Robotic-Assisted Total Laparoscopic Hysterectomy Versus
Conventional Total Laparoscopic Hysterectomy
Abraham R. Shashoua, MD, Diana Gill, MD, Stephen R. Locher, MD
Objectives: To compare patient characteristics, operative
variables, and outcomes of 24 patients who underwent
robotic-assisted total laparoscopic hysterectomy (TLH)
with 44 patients who underwent conventional TLH. We
retrospectively reviewed the charts of 44 patients with
TLH and 24 patients with robotic TLH.
Results: Robotic TLH was associated with a shorter hos-
pital stay (1.0 vs 1.4 days, P?0.011) and a significant
decrease in narcotic use (1.2 vs 5.0 units, P?0.002). EBL
and drop in hemoglobin were not significantly different.
The operative time was significantly longer in patients
P?0.027). However, only need for laparoscopic morcel-
lation, BMI, and uterine weight, not robotic use, were
independently associated with increased operative times.
Conclusions: Robotic hysterectomy can be performed
safely with comparable operative times to those of con-
ventional laparoscopic hysterectomy. Postoperative mea-
sures were improved over measures for conventional
Key Words: Hysterectomy, Laparoscopic hysterectomy,
Laparoscopy, Minimal invasive surgery, Robotic surgery.
Every year about 600,000 hysterectomies are performed in
the United States, the majority of them via laparotomy.1
The introduction of advanced laparoscopic technology
made total laparoscopic hysterectomy more feasible. Con-
ventional laparoscopy however has its limitations. Limited
dexterity, range of movement, 2-dimensional vision, and a
slow learning curve make complex surgical tasks difficult.
As a result, many physicians are deterred from utilizing a
laparoscopic approach to hysterectomy, especially in pa-
tients with larger uteri, obesity, and prior surgery.
Robotic surgical systems attempt to improve the short-
comings of conventional laparoscopy. In 2002, the first
small case series on robotic-assisted total laparoscopic
hysterectomy (TLH) was published.2While data suggested
safe use of the techniques in humans, operative times
ranging from 4.5 hours to 10 hours and an estimated
blood loss of 50 mL to 1500 mL made it seem unaccept-
able for routine clinical use.2With improved robotic sys-
tems however, operative times improved significantly.
Reynolds and Advincula3performed robotic-assisted lapa-
roscopic hysterectomy on 16 patients in 2006 with a mean
operating time of 242 minutes and estimated blood loss of
50 mL to 300 mL.
In 2005, the FDA approved robotic surgical systems for
gynecologic applications. Since then, an increasing num-
ber of case reports have demonstrated the safety of robot-
ic-assisted laparoscopic hysterectomy and several other
gynecologic procedures.4Often criticized are high costs
and still longer operating times associated with robotic-
assisted procedures. Payne and Dauterive5demonstrated
a difference in operative times between robotic-assisted
TLH and conventional TLH of only 27 minutes with a
conversion rate to laparotomy of 0% compared with 11%
with the conventional approach. With a mean robotic
docking time of only 2.9 minutes, Kho6demonstrated an
operative time of 122 minutes in 91 patients operated on
between 2004 and 2005.
With operative times approaching those of conventional
laparoscopy, the robotic approach became more feasible
for routine clinical use. Increased precision, 3-dimen-
sional vision and faster learning curves are possible ad-
Advocate Illinois Masonic Medical Center, Department of Obstetrics and Gynecol-
ogy, Chicago, Illinois, USA (all authors).
Address reprint requests to: Abraham Shashoua, MD, Director of Minimally Inva-
sive and Robotic Gynecologic Surgery, Assistant Professor of Obstetrics and Gy-
necology, University of Illinois at Chicago, Advocate Illinois Masonic Medical
Center, 3000 N Halsted St, Ste 405, Chicago, IL 60657, USA. Telephone: (773)
296-7300, Fax: (773) 296-7390, E-mail: email@example.com
We would like to thank Nancy Davis, MA-Director of Research Services-Advocate
Health Care- for assisting us with the data analysis.
