Robotic Surgery in Gynecologic Oncology: An Expert Interview with Dr. Zaher Halwani, M.D.

Dr. Zaher Halwani, M.D., is a recognized specialist in gynecologic oncology and endometriosis at Vivantes Humboldt Hospital in Berlin. As director of the certified Gynecologic Cancer Center, he focuses in particular on the diagnosis and treatment of ovarian, peritoneal, and uterine cancers, as well as other gynecologic tumors.

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 surgeries. His expertise ranges from radical surgical treatment of uterine and cervical cancer to specialized therapy for vulvar and vaginal carcinomas. Another focus of his work is the treatment of endometriosis, an often complex condition that he treats using state-of-the-art surgical techniques.

Patients benefit not only from highly specialized surgical procedures but also from comprehensive counseling services, including second opinions and individually tailored treatment plans. In addition to his clinical work, Dr. Halwani is actively involved in medical research, gives presentations at national and international medical conferences, and organizes scientific events. His close ties to university research and the continuous refinement of his treatment methods ensure that patients receive care based on the latest medical findings.

The well-being of his patients is always at the center of his work. In addition to his high level of professional expertise, Dr. Halwani places great importance on a trusting doctor-patient relationship and empathetic support throughout the entire course of treatment. Thanks to his many years of experience, his technical expertise, and his commitment to innovative treatment approaches, he offers patients first-class medical care of the highest standard.

 

 

Robotic surgery is a modern advancement in minimally invasive surgery that enables the highest precision and minimally invasive procedures. With the help of a robot-assisted system, such as the da Vinci robot, the surgeon can perform the finest movements with high precision, thereby sparing 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 those in urology, cardiac surgery, and visceral surgery. It is also playing an increasingly important role in gynecologic 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. 

A key aspect is the highly precise control of the instruments, which is made possible by a computer-assisted, robot-assisted system. The da Vinci robotic system, which is frequently used in gynecologic oncology, allows the surgeon to control the instruments intuitively with significantly greater freedom of movement, as the robotic arms offer greater flexibility than the rigid instruments used in traditional laparoscopy. 

“Minimally invasive surgery is fundamentally aimed at being as gentle as possible on the patient. It reduces surgical trauma, enables precise work, and delivers results that are at least equivalent to—and often even better than—those of open or vaginal surgical procedures. A key advantage lies in the significantly lower burden on patients. In traditional open surgery, complications such as impaired wound healing, increased blood loss, or longer hospital stays were common. Minimally invasive procedures have already significantly reduced these risks. Robotic surgery takes this a step further. It allows surgeons to work within the tissue with the utmost precision and delicacy. This not only makes particularly complex procedures possible but also enables even more precise and gentler treatment. Especially for patients with challenging conditions—such as obesity—robotic technology can help make procedures more effective and better tolerated by those affected. The combination of minimal trauma, high precision, and the ability to safely perform complex procedures makes robotic surgery a valuable tool in modern gynecologic cancer treatment. “Especially for overweight patients, who are statistically more likely to develop uterine cancer, minimally invasive—and in particular robot-assisted—surgery represents an important and gentle treatment option,” explains Dr. Halwani at the beginning of our conversation.

The introduction and application of robotic technology in gynecologic oncology present both technical and economic challenges that require careful planning and substantial 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, the surgeon controls the instruments with high precision—much like an exceptionally sensitive extension of his own hands. This allows even difficult procedures to be performed with extreme precision and minimal tissue damage. However, the introduction of such a system requires not only significant financial investment but also a lengthy and intensive training phase. Surgeons must already be experienced specialists before they are even allowed to begin training. This training includes several courses using models, cadavers, and animals. Only then are they permitted to perform procedures on living patients—under the supervision of an experienced trainer, known as a proctor. “Performing complex surgeries independently, such as those in gynecologic oncology, is only possible after about a year of intensive training,” says Dr. Halwani, going on to elaborate specifically on the Vivantes Clinic in Berlin:

“The Da Vinci system was introduced at the Vivantes Women’s Clinic in Berlin as early as 2016—making it the first facility of its kind in the capital. Since then, it has been used routinely there, and about half of all oncological procedures are now robot-assisted. The selection of suitable surgeries and surgeons is carried out with great care. Just as with a valuable musical instrument, success depends not only on the technology itself, but above all on the experience and skill of the person using it. A key technical challenge is the high complexity of robot-assisted systems. Unlike conventional surgery, in which the surgeon works directly with instruments, robotic surgery is controlled via a console. This requires an adjustment in hand-eye coordination and a longer training period. “Surgeons must undergo specialized training to master the intricacies of robotic technology, as the system enables highly precise movements but also requires a different surgical approach,” said Dr. Halwani.

