The da Vinci Xi - Robot-assisted system for minimally invasive gynecologic surgery

Gynecologic diseases are the conditions that affect the female reproductive system, such as the uterus, cervix, ovary, fallopian tube and vagina. Symptoms of gynecologic diseases might widely vary among individuals, depending on disease severity. Alarming signs that medical assistance must be sought often involve heavy menstrual bleeding, severe pelvic pain, vaginal bleeding and palpable mass in the lower abdomen. If these symptoms largely disrupt patient’s quality of life and non-invasive procedures are unable to relieve symptoms, surgery might be a recommended treatment option. Medical advancements in surgery have continued to expedite the pace of changes, allowing better treatment outcomes for patients who require gynecological surgery. Besides laparoscopic surgery, the da Vinci Xi robotic system is designed to accommodate and seamlessly integrate a range of current technologies in surgical areas, including intraoperative imaging, advanced instruments and anatomical access, enabling the surgeons to perform minimally invasive procedures in hard-to-reach surgical sites through small incisions. Indeed, the use of the da Vinci Xi in gynecological conditions, particularly uterine fibroid, uterine cancer, benign ovarian tumor or ovarian cancer, and pelvic organ prolapse as well as severe or complex endometriosis is associated with less pain and a shorter operative time. Moreover, due to the small incisions, it greatly yields cosmetic superiority over the conventional approach. 

Advances in gynecological surgery

Surgery remains a treatment of choice for a wide variety of abdominal diseases, particularly those that can potentially progress to severe and life-threatening conditions. Abdominal surgery covers a broad range of procedures. Certain abdominal issues can be successfully treated with minimally invasive techniques whereas open or conventional approach is a preferred option in some abdominal conditions. Minimally invasive surgery using laparoscope only requires small incisions with superior advantages of less pain, reduced postoperative complications and faster recovery, compared to one large incision with more pain and typically delayed recovery. Laparoscopic surgery uses the aid of a laparoscope — a thin rod attached with a camera at the end to visualize the inside of abdominal cavity on the monitor. Laparoscopic surgery requires small incisions, one is for the camera and the others are for the surgical instruments, enabling the surgeon to manipulate the surgical area without opening it all the way up. The da Vinci system is an advanced technology designed to enable surgeons to perform robotic-assisted, minimally invasive surgery, particularly in anatomically challenging areas. It is considered an effective treatment alternative for treating a range of gynecologic conditions, e.g. uterine fibroids, uterine cancer, benign ovarian tumor, ovarian cancer and pelvic organ prolapse.

When non-invasive approaches, e.g. medications are unable to relieve symptoms, surgery remains the most effective treatment option for treating gynecological conditions, particularly tumors and cancers. There are two main surgical techniques: open surgery and minimally invasive surgery. As a conventional approach, open gynecologic surgery involves a large incision made to access the reproductive system and surrounding anatomy. Yet with open surgery can come significant pain, damages to adjacent organs and nerves, leading to a long recovery process. Thanks to a breakthrough surgical technology, laparoscopic gynecological surgery has been widely used as minimally invasive approach. Superior advantages over traditional technique are smaller incisions, less pain, fewer postoperative complications and shorter recovery time. Due to medical advancements, the da Vinci system is a cutting-edge technology designed to enable surgeons to perform robotic-assisted, minimally invasive surgery, particularly in anatomically challenging areas. With the better dexterity, surgeons are able to efficiently perform complex surgery alongside high degree of safety while minimizing operative complications and promoting a fast recovery.     

What is the da Vinci Xi?   

The da Vinci Xi is an advanced robotic surgical system using specialized technology that enhances the capabilities of surgeon’s hands. Controlled by the computer system, four surgical arms consisting of tiny of instruments with wrists at the tip allow surgeons to perform procedures in difficult-to-reach or complex areas with precise movements, better dexterity and enhanced magnification. Special high-definition camera attached provides magnified 3D views of the operating area, leading to high degree of surgical accuracy and patient’s safety. For every movement, the surgeon makes at the console standing next to the surgical arms. The da Vinci robot replicates every move inside patient’s body on a smaller scale. The surgeon has complete control during the entire procedure. Robot-assisted surgery is considered an alternative surgical tool for minimally invasive gynecologic surgery as it results in an improved surgical precision with highly satisfactory outcomes. 

What are gynecological conditions that can be treated with the da Vinci Xi? 

The da Vinci Xi has been widely applied to the surgical treatment of gynecological diseases, such as: 

