Hysterectomy is the second most common surgery performed on women after cesarean section. The advantages of minimally invasive hysterectomy such as reduced hospitalization, quick recovery with more rapid return to normal activities, and less postoperative morbidity are well known. Although most guidelines recommend that minimally invasive hysterectomy should be the standard of care, the gynecologists have been slow in adopting minimally invasive laparoscopic techniques to perform this operation. Since its approval in 2005 for gynecological surgeries, robot-assisted hysterectomy has been found to be feasible and safe both in benign and malignant indications. This significant difference is mainly due to ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional magnified vision. The specific indications for hysterectomy where the robotic technology can benefit women are the ones with adhesions such as severe endometriosis, large uterus with large or multiple fibroids, early carcinoma cervix, and/or endometrial carcinoma. However the main benefit of this procedure was seen in the reduction of open surgery including conversions during laparoscopic hysterectomies. In the long run, we need to critically examine the long-term benefits and appropriate indications for robot-assisted hysterectomy especially in benign conditions, thus reducing the incidence of open surgery in gynecology. This review describes the operative procedure of robotic hysterectomy in eight steps.

1. Robotic hysterectomy: A review of indications, technique,
outcome, and complications

2. Review Article
Robotic hysterectomy: A review of indications,
technique, outcome, and complications
Rooma Sinha a,
*, S. Madhumati a
, Rupa Bana b
, Fozia Jeelani b
,
Samita Kumari c
a
Senior Consultant, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India
b
Senior Registrar, Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India
c
Resident (DNB), Department of Obstetrics and Gynecology, Apollo Health City, Hyderabad, Telangana, India
1. Introduction
Hysterectomy is the second most common surgery performed
on women after cesarean section, and most are done for benign
condition. Harry Reich was the first to describe laparoscopic
hysterectomy in 1989, 50% are still conducted by open method.
The gynecologists have been slow in adopting minimally
invasive technique to perform this operation. Both the Ameri-
can Association of Gynecologic Laparoscopists (AAGL) and the
American Congress of Obstetricians and Gynecologists (ACOG)
issued statements that minimally invasive hysterectomy
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 9
* Corresponding author at: A 402, Aparna Towers, Kondapur, Hyderabad 500084, Telangana, India. Mobile: +91 9849008180.
E-mail addresses: drroomasinha@hotmail.com, drsanjaysinha@hotmail.com (R. Sinha).
a r t i c l e i n f o
Article history:
Received 14 May 2015
Accepted 14 May 2015
Available online 15 June 2015
Keywords:
Hysterectomy
Robotic hysterectomy
Laparoscopic hysterectomy
Endometriosis
Fibroid
a b s t r a c t
Hysterectomy is the second most common surgery performed on women after cesarean
section. The advantages of minimally invasive hysterectomy such as reduced hospitaliza-
tion, quick recovery with more rapid return to normal activities, and less postoperative
morbidity are well known. Although most guidelines recommend that minimally invasive
hysterectomy should be the standard of care, the gynecologists have been slow in adopting
minimally invasive laparoscopic techniques to perform this operation. Since its approval in
2005 for gynecological surgeries, robot-assisted hysterectomy has been found to be feasible
and safe both in benign and malignant indications. This significant difference is mainly due
to ergonomics, endowrist movements of instruments, and stereoscopic three-dimensional
magnified vision. The specific indications for hysterectomy where the robotic technology
can benefit women are the ones with adhesions such as severe endometriosis, large uterus
with large or multiple fibroids, early carcinoma cervix, and/or endometrial carcinoma.
However the main benefit of this procedure was seen in the reduction of open surgery
including conversions during laparoscopic hysterectomies. In the long run, we need to
critically examine the long-term benefits and appropriate indications for robot-assisted
hysterectomy especially in benign conditions, thus reducing the incidence of open surgery
in gynecology. This review describes the operative procedure of robotic hysterectomy in
eight steps.
# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.05.014
0976-0016/# 2015 Published by Elsevier B.V. on behalf of Indraprastha Medical Corporation Ltd.