© 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
vantages that might enable more providers to offer a
laparoscopic approach to a broader patient population
with more advanced pathology. This could ultimately lead
to decreasing numbers of total abdominal hysterectomies.
The goal of our study was to compare the patient charac-
teristics, operative variable, and outcomes of 24 patients
who underwent robotic-assisted total laparoscopic hyster-
ectomy (TLH) with 44 patients who underwent conven-
tional TLH. We wanted to demonstrate that robotic-as-
sisted TLH could be performed with similar operating
times and comparable outcomes, especially in more chal-
MATERIALS AND METHODS
The study was approved by the AIMMC and the Macneal/
Weiss IRB by expedited review.
Forty-four consecutive woman who underwent total lapa-
roscopic hysterectomy between January 2003 through
May 2005 were compared with 24 consecutive women
who had robotic-assisted TLH between May 2005 and
November 2007. The cases were performed at Advocate
Illinois Masonic Medical Center (AIMMC), Chicago and
Weiss Memorial Hospital, Chicago. All cases were per-
formed by the same surgeon, assisted by OB/GYN resi-
dents from AIMMC with different levels of training. The
total laparoscopic hysterectomies were performed with a
12-mm camera port and three 5-mm operative ports. The
surgical technique used was similar to that previously
described by Koh.7The da Vinci Robotic Surgical System
(Intuitive, Inc., Sunnyvale, CA) was used for all robotic-
assisted procedures. A 12-mm camera port, 5-mm assistant
port, and 3 working 8-mm robotic ports were utilized.
Data were collected via retrospective chart review. Ex-
cluded were laparoscopic-assisted vaginal hysterectomies,
laparoscopic supracervical hysterectomies, and cases with
concomitant sacral colpopexies. Additional other surger-
ies performed at the same time were salpingo-oophorec-
tomies, hernia repairs, and mid urethral sling procedures.
These cases were noted but not excluded.
We compared the following preoperative and operative
variables between both groups: patient age, BMI, present
or absent history of prior abdominal or pelvic surgery,
uterine weight, additional other procedures performed,
type of morcellation if necessary, operative times, and
room time in the OR and EBL.
Postoperative factors investigated were length of stay,
drop in hemoglobin and number of parenteral narcotic
units needed for pain control. Parenteral narcotics used in
the 2 centers were intravenous or intramuscular injections
of morphine, Demerol or fentanyl. One narcotic unit was
defined as either 2 mg of morphine or 25 mg of Demerol
or 0.4mg of fentanyl.
Descriptive statistics (mean SD) for continuous data and
[N (%)] for categorical data were calculated on all patient
characteristics. Between groups (TLH vs robotic-assisted)
statistical comparisons were performed via independent t
test for continuous data, chi-square test or Fisher’s Exact
test for categorical data, and Mann-Whitney test for non-
parametrically distributed data. Bivariate correlations and
Forward Stepwise Multiple Regression was performed to
examine the effect of BMI, uterine weight, group and
other potential predictor variables, on the dependent vari-
able operative time. Predictor variables were selected a
priori by the investigators. A 3-tailed P level of 0.05 was
considered statistically significant in all analyses. Analyses
were performed with SPSS software (version 16.0, SPSS,
Indications for surgery are listed in Table 1. The 2 groups
were of similar age and BMI. More patients in the TLH
group than the robotic hysterectomy group had prior
surgery (Table 2). All cases were completed without
conversion to laparotomy. We did not encounter any
procedure-related operative complications. One patient
with conventional TLH was readmitted for vaginal cuff
dehiscence, which was repaired vaginally with the patient
Indications for Hysterectomy
Conventional Total Laparoscopic Hysterectomyn
Robotic Total Laparoscopic Hysterectomy
Pelvic pain/ adenomyosis
CA in situ of the cervix
under spinal anesthesia. One patient developed pneumo-
nia 2 weeks after robotic-assisted TLH (Table 3).
