Surgical aspects in obstetric practice: modern approaches and technologies

Adelina A. Kobleva, Kamila A. Shautaeva, Amaliya I. Namazova, Karina B. Didaeva, Mekhin Sh. Alieva, Ksenia V. Volodina. Surgical aspects in obstetric practice: modern approaches and technologies. Cardiometry; Issue No. 33; November 2024; p. 95101; DOI: 10.18137/cardiometry.2024.33.95101; Available from:

Minimally invasive surgery has revolutionized the field of obstetrics and gynecology, providing patients with many benefits such as reduced postoperative pain, shorter hospital stays and faster recovery. In this regard, it is extremely important to study the latest achievements in the field of minimally invasive surgical methods used in obstetrics and gynecology. These are methods such as laparoscopy, robotic surgery, hysteroscopy and other innovative approaches. The introduction of advanced imaging technologies, advanced surgical instruments and the use of simulation-based training programs have contributed to the further development and implementation of minimally invasive surgery in obstetrics and gynecology. Understanding the latest developments in this field is crucial for healthcare professionals to ensure optimal care for their patients and improve surgical outcomes.

MATERIALS AND METHODS

In the process of writing the work, an array of Russian and foreign publications were analyzed within the framework of the research topic, and a number of research methods were also applied. Through the use of the analysis method, the main aspects of surgical interventions in obstetrics (cesarean section, episiotomy, operations for complications of childbirth, bleeding) were detailed. Using the synthesis method, various approaches and technologies in obstetric practice were combined and modern trends and methods were highlighted.

Based on the methods of classification and systematization, various methods of surgical intervention in obstetrics were grouped by types, techniques, indications and complications, and information was organized to create an overall picture of the current state of surgical practice in obstetrics. In addition, various approaches in obstetric surgery, both classical and modern, were compared. A prognostic method was also used, which made it possible to assess current trends and prospects for the development of surgical interventions in obstetrics and a generalization of the clinical experience of leading surgeons and obstetri-cians-gynecologists, as well as the study of international recommendations and protocols on surgical interventions in obstetrics.

The use of these methods made it possible to examine the topic more deeply and systematically, evaluate modern technologies in surgery, their effectiveness and prospects for implementation in obstetric practice.

RESULTS

In recent years, significant progress has been made in the development of minimally invasive surgery methods specifically designed for obstetrics and gynecology. This became possible thanks to technological innovations, improved surgical instruments and a deeper understanding of the anatomical features of the female reproductive system[1]. Patients experience less postoperative pain, reduce blood loss, shorten hospital stay, accelerate recovery and improve cosmetic results compared to traditional open surgery. These methods also minimize the risk of complications such as infection and adhesions. Consequently, patients can resume their daily activities and return to normal life.

However, like any surgical approach, minimally invasive surgery has its limitations and possible complications. The learning process associated with the development of these methods can be difficult and require special training and special knowledge. Widespread adoption of these procedures may also be affected by problems such as limited access to equipment, increased operation time and higher costs. To solve these problems and further improve the results of minimally invasive surgery in obstetrics and gynecology, advances in imaging technologies are needed, including three-dimensional visualization and high-resolution images, which have played a key role [2].

Today, the method of robotic surgery is increasingly being used in obstetrics and gynecology. Robotic surgery has become a transformative technology in obstetrics and gynecology, offering enhanced precision and minimally invasive techniques for a variety of procedures.

The introduction of traditional laparoscopy (TL) in gynecological surgery has led to significant bene- 96 | Cardiometry | Issue 33. November 2024

fits for women and health care providers in terms of shorter hospitalization and faster recovery and return to normal activities. However, in complex pelvic procedures where greater precision is required, TL has found limited use due to the limited space and complex anatomy of the pelvis. The introduction of the robot as an additional tool in laparoscopic procedures overcame many of these limitations, providing superior dexterity, intuitive movement, 3D vision, improved ergonomics, autonomous camera control and a shorter learning curve. Compared to TL, robotic movements are filtered for tremors, which allows you to perform precise operations. The 3D camera is fixed and controlled by the surgeon, providing a stable view and allowing for more accurate dissection due to depth assessment. To overcome the lack of depth perception in 2D cameras, 3D laparoscopic cameras have been developed, but published data comparing 3D cameras and robotic laparoscopy (RL) are scarce. Although the benefits of 3D cameras are well documented, the cantilever vision of surgeons in RL can make the operational stresses reported when using a 3D camera in TL, such as headache, dizziness and eye strain, less severe [3].