While procedures on the uterus or ovaries benefit from the precision of robotic technology, in certain cases—such as very advanced stages of cancer or extensive metastasis—it may still be advisable to resort to open surgical procedures. Last but not least, integrating robotic technology into daily clinical practice requires a restructuring of surgical planning. Robot-assisted procedures often take longer than conventional methods in the initial phase, as setting up the system and positioning the instruments take additional time. Only with increasing experience can these processes be optimized and operating times shortened. 

“Especially with more complex procedures, we regularly receive referrals of patients from other hospitals—with the clear indication that these are cases that are better handled by a specialized center with robot-assisted surgery, such as the da Vinci system. In urology, the use of such technologies has now become virtually standard—for example, prostate surgeries are performed almost exclusively with the robot today. In gynecology, this standard has not yet been universally established, but it is now enshrined in medical guidelines. When surgeons at other hospitals do not feel confident performing certain procedures using minimally invasive techniques, they often opt for traditional open surgery. However, this can have disadvantages for patients. “If complications then arise, it is very regrettable—especially because they could often have been avoided,” criticizes Dr. Halwani, adding:

“We are therefore seeing a steady influx of patients from other hospitals—not least because we have a very high volume of cases. In the field of gynecologic oncology alone, we perform around 100 robot-assisted surgeries per year. That makes a big difference—both in terms of the surgical team’s experience and the quality of care. For example, performing a robotic uterine cancer surgery three times a week is, of course, quite different from performing such a procedure only once a month. The postoperative care process at our hospital is also very patient-friendly. For procedures such as those for uterine or cervical cancer, patients can usually leave the hospital after a maximum of 48 hours. This is very appealing to many because it involves less stress and a faster recovery. However, this puts us at odds with the German healthcare system. Hospitals lose money if they discharge patients too early—even though it would be medically justifiable and in the patient’s best interest. The economic structures here are problematic.”

Robotic surgery offers significant advantages, particularly for certain patient groups and tumor stages, while it may be less suitable in other cases. 

Patients with early-stage gynecological tumors benefit particularly, as the procedure’s high precision allows for complete tumor removal without unnecessarily damaging surrounding healthy tissue. Women with comorbidities 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, thereby reducing the risk of postoperative complications. Even in cases of complex anatomical conditions—such as those following previous surgeries or involving severe adhesions—robotic surgery facilitates the procedure and minimizes the risk of tissue damage.

When it comes to the question of whether there are certain stages of cancer or patient groups for which robotic surgery should be the exclusive method, there are clear recommendations—and also limitations. Dr. Halwani comments on this: “One example is ovarian cancer: Despite the technical capabilities, open surgery is still necessary in many cases for this disease. This is in line with current guidelines. Even though it would be theoretically 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, the ability to palpate and feel the tissue during open surgery is a crucial factor in identifying all affected areas. In practice, therefore, an open approach is preferred to minimize the risk,” and he adds:

“When it comes to future technical developments, both advances in robotics and the use of artificial intelligence (AI) will play a major role. The expertise of surgeons, combined with new technologies, could help further optimize treatment. AI could play an increasingly important role, particularly with regard to improving the training of surgeons and the ability to use collective data for better patient assessment. This would not only lead to better diagnostics but also shorten the training time for surgeons. In the future, we may also see a greater shift toward hybrid treatment approaches that combine robotics with traditional methods, which would be particularly beneficial for outpatients. With regard to the challenges surgeons face in oncological surgery, there are still complex cases that place high demands on the surgeons’ skills. “Despite the longer procedure times in complex cases, the success of robotic surgery in such difficult situations is a positive sign for the future of this technology in surgery.”

It is impossible to say exactly how quickly developments in oncological surgery will advance, but there is hope that progress will be made in the near future. 

“As a surgeon, despite years of experience, you are constantly confronted with new challenges. Even today, there are surgeries that involve complex decisions and where you cannot be certain how the procedure will go. Patients who have already undergone several abdominal surgeries are often particularly difficult cases. In these situations, the goal is to perform the procedure as minimally invasively as possible despite the oncological nature of the surgery, though this is not always feasible. One example of such complex cases is a patient who had to undergo surgery again after many previous abdominal operations. She had been classified by other doctors as “no longer operable,” but due to her cancer, surgery was unavoidable. “Despite the difficult initial situation, the surgery was successfully performed using the robot, although it took more time. While normal procedures typically last between one and a half and two hours, particularly complex cases required up to four hours of surgery,” explains Dr. Halwani.

Within the Vivantes Group, the Cancer Center at the Humboldt Clinic is the first of its kind. It offers a particularly high level of expertise in oncological treatment. 

“Although other Vivantes clinics also perform oncological surgeries and use the Da Vinci robot, they were certified later and received the robot only 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 a major institution both regionally and internationally. In Europe, other surgeons are also being trained, both on-site and at other hospitals. This high level of expertise and continuous training contribute to the center’s leading role in minimally invasive oncological surgery,” Dr. Halwani emphasized at the conclusion of our conversation.

Thank you very much, Dr. Halwani, for this insightful look into robot-assisted gynecological surgery!