AFJOG

African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | 38 POSITION STATEMENT African Journal of Obstetrics and Gynaecology | Volume 2 | Issue 2 | 2024 | Robotic Assisted Surgery in Gynaecology in the South African setting blood loss and shorter hospital stay. RAS myomectomy can result in MIS for patients who would otherwise have had to undergo open surgery. 2,23 3.7. MIS sacrocolpopexy for pelvic organ prolapse MIS for pelvic organ prolapse procedures have the same outcomes compared to open surgery. Because of the complexity of a sacrocolpopexy procedure, SL MIS has not gained any momentum in this field. RAS sacrocolpopexy for organ prolapse has also resulted in an increase in the MIS for organ prolapse, with the procedure reported to be cost- effective compared to open surgery. 24 3.8. Tubal reanastomosis This is another complex procedure where the robotic platform can provide benefits. Three-dimensional view, tremor avoidance and enlargement of the operation field is the ideal platform for a microsurgical procedure such as this. 21,23 3.9. Adnexal pathology such as endometriomas Adnexal pathology is another complex procedure where the robotic platform can be beneficial to women undergoing this procedure, including surgical treatment of endometriomas. 25 3.10. Abdominal cerclage This is another complex procedure that is frequently performed in early pregnancy, and robotic surgery can prevent laparotomy in many of these cases. 26 3.11. Procedures where the robotic platform should not be used Tubal ligation; Simple ovarian cystectomy; Surgical management of tubal ectopic pregnancy; Bilateral salpingo-oophorectomy; Bilateral salpingectomy; Diagnostic laparoscopy or other surgeries when diagnosis is unknown. 4. ROBOTIC SURGERY IN THE PUBLIC SECTOR IN SOUTH AFRICA In the public sector, both Tygerberg and Groote Schuur Hospitals have introduced robotic surgery. 27 Robotic surgery provides several benefits to both surgeons and patients. The implementation of robotic surgery at Tygerberg Hospital has been successful, with three gynaecological surgeons already trained and performing cases since May 2022. 28 The areas where the hospital has found benefit so far are in advanced endometriosis (with over 40 cases, October 2023) and gynaecologic oncology, specifically endometrial cancers (with 16 cases thus far). Robotic surgery has proven especially advantageous in these complex procedures, offering improved precision and control for the surgeons. One of the main advantages of robotic surgery is the reduced mental and physical fatigue experienced by surgeons. 21 The robotic system allow for better ergonomics and provide more comfortable working positions compared to traditional laparoscopic or open surgeries. This can lead to improved mental function, reduced physical fatigue, improved surgical outcomes and decrease the risk of errors or complications. Additionally, robotic surgery has benefited patients with a high BMI (body mass index). Traditional laparoscopic surgery can be technically challenging in patients with a high BMI due to limited visualisation and manoeuvrability. The enhanced visualisation, dexterity, and control offered by robotic systems can help overcome these challenges, allowing surgeons to perform procedures more effectively and safely in patients with higher BMIs. Overall, the introduction of robotic surgery at both hospitals is a positive development that offers benefits to both surgeons and patients. 5. SUMMARY The following procedures in general gynaecology and gynaecologic oncology should be considered for MIS on the robotic platform where available: 5.1. Women treated for presumed early stage endometrial cancer as follows: hysterectomy, BSO, pelvic with or without para-aortic lymphadenectomy or sentinel lymph node biopsy algorithm. 5.2. Women diagnosed with endometrial hyperplasia with atypia or endometrial carcinoma in situ as follows: hysterectomy, with sentinel lymph node biopsy algorithm. 5.3. Women with stage one cervical cancer as follows: simple or radical hysterectomy, simple or radical trachelectomy, with or without BSO, pelvic lymphadenectomy or sentinel lymph node biopsy algorithm; 5.4. Selected women with stage one ovarian cancer requiring completion surgery consisting of: BSO with or without hysterectomy, pelvic and/or paraaortic lymphadenectomy and omentectomy. 5.5. Sacrocolpopexy with mesh. In some of these women, subtotal hysterectomy will be indicated as well. 5.6. Hysterectomy for benign conditions where complex surgery is anticipated 5.7. Women with endometriosis 5.8. Women requiring myomectomy 5.9. Women requiring surgery for adnexal pathology 5.10. Tubal reanastomosis 5.11. Insertion of abdominal cerclage in pregnant and non-pregnant patients This position statement is endorsed by the following groups South African Society of Gynaecologic Oncology (SASGO) South African Society of Gynaecological Endoscopy (SASGE) South African Urogynaecology Association (SAUGA) South African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG) This document was approved by the South African Society of Obstetrics & Gynaecology (SASOG at a council meeting on 11 November 2023. Date: 21 November 2023