Robotic-assisted gynaecological surgery

What is robotic-assisted gynaecological surgery?

Robotic-assisted gynaecological surgery is a minimally invasive “keyhole” surgery.

During the procedure, the surgeon does not hold the instruments directly, instead they sit at a console. The surgeon controls the robot at all times. It does not work on its own.

The robot is connected to the patient. Very small instruments are inserted through small surgical incisions (cuts) in the abdomen (tummy) wall. The surgeon sits at a separate console and carries out the operation without touching the patient. It is important to know that the robot does not perform the surgery on its own. Your surgeon has complete control at all times.

Common robotic-assisted gynaecological surgical procedures

These are two of the most common gynaecological procedures where a robot is used. However, we also use them for other operations and for benign pathologies like endometriosis and fibroids as well.

1. Total hysterectomy with bilateral salpingo-oophorectomy. This is the removal of uterus, cervix, tubes and ovaries.

2. Total hysterectomy with bilateral salpingo-oophorectomy and sentinel lymph-node biopsies. This is the removal of the uterus, cervix, tubes, ovaries and sampling of pelvic sentinel nodes. This procedure is usually carried out for endometrial cancer (cancer of the lining of the womb).

Can the robot breakdown?

This happens in less than 1 in every 200 operations. If this happens, either we reschedule your operation or it is done as a laparoscopic or open operation.

Is the surgeon able to do the same operation as an open or laparoscopic procedure with the robot?

Yes. In terms of cancer treatment, it is regarded as the same as open surgery. It does not compromise cancer control.

What are the advantages of robotic surgery?

Patient advantages

• Lower complication rates.

• Lower infection rates.

• Less pain.

• Quicker recovery.

• Shorter hospital stays.

• Less blood loss and a lower rate of needing a blood transfusion (affects 1 in every 100 patients).

• Earlier return to work and other normal daily activities.

• Improved cosmetic result.

Surgical advantages

• A highly magnified high definition view of your operation.

• A complete 3D view of your abdomen and pelvis when operating.

• Much finer, more delicate dissection.

• Far more precise surgery.

• It eliminates tremor.

Are there any alternatives to this treatment?

Yes. Depending on your age, type of disease, and other health issues there may be other options. However, this type of surgery is only chosen if we feel it is the most appropriate treatment option for you, and you are happy to proceed. Please discuss any alternatives with your surgeon or oncologist before you make any decisions. 

Are there any risks to having this surgery?

Yes. All surgery has the potential for complications. However, robotic surgery minimises these risks. Your surgeon will discuss the following risks with you, before they ask you to sign a consent form.

• Infections

  Urinary tract, chest or wound infections are the most common type of infection. We will give you antibiotics at the beginning of your operation, to try and prevent these.

  Most patients have a catheter during and after surgery to help drain urine (pee). We will remove the catheter as soon as it is safe to do so. This will reduce the chance of a urinary infection.

  After surgery, it is important to practice deep breathing exercises. These exercises will reduce the risk of a chest infection. Ask your nurse for more information about these exercises.

  The cuts made for robotic surgery are small, so the risk of wound infection is much lower than open surgery.

  It is important to eat a healthy, protein and vitamin rich diet during the recovery period. Eating a healthy diet helps the body fight infections. For more information, go to the NHS Eatwell Guide.

• Pelvic collection
  A collection of fluid may develop in the pelvis after surgery. The fluid can be from the tissue or it could be a collection of blood. Sometimes, this fluid can become infected. Please contact one of the Gynaecological Assessment Units for advice, if you experience:

  • fever

  • abdominal discomfort, or

  • you feel unwell.

  We treat most cases with a course of antibiotics. However, in some cases you may need to return to hospital. We may need to drain the collection either:

  • on the ward if it is easily accessible;

  • under ultrasound guidance; or

  • rarely under anaesthesia.

