to be open surgery. With laparoscopy, a uterus of around 18 to 20 weeks' size becomes tricky, and that is where robotic surgery comes in, because you can be confident of doing it robotically. Severe endometriosis with many adhesions between the bowel, uterus and ovaries needs excellent precision, and the robot gives a magnified three-dimensional view and wristed instruments with greater precision than the laparoscope, so those patients should definitely consider robotic surgery. The same applies to multiple fibroids: Afro-Caribbean women are very prone to fibroid uterus and usually have multiple fibroids, so they would benefit more from robotic than from laparoscopic surgery.

Question 3

With robotic surgery, is there no longer an indication for hysterectomy in women with fibroids?

Dr. Deepika Aggarwal · Accepted Answer

It depends on the age of the patient and her fertility desire, so sometimes we offer hysterectomy as well. If a perimenopausal woman of around 48 has completed her family and has multiple fibroids, it is her choice whether she wants just the fibroids removed or the uterus removed. Women sometimes have very small, peanut-sized fibroids that cannot be taken out at the time of surgery; we remove the ones larger than 1 to 2 cm, so the small ones can recur and regrow. In many such women it is better to consider removing the uterus rather than saving it. I take the patient through the pros and cons of each option, and then she makes the call.

Question 4

Where patients have the financial resources, how should partner doctors decide whether to manage a case locally or to discuss referral with a specialist?

Dr. Deepika Aggarwal · Accepted Answer

It depends on the expertise available in their area for that patient. Complex cases with big fibroids or endometriosis, where the local experts are not confident or feel the patient may need to be opened, are the patients to refer, because we have the technology to do them robotically and laparoscopically. Doctors should first gauge how much the local surgeons and gynaecologists are able to do. They can always share a query with me and I will answer it.

Question 5

Taking into account the patient's age, family plans and fibroid size, for whom is robotic surgery a boon?

Dr. Deepika Aggarwal · Accepted Answer

Robotic surgery is a boon for women with a high BMI, above 30, because we want less anaesthesia time for them, and for women with severe endometriosis or multiple fibroids. Take a woman with three fibroids of 6, 4 and 2 cm: the surgery involves enucleating all three, reconstructing the uterus and then morcellating the fibroids to remove them. Laparoscopically that can take four to five hours; robotically, perhaps a couple of hours. The anaesthetic risk, blood loss and hospital stay are all lower. This applies even more to a young woman who wants children in future, because robotic suturing makes a secure multilayer repair of the uterus easier than conventional laparoscopy.

Question 6

Data suggest proficiency in complex cases such as endometrial cancer may be reached in fewer than 10 cases with robotic systems, compared with 40 for standard laparoscopy. What is your comment?

Dr. Deepika Aggarwal · Accepted Answer

Most surgeons who train in robotic surgery are already laparoscopic surgeons who have done many laparoscopic procedures; very few are de novo robotic surgeons who never operated laparoscopically. If you have driven a manual car and move to an automatic, proficiency comes sooner. A surgeon who has done many laparoscopic endometrial cancer surgeries already knows what to do and only needs to learn how to drive the robot, so I would expect proficiency after about 10 cases. I am not aware of data showing better outcomes with laparoscopy: with robotic surgery, complications, readmissions, blood loss and post-operative pain are all less than with laparoscopic surgery.

Question 7

Have you had any cases in your practice that you had to convert to open surgery?

Dr. Deepika Aggarwal · Accepted Answer

I had one case in the last three to four years. In robotic surgery the patient's head is tilted down at a 30-degree angle, and this patient had a lung compromise and could not maintain her oxygen saturation. We undocked the robot, raised her head, waited 10 minutes and restarted, but her saturation kept falling, so we had to open her up. That is the only case I can recall in three years, so it is very rare, around one in 100 cases. The most important factor is patient selection: surgeons beginning robotic surgery should select their patients very carefully and take on more complex cases gradually as their numbers grow. Even so, the chance of conversion is never zero.

Question 8

How many robotic surgeries have you done in your career, and how many were successful, including the post-operative recovery stage?

Dr. Deepika Aggarwal · Accepted Answer

None of my patients has ended up in the ICU; they have all recovered well. I have done more than 400 to 500 robotic surgeries so far, and I cannot recall any complications in terms of injury to the bladder, bowel or ureter.

Question 9

Are success rates with robotic surgery better than with traditional open surgery?

Dr. Deepika Aggarwal · Accepted Answer

There is no second thought about it. The magnification is so good, for structures such as the ureter and the lymph nodes, that the complication rate is lower than in open surgery. In traditional open surgery we lose more blood and make a big incision, which adds to the patient's morbidity. I did a lot of open surgery before 2000, then moved into laparoscopy and now robotics, so I can make the comparison directly. Open surgery is still needed in certain cases of ovarian cancer and in a very large fibroid uterus.

Question 10

What is the failure rate in robotic surgery?

Dr. Deepika Aggarwal · Accepted Answer

Failure can mean conversion to open surgery, a complication, or not being able to do the surgery robotically at all. Whether a case is viable robotically is a decision an expert robotic surgeon should make pre-operatively, not after docking the robot: that is pre-operative planning, and if the ultrasound report is not satisfactory I get an MRI or CT done. Injury can happen in robotic surgery, but the risk is less than 1%. For a gynaecologist the four main injuries are bladder, bowel, ureter and vessel injury; with robotic surgery the risk of bowel, vessel and bladder injury is less than 0.5%, compared with around 1 to 2% with laparoscopic surgery.

Question 11

How do we clearly distinguish when robotic surgery should be preferred over laparoscopic surgery?

Dr. Deepika Aggarwal · Accepted Answer

There are three clear indications for robotic surgery: severe endometriosis, a uterus with multiple fibroids, and obese women with a high BMI. These patients should seriously consider robotic surgery.

Question 12

In gynaecological cancer, where surgery becomes multidisciplinary, is robotic surgery still relevant?

Dr. Deepika Aggarwal · Accepted Answer

Robotic surgery has a huge role in cancer surgery, and in gynaecology its use began there. Cancer surgeries are long, intricate operations: lymph node removal requires extensive dissection around the ureter, the lymph nodes lie around the para-aortic and pelvic vessels, and many nerves and blood vessels run through the area, which is why the robot is so valuable.

Question 13

What is your plan to expand this clinical activity in developing countries such as Ethiopia, so that gynaecologists there can become expert in robotic or laparoscopic surgery? Are there plans for training at the level of Artemis Hospital?

Dr. Deepika Aggarwal · Accepted Answer

Artemis has been very proactive with all sorts of expansion and is very much engaged internationally, and we are there to support it. With digital tools such as today's Zoom session, this can happen. I would also be very happy to travel, taking time out once every couple of months to be with the doctors and the patients there. Further suggestions are welcome.

Question 14

Artemis has been working towards training fellowships where surgeons from other countries can spend a few months training with a doctor. When will that be launched?

Dr. Deepika Aggarwal · Accepted Answer

I will put it forward. We already have Indian fellows and consultants who come to watch and learn with us. I am very proactive about teaching and training: the skills we have acquired should be spread so that more people can gain the expertise.

Live Discussion with Dr. Deepika Aggarwal