3. should be the standard of care.1,2
The slow adoption of
minimally invasive hysterectomy techniques among practicing
obstetrician-gynecologists is mainly due to conventional
‘‘straight-stick’’ laparoscopic skills requiring long learning
curve along with insufficient laparoscopic training and expo-
sure during their residency program.3
So when FDA approved
robotic technology for hysterectomy in 2005, the incidence of
minimally invasive hysterectomy was expected to rise with 3-
dimensional optics, wrist like motion with robotic instruments,
and shorter learning curves than traditional laparoscopy for the
surgeons.4
The advantages of minimally invasive hysterectomy
are well known such as reduced hospitalization, quick recovery
with more rapid return to normal activities, and less postoper-
ative morbidity.2
These advantages have been also shown in a
meta-analysis, comparing total laparoscopic hysterectomy
(TLH) with total abdominal hysterectomy (TAH). These advan-
tages are reduction in morbidity—specifically, fewer periopera-
tive morbidity and complications, lower estimated blood loss,
and shorter hospital stay.5
2. Indication of robotic hysterectomy
Hysterectomy for any benign indication can be performed with
robotic assistance. It has its application in gynecological
oncology, especially in early cervical carcinoma and endome-
trial carcinoma. However, choosing the route of hysterectomy
in benign cases is important. Vaginal hysterectomy especially
non-descent vaginal hysterectomy (NDVH) is the ultimate
minimally invasive method of performing hysterectomy.
There is no doubt about that. Laparoscopic or robotic
hysterectomy should not replace vaginal hysterectomy.
Minimally invasive techniques become crucial in situations
where NDVH is not feasible or is contraindicated. In today's
era, surgical situation that pose difficulty in performing
hysterectomy via a laparoscope like pelvic adhesive disease
or significant endometriosis, the robotic assistance is of great
value and should be used where available to avoid open
surgery and its associated morbidity. Robotic hysterectomy is
also a good option in patients who need concomitant sacral
colpopexy. The route of hysterectomy is often influenced by
uterine weight and size, previous surgeries, pelvic adhesions
or endometriosis, and presence of uterine descent as well as
the body habitus and BMI of the patient. Landeen et al. carried
out a retrospective study of 1474 hysterectomies, comparing
four techniques: abdominal, vaginal, conventional laparos-
copy, and robotically assisted laparoscopy. Their analysis of
this study showed reduced blood loss and hospital stay with
robotic surgery (P < 0.0001), and higher overall complication
rate with the laparotomy (14%). However, the rate of
complications was lowest with the vaginal hysterectomy.
The conversion to open surgery is four-fold higher with the
laparoscopic technique.6
3. Hysterectomy and robotic assistance
The da Vinci Robotic Surgical System (Intuitive Surgical) is an
advanced laparoscopic-assisted surgical system that can
address many of the current limitations of conventional
laparoscopy. It is a logical next step in performing minimally
invasive gynecological surgeries, and is only the beginning of
numerous advances in the field of gynecological surgeries in
the future.
It has 3 components. The first component of the da Vinci
system is the vision cart. It has vision system that provides 2-
dimensional imaging through a 12-mm, dual optical endo-
scope. The endoscope has 2 telescopes that gives a 3D vision to
the surgeon on the console. The second component of the da
Vinci system is the patient-side cart with robotic arms and
endowrist instruments. Most da Vinci system now has
provision for 3 robotic arms in addition to the arm that is
docked to the camera port. Whether to use two or three
instruments will depend on the surgeon's decision depending
on the case profile. The third component is the surgeon
console that is located away from the patient bedside but in
the same operating room. The surgeon seated at this console,
with the help of masters can control instruments that are
inserted via the 8 mm ports into the patient's abdomen. This is
aided by the surgeon's 3D view with the aide of a stereoscopic
viewer. The surgeon console has additional foot pedals for
energy sources, camera adjustment, and a swapping mecha-
nism that helps the surgeon to control 3 instruments all by
herself. Thus, maneuvers such as lysis of adhesions, suturing,
and knot tying are easier due to wristed movements of the
instruments and magnified vision, thus providing unique
advantages over 2D straight stick approach of standard
laparoscopy.
4. Selection of cases for robotic hysterectomy
Three situations that often tip the balance towards open
surgery are presence of severe adhesions, large uterus, and
malignancy. In all these three situations robotic assistance can
help overcome the surgical challenges and reduce incidence of
open surgery thus reducing the post operative morbidity.
Advanced scarring of the pelvis poses challenges to hyster-
ectomy by any route. Especially, when attempted by minimally
invasive hysterectomy with conventional laparoscopic equip-
ment, the altered anatomy poses technical limitations and the
conventional laparoscopic surgical skill limits the ability to
compensate for the altered anatomy. Hysterectomy for the
larger uterus is also difficult by minimally invasive method.