• Blood clot (deep vein thrombosis (DVT))
  DVT is the name given to a blood clot which forms inside a vein. It usually develops in the deep veins of the leg, and blocks blood flow. 

  To avoid this, you will receive a small daily injection of a blood-thinning medication. This will start on the day before surgery and continue once daily whilst in hospital. We will prescribe you with blood thinning injections or tablets (such as Apixaban) at discharge. You will need to take these for 2 to 4 weeks, depending on your risk of developing a blood clot.

  Blood-thinning tablets are the first choice. If tablets are not suitable for you, the ward staff will teach you (or a family member / carer) how to give the blood thinning injections at home. We will also give you knee-length surgical stockings to wear after surgery.

• Bleeding

  The pelvic organs have a rich blood supply. You may need a blood transfusion if a large artery is injured during surgery, and you lose a lot of blood. If you lose a lot of blood, we may prescribe iron tablets for you to take at home. You will need to take these tablets for 4 to 6 weeks.

  If you have objections to receiving a transfusion, please discuss this with your consultant before surgery.

• Injury to internal organs

  Internal organs include the bowel, bladder, ureters, nerves, or blood vessels. The ureter is the tube that drains urine (pee) from the kidney into the bladder.

  Injury to internal organs occurs in between 1 and 2 in every 100 patients.

  This risk exists with all types of abdominal / pelvic surgery, whether robotic, laparoscopic or open. Your surgeon will explain these risks in more detail before your operation.

• Admission to Intensive / High Dependency Care

  You may have existing medical conditions or complications during surgery. For example, heavy bleeding or anaesthetic difficulties. If you do, we may need to monitor you in the High Dependency Unit or Intensive Care Unit for a short time after surgery.

  Your surgeon will explain all potential risks before the operation. If you have any questions or concerns, please speak to your surgeon.

• Lymphoedema

  A lymphadenectomy involves the removal of lymph nodes. This surgery can sometimes lead to issues with the body's lymphatic system, especially lymphoedema. Lymphoedema is a condition where fluid builds up, causing swelling. This mainly happens in the legs. It usually develops around 3 months after surgery.

  This can happen to between 5 and 10 in every 100 patients having a full pelvic lymphadenectomy.

  Lymphoedema can occur after a sentinel lymph node biopsy (SLNB). However, the risk is much lower here since only one or two nodes are removed, compared to a more extensive lymphadenectomy. Often, lymphoedema is temporary and resolves within 6 months. However, it can become a long-term issue, needing ongoing management and referral to specialised services.

• Port site hernia

  A small part of the bowel can push through one of the surgical cuts (port sites) used during your operation. This is known as a hernia, which is a rare complication after robotic or laparoscopic surgery. Rare means it affects between 1 in 10,000 and 1 in 1,000 people.

  You may notice a lump or swelling at a port site, with pain, nausea, or difficulty passing gas or stools (poo). You may need to return to theatre, so the loop of bowel can be safely repositioned inside the abdomen. The port site will be repaired to prevent it happening again.

How can I prepare for my surgery?

While you wait for your surgery date, you can start preparing for your operation. Research shows that fitter patients, who are able to improve their health and activity levels before surgery, recover more quickly. Taking an active role in planning and preparing for your operation will help you:

• feel in control

• leave hospital sooner, and

• get back to normal more quickly.

To help with this, a member of the One You Kent (OYK) team may contact you. OYK work in the community, and help patients improve their general health. This includes help and advice on:

• Stopping smoking

• Losing weight

• Getting more exercise

More information can be found on the following web sites.

• One You Kent (ABL Health)

• Fitter Better Sooner Toolkit (Royal College of Anaesthetists)

What will happen before the day of my operation?

It is important that all existing medical conditions are well controlled before your operation.

Before your surgery, you will have a pre-assessment appointment. At this appointment a nurse will plan your care for your stay and will discuss your discharge home.  

