Robotic Surgery - Elvira Bratila, MD, PhD

Robotic Surgery. The Most Advanced Technique in Endometriosis Surgery

Da Vinci Surgical Robot. Better visibility. Higher precision. Superior outcomes for the patients’ quality of life.  

Robotic surgery is an advanced form of minimally invasive surgery. During surgery the abdominal wall is no longer incised, 4 small incisions are made, allowing for rapid post-operative recovery.

Da Vinci system is a sophisticated robotic surgery platform designed to enhance and extend the surgeon’s capabilities. With the da Vinci, 4 specially designed trocars are inserted through these incisions to reduce trauma to the abdominal wall in order to reduce post-operative pain. Through these trocars are inserted miniaturized working instruments and a high definition 3D camera. The 3D view of the operating field allows superior clarity for visualizing anatomy, up to 10 times magnification of structures in the pelvis. Because of this, surgical gestures are much safer because there are vascular and nervous structures in these spaces that need to be protected.

Prof. Dr. Elvira Bratila

Professor Elvira Bratila, MD, PhD, the first gynecological surgeon in Romania who introduced the robotic technique in gynecology: “Training and over-specialization in this new technique is by no means simple, it is a combination of theory, practice and a lot of vision about integrating previous practice, gained in years of classical, vaginal and laparoscopic surgery. Becoming certified in robotic surgery is a continuous learning process. The learning process starts online, with courses and distance learning in specialized centers in France, Belgium, Italy for Europe or in the USA. The next step is a specialized training, training in robotic surgery in a dedicated mentoring center. Specialization is carried out gradually, differently for the surgeon working at the console and for the surgeon’s assistant, each one undertaking a specific type of training, resulting in a type of certificate. The next stage consists of surgeries assisted by a mentor, an external proctor, who supervises the surgery and can facilitate one’s learning process. This stage lasts between 3-4 months, supervising 9 operations, considered the standard for mastering this new technique. It is very important that after the first 9 operations the surgeon start to perform these operations frequently, so that it starts to get into a manual and practical “routine”, in order to maximize the surgeon’s skills.  This is followed by a “case observation” phase, lectures and training where one can assist on complex cases, ask questions, learn from colleagues in leading robotic centers. After 50 surgeries, one can become a mentor for other surgeons or choose center where one can take up the baton as a “robotic surgeon locator”.


What is the addressability of robotics in endometriosis surgery?

We approach deep endometriosis cases with the Da Vinci robot. We are talking in particular about women who are confronted with the deeply infiltrative form of the disease, which involves the organs around – the rectum, colon, bladder, ureters, the entire abdominal cavity, forms that produce adhesions where one would little think they could appear and which progressively evolve, relapsing in some cases, disabling by the extent of the lesions, by the effects on reproductive capacity and by the innervation of the affected areas.

These are interventions of maximum complexity, which require extensive experience in endometriosis excision surgery and multidisciplinary team to collaborate in complex cases of endometriosis excision surgery such as: bowel endometriosis, bladder endometriosis, sacral roots endometriosis.


Compared to laparoscopy, robotic surgery has brought in terms of surgical technique: integration, 3D visibility, better precision, flexibility, manuality and access to hard-to-reach lesions.

A superior surgical act translates into undeniable benefits for patients who benefit from the robotic technique: less perioperative blood loss, reduced post-surgery complications, reduced surgical trauma and a faster recovery from the procedure, which can integrate a multidisciplinary team for excision surgery of deep infiltrating endometriosis (DIE): gynecological surgeon, abdominal surgeon specializing in colorectal surgery, urological surgeon, thoracic surgeon, if the endometriosis has affected a territory beyond the pelvic area.


Benefits of robotic surgery for post-surgery recovery

Robotic-assisted surgery reduces average length of hospital stay, post-surgery recovery time, reduced need for post-operative pain medication.

Robotic approaches to difficult cases – reduced postoperative pain and reduced intraoperative blood loss – are important benefits for the patient.

Patients will be discharged within 48 hours of surgery coming back to their routine and their daily activities in the best possible conditions.


The advantages of robotic surgery in endometriosis are obvious, but are there any risks too?

da Vinci Robotic Surgery in Endometriosis

Robotic surgery is the most advanced minimally invasive surgery. During robotic surgery, the traction on the tissues is very fine and must be strictly controlled by the surgeon to avoid tissue damage. The risk of complications is substantially reduced, which is why it is reserved for cases that are difficult to treat with other known techniques.     

The success of robotic interventions is closely related to the expertise of the surgeon who performs the robotic approach frequently as a routine having the exposure to this type of complex interventions of deep infiltrating endometriosis excision surgery (bowel endometriosis, bladder endometriosis, sacral roots endometriosis surgery).