This is true for both laparoscopic surgery as well as robotic
assisted surgery, and to our experience is the most challeng-
ing. Port positioning is tricky, the ability to maneuver
instruments is compromised in the presence of a large uterus.
Moreover, vaginal removal of the specimen is difficult, when
the specimen is >150 g and often requires morcellation.
5. Special situations suitable for robotic
assisted hysterectomy
5.1. Endometriosis
Conventional laparoscopy in endometriosis is a challenging
task due to the complexity of pelvic dissection. The adhesive
nature of the disease with obliteration of the surgical planes
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 992

4. makes dissection and ability to remove all endometriotic
implants difficult. Added to this is the variability of surgical
skill levels of surgeons. The straight stick laparoscopy limits
the surgeons from reaching the corners of the pelvis to
complete the surgery. Robotic endowrist instruments simulate
the normal mechanics of the human hand and is of great
advantage in such situation along with the 3-dimensional
visualization. Decreased surgeon's fatigue and hand tremors
help in improving surgical precision. Eight international
clinical centers participated in a study including 164 women
from November 2008 to April 2012, with stage IV endometriosis
who underwent robotic-assisted laparoscopy. Patients were
divided into 4 groups according to the localization of the
nodule(s): rectum (n = 88), bladder (n = 23), ureter and uter-
osacral ligaments (n = 115), and on uterus in case of hyster-
ectomy (n = 28). In the rectal nodule group, one laparotomy
conversion, 2 cases needed suturing for rectal injuries. In the
bladder group, one vesicovaginal hematoma and one case with
prolonged intermittent self-catheterization were reported. In
the ureter and uterosacral ligaments group, there were 2
ureteral fistulas. The hysterectomy group did not report any
complication. This is one of the largest series published in the
literature on robotic-assisted laparoscopy for deep infiltrating
endometriosis. Robotic-assisted laparoscopy in deep infiltrat-
ing endometriosis appears to be a feasible option with no
increase in surgical time, blood loss, and intra- and postoper-
ative complications.7
5.2. Previous surgery
Dense adhesions are often encountered in cases with multiple
previous surgeries such as cesarean sections, myomectomy,
and hysterotomy. This is a common reason for surgeons to
convert their surgeries to laparotomy. A series of six patients
with suspected pelvic adhesive disease involving the anterior
cul-de-sac, who underwent robot-assisted laparoscopic
hysterectomy were reported by Advincula. All the cases were
for benign indications, and none were converted to laparoto-
my. The average length of hospital stay was 1.3 days. They
concluded that robot-assisted laparoscopic hysterectomy is a
feasible technique in patients with a scarred or obliterated
anterior cul-de-sac, and may provide a tool to overcome the
surgical limitations seen with conventional laparoscopy.8
Chiu
published a series of 216 patients, robotic total hysterectomy
in 88 and laparoscopic total hysterectomy in 128. For cases
with severe adhesions (adhesion score greater than 4), robotic
surgery was associated with a less operation time (113.9
Æ 38.4 min versus 164.3 Æ 81.4 min, P = 0.007) and reduced
blood loss (187.5 Æ 148.7 mL versus 385.7 Æ 482.6 mL, P = 0.044)
compared with laparoscopy. Additionally, robotic group had
lower postoperative pain, and this was found to be indepen-
dent of adhesion score or uterine weight. Comparing to
laparoscopic approach, robotic surgery is a feasible and
potential alternative for performing total hysterectomy with
severe adhesions.9
5.3. Large uterus
Multiple fibroids or large adenomyotic uterus presents
challenges due to its large size that tends to occupy the pelvis
leaving little space for movement of instruments. With the use
of robotic platform, the surgeon's ability to manipulate and
control the third arm by herself is of great advantage in such
situations. This manipulation helps to reach the corners in the
pelvis and access tissues and planes that would have been
difficult with straight stick laparoscopic instruments. A
multicenter study was done in five community practice
settings across the United States. 256 patients who had
hysterectomy with robotic assistance from March 2006 to July
2009 and uterine weights of at least 250 g were included. The
study concluded that robotically assisted hysterectomy with
low morbidity was successful in this population with large
uteri with low blood loss, and minimal risk of conversion to
laparotomy. Results were reproducible among general gyne-
cologists from geographically diverse community settings.10
5.4. Early carcinoma of cervix
Skills to perform robotic radical hysterectomy can be acquired
not only in a shorter time but also by a larger number of
surgeons who perform open radical hysterectomy and
encounter difficulties with conventional laparoscopy. Thus,
converting open surgery to minimally invasive surgery offers a
means to decrease the morbidity associated with endometrial
cancer surgery. The first published report regarding robotic
radical hysterectomy was in 2006.11
Sert et al. initially
described the feasibility of robotic-assisted laparoscopic
radical hysterectomy in 2007 for early stage cervical carcinoma
cases. They reported better results than with traditional
laparoscopic radical hysterectomy in 15 patients with early-
stage cervical carcinoma as a pilot case-control study at a
comprehensive cancer center-university teaching hospital
setting.12
Subsequently in 2008, Ramirez reported a series of
5 cases with invasive squamous cell carcinoma of the cervix.