• Uterine fibroid: Uterine fibroid is a non-cancerous tumor that grows in and around the uterus. The growths are made up of muscle and fibrous tissue. The size of fibroid might vary among women. There are three major types of uterine fibroids, classified by their locations. Intramural fibroids grow within the muscular uterine wall whereas submucosal fibroids bulge into the uterine cavity and subserosal fibroids project to the outside of the uterus. Alarming signs potentially indicating uterine fibroid are heavy menstrual bleeding, periods that may last longer than normal, pelvic cramping and pain during intercourse. If the fibroid gets larger, it might be palpable in the pelvic or lower abdominal area. Treatment of choice to remove uterine fibroid is surgery. Besides laparoscopic surgery, the robotic-assisted surgery to remove fibroids using the da Vinci Xi system allows the surgeon to access difficult-to-reach areas, particularly when fibroids compress the adjacent organs.  However, selected surgical approach depends on how many fibroids the patients have, how big the fibroids are and where they are located as well as whether or not the patients want to have children in the future. 
• Endometriosis: Endometriosis is a common condition when endometrial-like tissue grows outside the uterus, e.g. on peritoneal membrane lining the abdominal cavity and on or through the walls of the bladder. Most often, endometriosis is found on the ovaries, the muscular wall of the uterus, fallopian tube and tissues that hold the uterus in place. Warning symptoms are pelvic pain often associated with menstrual periods, abnormal menstruation and pain during or after sex. Treatment depends on symptoms and disease severity. In complex or severe endometriosis, laparoscopic surgery is considered an effective treatment approach since it only requires small incisions that lead to less pain with minimized chance of adhesion formation after surgery. The use of the da Vinci Xi enables the surgeon to reach areas with complex structure while preserving surrounding tissues and organs, resulting in less damages and a quick recovery to daily life and activity. Moreover, surgery in women who have undergone previous abdominal or gynecological surgeries, e.g. peritonisis and pelvic adhesion becomes more challenging and complicated since previous surgery can induce abdominal adhesions as a likely postoperative complication. Besides a laparoscopic surgery conducted by well-trained surgeons, robotic-assisted surgery using the da Vinci Xi also helps the surgeon to visualize the surgical site, enabling the operation to be more precise and cause less damages to the adjacent areas.
• Uterine cancer: Cancer of the uterus develops when abnormal cells form in the uterus and begin growing out of control. The exact causes remain unknown, but the condition most often occurs after age 40. Warning signs that need medical attention are vaginal bleeding, irregular menstruation, palpable lump in the pelvic and pelvic pain. Back pain might also exhibit if the mass compresses nearby structures and nerves. If detected at an early stage, surgery to remove the whole uterus and cervix, known as hysterectomy, is the main treatment option with greater chance of cure. However, if the condition progresses to stage 2 or 3 where the cancerous cells spread to cervix or lymph nodes in the pelvis, surgery becomes more challenging and radiation or chemotherapy might be concurrently required. In metastatic stage or stage 4 when cancer further spreads to other organs, surgery might serve as an option to only alleviate relevant symptoms. During laparoscopic hysterectomy, the surgeon inserts a laparoscope, a thin, flexible tube containing a video camera and other surgical instruments through small incisions. With advantages of the da Vinci Xi system, robotic-assisted hysterectomy offers a better access to hard-to-reach or complex areas with an enhanced magnification and improved dexterity within the deep and narrow confines of the female reproductive system and surrounding structures. Moreover, it helps shorten operating time while minimizing postoperative complications and speeding up recovery process. 
• Benign ovarian tumor / ovarian cancer: Ovarian tumors can be noncancerous (benign) or cancerous (malignant). Warning signs usually include irregular menstruation, frequent urination, constipation, sudden abdominal pain and bloating. Nevertheless, patients are often asymptomatic until their conditions advance. Treatment varies depending on the type of ovarian tumors. Management of benign ovarian tumors is generally done through observation and follow-ups. If the tumor becomes bigger present with bleeding or cancer is suspected, surgery conducted in a timely manner is needed. Apart from laparoscopic surgery, robotic-assisted surgery using the da Vinci Xi is an alternative option offering a promising outcome due to less injury to the surrounding nerves and less operative time.  
• Pelvic organ prolapse: Pelvic organ prolapse develops when pelvic organs, e.g. uterus, bladder or bowel slip down from their normal positions and bulge into the vagina. When the muscles and ligaments supporting a woman’s pelvic organs weaken, the pelvic organs can drop lower in the pelvis. The most common causes are advancing age and childbirth. Manifestation involves a feeling of pressure, discomfort, aching, or fullness in the pelvis, especially when sneezing or coughing, urinary retention and abnormal vaginal discharge. In severe cases, the patients might see or feel a bulge coming out of the vagina. Non-surgical approaches are, for example, lifestyle and behavioral changes pelvic floor exercises and using a vaginal pessary – a removable device made of rubber or silicone to hold prolapsed organs in place. In patients with severe prolapse, surgery is often recommended to pull up the tissues and move the organs back into place. With the aid of the da Vinci Xi system, robotic-assisted repair of pelvic organ prolapse (robotic-assisted sacrocolpopexy) enables the surgery to be carried out through small incisions with a greater surgical precision, less complications and quick recovery. Nonetheless, surgical procedure best suited for each patient will be recommended by the expert surgeon, based on disease severity and individual’s condition. 

What are advantages of the da Vinci Xi for minimally invasive gynecological surgery? 

The fourth generation of the da Vinci system yields benefits, including: 

• Better access: Robotic arms are capable of free movements of nearly 360° on seven axes, thereby improving access to anatomically challenging or hard-to-reach areas  
• Improved visualization: A sophisticated camera provides magnified, high-definition views of the surgical area with a better visualization of vessels, nerves and muscles nearby, resulting in less complications caused by damages to the surrounding areas. 
• More precise surgery: Surgery can be carried out efficiently since the robotic arm’s movements are highly precise with greater range of motion. The arms rotate instruments interchangeably in tight spaces in ways that are not otherwise possible.
• Enhanced safety: Improved surgical precision results in minimized postoperative complications while operative time can be reduced.
• Faster recovery: Due to small incisions, patients often experience less pain, shorter hospital stay with a quick return to daily life.