Robotic Assisted Laparoscopic Gynaecological and Gynaecological Oncological Procedures: Single Surgeon Experience

Introduction

The positive influence of technological advancements in surgery cannot be denied. In the present day scenario in India, more than 70 institutions have been equipped with facilities for robotic surgeries. Indeed, it is true that minimally invasive surgeries have revolutionized health care. Laparoscopic surgeries and robotic-assisted laparoscopic surgeries improved the post-operative prognosis by facilitating shorter hospital stays, minimum blood loss, smaller incisions, quicker recoveries, and fewer complications.¹ However, the longer learning curve and counterintuitive motions make training for traditional laparoscopic surgeries difficult. But this needs to be improved, as it is well known that robotic assistance provides the advantage of superior visualization with 3D vision and rapid zooming, seven ranges of intuitive movements through brilliantly designed Endowrists, and increased stabilization of the instruments, which improves the precision and thoughtful ergonomics thereby eliminating operator fatigue.^2-4 Robotic-assisted laparoscopy has a great scope in gynaecology. After the Food and Drug Administration (FDA) approved the use of da Vinci Robotic System in gynecology in 2005, a tremendous growth in the use of robot has been witnessed in this field. Although initially it was limited to benign cases, gradually, the real potential of robotic surgery in the more complex oncology procedures has been recognized.

However, surgeons need special training in robotic surgery and few structured training programs are available for many specialties.⁵ Moreover, it has been many years since the induction of the first robot in India in 2012, but only a few centers use robot in gynecological oncology. Further, there are not many articles published about a single surgeon’s experience on robotic-assisted laparoscopic gynaecological and gynaecological oncological procedures. Hence, the aim of this paper was to review the experience of a single gynaecological onco-surgeon in robotic surgery.

Materials and Methods

All the patients who underwent robotic surgeries performed by our consultant gynaecological oncologist from December 2016 to March 2021 were identified. The patient and treatment details and short-term outcomes were collected retrospectively from the database. Preoperative work was the same as for any pelvic surgery.

Patient Positioning

Most robotic gynaecological procedures were conducted in the steep Trendelenburg position. For this, bean bags, gel pads, or shoulder pads were used to provide adequate support. The lower limbs were abducted at the hip, with legs placed on stirrups and knees flexed less than 60°. Proper padding was done to avoid nerve palsies. Pressure‐controlled anesthesia was administered, as is required for ventilation in steep Trendelenburg position. Two peripheral intravenous cannulae were placed prior to tucking the arms, for ease of access in the event of major bleeding. Uterine manipulators were used in benign cases and selected oncology cases and were placed prior to docking.

Port Placement

Port placement was almost the same for all the procedures (Figure 1).

1.  C-da Vinci camera port, 12 mm – placed supraumblically around 24–28 cm from pubic symphysis.
2. R1-right da Vinci instrument arm, 1 port, 8 mm – placed on the patient’s right side, 8–10 cm lateral and 3–5 cm inferior to the camera port.
3. R2-left da Vinci instrument arm, 2 port, 8 mm – placed on the patient’s left side, 8–10 cm lateral and 3–5 cm inferior to the camera port. 
4. R3-da Vinci instrument arm, 3 port, 8 mm – placed on the left side of the abdomen, 8–10 cm from the arm 2 port (R2) laterally, at the same level or cephalad.
5. The surgeon, for most of the cases, preferred to place the assistant port A, 12 mm, on the right side of the abdomen, 8–10 cm lateral to the arm 1 port (R1). In two cases, the assistant port was placed on the left, 1 cm inferior to the subcostal margin.

The standard steps of the procedures were followed. During surgery, one of the trainee surgeons assisted at the bedside, and another helped in manipulating the uterus.

The count of lymph nodes removed during the procedure were obtained from the final histopathology reports from the database.

Complications

Clavien–Dindo classification was used to grade the surgical complications.⁶

Statistics

The categorical variables were presented in percentages, while continuous variables were presented as mean and median values with range.

Results

The mean age of the patients was 54 years (range: 27– 84; Table 1). The average body mass index (BMI) of the women was 25.45 (range: 17.5–38.8). Out of 102 women, 22 had a BMI higher than 35 (Table 1).

Out of 102 robotic procedures conducted by the surgeon, 22 were for benign pathology and 80 were oncology cases, including 53 cases of endometrial cancer, 20 of cervical cancer, one of vaginal cancer, one ovarian cancer, one borderline ovarian tumour and four of cervical intraepithelial neoplasia (Chart 1). After the Laparoscopic Approach to Cervical Cancer (LACC) trial, the surgeon changed the selection criteria for patients undergoing robotic surgery for cervical cancer.

A total of 70 (69%) procedures were extrafascial hysterectomies (with 17 benign cases, 4 cases with CIN II/III, and 48 carcinoma endometrium cases where pelvic lymphadenectomy was also performed, 1 early borderline ovarian tumour where robotic staging, hysterectomy, bilateral salpingo-oopherectomy, pelvic lymph node dissection and omentectomy were done), 17 (17%) were radical hysterectomies, four were anterior exenteration surgeries, one vault mass excision, three robotic pelvic lymphadenectomy in which patients were diagnosed with carcinoma endometrium post hysterectomy, one robotic pelvic lymphadenectomy and omentectomy performed in a patient diagnosed with early stage germ cell ovarian tumour post ovarian mass excision, four benign ovarian cystectomies, one Burch colposuspension, and one posterior exenteration. Pelvic lymphadenectomy was performed in a total of 68 cases. Para- aortic lymph node dissection was performed in six patients. Omentectomy was performed in four cases.

