Robot to the rescue MYB

3 Oct 2013

Robot to the rescue MYB

More patients suffering from endometriosis are finding relief through robot-assisted surgery, which results in less trauma and shortens down-time


For years, Mrs Serene Chiang, 44, put up with what she thought were menstrual cramps every month.4In January, the pain become so bad that she could not get out of bed. When she finally did, she could not stand up straight.

Painkillers did not work.
“It was so bad, I cried,” she said.

An x-ray at the emergency department found nothing wrong.

A month later, the pain returned. This time, she took the advice of her general practitioner to see a specialist, who ordered computed tomography and magnetic resonance imaging scans, and a colonoscopy.

Doctors found a 4cm fibroid, which is an abnormal growth, in her womb ad said she also had endometriosis, a condition in which the cells of the lining of the womb cavity are deposited outside the womb, often on the pelvic organs. These abnormally sited cells are still shed by the body during menstruation and can cause severe menstrual cramps.

If the cells are deposited on the bowel, they may irritate it and cause diarrhoea during menstruation.

Mrs Chiang was referred to the department of obstetrics and gynaecology at Singapore General Hospital (SGH), to its new severe endometriosis robotic surgery service, which was set up in January.

Since 2009, the hospital has performed robotic surgery on more than 28 cases of benign gynaecological conditions, but this figure does not include endometriosis.
It has now one robot-assisted surgery on several patients with severe endometriosis, including Mrs Chiang, who was the first one. She had her operation in April.

Dr Peter Barton-Smith, a senior consultant who recently joined SGH from Britain to head the new service, removed Mrs Chiang’s womb and endometrial tissue outside it, including a mass that has glued her womb to her bowel.

She lost just 100m of blood – in comparison, during a blood donation, the amount collected from each donor is about 450ml – and stayed in the hospital for one night. She was back at work in her family’s business in less than a month.

Most patients who have open surgery for endometriosis would lose two to three times more blood, be hospitalised for a few days and take about six weeks to return to work.

SGH is the latest mong four hospitals here to offer robot-assisted surgery for severe endometriosis.

The first was Mount Elizabeth Hospital, run by private health-care group Parkway Pantai, where Dr Suresh Nair, a senior consultant obstetrician and gynaecologist, started offering the service in 2005.

It was followed by National University Hospital (NUH) in 2008m and KK Women’s and Children’s Hospital (KKH) in 2011.

Gynaecological surgery is fast coming around now to robotic surgery, which has already made inroads in other areas such as prostate and cardiac surgery.

In fact, ore types of surgery are now being done with the help of a robot. In August, a surgeon at Mouth Elizabeth Novena Hospital used a robot to help remove a large adrenal tumour from a patient.

It is the first robotic adrenalectomy done in Singapore.

Gynaecology is now the fastest growing market in the United States for robotic surgery as many robot-assisted procedures can be done for women with endometriosis, of whom half had the severe form.

More than 80 women with benign gynaecological conditions have had robotic surgery at NUH Women’s Centre. Close to 40% per cent of them had their wombs removed because of moderate to severe endometriosis.

More cases, including difficult ones, at NUH are being done using robots, says Dr Fong Yoke Fai, head and senior consultant at the division of benign gynaecology at NUH.

This is what happened in the IS, where more than 360,000 operations were carried out last year using the Da Vinci Robotic system, compared with 114,000 in 2008, said Dr Cynthia Kew, consultant at the minimally invasive surgery unit at the department of obstetrics and gynaecology at KKH.
In the last two years, KKH has done nearly 20 operations using the robot on patients’ benign gynaecological conditions of which 25 per cent were for endometriosis.


Though there are no local figures, the World Endometriosis Research Foundation estimates that 170 million women suffer from the condition globally.

Dr Barton-Smith said: “In Britain, about 8 per cent to 10 per cent of the female population have endometriosis. Of these, 10 per cent to 15 per cent have severe endometriosis.”

Since joining SGH in January, he has seen 30 to 40 women with the condition. He thinks the incidence here would be similar to or even higher than in Britain as Asian women’s menstrual flow tends to be 20 per cent heavier than that of Caucasian women.

Associate Professor Tan Hak Koon, head of obstetrics and gynaecology at SGH, said that in the last 10 years, the hospital has been seeing more women, especially younger ones, seeking help for the condition and more are undergoing surgery.

Whether a patient will be offered surgery depends on many factors, including how badly the condition has affected her and if surgery would help, making it worth the risk.

Because of the complexity of the conventional laparoscopic surgery, about 75 per cent of endometriosis operations at SGH are still done through a large abdominal incision. This gives surgeons a better view of all the organs in that area, but it means patients have a bigger scar and require a longer recovery period.