Robotic-assisted TLH was associated with a shorter hos-
pital stay (1.0 vs 1.4 days, P?0.05) and a significant de-
crease in narcotic use (1.2 vs 5.0 units, P?0.005) (Table
3). EBL and drop in hemoglobin were not significantly
different in both groups. The operative time was signifi-
cantly longer when robotic-assisted TLH was performed
(142.2 vs 122.1 minutes, P?0.05). The total room time was
also longer in the robotic arm (185.7 vs 161.7 minutes,
P?0.5). The uterine weight was higher in patients who
underwent robotic-assisted TLH, but did not reach statis-
tical significance (212.1 g vs 170.4 g, P?0.120). A higher
number of patients undergoing robotic hysterectomy had
laparoscopic morcellation (23.1% vs 2.3%, P?0.010) (Ta-
ble 4). The relationship between operative time and BMI
is shown in Figure 1. The relationship between operative
time and uterine weight is shown in Figure 2.
Multiple linear regression analysis was performed. We
found that laparoscopic morcellation, a higher uterine
weight, and a larger BMI were independently associated
with longer operative times (Table 5). After controlling
for these 3 variables, robotic assistance was no longer
associated with increased operative times.
Robotic-assisted TLH can be performed safely, with ac-
ceptable operative times even in challenging patients.
Average uterine weight and BMI were considerably
greater in our series than in those recently published.3,4,5,6
Despite this, average operative time compares favorably
with operative times in previous reports. Within our se-
ries, need for laparoscopic morcellation, uterine size, and
BMI were independently associated with longer operative
times. After controlling for these factors, robotic assistance
was no longer associated with longer operative times.
Postoperative outcomes were improved with robotic as-
We demonstrated a decrease in length of stay and paren-
teral narcotic use, while EBL and complication rate were
equally low in both groups. While decreased pain associ-
ated with robotic surgery has been reported previously, it
is unclear how this benefit is achieved. In this review, it is
possible that physician experience with surgical tech-
nique improved over time. It is also possible that reduced
tissue destruction with robotic dissection improves post-
The difficulty of robotic surgery in obese patients has
previously been reported. Herman et al8showed that
increasing BMI negatively impacted operative time, blood
loss, and positive surgical margin rate in men undergoing
radical prostatectomy. Multiple factors may account for
the difference in operative time we experienced with
increasing BMI. Bowel retraction, limitation of Trendelen-
burg positioning, and limited vaginal access may all con-
tribute to increased operative time.
TLH* (n ? 44) Robotic TLH*
*TLH?total laproscopic hyateretomy; BMI?body mass index.
†Ind. t test.
MeansTLH*Robotic TLH* P Value
Length of stay (days)
Hgb* drop (g/dL)
Narcotic use (Units)
1 (cuff dehiscence)
*TLH?total laparoscopic hysterectomy; Hgb?hemoglobin.
‡Ind. t test.
Robotic-Assisted Total Laparoscopic Hysterectomy Versus Conventional Total Laparoscopic Hysterectomy, Shashoua AR et al.
Several challenges are also present with larger uteri. Port
positioning and the ability to limit instrument exchanges
are compromised in the presence of a large uterus. Addi-
tionally, vaginal removal of the specimen is difficult when
the specimen is ?150 grams. In patients undergoing tra-
ditional total laparoscopic hysterectomy, our preference
was to vaginally morcellate the specimen. Robotic surgery
limits visualization for morcellation and may require un-
docking the robot to safely remove the specimen vagi-
nally. This may have led to a greater utilization of laparo-
scopic morcellation in this series.
Our study has some limitations. It is a retrospective review
of a small number of patients. Procedure time may be
impacted by the experience of the operating room staff, a
factor not taken into account in our review. In addition, as
with other series published on robotic surgery,3,4,5,6the
primary surgeon had extensive experience with advanced
laparoscopy prior to implementing robotics. As robotic
surgery gains popularity, further studies are needed to
TLH* Robotic TLH*P Value
Uterine weight (g)
Operative time (min)
Room time (min)
*TLH?total laparoscopic hysterectomy; EBL?estimated blood loss.
