AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 37 POSITION STATEMENT African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Robotic Assisted Surgery in Gynaecology in the South African setting compared to open surgery, RAS is either cost-neutral or cost-effective. The most important aspect of RAS is the platform’s ability to increase the uptake of MIS, which is a major benefit to women undergoing gynaecological surgical procedures. 5-6 3. INDICATIONS FOR USE OF THE ROBOTIC PLATFORM IN MINIMALLY INVASIVE GYNAECOLOGICAL SURGERY Gynaecologic Oncology Surgery 3.1.Endometrial cancer Althoughcervical cancer is themost commongynaecological cancer in South African women, endometrial cancer is the most common gynaecological cancer in women appropriately screened for cervical cancer, which to a large extent reflect the majority of the female population in the private health care system in South Africa. Endometrial cancer is mainly a disease of post-menopausal women, is strongly assosciated with obesity, and these women frequently have co-morbidities such as type II diabetes mellitus and hypertension with its associated risks. Endometrial cancer is surgically staged, and the primary modality of treatment is surgery. The surgical treatment of endometrial cancer consists of hysterectomy, removal of both ovaries, pelvic sentinel lymph node biopsy (SLNB) using indocyanine green (ICG), or alternatively, pelvic lymphadenectomy with or without para-aortic lymphadenectomy. The international accepted standard of care for the surgical treatment is MIS, using either robotic assisted laparoscopy (RAS) or standard laparoscopy (SL). 11 Women diagnosed with endometrial hyperplasia with atypia or endometrial carcinoma in situ, will also fall in this category, as up to 37% of these women will have invasive endometrial carcinoma diagnosed on the final histology of the uterus. 12 3.2.Cervical cancer With regards to cervical cancer, the standard of treatment at this point in time is radical hysterectomy (RH) with pelvic lymphadenectomy or SLNB using ICG. Although there is good evidence suggesting open RH has superior outcomes compared to radical hysterectomy performed though MIS, many leading centres in the world still perform MIS RH, as the low recurrence rates reported with open surgery are not being seen in these centres. 13 In addition, there is a subset of women who are candidates for MIS RH or simple hysterectomy and SNLB. These include women undergoing fertility sparing procedures and women who had pre- operative conization for small tumours. 14 Current European guidelines still suggest a place for MIS in cervical cancer. RAS is the preferred modality of surgical treatment for women with early stage cervical cancer and tumours smaller than 2 cm. 15-17 3.3. Ovarian cancer There is a subset of women with stage one ovarian cancer who will benefit from MIS for staging purposes. Surgery in these cases will consist of hysterectomy, bilateral salpingo- oophorectomy, omentectomy and pelvic with or without para-aortic lymphadenectomy. Published data in this regard is very limited. 18-19 Surgery for benign gynaecological conditions RAS in women with benign conditions should be reserved for those cases that can be regarded as complex. Although there is no uniform definition or objective metrics that define “complex” gynaecological surgery, this group would include combinations of previous pelvic surgery, previous pelvic infection, large uteri, obesity, severe endometriosis, and retroperitoneal pelvic pathology. There is limited data to suggest benefit of RAS compared to SL MIS. 20 If the objective is to reduce the negative short and long- term impact of laparotomy, then MIS in any form should be the standard of care. Adding robotic surgery as one of our armaments, will benefit patients and the health care system. Because of the cost involved in RAS, only an agreed set of conditions should be included in the robotic surgery list. 3.4. Hysterectomy The robotic platform is indicated for hysterectomy in women where cancer is not suspected, where the procedure is complex or where the use of RAS can prevent open surgery. These would include patients undergoing hysterectomy for enlarged multi-fibroid uterus (measuring more than 14 cm), women with BMI ≥ 30 kg/m 2 , women where significant anatomical distortions are expected (endometriosis, previous myomectomy, previous pelvic inflammatory disease, pelvic infections or abscesses). 21 3.5. Endometriosis Endometriosis surgery is very complex and, SL MIS has a steep learning curve, compared to RAL MIS. RAS for ASRM stage 3 and 4 endometriosis cases offers several advantages for both patients and surgeons. The superior three-dimensional vision, precision and obvious ergonomic advantages of RAS surgery make it particularly beneficial in managing severe endometriosis cases. One specific advantage is the use ICG fluorescence angiography during surgery. This helps in assessing the vascularisation of ureters and bowel anastomosis, which can contribute significantly in preventing postoperative complications such as leakage. By providing real-time imaging, this technique improves the accuracy and safety of the surgical procedure. Surgery in women with advanced endometriosis often require lengthy and complex surgeries. The use of the robotic platform with its superior ergonomics contribute to less physical demanding and more efficient surgery in these women. 2,20,22 3.6. Myomectomy Myomectomy is a complex procedure requiring enucleation of the fibroid and suturing of the myometrium. Suturing when performing CL MIS is challenging. And RAS with wristed instrumentation overcomes this challenge. Myomectomy performed using RAS is associated with less