Another advantage of RL is that the movement of the instrument repeats the movements of the surgeon’s hands, unlike TL, where the movements of the hand and the instrument are illogical. Using a third hand allows the surgeon to control the placement of the instrument, fixed in a secure place for safe care, instead of requiring an assistant. The ergonomic advantages of RL compared to TL were recorded using abdominal models representing a healthy weight range (BMI 18.5–24.9 kg/m2) and obese patients (BMI 30 kg/m2 or more according to the WHO classification). The presence of a dual console ensures collaboration and facilitates learning. Disadvantages of RL include the lack of tactile feedback, the position of the surgeon away from the patient and the higher cost compared to TL [4].

Robotic surgery uses advanced robotic systems to perform surgical procedures. These systems usually consist of robotic arms controlled by surgeons, equipped with miniature instruments and a high-definition camera, which provides increased accuracy and dexterity during operations. The robotic platform transforms the movements of the surgeon’s hand into precise actions inside the patient’s body, allowing minimally invasive procedures to be performed with increased accuracy.

Robotic surgery has become a valuable tool in obstetrics and gynecology, offering numerous benefits to patients and healthcare providers. In gynecological surgery, robots are increasingly being used for procedures such as hysterectomy, myomectomy, and ovarian cystectomy, among others. In obstetrics, robotic techniques are used for complex operations such as cesarean section and fetal interventions. The importance of robotic surgery in this field lies in its ability to minimize injuries, reduce blood loss, shorten hospital stays and speed up patients’ recovery time. In addition, improved visualization and precision of robotic systems allow surgeons to perform complex procedures with greater ease and safety [5].

The first robotic gynecological procedure was performed using the Zeus Robotic Surgical System (ZRSS), marking the beginning of this sophisticated surgical approach. The integration of robotic surgery into obstetrics and gynecology has accelerated the shift in surgical management, with increasingly complex procedures performed using this advanced technology. This trajectory continues to expand as ongoing research and innovation in the field of robotic systems continually expand their capabilities and potential to improve patient care.

A comprehensive review of the literature highlights the key role of robotic surgery in advancing notable advances in medical technology over the past decades. The integration of robotics into gynecological surgery represents a significant leap forward in surgical methods and patient care [6].

Robotic surgery has had a profound impact on the field of obstetrics and gynecology, initiating advances in surgical techniques and improving patient outcomes. Research shows that robotic gynecological surgery performed by experienced surgeons can be performed safely, with perioperative results similar to those of traditional methods. Moreover, robotic surgery has demonstrated superiority over open surgeries in reducing postoperative hospital stays, highlighting its potential to improve recovery time and patient experience.

The use of robotic systems in gynecological surgery has undergone constant evolution, and ongoing research efforts are aimed at elucidating trends and patterns of robotic surgery in obstetrics and gynecology. Collectively, robotic surgery has left a significant mark by increasing surgical accuracy, improving visualization, and potentially contributing to improved patient care outcomes during gynecological procedures [7].

Robotic hysterectomy is a commonly used procedure for removing the uterus, usually performed to treat benign diseases such as uterine fibromyoma or endometriosis. This minimally invasive approach has a number of advantages over traditional methods, including smaller incisions, less blood loss and faster recovery time. Using robotic technology, surgeons can navigate complex anatomical structures with increased precision, thereby minimizing the risk of complications and optimizing patient outcomes.

Robotic myomectomy allows fibromyomas to be removed from the uterus, preserving the organ for future fertility prospects. This approach provides a delicate balance between careful removal of fibromyoma and preservation of reproductive capabilities, which makes it an attractive option for patients seeking both symptom relief and the possibility of conception. The robotic platform facilitates thorough tissue dissection and suturing, allowing surgeons to perform precise maneuvers in a confined pelvic space, ultimately increasing surgical success rates and patient satisfaction.

Robotic tubal reanastomosis is a method used to reconnect the fallopian tubes after the tubal ligation procedure, restoring the potential of future fertility. Using robotic instruments, surgeons can meticulously manipulate thin tubal structures with increased precision and control, facilitating precise anastomosis and optimizing reproductive outcomes. This minimally invasive approach offers patients a less invasive alternative to traditional open surgery, resulting in reduced postoperative pain and shorter recovery periods.

