Interview with Dr Jafaru Abu, Director of Gynaecological Oncology and Robotic Surgery for Burjeel Medical Group, Abu Dhabi.

Dr Jafaru Abu is a Consultant Gynaecological Oncologist at Burjeel Medical City (BMC) in Abu Dhabi. Dr Jaf relocated from Nottingham in the United Kingdom in April 2022 to set up a world class gynaecological oncology surgical unit at BMC.

The unit delivers surgical procedures comparable to the best anywhere in the world, from minimally invasive surgeries (performed laparoscopically or using robotic surgery technology), to ultraradical cytoreductive surgeries for advanced stages of ovarian cancer.

As well as the Director of Gyn Oncology, Dr Jafaru is also the Director of Robotic Surgery for the Burjeel group of hospitals. His extensive robotic surgery experience, gained in the UK, led him to introduce the latest Xi da Vinci robotic technology to Burjeel Medical City.

Dr. Jaf received a certificate of professional recognition from the European Society of Gynaecological Oncology (ESGO) at their recent congress in Istanbul, for his many years of experience and accomplishments in the field of gynaecology oncology.

At Allocation Assist, we like to keep in touch with our doctors and follow their careers. We were excited to talk to Dr Jaf about his experiences and achievements since relocating to the UAE.

Dr. Jaf, thank you so much for making the time in your very busy schedule to speak to us. Can you tell us a bit about your background and how you got into robotic surgery?

I was appointed as a Consultant Gynaecological Oncologist at Nottingham University Hospitals NHS Trust in 2006. I remained in that post for over 16 years, where I was one of the first laparoscopic gyn-oncology surgeons in the UK. Minimally-invasive, laparoscopic surgery can be physically demanding. I would regularly perform laparoscopic procedures for endometrial cancer, which is more common in women who are obese and this took a toll on my shoulder joint. In 2017, my shoulder problems became so bad that I required surgery. Following shoulder surgery, I was instructed not to operate for 6 weeks. This was the first time in my career that I had taken time off sick and, after 2 weeks I got bored! I realised that if I wanted to prolong my career as a surgeon, I would need to take up robotic surgery. The hospital I was working in had a robotic surgery system that was only being used by the urology department at that time. I travelled to Denmark and France, getting someone to carry my suitcase for me, to train in robotic surgery. Exactly 4 weeks after my shoulder surgery I was sitting at a console, doing my first robotic procedure! I am thankful to say that my shoulder has been fine since then.

Can you tell us about the robotic surgery system you use?

I trained on, and have been using, robotic systems from da Vinci, considered to be the world leader in robotic surgery technology. I started off using the da Vinci S and later the da Vinci X, in the UK. Now, here in the UAE, we are using the most advanced da Vinci robotic system, the Xi. This system consists of 3 main components. There is the surgeon’s console, where the surgeon sits and controls all movements of the robotic arms using both hands, as well as feet, while viewing a magnified, 3D, highly detailed image of the operating field. The vision cart, with a camera and a stack of energy devices, makes communication between components possible and supports the 3D high-definition vision system. Thirdly, there is the patient cart with 4 arms; one with the camera attached and the other 3 that carry surgical instruments.

What does the training for robotic surgery involve?

Robotic surgery training is exacting, with da Vinci overseeing and certifying the training process for their own systems. It begins with online modules to learn about the various robotic system components. The surgeon then undergoes 30 hours of simulation training on the console. Following this, 8 to 10 hours of dry-lab training with a Da Vinci certified trainer, in which the robotic system is docked onto a mannequin. Once these stages are completed, there is a test or examination on a live animal, for which the surgeon has to successfully carry out up to 20 procedure steps. On passing this test, a certificate is issued to show that the surgeon is certified by da Vinci. However, it does not stop there. The first 5 to 10, or sometimes more, robotic surgery cases that a surgeon performs are observed by a proctor, appointed by Da Vinci. If a surgeon concentrates their focus on the training, this process can be completed in around a month. This is different from a pure robotic surgery fellowship, which can take between 6 and 12 months. My training gives me the flexibility to choose the best operating technique for each patient. Robotic surgery is not suitable for every case. For example advanced ovarian cancer which spreads all over the abdomen and requires radical open surgery to make sure that even the tiniest tumours are removed.

How and why did you introduce the Da Vinci Xi robotic surgery system at Burjeel Medical City?

When I first started at BMC, I initially found it challenging not having the robotic surgery system. Having experienced the benefits of robotic surgery, both for patients and surgeons, I was convinced that having the da Vinci robotic surgery system would also be beneficial for Burjeel Medical City. However, starting a robotic surgery service requires a major financial investment into the robotic system and maintenance costs. It took time and persistence, to show that I was committed and make the case that the initial investment would reap huge rewards for the hospital over the long term. We got the da Vinci Xi system in around August 2023. Returning to robotic surgery after a time gap meant that I had to refresh my skills, as well as train my staff who had not seen robotic surgery before. I went with my team to other centres in the UAE that were using the da Vinci Xi, such as Mediclinic Dubai. Before restarting robotic operating, I was coming into the hospital on my weekends or days off to sit at the console and re-familiarise myself with the system and controls. I soon got back up to full speed and I am now able to perform all the procedures I was doing before in the UK.

