AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 36 POSITION STATEMENT African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Robotic Assisted Surgery in Gynaecology in the South African setting 1. INTRODUCTION During the past 15 years minimally invasive surgery (MIS) has become the standard of surgical treatment for almost all benign and malignant gynaecological conditions. It is widely accepted that MIS reduces hospital stay, is associated with less pain, morbidity, and also associated with a quicker recovery and return to normal function. The first robotic assisted surgery (RAS) system (Da Vinci Surgical System, Intuitive Surgical, Sunnyvale, California) was approved by the US Food and Drug Administration in 2000 for general laparoscopic procedures, and in 2005 for gynaecological conditions. Since then, there has been a rapid and wide uptake of the use of this system in the USA and Europe, resulting in major changes in the surgical care of women with gynaecological malignancies. 1 Before the availabilityof RAS in these settings,mostwomenunderwent laparotomy procedures, with few women benefitting from standard laparoscopic (SL) MIS. Limitations impeding the uptake of SL include limitation of instrument movement, two dimensional view, complex hand-eye co-ordination, the fulcrum effect, as well as physical strain and discomfort experienced by the surgeon. 2-3 In other regions of the world, the discipline of gynaecology is the single largest user of the robotic platform for different types of benign and malignant gynaecologic surgery, allowing many patients to experience the significant benefits of MIS. 4 The availability of the robotic surgical platform in South Africa is increasing, and this platform is now also available for gynaecology procedures in both the public and private sector. It is necessary to draft a position statement endorsed by the different interest groups within the South African Society of Obstetrics & Gynaecology (SASOG). 2. ADVANTAGES AND DISADVANTAGE OF ROBOTIC ASSISTED LAPAROSCOPY The efficacy and safety of this platform have been well established, as it is the most used platform for MIS for women undergoing gynaecologic surgery in Europe and in the USA. 2.1. Robotic surgery increase the uptake of MIS One of the most important effects of the robotic platform, is certainly that of resulting in a significant uptake of MIS by open surgeons not previously performing standard laparoscopic procedures, with a consequent drop in the percentage of open surgery. Over time, there has been a larger uptake of MIS through the robotic platform compared to conventional laparoscopy. The main drivers for this are the shorter learning curve and probably the added improved surgeon ergonomics provided by the robotic platform. Data from the USA have shown a 43% (from 27.6% in 2008 to 70.6% in 2015) increase in MIS in the proportion of women undergoing treatment for uterine cancer. In one study, endometrial cancer treatment showed an absolute increase of 47.3% (from 9.5% in 2008 to 56.8% in 2015), with a 42.3% absolute decrease in open surgery. Similar to the situation in SA, SL surgery for endometrial cancer rates in the USA have remain static at around 17% of all procedures. 5 In one institution, after the introduction of the robotic platform, the rate of minimally invasive surgery increased from 17% performed by laparoscopy, to 98% performed on the robotic platform over a period of two years in the treatment of uterine cancer with an overall lower cost compared to open surgery. 6 2.2.ImprovedergonomicsforthesurgeonsperformingMIS The one important part of the equation that is frequently ignored in the cost related discussions around MIS, is that of ergonomics. The disadvantages to the physical well- being of surgeons performing complex MIS procedures, especially on obese women, has been well described. The available evidence suggests robotic surgery has drastically decreased the musculoskeletal fatigue over time in surgeons and perhaps improves overall productivity and longevity of practice. 7-10 2.3. Superior instrumentation tremor prevention The instruments used on the robotic platform can simulate themovements of the humanwrist (wristed instrumentation) and the system reduces surgeon’s tremor to zero. This allows for additional surgical precision and fineness. 2.4. Superior vision The three dimensional, high definition vision capabilities and image magnification through the angle of the cameras, allows the surgeon to have better vision improving the ability to identify tissue planes, blood vessels, and nerves, and these character¬istics contributes to a decrease in patient blood loss. 2.5. Additional instrument usage capability The robotic platform allows for the capacity to control three surgical instruments, which allows additional assistance to the surgeon. The camera is controlled by the surgeon and is completely static. 2.5. Cost The robotic platform is associated with higher costs when compared to the conventional laparoscopic platform, and this is in essence the major disadvantage of RAS. The issue of cost however, should be seen in perspective, and in most scenarios the cost should be compared to open surgery, as the vast majority of benign and oncological gynaecological surgical procedures are performed through open surgical access. Several studies suggest that when SASOG Position Statement: Robotic Assisted Surgery in Gynaecology in the South African setting