Dr. Zaher Halwani is a renowned specialist in gynecological oncology and endometriosis at Vivantes Humboldt Hospital in Berlin. As head of the certified Gynecological Cancer Center, he is particularly dedicated to the diagnosis and treatment of ovarian, peritoneal and uterine cancer as well as other gynecological tumor diseases.
Having performed more than 1,000 surgical procedures, Dr. Halwani has extensive experience, particularly in minimally invasive surgery and robot-assisted procedures such as da Vinci technology, which enable particularly gentle and precise interventions. His expertise ranges from the radical surgical treatment of uterine and cervical cancer to the specialized treatment of vulvar and vaginal carcinomas. Another focus of his work is the treatment of endometriosis, an often complex disease that he treats using the latest surgical techniques.
Patients benefit not only from highly specialized surgical procedures, but also from comprehensive consultation services, including second opinions and individually tailored treatment plans. In addition to his clinical work, Dr Halwani is actively involved in medical research, gives lectures at national and international specialist congresses and organizes scientific events. His close ties to university research and the continuous development of his treatment methods ensure that his therapy is based on the latest medical findings.
His work always focuses on the well-being of his patients. In addition to his high level of professional expertise, Dr. Halwani attaches great importance to a trusting doctor-patient relationship and empathetic support throughout the entire treatment. Thanks to his many years of experience, his technical expertise and his commitment to innovative therapeutic approaches, he offers patients first-class medical care at the highest level.
Robotic surgery is a modern advancement of minimally invasive surgery that enables the highest precision and gentle procedures. With the help of a robotic system, such as the da Vinci robot, the surgeon can perform the finest movements with a high degree of precision, thereby protecting the surrounding tissue as much as possible. This technology offers numerous advantages, including smaller incisions, less pain and a faster recovery for patients. Robotic surgery has proven particularly effective in complex procedures such as urology, heart surgery and visceral surgery. It is also playing an increasingly important role in gynecological oncology, particularly in the treatment of uterine and ovarian cancer, where it enables precise and effective treatment options.
Robotic surgery has established itself in gynecologic oncology as a significant advancement in minimally invasive surgery and offers a number of specific advantages over conventional laparoscopic procedures.
One crucial aspect is the high-precision control of the instruments, which is made possible by a computerized, robot-assisted system. The da Vinci robotic system, which is frequently used in gynecological oncology, allows the surgeon intuitive control of the instruments with significantly greater freedom of movement, as the robotic arms offer greater flexibility than the rigid instrumentation of classic laparoscopy.
“Even minimally invasive surgery aims to be as gentle as possible for the patient. It reduces surgical trauma, enables targeted work and delivers at least equivalent, often even better results than open or vaginal surgical procedures. A decisive advantage is the significantly lower stress for patients. Classic open surgery often resulted in complications such as wound healing disorders, increased blood loss or longer hospital stays. Minimally invasive procedures have already significantly reduced these risks. Robotic surgery goes one step further. It makes it possible to work with maximum precision and sensitivity in the tissue. This not only makes particularly complex procedures possible, but also enables even more targeted and gentle treatment. Robotic technology can help to carry out procedures more effectively and with greater patient tolerance, particularly in patients with more difficult conditions, such as obesity. The combination of minimal trauma, high precision and the ability to perform complex procedures safely makes robotic surgery a valuable tool in modern gynecological cancer treatment. Minimally invasive - and in particular robot-assisted - surgery is an important and gentle treatment option, especially for overweight patients, who statistically are more likely to develop uterine cancer,” explains Dr. Halwani at the beginning of our conversation.
The introduction and application of robotic technology in gynecologic oncology poses both technical and economic challenges that require careful planning and extensive investment.
“Robotic technology, such as the Da Vinci system from Intuitive, essentially consists of two components: a patient module with robotic arms that are inserted through small incisions in the skin, and a separate control console where the surgeon sits. From there, he controls the instruments with high precision - comparable to a particularly sensitive extension of his own hands. This means that even difficult procedures can be carried out in an extremely targeted and tissue-friendly manner. However, the introduction of such a system requires not only high financial investment, but also a complex and lengthy training phase. Surgeons must already be experienced specialists before they are even allowed to start training. This involves several courses on models, cadavers and animals. Only then are they allowed to operate on live patients - under the supervision of an experienced trainer, a so-called proctor. Independent performance of complex operations, such as in gynecological oncology, is only possible after around a year of intensive training,” says Dr. Halwani and goes on to explain the Vivantes Clinic in Berlin in particular:
“The Da Vinci system was introduced at Vivantes Women's Hospital Berlin back in 2016 - as the first facility of its kind in the capital. Since then, it has been routinely used there, and around half of all oncology procedures are now robot-assisted. The selection of suitable operations and surgeons is carried out with great care. After all, as with a valuable musical instrument, it is not just the technology that determines success, but above all the experience and skill of the person using it. A key technical obstacle is the high complexity of robot-assisted systems. In contrast to conventional surgery, where the surgeon works directly with instruments, robotic surgery is controlled via a console. This requires a change in hand-eye coordination and a longer training period. Surgeons have to undergo special training to master the intricacies of robotic technology, as the system enables high-precision movements but also requires a different surgical approach,” says Dr. Halwani.