One patient in their series experienced two postoperative
complications, a vesicovaginal fistula and a lymphocyst
formation post-operatively. These are complications known
to radical hysterectomy procedure and cannot be attributed to
the robotic technology alone. However, no patient had residual
tumor as well as no patient underwent adjuvant therapy, but
in the average follow-up of 7.5 months, there were no
recurrences.13
Nerve-sparing radical hysterectomy by use of
robotic assistance is a feasible approach for the treatment of
cervical cancer patients, due to ergonomics and articulated
movements of endowrist instruments and image magnifica-
tion. These features contribute for correct identification and
preservation of the pelvic anatomy in terms of innervation,
reducing the risk of postoperative neurological sequelae.
5.5. Carcinoma of the endometrium
Veljovich in 2008 published a case series of 118 patients
underwent robotic surgery for endometrial carcinoma and
compared their results with open surgery for the same
indication. Patients who underwent robotic surgery had shorter
length of stay (40.3 h versus 127 h, P < 0.0001) with comparable
node yields (17.5 versus 13.1, P = 0.1109). 8 patients in the robotic
group had major and 13 minor complications. They concluded
that robotic surgery is feasible in gynecologic oncology. Despite
longer operative times, estimated blood loss and length of stay
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 9 93

5. are reduced and lymph node yields are comparable.14
Using a
prospective protocol, Pearson et al. performed robot assisted
laparoscopic radical hysterectomy and pelvic lymphadenecto-
my on 80 women. All tumors were radically removed. Median
number of retrieved lymph nodes was 26 (range 15–55). Five
women needed resuturing for vaginal cuff dehiscence, two
womenwerere-operatedfortrocarsitehernias,andonewoman
had a ureteric stricture that resolved following stent treatment.
43 of eligible 46 women (93%) had a long-term follow-up (> or
=12 months). They concluded that though this technique was
feasible, effort should be made to ensure proper closure of the
vaginal cuff, trocar sites, and to develop nerve-sparing
techniques.15
Various studies have consistently reported that
the number of lymph nodes retrieved is similar in the range
between 17 and 32 for the robotic cohort and 16–23 for the
laparoscopic cohort.16–18
6. Operative technique
6.1. Preoperative preparation
Preoperative preparation is of importance and can help in
successful completion of the procedure. There is no evidence
to use mechanical bowel preparation routinely, and we do not
recommend it either. The patients will be advised clear liquid
diet a day before and two tablets of Bisacodyl (Dulcolax®
) in the
night before surgery for clearing their bowels. Use of charcoal
tablets on the night before the surgery helps to deflate the
bowels for visualization, and is also part of our preoperative
protocol. The patients will be advised to remain nil by mouth
for 6 h prior to surgery. All the patients are screened for any
preoperative use of blood thinners and medical conditions
that need to be addressed before surgery. All the patients are
given antibiotic prophylaxis preoperatively.
6.2. Anesthesia and patient positioning
After induction of general anesthesia with endotracheal tube,
the patient is positioned in the dorsal lithotomy position with
buttock just off the table. The arms are tucked to the side and
secured in neutral position with the thumb pointing up. This
is done so that the arms do not slip during surgery nor do they
obstruct the movement of robotic arms. The chest of the
patient is strapped to avoid slipping when the patient is finally
positioned in Trendelenburg position. Some form of protec-
tion of the face is usually done, and this can be done with the
help of foam. The stomach is not routinely decompressed
with a nasogastric tube but if the uterus is large, and the
primary port needs to be put above the umbilical level, then
we prefer to do this.