Please ask any questions about your surgery and hospital stay at this appointment. The aim is to make your stay in hospital short and allow you to recover better at home. Patients that follow the plan are less likely to have complications after surgery and be readmitted to hospital.

You may need to have your bowels completely emptied before surgery. If this applies to you, we will give you bowel preparation to take at home. For more information, please read the Instructions for MOVIPREP and PLENVU bowel preparation leaflet.

Stopping smoking will have a big positive impact on your health and wellbeing in general. It will also reduce your risk of developing a wound infection and chest related issues after a general anaesthetic.

If you need support to stop smoking please contact One You Kent on 03001 231 220, or email.

What happens on the day of my surgery?

• This surgery is performed at the Queen Elizabeth the Queen Mother (QEQM) Hospital Margate.

• The team will have told you at your pre-assessment appointment, whether you can take your usual medication on the day of surgery.

• Please bring something to occupy yourself whilst in hospital. For example, a book or magazine. If you wish to listen to music, please make sure you also bring headphones.

• Do not bring anything valuable to hospital.

If you have any concerns or questions, please ask.

What happens before my surgery?

• We will ask you to change into a surgical gown. Please bring a dressing gown and slippers, to wear whilst you wait.

• If we have not done so already, we will ask you to sign a consent form. If you have any questions, please ask. Remember, you can withdraw your consent for treatment at any time.

• The anaesthetist will discuss what anaesthesia you will have during your surgery. If you have any questions, please ask.

What happens during my surgery?

• Guided by your surgeon, the robot will make 5 incisions (cuts) in your abdomen (tummy). This is similar to laparoscopic or key hole surgery.

• Once your surgeon makes the incisions, they will guide a small camera into the port. This allows them to clearly see the area they are operating on.

• Instruments are also inserted through the incision sites.

• Once the surgery is complete, the instruments and cameras are removed. Your surgeon will close the incision sites with stitches.

What happens after my surgery?

• Recovery time
  After your operation, you will spend approximately 1 hour in the theatre recovery area. Once you are recovered, we will take you back to the ward.

• Tubes and monitoring equipment
  When you wake up, you may have some tubes attached to your body. These are temporary and will help with your recovery. The oxygen mask is usually removed in recovery. We will remove the IV drip either on the same day, or the day after your surgery.

• Intravenous (IV) drip
  A drip will be inserted into your arm through the cannula. The drip will give you fluids and medications, as needed.

• Pain relief
  Depending on what is appropriate for your procedure, we will give you pain relief either:

  • orally;

  • through the IV drip in your arm; or

  • via spinal anaesthesia.

• Urinary catheter
  A catheter will be temporarily in place to drain urine from your bladder into a bag. We will remove this once it is no longer needed (usually the following morning).

How will I feel after my surgery?

• You may feel the effects of the general anaesthetic for up to 24 hours after your operation. You may feel drowsy (sleepy), sick, or unable to make decisions during this time.

• We will offer you food and drink as soon as you return to the ward. You may not want to eat much, which is normal.

• You may have an intravenous (IV) drip in your arm. We will remove this once you are able to eat and drink again on your own.

• After we remove the catheter, you may have difficulty passing urine (pee). If this happens, you may go home with the catheter still in place. The catheter will remain in place for 1 week, to rest your bladder.

  If you go home with a catheter, a nurse will teach you how to care for it before you leave hospital. We will make arrangements to remove the catheter in one of our Gynaecological Assessment Units.

• You will have four or five small incisions (cuts) on parts of your abdomen (tummy) after surgery. Each will be up to 1cm long. Most patients have dissolvable stitches in place, which dissolve on their own.

  If you have non-dissolvable stitches we will need to remove these 7 to 10 days after surgery. We will make an appointment to do this before you leave hospital.

• We will cover the incision sites with dressings. You can remove these 24 hours after your operation. Your wounds should heal well, with a small amount of scarring. Please keep the dressing dry until it is removed.