†Ind t test.
Figure 1. Operative times (min) with increasing body mass
Figure 2. Operative times (min) with increasing uterine weight
examine operative times, learning curve, costs and clinical
outcomes for less experienced surgeons.
We do not believe laparoscopic or robotic hysterectomy
should replace conventional vaginal hysterectomy. Dur-
ing the study period, vaginal hysterectomy was utilized
when indicated. As with any new technology, however,
there is opportunity for overutilization of robotic surgery
as the approach is learned, with a reduction in the number
of vaginal hysterectomies performed. While more costly,
outcomes for laparoscopic and robotic hysterectomy are
similar to costs for vaginal hysterectomy. A Cochrane
review of surgical approaches to hysterectomy9found no
evidence for a benefit of one technique over the other. A
recent randomized prospective trial comparing laparo-
scopic and vaginal hysterectomy showed a shorter hospi-
tal stay, less blood loss, and less postoperative pain in the
Adoption of new technology is potentially costly to the
healthcare system, but cost alone should not limit the use
of new technologies. Determining return on investment
for a hospital’s robotic system is complicated. Multiple
issues affect cost and revenue including operative time,
length of stay, disposable instrument use, complication
rate, payer mix, and payer contracting. Many hospitals
now consider a robotic surgical system a sunk cost, or an
unrecoverable cost of business, and do not include the
capital outlay in the cost analysis of the hospital’s robotic
program. Certainly, if the capital outlay for a robotic sys-
tem is included in determining cost of procedure, the cost
of robotic hysterectomy increases significantly.
Based on our experience with robotic surgery, we believe
patients should be counseled individually on mode of
hysterectomy. The indication for surgery, uterine weight,
patient weight, previous surgeries, uterine descent,
known pelvic adhesive disease or significant endometri-
osis should be taken into account when considering the
surgical plan. We currently use robotic surgery for hyster-
ectomy in patients who are not good candidates for vag-
inal hysterectomy, and in whom the likelihood exists for
significant pelvic adhesive disease or significant endome-
triosis. We also perform robotic hysterectomy for patients
undergoing concomitant sacral colpopexy. We recom-
mend total laparoscopic hysterectomy in patients who are
not good candidates for vaginal hysterectomy and have
pelvic pain as the indication for surgery. In patients with
larger uteri that may require morcellation, we prefer tra-
ditional total laparoscopic hysterectomy over robotic hys-
terectomy. Further study is needed to validate this deci-
Multiple issues regarding the utilization of robotics in
gynecology remain. Short- and long-term patient out-
comes need to be further evaluated with randomized
prospective trials. Surgical costs, taking into account post-
operative variables, need critical review. Robotic surgical
systems can facilitate a minimally invasive approach in
very challenging surgical candidates who traditionally
would have undergone abdominal hysterectomy. Ran-
domized controlled trials evaluating this hypothesis are
needed. Of concern are also issues related to resident
training and the potential decline in vaginal hysterecto-
mies with routine introduction of robotics. Further studies
are needed to address these questions.
Robotic hysterectomy is safe. Operative times were rea-
sonable, even in challenging cases. The use of robotics
was not associated with longer operative times than tra-
ditional laparoscopy. In addition, we demonstrated a
shorter hospital stay and reduced narcotic use in patients
undergoing robotic-assisted TLH.
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Reynolds RK, Advincula AP. Robot-assisted laparoscopic
Multiple Linear Regression Analysis Model Summary
ModelR R Square Adjusted R
Standard Error of
*Predictors: (Constant), Laparoscopic Morcellation
†Predictors: (Constant), Laparoscopic Morcellation, Uterine
weight in gram
‡Predictors: (Constant), Laparoscopic Morcellation, Uterine
weight in gram, Body Mass Index
§With R square value of .529, the model explains 52.9% of the
difference in operative time. P value ? .001.
Robotic-Assisted Total Laparoscopic Hysterectomy Versus Conventional Total Laparoscopic Hysterectomy, Shashoua AR et al.