6.3. Uterine manipulation
The bladder is drained with a Foley catheter, and is placed
in situ. There are various types of manipulators available, and
can be chosen according to individual surgeon's choice. We
prefertouse RUMIuterinemanipulator (Cooper Surgical), which
is placed with a Koh colpotomy ring and vaginal pneumo-
occluder balloon for uterine manipulation, which is done by the
assistant at the vaginal end. Good access to this area by the
second assistant is important and needs special attention.
Hence, we position our patient cart to the right side, parallel to
the operation table to keep the vaginal access free. An expert
assistant for uterine manipulation can make hysterectomy
simple and safe. When needed, the bedside assistant addition-
ally provides traction or manipulation by using a myoma screw
or laparoscopic forceps from the 5 mm port.
6.4. Trocar placements and docking
We introduce our primary trocar (12 mm) with open method
and the intraperitoneal position checked by pressure in
pneumo-insufflator (<5 mm). Direct introduction of the
camera through the primary trocar can also confirm intraperi-
toneal position of the primary trocar before we proceed with
other 8 mm port placements. We choose 12 mm extra long
(Ethicon) trocar; the extra length is important for docking of
the camera arm as the subcutaneous fat at times can be up to
2 in. The 12-mm trocar is placed 2–5 cm above umbilicus, the
location of this depends on several factors – upper level of the
uterus, previous surgical scars, or any previous mesh repair.
Two 8-mm robotic trocars are placed bilaterally: 10 cm lateral
to and anywhere between 3 and 6 cm above the anterior
superior iliac spine. This can at times be even at the level of the
umbilicus if the size of uterus is large. The 8 mm trocars are
classically placed with one on the left of the patient and 2 on
the right. An accessory 5-mm trocar is placed in the left upper
quadrant. Monopolar scissors is inserted through the right
upper 8 mm port (arm 1); a prograsp through the right lower
8 mm port (arm 3) and a fenestrated bipolar dissecting forceps
was inserted through the left 8 mm port (arm 2).
6.5. Operative steps
The surgical team in the operating room consists of a console
surgeon, a bedside assistant, and a nurse standing on the left
side of the patient and a second assistant or a nurse at the
vaginal end of the patient for uterine manipulation. A 308
camera is used by our surgical team.
6.5.1. Eight steps
1. Survey of the pelvis and adhesiolysis: In the beginning, a survey
of the operative field is performed to understand the altered
anatomy. In cases where severe adhesions are expected, we
recommend ureteric catheters placement preoperatively.
The ureters are identified on both sides at the beginning of
the procedure. Adhesiolysis is begun from either left or right
side depending on the availability of surgical planes (Fig. 1).
In cases of dense adhesion of endometrioma to the lateral
pelvis wall, we try to lift the endometrioma from the lateral
pelvis wall but are always alert regarding the location of
ureter at this step. Also considered the crucial step as we
believe that once the lateral wall adhesions are released it is
easier to open the broad ligament after ligating the round
ligament and reach for the uterine artery.
2. Opening of the broad ligament – both sides: The surgery is
started with identification and transection of the round
ligament. This is achieved by cauterizing using the
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 994

6. fenestrated bipolar and cutting using the monopolar hot
shears.Oncethisisdone,thebroadligamentisopened,andis
dissected anteriorly and posteriorly. The anterior leaf of the
broad ligament is then dissected and incised towards the
bladder (Fig. 2). The traction at this point on the uterus is
provided by the prograsp in arm 3 and the uterine
manipulator inside the uterus. The infundibulopelvic liga-
ment is then identified, cauterized with bipolar, and cut with
hot shears where ovaries are being removed. At this step, it is
essential to identify the ureters on the same side. If the
ovaries are to be conserved, then the utero-ovarian ligament
is cauterized, and cut using bipolar forces and hot shears.
3. Vesico-uterine reflection: The anterior leaf of the broad
ligament is completely incised from both sides up to the
vesico-uterine fold anteriorly (Fig. 3). The vesico-uterine
reflection is tented up using the prograsp in arm 3; hot
shears in arm 1 and the bipolar in arm 2 are used to dissect
bladder gently but sharply off the uterus and cervix. By
doing this step, the colpotomy ring (Koh ring) is adequately
visualized. Cases where the anterior cul-de-sac adhesions
are encountered or there is scarring of the vesico-uterine
reflection, the bladder was filled with 100 mL of methylene
blue stained saline to facilitate dissection.