• Once the dressing is removed you will be able to shower. Please avoid baths until your wounds have healed. It is safe for the wounds to get wet, but avoid getting soap directly on your wounds until they have healed.

  Following your shower, pat your wound areas dry. Use a clean towel to prevent infection. Do not reapply the dressing, leave the wounds open to the air.

• Most patients will have some vaginal bleeding for up to 2 weeks after surgery. It is usually light bleeding similar to a period, and is red or brown in colour. Do not be alarmed if you do not lose blood in the first few days and then have sudden loss days later, this is normal.

  Use sanitary pads not tampons. Tampons increase the risk of developing an infection.

• It is normal to feel pain and discomfort in your abdomen for a few days after your surgery. While in hospital ask your nurse for pain relief, as this will help you to get out of bed and move around. Moving around will help speed up your recovery and help prevent blood clots forming in your legs and lungs.

  At home, take simple painkillers such as paracetamol and ibuprofen for any pain. Please make sure that you have a supply of these at home before you come into hospital.

  If you need them, we will give you stronger painkillers. Stronger painkillers can cause constipation, so make sure you:

  • eat a high fibre diet;

  • take laxatives, if needed; and

  • ask for advice from your GP or ward staff if you become constipated.

  For more information, please go to the NHS Eating a balanced diet web site.

• A common side effect after surgery is pain in your shoulder, caused by trapped air. Walking around and drinking peppermint water can help your discomfort. Tell your nurse if you have trapped wind.

• The first few days after your surgery, you may feel more tired than usual, as your body uses a lot of energy to heal itself. Taking a nap during the day can help with this.

  You may also notice that you feel more emotional. This can be a side effect of what has been a stressful unsettling time and is completely normal.

What can I do to help myself recover after surgery?

It will take time for your body to recover following surgery. Every body heals and recovers differently. Having a positive attitude towards your recovery will help your body heal and feel better. Making a change to your exercise and eating a healthy diet could become a positive long-term change to improve your general health.

It is important that you rest for the first few days once you are home. The term ‘rest’ does not mean do nothing at all. Try to keep to your usual daily routine, get up, have breakfast, shower and get dressed. Avoid lying in bed as this can cause complications, such as blood clots. It may also make you feel depressed. Where possible, go out for short walks and move around the house. Do gentle leg and ankle exercises whilst sitting. Do not cross your legs for long periods of time. Following the advice above will help with your recovery.  

As the days and weeks pass you will be able to increase the amount you do. However, if you feel pain during an activity stop for a few days and then try again. In the first few weeks you could sit when ironing or preparing dinner. Lift nothing heavier than 1 litre of water.

For the first 4 weeks avoid lifting anything heavy, including children, and jobs such as hoovering. These can affect how your wound heals. When you do begin lifting things again, remember to do so correctly.

• Keep your feet apart.

• Bend your knees and keep your back straight.

• Tighten your stomach muscles as you lift.

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Make sure your body has all the nutrients it needs for a speedy recovery by eating a healthy balanced diet. Eat a high fibre diet with at least 5 portions of fruit and vegetables a day. Also include 2 litres of fluid, such as water or squash.

• Exercise

  We recommend gentle walking during your recovery. As soon as you get home begin taking slow walks. Gradually build up the pace and length of your walk. Most patients will be able to complete a 30 to 60 minute walk after the first 3 weeks following surgery.

  You can return to exercise (such as swimming) after 2 to 3 weeks. If you build-up gradually, you should be able to return to your usual activity level within 6 weeks.

  Avoid contact sports for the first 6 weeks following surgery.

  Pelvic floor muscles keep your pelvic organs in their correct position, to stop incontinence. Pelvic floor muscles include the bladder, small bowel, uterus, vagina and rectum. You must exercise your pelvic floor muscles once you have had surgery, even if you have had stitches.

  For more information, please read the Pelvic floor muscle exercises (for women) leaflet.