Robotic sacrocolpopexy is a surgical intervention to correct pelvic organ prolapse by suspending the uterus and vagina to the sacrum. This procedure eliminates the anatomical defects underlying pelvic organ prolapse, while minimizing the risk of recurrence. The robotic platform allows surgeons to navigate complex pelvic anatomy with improved visualization and dexterity, facilitating precise placement of mesh implants and providing optimal pelvic support. Consequently, patients experience improved symptom relief and recovery of pelvic function after surgery [8].

Robotic surgery offers many benefits that have changed the landscape of surgical practice in gynecology. Firstly, it improves the visualization of the surgical field, contributing to more accurate and accurate procedures. Surgeons benefit from a more transparent and enlarged view of anatomical structures, which allows them to confidently navigate complex surgical pathways. This increased visual clarity contributes to improved surgical outcomes and patient safety. Secondly, robotic surgery enhances the surgeon’s dexterity with the help of robot arms, which provide greater precision and control. Surgeons can perform complex procedures with greater ease and efficiency, achieving optimal results while minimizing the risk of errors. Intuitive motion scaling technology enables precise tissue manipulation, allowing surgeons to precisely navigate delicate anatomical structures.

Moreover, robotic surgery eliminates the effects of a surgeon’s tremor by providing stable robotic arms, thereby reducing the risk of complications. Surgeons can perform precise maneuvers without interference from involuntary movements, ensuring constant control of the instrument and minimizing tissue injury. This feature improves surgical accuracy and patient safety, especially in delicate procedures.

In addition, the ergonomic design of the robotic platform reduces the fatigue and tension of the surgeon, which provides a more comfortable environment for surgical intervention. Surgeons work sitting at a console with ergonomic controls and adjustable display settings, which minimizes physical discomfort during lengthy procedures. Such ergonomic optimization contributes to the well-being of the surgeon and increases the overall effectiveness of surgical intervention [9].

In addition to these technical advantages, robotic gynecological procedures offer significant clinical benefits. They are associated with a reduction in postoperative pain compared to traditional laparoscopic or open surgical methods. Patients who have undergone robotic surgery are often in the hospital less because of a faster recovery, which allows them to return to normal activities and daily life faster. Some studies show that the introduction of robotic surgery can lead to cost savings for medical institutions as the frequency of laparotomy decreases. In addition, robotic surgery allows less experienced laparoscopic surgeons to perform more complex procedures, improving patient care and expanding access to advanced surgical techniques. Overall, robotic surgery has revolutionized the field of gynecology by offering unmatched precision, improved patient outcomes, and enhanced surgical capabilities.

A comparative analysis of robotic surgery and traditional methods in obstetrics and gynecology reveals the clear advantages inherent in each approach. Robotic surgery, characterized by greater precision, 98 | Cardiometry | Issue 33. November 2024

improved visibility and shorter recovery time, provides a compelling alternative to traditional methods. Its minimally invasive nature leads to a reduction in risk factors and complications usually associated with large incisions, thereby improving patient outcomes. In contrast, traditional surgery offers a more practical approach, but may entail increased pain levels and longer recovery periods. In terms of surgical outcomes, robotic surgery often results in fewer complications and a lower risk of infection, making it the preferred choice for many patients undergoing gynecological procedures. The future landscape of gynecology increasingly includes robotic surgery due to its significant superiority in various benign and malignant gynecological surgeries, which highlights its transformative potential in improving patient care.

DISCUSSION

The development of surgical robots is a revolutionary achievement in the field of medicine, facilitating the implementation of precise and minimally invasive procedures in various medical specialties. These sophisticated robotic systems have transformed surgical practice, offering surgeons unprecedented control and precision during complex operations. Using robotic technology, surgeons can perform complex procedures with increased precision, resulting in improved patient outcomes and shorter recovery time. Robotic systems are increasingly being used to precisely move catheters and endoscopes, increasing the accuracy and results of procedures [10]. The advanced technology in question allows surgeons to maneuver catheters and endoscopes with unsurpassed precision, ensuring optimal placement and trajectory during diagnostic and interventional procedures. The integration of robotic navigation systems increases the success rates of procedures and minimizes the risk of complications, ultimately improving patient care and safety.