4. Uterosacral ligaments transection: The uterosacral ligaments
are coagulated and transected bilaterally after anteverting
the uterus. The uterine manipulator is often sufficient at this
step (Fig. 4). If the uterus is large as in the case of multiple
fibroids or the posterior pouch has adhesions, then the use of
prograsp to push the uterus anteriorly is irreplaceable.
5. Ligation of the uterine vessels on both sides: Upward push by the
assistant at the step of uterine artery coagulation ensures
that the distance between the uterine artery and ureter is at
least 2 cm preventing its damage. Adequate skeletonization
of the uterine arteries ensures sufficient lateral displace-
ment of the ureters. The uterine arteries are coagulated
using the bipolar and cut with the shears (Fig. 5). Coagula-
tion of the ascending branch of the uterine artery reduces
backflow of blood making surgery at the level of Mack-
enrodt's ligament safer and neater.
6. Colpotomy: Anterior and posterior colpotomy is facilitated
by the Koh colpotomy ring, while upward uterine traction is
provided by the vaginal assistance as well as with the help
of prograsp in the arm 3 (Fig. 6). The same upward push at
and at the level of vaginal cuff incision pushes the ureter
and bladder laterally, hence reducing the chances of
ureteric injury. Colpotomy can begin either anteriorly,
posteriorly, or from the lateral angles, but all depends
on the anatomy encountered or sometimes the
surgeon's comfort. After colpotomy the uterus is extracted
vaginally.
[(Fig._1)TD$FIG]
Fig. 1 – Step 1: Survey of pelvis and adhesiolysis.
[(Fig._2)TD$FIG]
Fig. 2 – Step 2: Opening of broad ligament.
[(Fig._3)TD$FIG]
Fig. 3 – Step 3: Dissection of vesico-uterine fold.
[(Fig._4)TD$FIG]
Fig. 4 – Step 4: Uterosacral ligament transection.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 9 95

7. 7. Vaginal cuff closure: Pneumoperitoneum is now maintained
by repositioning the inflated vaginal pneumo-occluder
balloon. Irrigation is done to check oozing any significant
bleeding is controlled. Excessive cautery for minimal oozing
should be avoided. The bipolar fenestrated and shears are
replaced with needle holders for vault suturing. At times we
only replace the hot shears in arm 1 with needle holder and
continue using the bipolar in arm 2 during suturing. It
serves two purpose – hemostasis during suturing can be
done easily, and it also economical. The vault is closed
using either 0-Vicryl or 1-0 V loc suture. The vault is closed
with continuous sutures (Fig. 7). The suture is passed
directly into the pelvis via the open vagina and retrieved by
the 5 mm assistant port using the same technique we use in
laparoscopic suturing. The needle is held about 3–4 cm from
the needle hub, and removed along with the trocar tract.
8. Survey of the pelvis: A low-pressure check as well as
underwater check is performed for ensuring hemostasis,
and the robotic arms are undocked after removing the
instruments under vision (Fig. 8). The abdomen is deflated,
and the primary trocar site is repaired using 1-0 Vicryl. The
rate of bowel herniation at the 12 mm bladeless trocar sites
has been reported to be 0.7%; hence attention to the closure
of this port is warranted.
7. Specimen retrieval
In cases with benign indications, we retrieve our specimen via
the vaginal route. If the specimen is large, then we fall back on
our long standing experience of NDVH, and the technique of
morcellation of the uterus will be used during this procedure.
The specimen can also be put in a bag and retrieved vaginally.
Procedures such as hemisection, intramyometrial coring,
wedge morcellation, and perhaps myomectomy can help in
retrieval of the specimen.19
At times to gain access to the
vagina, the robot has to be undocked, as one proceeds with
morcellation. In such situations, the vaginal opening is closed
vaginally by standard suturing.
[(Fig._6)TD$FIG]
Fig. 6 – Step 6: Colpotomy with Koh cup in view.
[(Fig._5)TD$FIG]
Fig. 5 – Step 5: Ligation of uterine vessel (right).
[(Fig._7)TD$FIG]
Fig. 7 – Step 7: Vaginal cuff closure.
