Safety and Efficacy of Robotic Hysterectomy Using an Indigenous Robotic System: A Retrospective Study

Abstract

Background Minimally invasive hysterectomy approaches, including vaginal, laparoscopic, and robotic hysterectomy, offer advantages over laparotomic hysterectomy. However, vaginal hysterectomy is less feasible for patients with a large uterus, prior pelvic surgery, adnexal surgery requirements, or malignancy, making laparoscopy or robotic surgery preferable. The SSI Mantra robotic system (Sudhir Srivastava Innovations Pvt. Ltd., India) features an ergonomic open-faced console with a 32-inch 3D 4K monitor, a 23-inch 2D touch monitor for system control and DICOM applications, a head-tracking safety feature, and advanced ergonomic controls. This study evaluates the safety and efficacy of robotic hysterectomy using this indigenous system. Materials and methods From February to September 2024, 15 patients underwent robotic hysterectomy at Government Medical College, Nagpur. Patients were counseled about using the SSI Mantra robotic system and surgical risks, including possible conversion to laparotomy or robotic arm injury. The procedure followed a standard robotic port approach with accessory laparoscopic ports. Multiple surgeons performed the surgeries. The primary outcome was operative time, defined from incision start to closure. Additional data collected included patient intubation time, draping time, port placement, docking time, console time, surgical end time, patient out time, and estimated blood loss (fluid volume difference between irrigation and suction). Perioperative complications, readmissions, surgeon experience impact on operative time, conversion to laparotomy, hospital stay duration, hemoglobin drop, Visual Analogue Scale (VAS) pain scores, and intraoperative strategies (e.g., adhesiolysis, myomectomy) were analyzed. The weight of the excised uterus was also recorded. Results All 15 cases were successfully completed. The mean body mass index was 22.36 kg/m² (range: 19-25). The mean operative time (console use) was 169.41 minutes. Docking time improved from 25 minutes in the first case to five minutes by the 12th. The mean hospital stay was 4.5 days. The average uterine weight was 104.58 g (range: 25-250 g). Estimated blood loss averaged 129.16 mL (range: 30-400 mL). Vaginal cuff closure time was recorded in one case (20 minutes). The mean VAS pain score was 3.91. A hemoglobin drop occurred in four cases, but no postoperative blood transfusions were required. There were no conversions, major complications, or readmissions. Conclusions This study demonstrates that the indigenous robotic system provides enhanced ergonomics, seven degrees of freedom, ease of operation, and improved safety with a shorter learning curve for large uteri. Further studies are needed to assess postoperative and long-term outcomes.

Keywords: laparoscopy; robotic hysterectomy; safety and efficacy; ssi mantra; vas score.

Figure 1. SCC with 3D HD monitor and 2D touch monitor

The SCC is an open console featuring a 3D HD monitor and a head-tracking camera. It includes a surgeon hand control device, foot pedal controls at the bottom that house the primary functions of clutch, camera toggle, robotic arm toggle (left and right), cut cautery (left and right), and coagulate cautery (left and right). The SCC also has a 2D touch monitor on the right for turning on the system controls. SCC: surgeon command center, 3D: three dimensional, 2D: two dimensional, HD: high definition Image Credit: Sudhir Srivastava Innovations Pvt. Ltd., with permission

Figure 2. Vision cart

The vision cart consists of a 3D HD monitor, a 3D HD recording system, a compartment for the cautery unit, and an endoscope control unit. 3D: three dimensional, HD: high definition Image Credit: Authors

Figure 3. Patient side arm carts

The patient side arm carts consist of parking locks, a vertical column, a telescoping column, a cart registration laser, active joints, a tool interface, a camera and instrument actuator, an instrument clutch button, a primary clutch button, and a secondary clutch button. Image Credit: Authors

Figure 4. Port placement for hysterectomy

The camera port is inserted 2 cm above the umbilicus, and the right and left robotic ports are inserted 5 cm lateral to the camera port on either side. The laparoscopic accessory port is inserted between the camera port and the left robotic port. Image Credit: Authors

Figure 5. Docked patient side arm cart with robotic arms

Patient side arm carts are labeled as C (camera), 1 (right), and 2 (left). Patient side arm carts with active and passive robotic arms are docked. A monopolar scissor is used in the right arm, and fenestrated bipolar instruments are used in the left arm. Image Credit: Authors