A woman whose uterus is very big or who has had repeated open surgery before, would also probably not be offered laparoscopic surgery, because there would be adhesions (sticky scar tissue) from previous surgery, making laparoscopic surgery more challenging, said Dr Fong.

Most of the remaining operations at SGH are done through conventional laparoscopic surgery, which involves the surgeon making three to four small cuts on the abdomen to allow medical instruments to be inserted.

In robot-assisted surgery, the surgeon sits at a console where he has a magnified 3-D view and controls the robotic arms to perform laparoscopic surgery.

With more surgeons mastering robot-assisted laparoscopic techniques, which Dr Barton-Smith said are easier to learn than traditional laparoscopic techniques, he foresees that more women will be offered robotic surgery.

For 5 per cent to 10 per cent of patients, laparoscopic surgery holds the risk of having major complications, including bleeding, infection and having to be converted to open surgery midway.
While doctors say that complication rates of robot-assisted surgery are comparable with laparoscopic surgery, none of the robotic operations for severe endometriosis at Mt Elizabeth Hospital, NUH, KKH and SGH has had any complications so far.

Some studies suggest that patients appear to be able to go home from hospital earlier if they had robotic surgery, Dr Kew said.


This may be because robotic surgery is more precise and results in less trauma to patients, doctors said. The instruments are designed for better ergonomics and allow greater manoeuvrability than conventional laparoscopic instruments, which were straight like chopsticks, said Dr Kew.

Fine tremors on the surgeon’s hands are also eliminated when translated to the movements of the robotic arms, she said.

As the surgeon can sit comfortably while operating from a console, fatigue is reduced especially in long operations, she added.

The high-definition camera system gives three-dimensional vision, allowing surgeons to better see the internal organs and perceptive depth, said Dr Kew.

Another benefit of using the robot is that the platform allows a multidisciplinary approach for difficult cases, said Dr Fong.

In two cases of bladder endometriosis at NUH, the advanced surgery was performed by both the gynaecologist and urologist using the robot at the same sitting.

But when a surgeon operates using the robot, he lacks tactile sensation, meaning he is unable to “feel” the tissue he is operating on, unlike in conventional laparoscopy, said Dr Kew. This limitation can be overcome by visual feedback monitoring, it does not necessarily mean it has a higher risk of mistakes.

But the higher cost of using the robot is a deterring factor, she added.

Traditional keyhole surgery costs about $6,000 to $7,000 less than robotic surgery.

For example, a robot-assisted hysterectomy costs up to $19,000 for unsubsidised patients at NUH, which conventional laparoscopy costs up to $12,000 and open surgery, up to $10,000.

The extra cost did not bother Mrs Chiang, who has been pain-free since her surgery,
She said: “I’m glad I chose robotic surgery. My recovery was quick and my pain relief almost immediate after the surgery. I hope my endometriosis does not come back.”

A decision to tackle fertility issues

For some women suffering from endometriosis, pain is not the only thing they are concerned about.
The condition – in which the cells of the lining of the womb cavity are deposited outside the womb – may also lead to the development of ovarian cysts.

These abnormal fluid-filled growths in the ovaries can make conceiving difficult.

Even if a patient becomes pregnant, endometriosis can lead to a miscarriage.

At National University Hospital (NUH), about 25 per cent to 30 per cent of robotic surgery for endometriosis is done to address the women’s fertility issues.

Removing abnormally located endometrial tissue can help to restore a woman’s pelvic anatomy back to normal to allow the ovaries and fallopian tubes to work better, thus increasing the chances of becoming pregnant naturally.

“Two of our patients with fibroids and endometriosis conceived soon after surgery delivered babies,” said Dr Fong Yoke Fai, head and senior consultant at NUH’s division of benign gynaecology.

It was partly for this reason that Ms Xu Lin Pu, 30, an assistant manager at a food and beverage business, decided to go for surgery.

Although she is not married, she would like to have children one day.

“When I was 206 and 27 years old, I used to dismiss my menstrual cramps. I put up with the pain, which was very bad for about three days each time. I would take painkillers and hope it would get better,” she said.

But her friends advised her to get it checked.

She had cysts ad severe endometriosis ad was referred to Singapore General Hospital. There, a senior consultant who heads the hospital’s robotic surgery service for benign gynaecological conditions. Dr Peter Barton-Smith, operated on her in August using robotic surgery,
She said: “I had my period last month and there was no pain. More importantly, I hope that when it is time to have children I won’t have any issues.”