[(Fig._8)TD$FIG]
Fig. 8 – Step 8: Survey of pelvis and checking for hemostasis
under water.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 996

8. 8. Robotic hysterectomy in contemporary
gynecological practice
Until 2005, although it had been approximately 40 years, since
the early publications of laparoscopic approach, most hyster-
ectomies are still performed through laparotomy. Only after
the introduction of robotic-assisted da Vinci platform, did the
rate of open surgery begin to decrease. An interesting
publication by Payne et al. compared cases of total laparo-
scopic hysterectomy to robotic assisted hysterectomy in a
community hospital. They did a retrospective analysis of 100
patients who underwent laparoscopic hysterectomy before
the robotic program, and 100 patients who underwent robotic
hysterectomy after the implementation of robotic program.
Overall the robotic group experienced longer operative
times by an average of 27 min. However, when compared with
the last 25 robotic cases laparoscopic group had longer
operative times. The mean blood loss in the pre-robotic group
was twice that of the robotic group. The mean length of
hospital stay was half a day longer in the pre-robotic group
than in the robotic group. The incidence of adverse events was
the same in both groups. The total number of exploratory
laparotomies in the pre-robotic group was significantly greater
than in the robotic group (11% versus 0%). The rate of intra-
operative conversions to total abdominal hysterectomy from
laparoscopy was approximately 2-fold higher in the pre-
robotic group as compared with the robotic group (9% versus
4%). The most important benefit of robotic hysterectomy
highlighted in this study is the reduction in conversion to open
surgery.20
As the robotic assisted surgery began to integrate
into clinical practice, robotic assisted hysterectomy increased
from 4.1% to 6.3% of all hysterectomies. This was mainly due to
the reduction in the rates of abdominal hysterectomy,
however the vaginal hysterectomy rates remained unchanged.
At present, numerous studies do not show any significant
difference between analgesic use and return to normal
activity. Robotic hysterectomy is associated with longer
operative time although the quality-of-life index was better.21
However, the main benefit of this procedure was seen in the
reduction of open surgery including conversions during
laparoscopic hysterectomies.
Analysis of the impact of robotic surgical system on
hysterectomy trends on 4440 women who underwent a
hysterectomy in a period of 5 years was published in 2015.
There were 3127 cases of benign gynecology, 1001 cases of
gynecologic oncology, and 312 cases of urogynecology. The
overall rate of hysterectomy performed via laparotomy de-
creased from 62.2% to 39.1% (P < 0.001). The rate of robotically
assisted hysterectomy increased from 0.0% to 26.4% (P < 0.001).
Re-analyzing the data for subspecialty the rate of radical
hysterectomy by a gynecologic oncologist via laparotomy
decreased from 89.7% to 20.0% (P < 0.001). The rate of robotically
assisted hysterectomy for general gynecologist increased from
0.0% to 78.3% (P < 0.001). Amongst urogynecologists, the rate of
hysterectomy performed vaginally decreased from 80.0% to
33.6%, P < 0.001, while the rate of robotically assisted hyster-
ectomy increased from 0.0% to 54.2%, P < 0.001.22
Luciano has published similar results in a recent publica-
tion. In the period of 2005–2010, of 289,875 hysterectomies,
abdominal cases decreased, and minimally invasive
approaches increased from 40% to 67%. Conversion rates
were 0.04% for vaginal, 2.5% for robotic, and 7.2% for
laparoscopy (P < 0.001).23
9. Complications
Intra-operative surgical complications like vessel injury,
bladder, or bowel injury are known, and may not be attributed
to robotic technology alone. Complication rates are different,
and expected to be higher for gynecologic oncologic surgeries
than that of benign gynecologic cases due to more dissection
and longer operating time. Early post-operative complications
such as febrile morbidity, leg pain or edema, leg weakness,
vaginal vault bleeding or infection can be seen. Additionally
problems like urinary tract infection, voiding difficulty or
hematuria are also encountered at times. Delayed complica-
tions that may present are leg weakness, voiding difficulty,
and hydronephrosis or urinary fistula. Two complications
require special mention – port site metastasis and vaginal
vault dehiscence.