Automation of positioning of surgical instruments using robotic systems has become a significant achievement, increasing efficiency and accuracy during operations. The robotic positioning of surgical instruments allows surgeons to perform precise maneuvers with greater ease and precision, minimizing the risk of errors and optimizing surgical results. This automation optimizes surgical procedures, allowing surgeons to focus on critical aspects of the operation, while ensuring consistent placement and movement of instruments [11].

Robotic systems for intraoperative camera manipulation offer surgeons improved visualization and control during procedures. These sophisticated robotic platforms allow real-time configuration and manipulation of the surgical camera, providing surgeons with a clear and detailed overview of the surgical field. By optimizing imaging, these systems promote accurate tissue identification, precise instrument placement, and careful surgical technique, ultimately improving the effectiveness of the procedure and the results for the patient.

Today, specialists are developing so-called miniature robots, commonly called microbots, characterized by smaller size, increased speed and increased efficiency compared to traditional robotic systems. These microbots represent a significant advance in surgical technology, offering a range of applications to further reduce the invasiveness of surgical procedures. Thanks to their tiny size, microbots can access anatomical structures and navigate complex pathways within the body with unprecedented precision. This capability allows for minimally invasive operations where traditional instruments may be too large or cumbersome. Using micro-robotics, surgeons can perform procedures with greater precision and accuracy, minimizing tissue injury and speeding up patients’ recovery time.

The integration of AI and machine learning algorithms into robotic surgery is poised to play an increasingly prominent role in this field. Such advanced technologies have the potential to revolutionize surgical practice, helping to make decisions in real time, optimizing surgical planning and increasing the accuracy of robotic procedures [12]. AI algorithms can analyze huge amounts of patient data and surgical outcomes to identify patterns and trends, allowing surgeons to make more informed decisions during procedures. Machine learning algorithms can also adapt and improve over time based on experience, further enhancing their usefulness in robotic surgery. Robotic systems can be continuously developed, providing excellent surgical results and improving patient safety through the use of AI and machine learning.

It is expected that the development of remote surgery, also known as telechurgery or telepresence, will continue to expand, allowing surgeons to perform procedures on patients in different geographical locations. This transformative trend has the potential to revolutionize the provision of medical care by improv- ing access to high-quality surgical care, especially in underserved or remote areas. Telepresence technology allows surgeons to remotely control robotic systems equipped with surgical instruments, cameras and other instruments, which allows them to perform procedures with precision and expertise from afar [13]. In addition, global translation technology facilitates communication between surgeons and patients, overcoming language barriers and ensuring effective collaboration during remote operations. By using telepresence technology, healthcare providers can expand their reach and experience to patients around the world, ultimately improving overall health outcomes and reducing health inequalities.

The development of robotic surgery in obstetrics and gynecology entails many ethical and societal considerations. The increased use of robotic surgeries has raised ethical questions about the quality of care provided, informed decision-making processes, potential conflicts of interest, innovations in healthcare practice, and ongoing education of healthcare professionals. Moreover, the integration of AI into medicine and healthcare introduces its own ethical issues. There are concerns about a potential decrease in compassion and empathy in clinical settings when interacting with robotic doctors and nurses. Patients may find it difficult to accept a medical machine-human relationship compared to traditional human-human interactions, which negatively affects treatment.

From a forensic perspective, robotic surgery presents challenges related to standardized training protocols, informed consent procedures, and legal liability due to the involvement of multiple stakeholders [14]. The development of comprehensive guidelines, regulations and training programs is essential to effectively manage the forensic aspects related to robotic surgery and unlock its full potential in the future. Despite the numerous advantages of robotic surgery, such as increased accuracy and reduced fatigue of the surgeon compared to traditional methods, there are disadvantages such as loss of tactile feedback (touch). As robotic technologies continue to evolve, solving ethical dilemmas, ensuring patient safety through appropriate training and guidance, and delineating legal liability for malfunctions are key steps for the future of robotic surgery in gynecology.

Evaluating the cost-effectiveness of robotic surgery is crucial and primarily takes into account the implementation of strategies and factors that maximize effi-

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ciency and minimize costs to facilitate its widespread adoption. Research highlights the challenges in estimating the costs associated with robotic surgery, highlighting the need for improved cost estimation methodologies to ensure an accurate understanding of the economic consequences of these procedures.