The average surgical time for procedures done in the year 2017 was 176 min, 231 min in 2018, 200 min in 2019, 214 min in 2020 and 182 min in 2021 (Chart 2). The docking time decreased from 15 to 9 minutes.

Pelvic lymphadenectomy was done in 68 cases, and the average node harvest was 15 nodes. In six cases, paraaortic lymph node dissection was performed along with pelvic lymphadenectomy. The average total retroperitoneal lymph nodes removed was 21.

Out of five exenteration procedures, four were anterior exenteration. The one posterior exenteration attempted had to be converted into open posterior exenteration with end sigmoid colostomy. Five patients had Grade II complications, while there was one Grade III and one Grade IV complication.

Discussion

Health care has been evolving owing to the continuous efforts being made to explore effective ways for diagnosis and treatment to improve the quality of life. The introduction of robotic assistance for surgeons is the biggest technological advancement in the field of surgery. Years after being introduced in developed countries, robotic assistance is now available in many hospitals in major Indian cities. The positive influence of this technological advancement in the surgical field cannot be denied. Earlier it was thought that robotic surgery may not find a place in a developing country like India. In the year 2020, over 70 institutions in India had facilities for robotic surgeries. However, even today, a majority of the population can neither afford quality health care nor have health insurance to cover the expenses.⁷

Even in wealthy Western countries, it was feared that the introduction of robotic-assisted surgeries might increase the premium of health insurance, making it unaffordable for many. However, if robotic-assisted surgery can provide undeniably remarkable advantages for patients, it is wiser to find ways to reduce the cost and make it widely available for the better care of the patients. For robotic-assisted laparoscopic surgeries to become costeffective, it must be taken up in high-volume centers with high-volume surgeons.^8,9

Operating time

It was observed that the time taken for performing a robotic procedure was longer in 2019, 2020 and 2021, than those operated before (Chart 2). This probably could be because the surgeon initially had chosen to operate on more benign cases to standardize the surgical techniques and later shifted to more complex surgeries.

Obesity

Obesity often becomes a limiting factor when performing hysterectomy and lymph node dissection procedures, which were traditionally done by open approach. Minimally invasive surgeries can make lymph node dissection in such patients much less cumbersome; thus, robotic assisted laparoscopy is gaining popularity.^10-12

A total of 19 out of 22 obese patients with BMI >35 had carcinoma endometrium and underwent robotic hysterectomy with pelvic lymph node dissection. In these cases, the average lymph node harvest was 12 nodes, and post-operative recovery was similar to that of the non-obese patients.

Procedures such as paraaortic lymph node dissection require surgical expertise, and the surgeon feels that the assistance of a robot provides a great advantage while operating very close to the major vessels.

Double docking

Since our institution has the Si Robot, double docking had to be done in four cases where complete omentectomy had been performed and in six cases where paraaortic lymphadenectomy had been conducted. With the newer robots like Xi, double docking is not required, which would save time.

Complications

About five patients (6%) had Clavien–Dindo Grade II complications and required a blood transfusion. Moreover, one patient, a case of recurrent vaginal carcinoma with vesicovaginal fistula who underwent robotic anterior exenteration had a Grade III complication and presented with rectovaginal fistula six months later, requiring surgical intervention. There was one postoperative mortality secondary to acute myocardial infarction. Further, one patient who had undergone robotic hysterectomy, pelvic lymphadenectomy, and omentectomy for carcinosarcoma of uterus had port-site metastasis. There were no re-admissions.

Learning curve

It is strongly believed that the learning curve is fast when developing robotic laparoscopic skills compared to traditional laparoscopy. This means, time taken to develop skills is less in robotic-assisted laparoscopy than in conventional laparoscopy.¹³

It was observed that the surgeon had gained confidence and started to perform more complex surgeries with time. The surgeon agreed with this observation about his learning curve. One study reported that a surgeon should perform approximately 20 robotic hysterectomy and pelvic-aortic lymphadenopathy procedures to become proficient.¹⁴

Scope for future research

The sexual and urinary function of the patients after undergoing robotic pelvic surgery could be assessed and compared with patients undergoing open pelvic surgeries. Also, more studies need to be undertaken to evaluate the advantages and disadvantages of robotic surgeries in cervical cancer.

Conclusion

Training in robotic-assisted laparoscopic surgery paves the way to perform minimally invasive oncology surgeries with fewer complications in patients and less inconvenience for the operating surgeons. If proven to be more advantageous, the number of patients opting for robotic surgeries would increase and soon training in robotic surgery might become an essential skill for a gynecological onco-surgeon. Therefore, more surgeons must be encouraged to publish their experiences with robotic-assisted gynecological onco-surgeries. Further, structured training programs in robotic gynecological onco-surgery needs to be made available.

Authors’ Contributions

RRR and SDRS instigated the article. RRR, SDRS, AK designed the research study. SDRS performed the research, analyzed the data, wrote the first draft, and revised the manuscript. AK and TJ contributed to the first draft and revision of the manuscript. RRR contributed to revision of the manuscript. All authors read and approved the final manuscript.

Ethics approval

The study was a retrospective study and the data had been collected from the medical database of the institute. The personal details of the patient had not been revealed at any point and the confidentiality has been maintained throughout. The institutional ethical committee clearance was given.

Conflict of interest

The authors declare no competing interests.

Acknowledgment

Intuitive Surgical, Inc. also sponsored a day’s preceptorship for RRR at Mazumdar Shaw Medical Centre in 2016. RRR has not worked for Intuitive Surgical, Inc. as a proctor. RRR is an executive member of Association of Gynecological Oncologists of India (AGOI) and member of International Gynecological Cancer Society (IGCS) and Federation of Obstetric and Gynaecological Societies of India (FOGSI).