Robotic surgery has become an increasingly common option in the treatment of endometriosis offering significant benefits to patients. What is robotic surgery?
Robotic surgery is definitely on the rise especially for complex surgical tasks. It is important to understand that a robotic console is just a surgical instrument in the surgery performed by the surgeon using their surgical skills, experience, risk management and safety rules. Surgical robot is by far more advanced surgical instrument if compared to something that we had previously. I’m talking about open surgery and traditional laparoscopy. Robotic surgery offers simplification of complex surgical tasks by offering more precision in cutting, better visualisation, better surgical access and much less physical and mental demand from the surgeon. This allows us to perform very complex operations with more precision, less fatigue and achieve full removal of the disease while preserving the nerves, for fertility, bowel function, bladder function and sexual function in the patient.
Robotic surgery is associated with less complications, shorter lengths of hospital stay, less risk of conversion to open surgery compared to traditional laparoscopy and quicker patient recovery.
When did you decide to train in robotic surgery?
I have performed my first robotic case in January 2021 and have not performed any traditional laparoscopy since. I am now heading towards 500 robotic endometriosis cases and have never looked back. The decision to switch completely to robotics came very easily after I had done my first five cases on the DaVinci Xi robot. It wasn’t only significantly less physical and mental demand on the surgeon, but the whole surgical procedure experience has become more satisfactory, more elegant and more efficient.
“The message to myself was very simple: I can do it much better, much quicker and much safer on the robot”
Do you remember your first robotic surgery?
You always remember your first time. Prior to starting robotics I was an established high-volume advanced laparoscopic surgeon specialising in complex benign gynaecology. The way my first robotic case was conducted was very organised and structured.
Before approaching real patients I had to perform multiple hours of robotic simulation practice which gave me scores for each exercise. After that I went to observe live robotic surgery in Europe and finally had advanced final training on the robot in one of the robotic training centres. For my first case, the robotic proctor was invited to supervise my surgery. It happened to be world-famous robotic surgeon Mr Tony Chalhoub, who is now my dear friend. His job was to observe my surgery and make sure I don’t have any difficulties using new surgical equipment. My learning curve was very steep as I did not have to learn surgery, I just needed to get used to using the robot as a new laparoscopic instrument. I am now a robotic surgery proctor myself going around the UK and Europe and supervising robotic surgeons at the start of their robotic programme.
Both laparoscopic and robotic surgery have multiple benefits for patients, but for some patients it is very hard to decide. What are the strongest benefits of robotic surgery for endometriosis that we can’t get with laparoscopy?
For me there is no doubt: robotic surgery allows me to see better, excise more endometriosis and damage less healthy tissues. Because of the robotic approach we are now doing much less full-length bowel resection for bowel endometriosis just because we can radically excise the disease robotically without reforming segmental resections. The benefits are well-known and published: reduced post-surgery pain and opioid demands, less blood loss, increased precision for more accurate endometriosis excision, faster recovery, shorter hospital stay, less risk of infection.
Postoperative adhesions and pain are the most common complaints of patients. Do robotic surgery reduce these issues?
Valuation of post-operative adhesions is a very difficult research task that in most cases requires repeat surgery to look at the adhesions. I don’t have any reliable data to support that robotic surgery causes less adhesions and scarring. However, my thought is this is definitely the case because we use much less surgical energy in tissue dissection compared with laparoscopic surgery and therefore less surgical trauma to tissues, which can influence excessive scar and adhesion formation.
Prof Horace Roman and others reported microscopic endometriosis. Can robotic surgery remove microscopic endometriosis?
Robotic vision is significantly better compared to traditional laparoscopy, simply because it’s a 3D high-definition video image. It does not go to microscopy level, but we can see small peritoneal endometriosis patches much better compared to conventional laparoscopy. Therefore robotics allows us to see more endometriosis and therefore perform more radical clearance of it.
Endometriosis is a complex disease and surgery can be very difficult, especially when it comes to multiple organs involvement, such as nerves and bowel. Is robotic surgery better indicated for nerve sparing and bowel resection?
Our specialist robotic multidisciplinary endometriosis team offers top surgical expertise in nerve-sparing and fertility-preserving treatment options for severe infiltrating endometriosis. Our aim is to avoid multiple surgical operations for deep endometriosis and clear the disease in a single surgical procedure, even if the disease affects multiple organs and systems. In order to achieve this, we use principles of “conservative radicality” described by Arnaud Wattiez, excising the disease in full while minimising damage to the ovarian reserve, other pelvic organs, nerves and blood vessels. For suspected deep infiltrating endometriosis of the bowel, we offer extensive pre-operative assessment including a special MRI scan to assess the extent of the disease before surgery. If the diagnosis is confirmed, patients will be offered a range of treatment options, all of which are performed as robotic keyhole surgery.
in my own audit comparing my last 50 laparoscopic cases in my first 50 robotic cases the surgical procedure time was 36 minutes quicker. In the robotic group length of stay came down from 2.4 to 1.6 days on the average robotic surgery compared to laparoscopy. There were less complications and conversions to open.
Our innovative robotic surgical techniques include stapler discoid bowel resection, which allows us to remove deep infiltrating endometriosis of the bowel without removing the length of the bowel. This results in a lower complication rate, a low recurrence rate and a quicker recovery. We are one of the first specialist units in the UK to offer this technique widely, and our surgical audit data shows excellent results in our patients’ quality of life, pain levels and sexual function.
In addition to performing surgeries, you are also training doctors. How do you see the future of robotic surgery in endometriosis?
My strong opinion is that robotic surgery is going to replace traditional laparoscopy fully. The benefits of robotics are obvious and complex endometriosis is treated much better with robotics. The surgeon will last longer physically and mentally at the top of their surgical expertise and capacity using robotics. We had a similar revolutionary trend 30 years ago, where pioneers of laparoscopy replaced the open surgery approach for most surgical procedures. Similar trend with robotics replacing laparoscopy is inevitable and is happening right now.