• Keep your bowels moving

  It may take some time for your bowel habits to return to normal following your surgery. To begin with you will be given a stool (poo) softener or laxative to help you go to the toilet without straining. If passing stools becomes a problem, contact your GP for advice.

  Eating a high fibre diet, drinking well, and moving around can also help.

• Support

  You may need support from your family and friends whilst you are recovering. This could be support with housework or shopping. It could also be emotional support, where you can talk to them about how you are feeling.

  If you live alone, try and plan ahead. Ask a relative or friend if they could stay with you for the first few days. If you have no network of support, please speak to your nurse before you leave hospital.

  If you are feeling low in mood, try and talk things through with someone. This can help you feel more positive. If you would like to speak to someone, you can contact the Women's Health Counselling Service. For more information, please read our leaflet or email us.

• Having sex

  Do not have sex until 4 to 6 weeks after your surgery. After this time, you should have healed enough. If you feel any discomfort, wait until it is more comfortable for you.

  If you had your ovaries removed during surgery you could have vaginal dryness. Using a lubricant can help with this. You can buy lubricants over-the-counter at your local chemist.

• Driving

  You must not drive again until you:

  • have stopped taking any medication which makes you feel sleepy;

  • can sit comfortably in a car and are able to use all the controls correctly (including doing an emergency stop);

  • can wear a seat belt without it hurting or feeling uncomfortable; and

  • you are able to look around to manoeuvre the car safely.

  It is important that you check with your insurance company that you are covered to drive after your surgery.

  It will take approximately 2 to 4 weeks following your surgery for you to be able to drive again.

• Returning to work

  Returning to work can help your recovery. It helps you get back to your usual routine and spend time with others. Your return to work will depend on how you feel and what you do for a job. Some patients will feel fine to return after 3 weeks but most return within 4 to 6 weeks.

  It may be possible to return to work and do shorter days or light duties. Gradually returning to your usual working hours. Please discuss this with your employer.

  We will give you a sick note when we discharge you from hospital. If you feel you need longer off work, please discuss this with your GP.

When should I ask for medical advice?

• If you have any questions or concerns, please contact one of our Gynaecological Assessment Units (GAUs). Their contact details are at the bottom of this leaflet.

• You can also speak with your GP or call 111 out-of-hours.

• If you have any of the following symptoms go to your nearest Emergency Department immediately.

  • Any signs of a urine infection. Symptoms of an infection include:  

    • An increase in how often you need to urinate (pee).

    • A burning or stinging sensation when you urinate.

    • Your urine smells bad.

  • Vaginal bleeding that is very heavy or smells bad. Plus having a fever or generally feeling unwell.

  • Redness or pain around the incision sites in your abdomen. You may have a wound infection, if:

    • any of your incision sites are hot to the touch; or

    • have redness or hardness surrounding them.

  • Increased abdominal pain, Including not wanting to eat, vomiting, or a fever.

  • Pain, swelling, or hot calf area could be a sign of DVT (a blood clot in the leg). Shortness of breath or chest pain could be a sign of a PE (a blood clot in the lungs).

Contact details

If you have any questions or concerns about your surgery or recovery, please contact one of the following.

• Birchington Ward, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 234201

• Gynaecological Assessment Unit, Queen Elizabeth the Queen Mother (QEQM) Hospital, Margate
  Telephone: 01843 235009

• Women’s Health Suite, William Harvey Hospital, Ashford
  Telephone: 01233 616107

• Gynaecological Assessment Unit, William Harvey Hospital, Ashford
  Telephone: 01233 651987

Ask 3 Questions

There may be choices to make about your healthcare. Before making any decisions, make sure you get the answers to these three questions:

• What are my choices?

• What is good and bad about each choice?

• How do I get support to help me make a decision that is right for me?

Your healthcare team needs you to tell them what is important to you. It’s all about shared decision making.

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