While operations on the uterus or ovaries benefit from the precision of robotic technology, in certain cases, such as very advanced tumor stages or extensive metastases, it may still make sense to resort to open surgical procedures. Last but not least, the integration of robotic technology into everyday clinical practice requires a restructuring of surgical planning. In the initial phase, robot-assisted procedures often take longer than conventional procedures, as setting up the system and positioning the instruments takes additional time. Only with increasing experience can these processes be optimized and operating times shortened.
“Particularly in the case of more complex procedures, we regularly receive patients from other clinics - with the clear indication that these are cases that would be better performed by a specialized center with robot-assisted surgery, such as the da Vinci system. In urology, the use of such technologies is now almost standard - for example, prostate operations are now performed almost exclusively using robots. In gynecology, this standard has not yet been established across the board, but it is now anchored in medical guidelines. If surgeons in other clinics do not have the confidence to perform certain procedures using minimally invasive techniques, they often opt for traditional open surgery. However, this can have disadvantages for patients. If complications then occur, it is very unfortunate - especially because it could often have been avoided,” Dr. Halwani criticizes and adds:
“We are therefore seeing a steady influx of patients from external clinics - not least because we have a very high number of cases. In the field of gynecological oncology alone, we perform around 100 robot-assisted operations per year. This makes a big difference - both in terms of the experience of the surgical team and the quality of the treatment. For example, if you perform a uterine cancer operation three times a week with the robot, this is of course different from an operation that only takes place once a month. The post-operative process is also very patient-friendly. For procedures such as uterine or cervical cancer, patients can usually leave the hospital after a maximum of 48 hours. This is very attractive for many because it means less stress and a faster recovery. However, we are at odds with the German healthcare system here. Hospitals lose out financially if they discharge patients too early - even though it would be absolutely medically justifiable and in the patient's best interests. The economic structures are problematic here”.
Robotic surgery offers considerable advantages, particularly for certain patient groups and tumor stages, while it may be less suitable in other cases.
Patients with early stages of gynecological tumors benefit in particular, as the high precision of the procedure enables complete tumor removal without unnecessarily damaging surrounding healthy tissue. Women with concomitant diseases such as obesity, diabetes or cardiovascular problems also benefit, as the minimally invasive technique is associated with less intraoperative blood loss and a faster recovery time, which reduces the risk of postoperative complications. Robotic surgery also makes the procedure easier and minimizes the risk of tissue damage in complex anatomical conditions, for example after previous operations or in the case of severe adhesions.
When it comes to the question of whether there are certain stages of cancer or patient groups that should only be operated on with the robot, there are clear recommendations and also limits. Dr. Halwani comments: “One example of this is ovarian cancer: despite the technical possibilities, in many cases it is still necessary to perform open surgery for this disease. This is in line with current guidelines. Even if it would theoretically be possible to perform minimally invasive surgery in early or certain stages, open surgery remains the preferred method. The main reason for this is the risk that metastases could be overlooked with a minimally invasive technique. In particular, palpation and feeling, which is possible during open surgery, is a decisive factor here in order to detect all affected areas. In practice, an open approach is therefore used to minimize the risk,” he adds:
“When it comes to technical developments in the future, both the improvement of robotics and the use of artificial intelligence (AI) play a major role. The expertise of surgeons, coupled with new technologies, could help to further optimize treatment. AI could play an increasingly important role, particularly with regard to improved surgeon training and the possibility of using collective data to improve patient assessment. This would not only lead to better diagnostics, but also to a reduction in training time for surgeons. In the future, we could also see a greater hybridization of treatment approaches, combining robotics and classical methods, which would be particularly beneficial for outpatients. In terms of the challenges surgeons face in oncological surgery, there are still complex cases that place high demands on surgeons' skills. Despite the longer duration in complex cases, the success in applying robotics in such difficult situations is a positive sign for the future of this technology in surgery”.
The question of how quickly developments in oncological surgery will progress cannot be answered precisely, but there is hope that progress will be made in the near future.
“As a surgeon, you are constantly confronted with new challenges despite years of experience. Even today, there are still operations that involve complex decisions and where you can't be sure how the procedure will go. Patients who have already undergone several abdominal operations are often particularly difficult. In such cases, there is a desire to work as minimally invasively as possible despite the oncological procedures, but this is not always possible. One example of such complex cases is a patient who had to be operated on again after many previous abdominal operations. She had been classified by other doctors as “no longer operable”, but surgery was unavoidable due to her cancer. Despite the difficult initial situation, the operation was successfully performed with the robot, but this took longer. While normal operations usually take between one and a half and two hours, particularly complex cases took up to four hours,” explains Dr. Halwani.
Within the Vivantes Group, the Cancer Center at the Humboldt Clinic is the first of its kind within the Vivantes Group. It offers a particularly high level of expertise in oncological treatment.
“Although other Vivantes clinics also perform oncological operations and use the Da Vinci robot, they were only certified later and only received the robot after the Humboldt Cancer Center. Since 2016, a particularly high number of robotic procedures have been performed here, and the center has established itself as an important institution both regionally and internationally. Other operators are also being trained in Europe, both locally and at other clinics. This high level of expertise and continuous training contribute to the center playing a leading role in minimally invasive oncological surgery,” emphasizes Dr. Halwani at the end of our conversation.
Thank you very much, Dr. Halwani, for this positive insight into robot-assisted gynecological surgery!