In addition, additional costs such as staff training, infrastructure upgrades, and marketing efforts contribute to the overall cost of introducing robotic surgery into obstetric practice. While potential subsequent benefits, such as shorter stays, may offset some of these costs, it is important to recognize that the financial implications of robotic surgery go beyond just equipment and maintenance costs. Therefore, it is extremely important for medical institutions to have a complete understanding of the detailed cost structure associated with robotic surgery in order to make informed decisions regarding its integration into obstetric and gynecological practice [15].

The training and education requirements for robotic surgery in obstetrics and gynecology imply a structured curriculum to develop proficiency and ensure safety in performing basic robotic skills. This training mode usually goes through several stages, starting with observation, case management assistance, and the acquisition of basic robotic skills in dry and wet laboratory conditions. Subsequently, trainees move on to individual and group non-modular console learning under supervision, culminating in independent practice. The comprehensive training program covers patient-side training, including tasks such as patient positioning, pneumoperitoneum, procedure-specific port placement, robot docking, and basic laparoscopic skills. At the same time, console training includes simulation exercises, supervised practical exercises and the development of non-technical skills necessary for novice surgeons. The curriculum sets a proven benchmark of qualifications before interns can move on to practical experience in the operating room. Efforts are currently underway to standardize robotic surgery training in various specialties, including general surgery. These initiatives emphasize the importance of systematically and consistently incorporating didactic elements, simulation training, practical practice, and expert mentoring. Evaluating residents’ robotic skills in an operating room environment using structured training programs facilitates monitoring their progress and confirms their ability to safely perform robotic surgery [16].

Robotic surgery in obstetrics and gynecology can face various problems, ranging from technical to ethical and legal. Technical failures, including hardware and software failures, create risks of interruptions or complications during surgery, which requires strict maintenance protocols and redundancy measures in medical facilities to reduce these risks. Surgeons must also anticipate and deal with intraoperative problems such as malfunctions of the robotic arm or problems with communication between the surgeon and the console. Moreover, the introduction of robotic systems creates new risks of infection if they are not sterilized properly between procedures. The establishment and strict observance of proper cleaning and sterilization protocols in accordance with manufacturer’s recommendations and best practices is a prerequisite to minimize the risks of infection.

Despite the advances, robotic surgical systems still lack full tactile feedback, which requires surgeons to rely on visual and auditory cues and their expertise to compensate.

Ethical and legal issues arise when integrating AI and autonomous functions into robotic surgery, especially with regard to liability in the event of errors or malfunctions. Health institutions and regulators need to establish clear guidelines and frameworks defining responsibilities and obligations in such cases. In addition, the privacy concerns associated with the collection and transfer of patient data during tele-surgery highlight the importance of setting ethical standards and legal norms to protect patient data throughout the process. Patient acceptance of robotic surgery can be difficult due to limited awareness of the technology, which underscores the need for healthcare providers to prioritize patient education and awareness campaigns. Addressing patient concerns about the safety and effectiveness of robotic surgery is essential to promote acceptance, requiring open and transparent communication from healthcare providers.

Differences in access to information about robotic surgery can influence decision-making, which highlights the importance of providing accessible and patient-friendly resources explaining its benefits. Economic considerations, including the high cost of robotic surgery equipment, create obstacles to widespread adoption, with upfront costs being a problem for many medical institutions. Surgeons must undergo extensive training to master the techniques of robotic surgery, which can affect patient safety during the training process. Regular hardware inspections, software updates, and backup systems are crucial to minimize the impact of technical failures on patient safety. Addressing these issues is essential to maximize the benefits of robotic surgery while ensuring patient safety and ethical practice in obstetrics and gynecology.

CONCLUSIONS

An analysis of the development of such a method as robotic surgery in obstetrics and gynecology reveals a dynamic landscape characterized by significant achievements, challenges and opportunities. Due to its precision and minimal invasiveness, robotic surgery has revolutionized surgical practice in this field, offering benefits such as reduced injuries, improved patient outcomes and enhanced surgeon capabilities. In the future, it is expected that constant technological innovations will further enhance the effectiveness and applicability of robotic procedures, expanding the scope of treatment of complex obstetric and gynecological conditions. However, issues such as financial implications, training requirements, and regulatory concerns remain relevant and require joint efforts from practitioners, researchers, and industry stakeholders.

Specialists in the field of obstetrics and gynecology should be aware of the latest developments in the field of robotic surgery and actively participate in training programs in order to fully master robotic methods. In addition, continuous evaluation of patient outcomes and safety profiles is crucial to maintain the highest standards of treatment.