Implementation of GYN Robotic surgery in our practice

In the last three decades, the gynecologic surgery has been transformed in the western world, from mostly open abdominal surgeries with increased length of stay and morbidity to modern minimally invasive surgeries with a short stay duration, decreased morbidity, faster return to normal activities and work. Long past the days of doing laparoscopic surgery with direct viewing through a scope and poor-quality imaging monitors which are now replaced with our current High defi nition 2D and 3D imaging. In the last decade, the introduction of Robotics to our surgical armamentarium has steadily increased the likelihood that patients will have a minimally invasive procedure instead of an open laparotomy.


Implementation of GYN Robotic surgery in our practice
Antony Brigoni, Oksana Mudra

American Hospital Dubai, Dubai, UAE
The Middle East has launched its fi rst comprehensive robotic surgery program, known as one of the most sophisticated laparoscopic surgical technologies available. The device -created by Intuitive -is part of a new program aimed at enhancing the group's "current comprehensive general surgery and laparoscopic surgery services".
American Hospital was selected as the hub for this robotic program as it is already considered a market leader in advanced laparoscopic surgery.
According to the manufacturer, the da Vinci Xi HD 4 works by combining conventional laparoscopic techniques with high precision robotic technology that uses four robotic arms controlled by the surgeon from a console. Using the console, the surgeon is also able to access a 3D high-defi nition view of the surgical area.
Robotic surgery is a state-of-the-art surgical procedure where the conventional laparoscopic technique is combined with high-precision robotic technology. Articulated instruments allow the same movement capacity as the human wrist and the tremor fi lter eliminates any small uncontrollable movement in the surgeon's hands.
We would like to share our experience in the implementation of Robotic-Assisted surgery in the gynecological practice of our hospital.
Commencement of our program coincided with a very diffi cult period for the entire world. Regardless of the COVID pandemic, we successfully launched on our robo-surgical journey, and within 6 months, we performed 150 Robotic-assisted surgeries, with 50 of them being gynecological.
In the last three decades, the gynecologic surgery has been transformed in the western world, from mostly open abdominal surgeries with increased length of stay and morbidity to modern minimally invasive surgeries with a short stay duration, decreased morbidity, faster return to normal activities and work. Long past the days of doing laparoscopic surgery with direct viewing through a scope and poor-quality imaging monitors which are now replaced with our current High defi nition 2D and 3D imaging. In the last decade, the introduction of Robotics to our surgical armamentarium has steadily increased the likelihood that patients will have a minimally invasive procedure instead of an open laparotomy.
Keywords: Robotic surgery, gynecology, women health, laparoscopy.  Our experience in the implementation of the Robotic program in our institution started not so long ago, in February 2020. Despite complicated times for everyone, the lockdown and the battle with COVID-19 pandemic, our commencement has been crowned with success and positive outcomes in the fi elds of Gynecology, General Surgery and Urology.
Robotic surgery, or robotic-assisted surgery, allows performing a variety of complex procedures with more precision, fl exibility and control than it is possible with conventional Laparoscopy or open abdominal surgery.
The advantages of robotic surgeries include smaller incisions, endo-Wrist articulating instruments, anti-tremor technology leading to enhanced precision during surgery, which lowers the risk of complications, morbidity, ensures less postoperative pain and shorter hospital stay.
The system provides better access, especially in highly complicated procedures when extensive dissection and adhesiolysis are required to reestablish proper pelvic Anatomy.
The three-dimensional (3D) imaging, unlike a two-dimensional (2D) one, provides signifi cantly improved visualization of the surgical area.  The surgeon can sit comfortably at a computer console operating Robotic instruments with precise fi ngertip control (Fig.2). The Tremor reduction technology allows keeping the tools stable while decreasing the surgeon's fatigue.
The main diff erence with robotic tools compared with conventional laparoscopic tools is that they are articulated -the same range of movements that can be performed by the wrists inside the body is available using these tiny (1-2cm) tools and a high-defi nition 3D view with up to ten times enlargement. Using these features, the surgery can be performed with minimal trauma to the tissue during the procedure, which will result in many the postoperative benefi ts for the patients.
The most widely used clinical robotic surgical system includes a surgeon's console, a patientside cart with three or four robotic arms. One arm is used for the 3D camera and the other robotic arms are intended for surgical tools.
The surgeon controls robotic arms while seated at a computer console near the operating table. The console gives the surgeon a highdefi nition, magnifi ed, 3D view of the surgical fi eld. The surgeon leads other team members who assist during the operation.
The use of robotic assistance in laparoscopy is rapidly becoming popular because of positive postoperative patients' feedback. Over the last 6 months, 50 robotic-assisted gynecological procedures were performed. Most of our gynecological cases are complicated, but we can perform them with robotic-assisted surgeries. We perform all types of noncancerous surgeries, such as myomectomy, hysterectomy, endometriosis resection, tubal anastomosis, and pelvic organ prolapse were performed in our institution. 87% of all operated patients went home the next day with minimum pain; in 92% of cases, blood loss was less than 50 ml (most of the time described as scant or minimum), 0.1% suff ered from the surgical site infection, 91% of patients required less opioid analgesics in the postoperative period.
Among the disadvantages that we experienced with robotic surgeries was increased surgery time, mainly due to the learning curve, compared to laparoscopy (Fig. 3).
The initial cost of robotic equipment is more expensive too. When it comes to the fi nancial impact of the conventional open surgery, for companies, families, the patient -no one can aff ord a person being out of work for two or three months. There's also the cost of pain medication, antibiotics, an ICU stay, blood transfusions to think about, as well as a risk of infection or hernia resulting from the larger incision.
Footnotes: Figures 1-3: written permission of copyright holders for reproduction was obtained (1.10.2020)