10. Port-site metastasis
The reported incidence of port-site metastases in patients
undergoing laparoscopic surgery for malignant disease is
approximately 1–2%. Port-site metastasis is a known compli-
cation of minimally invasive laparoscopic or robotic surgery,
although it has been described less in robotic surgery. The
reasons for port-site metastasis are unclear. Even low risk
patients can develop port-site metastasis. Multiple factors
contribute to this complication. One of the proposed mecha-
nism of tumor implantation at the port site the leakage of
insufflation gas through the ports (chimney effect) along with
the impact of pneumoperitoneum can lead to port site
metastasis. Local immune reaction of the patient has
contributory effect in its development. Careful patient selec-
tion, modifications of surgical techniques, through lavage of
the peritoneal cavity are some of the preventive measures
suggested. Some reports of applying cytotoxic agents at port
wounds are also in the literature. Grabosch and Xynos
reported isolated port-site metastasis in two patients who
underwent robotic-assisted radical hysterectomy for low-
grade, early-stage, and endometrial carcinoma. Both patients
required resection followed by chemotherapy and radiation.24
11. Vaginal cuff dehiscence
Vaginal cuff dehiscence is an uncommon but potentially
morbid complication after hysterectomy. The patient may
present with vaginal bleeding and sudden watery discharge
after hysterectomy. Once the dehiscence takes place, there is
a direct communication between the peritoneal cavity and
the vagina. The abdominal or pelvic contents may extrude
through the vagina. The incidence of this condition as
reported in the literature is 0–7%, and is generally reported to
be higher after laparoscopic and robotic surgery when
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 9 1 – 9 9 97

9. compared to vaginal or abdominal approaches.25
The risk
factors are not clearly defined, and may include factors that
influence wound healing. Hematoma at the vault level can
cause primary healing defect. Overuse of electro cautery to
achieve maximal hemostasis causes extensive tissue necro-
sis leading to poor healing of the vaginal scar. An over
cauterized vaginal edge with small suture bites tends to cut
through vaginal edges, or as the suture loses its tensile
strength, partial separation of the vaginal cuff occurs, and
the patients present with vault dehiscence. Perhaps a less
hemostatic surgical bed ‘‘slightly juicy rather than bone dry’’
at the vaginal cuff level may be better. Some mechanical
factors such as early resumption of sexual activity, trauma,
and increased intra-abdominal pressure can also cause this
complication in the postoperative phase. Study published in
2015 suggests that the risk of dehiscence is influenced
mainly by the scope and complexity of the surgical
procedure. Different colpotomy techniques do not influence
the rate of cuff dehiscence. This study concludes that
continuous suturing of the cuff may be superior to inter-
rupted suturing.26
Prevention of the risk factors causing
vault dehiscence is the most important intervention for this
complication.
12. Single port robotic hysterectomy
The single port robotic procedures are in use in various
surgical specialties, and in the last few years and single port
robotic hysterectomy is also slowly gaining ground. It is an
attractive option for benign gynecology surgery, however
some studies have also shown feasibility of robotic single-
port pelvic lymphadenectomy as well. This system of
surgical intervention allows several ports to be introduced
into the abdomen via one central incision.27
The size of the
port is about 4 cm and fits through a 2 cm incision. Once this
scar heals, it is almost unnoticeable. The ergonomic limita-
tions of single-port laparoscopy are now overcome by
development of articulated or flexible instruments and
camera in the robotic system. Single port robotic technique
is useful in patients whose uterus is less than 16 weeks in
size. The proficiency with the steps of conventional robotic
hysterectomy helps in performing the same via a single port.
Arm collision and difficult mobilization of the uterus are
some of the drawbacks.
13. Conclusion
In the last 10 years, robotic technology has seen an increased
application especially in gynecological surgery. Robotic
assisted hysterectomy is feasible and safe both in benign
and malignant conditions.28
The most important contribution
of robotic surgery is the reduction in open hysterectomies both
as a primary procedure as well as in conversion rates. This
significant difference is mainly due to the ergonomics,
endowrist movements of instruments, and stereoscopic
three-dimensional vision. Robotic hysterectomy is safe,
however issues such as lack of haptic feedback and cost will
have to be addressed. So will abdominal hysterectomy become
an operation of historical interest? In the coming years, this
technology will find its place in clinical practice of minimally
invasive gynecology, but we need to critically examine the
long-term benefits especially in benign situations. However
one thing is certain; the number of minimally invasive
hysterectomies and myomectomies will increase. But we
need to critically examine the long-term benefits especially in
benign conditions, thus reducing the incidence of open surgery
in gynecology.
Conflicts of interest
The authors have none to declare.
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