Robotic and keyhole surgery

Keyhole surgery in plain language

Keyhole surgery is surgery carried out through several small incisions rather than one large one. A slim camera, passed through an incision in or near the navel, shows the inside of the abdomen on a screen, and fine instruments are passed through the other incisions. The abdomen is gently inflated with carbon dioxide gas to create space to work safely.

There are two forms of keyhole surgery, and I use both:

• Laparoscopic surgery, in which I hold and move the camera and instruments directly.
• Robotic surgery, using the da Vinci system, in which I control the camera and instruments from a console beside you in the operating theatre.

For most women, keyhole surgery means smaller scars, less pain, a shorter stay in hospital and a quicker return to normal life than open surgery. It is not right for every operation or every patient, and I will tell you honestly whether it is right for you. In my own practice since 2013, more than 99% of my abdominal operations (not counting hysteroscopies) have been keyhole rather than open, and my conversion rate from keyhole to open surgery has been around 0.1% (about these figures).

What da Vinci surgery means for you

In robotic surgery I sit at a console in the operating theatre, a few metres from you, viewing a magnified, high-definition three-dimensional image of the inside of the pelvis. The instruments are mounted on robotic arms and follow the movements of my hands precisely, with wrist-like joints that can turn in ways a straight laparoscopic instrument cannot. The system filters out the small natural tremor of the hand. It has no independent movement of its own, and a full surgical team is beside you throughout.

These features are most useful in complex operations deep in the pelvis, which is why robotic surgery is my preferred approach for them: removing large or awkwardly placed fibroids and repairing the womb afterwards, freeing organs that are stuck together, and removing deep endometriosis close to the bowel, bladder and ureters. I will recommend the approach that suits your operation and explain my reasons.

This is in line with the Royal College of Obstetricians and Gynaecologists’ review of robotic surgery in gynaecology (Scientific Impact Paper No. 71, 2022). It concluded that, compared with conventional keyhole surgery, robotic surgery improves surgical performance without lengthening operations, reduces blood loss and complications during and after surgery, and lowers the chance of having to switch to open surgery. It also concluded that robotic surgery can be considered safe and a more effective tool for women having complex surgery, or with medical issues such as a BMI of 30 or more or lung problems. Much of this evidence comes from studies other than randomised trials.

My robotic operating lists run at Spire St Anthony's Hospital in Sutton and Nuffield Health Parkside Hospital in Wimbledon. On average I carry out more than 120 robotic operations a year, and I have carried out more than 2,000 keyhole operations in total.

Operations I carry out by keyhole surgery

Hysterectomy

A keyhole hysterectomy removes the womb, and usually the cervix, through small incisions, with the womb removed through the vagina. It may be recommended for heavy bleeding, fibroids, adenomyosis or endometriosis when other treatments have not helped, and it is a decision I never rush. Whether to remove the ovaries is a separate decision that depends on your age and circumstances, and we will make it together. You can read more about the alternatives on the pelvic pain, periods and general gynaecology page.

Myomectomy

A myomectomy removes fibroids while keeping the womb, for women who wish to preserve their fertility or their womb. Robotic myomectomy allows me to remove large fibroids and to stitch the muscle of the womb in layers. You can read more on the fibroids page.

Excision of endometriosis

I remove endometriosis by excision, cutting it out, wherever it is safe to do so, including deep endometriosis affecting the bowel, bladder and ureters. You can read more on the endometriosis page.

Other operations

I also carry out keyhole surgery for ovarian cysts, adhesions, hydrosalpinx (a blocked, fluid-filled fallopian tube), caesarean scar niche repair and some operations for prolapse.

Recovery after keyhole surgery

Recovery depends on the operation and on you, and I will give you a personal estimate before you decide. As a guide:

• Diagnostic laparoscopy or a short procedure: usually home the same day, with a week or so before you feel yourself again.
• Keyhole hysterectomy or myomectomy: usually one night in hospital. Most women are walking comfortably within a few days and return to desk-based work after two to four weeks, avoiding heavy lifting for around six weeks.
• Surgery for deep endometriosis: usually a few nights in hospital and around four to six weeks or more before you feel back to normal.

Shoulder-tip pain from the gas used during surgery is common for a day or two and settles on its own. All surgery carries risks, including bleeding, infection, injury to nearby organs and blood clots. Occasionally it is safer to convert a keyhole operation to an open one. I will explain how these apply to you, and you will have full written information well before your operation.

Training other surgeons

I have been on the faculty of the Royal College of Surgeons, the Royal College of Obstetricians and Gynaecologists and the Minimal Access Therapy Training Unit (MATTU). I am currently a da Vinci proctor, supervising other surgeons as they begin to operate with the robotic system, and I train surgeons in both robotic and laparoscopic surgery. Intuitive Surgical, which makes the da Vinci system, pays me for my work as a proctor.