In your experience, what are the advantages of robotic surgery for surgeons?

As I mentioned previously, the major advantage for me, given my previous shoulder problems, has been the ergonomics. When performing robotic surgery, I sit at the console and can precisely control all the movements of the camera and surgical instrumentation in 360 degrees using only my hands, fingers and wrists. This is much less strenuous and tiring than laparoscopic surgery, which uses rigid instruments and therefore requires more physicality and pressure. The system enables me to clearly see all the anatomy in high definition while operating, which makes procedures more precise. Over time and with experience, operating time can also be reduced.

What are the advantages of robotic surgery for patient outcomes in gynaecological cancer?

Compared to open surgical procedures, using robotics for minimally invasive surgery enables faster recovery time, minimal scarring, and less postoperative pain. There are also advantages over laparoscopic surgery, as less expansion of the abdomen with CO2 gas is required to place ports. For laparoscopic surgery I use a pressure of 12 to 16 mmHg, but for robotic surgery this can be reduced to 6 to 8 mmHg. This results in less trauma and pressure on the internal organs, less tissue damage due to the port placement, and less postoperative pain.

Have you experienced any challenges with robotic surgery?

Not all gyn-oncology procedures are suitable for robotic surgery, so cases must be carefully selected. Robotic surgery is especially useful for endometrial cancer, in which most cases can be done using robotics. However, about 10-15% of cervical cancer cases and only about 5% of ovarian cancer cases in the early stages may be suitable for robotic surgery. Getting pre-approval for robotic surgery from insurance companies can be a challenge. The costs of setting up a robotic surgery service are significant but with continued use over time, the costs start to reduce due to economies of scale. Some system components, such as the ports for the robotic arms, can be used multiple times, unlike laparoscopic surgery ports which are single use. Some patients may initially be wary when I recommend robotic surgery, as it is a relatively new technology. I am able to reassure these patients by explaining the procedure clearly so that they understand that the robotic system is only a tool, and that I, as their surgeon, am fully in control at all times.

How does having the robotic surgery system benefit the hospital?

Having an advanced surgical robotics system with experienced surgeons and theatre teams is beneficial for the status and reputation of the hospital. It helps to increase patient referrals. We are receiving referrals for robotic surgery from other hospitals in the Burjeel Holdings group, as well as from other centres within the UAE, and from abroad such as from Russia, Kazakhstan, and other countries in Africa and Europe.

Why did you decide to relocate to the UAE?

After more than 16 years in the same consultant post in the UK and having built up the service and my practice there, I wanted a new challenge. The healthcare sector in the UAE is growing rapidly, providing world-class care for citizens, residents and patients from further afield. Gynaecological oncology is a relatively new sub-speciality in this region and I was excited to be able to use my skills and experience to set up a new unit here.

How have you found the relocation experience?

Of course, I would be lying if I said everything has been easy. Relocating to a new country and system obviously comes with some challenges. Working in a private healthcare system and dealing with insurance providers is quite different from working in the NHS. However, I also had a private practice in the UK, so this experience has been advantageous. In the UK, there is a streamlined referral process with General Practitioners acting as the gatekeepers to direct patients to the right specialist service. Although there are waiting lists in the NHS, it is a well-established system. In the UAE, patients can self-refer to a specialist and may not know where to go, or how to find a specialist who has the training and experience that they need. Initially, I was surprised that many patients with gynaecological cancers who could benefit from my expertise were not coming directly to me. It took some time to create awareness about the new service and build up a patient base. When coming to the UAE, I did wonder how I may be accepted within the local culture as a male Gynaecologist, However, this has not turned out to be a barrier. I have been able to build rapport and trust with my patients and their families. I have found that for women who have gynaecological cancer, getting the best treatment is much more important than the surgeon’s gender.

What advice would you give to other consultants who are thinking of coming to the UAE, or who have recently relocated?

If you come with the right mindset, and have patience, you can be successful in the UAE. The first year can be a challenge and you need to view it as a work in progress. You will need to network, make connections and create awareness, to gain referrals and build up your patient base. Good communication is important, with patients, colleagues and the hospital management. Building trust works both ways; in my experience I needed to demonstrate that I was committed for the long term in order for hospital management to invest in robotic surgery. There may be some cultural differences, so sensitivity and understanding is required. I always say, “When in Rome, do as the Romans.”

What are your plans for the future, and how do you see robotic surgery expanding in the UAE?

Now that we have the da Vinci Xi system at Burjeel Medical City, other specialties, such as Hepatobiliary and Urology, have already completed their training and started robotic surgeries. We currently have over 10 surgeons from different specialties, and other hospitals in the Burjeel group, in training. Robotic systems can be used for many specialties that carry out complex, minimally invasive procedures, such as thoracic, bariatric, colo-rectal surgeries. In the future, I would like to set up a training fellowship in gyn-oncology surgery, with robotic surgery included.