Comparison of Perioperative Outcomes of Total Laparoscopic and Robotically Assisted Hysterectomy for Benign Pathology during Introduction of a Robotic Program.
ABSTRACT Study Objective. Prospectively compare outcomes of robotically assisted and laparoscopic hysterectomy in the process of implementing a new robotic program. Design. Prospectively comparative observational nonrandomized study. Design Classification. II-1. Setting. Tertiary caregiver university hospital. Patients. Data collected consecutively 24 months, 34 patients underwent laparoscopic hysterectomy, 25 patients underwent robotic hysterectomy, and 11 patients underwent vaginal hysterectomy at our institution. Interventions. Outcomes of robotically assisted, laparoscopic, and vaginal complex hysterectomies performed by a single surgeon for noncancerous indications. Measurements and Main Results. Operative times were 208.3 ± 59.01 minutes for laparoscopic, 286.2 ± 82.87 minutes for robotic, and 163.5 ± 61.89 minutes for vaginal (P < .0001). Estimated blood loss for patients undergoing laparoscopic surgery was 242.7 ± 211.37 cc, 137.4 ± 107.50 cc for robotic surgery, and 243.2 ± 127.52 cc for vaginal surgery (P = 0.05). The mean length of stay ranged from 1.8 to 2.3 days for the 3 methods. Association was significant for uterine weight (P = 0.0043) among surgery methods. Conclusion. Robotically assisted hysterectomy is feasible with low morbidity, a shorter hospital stay, and less blood loss. This suggests that robotic assistance facilitates a minimally invasive approach for patients with larger uterine size even during implementing a new robotic program.
- [Show abstract] [Hide abstract]
ABSTRACT: To analyse the steps taking place in the operating room (OR) before the console time starts in robot-assisted gynaecologic surgery and to identify potential ways to decrease non-operative time in the OR. Thirteen consecutive robotic cases for benign gynaecologic disease at the Department of Obstetrics and Gynecology at University of Texas Medical Branch (UTMB) were retrospectively reviewed. The collected data included the specific terms 'Anaesthesia Done' (step 1), 'Drape Done' (step 2), and 'Trocar In' (step 3), all of which refer to the time before the actual surgery began and OR charges were evaluated as level 3, 4, and 5 for open abdominal/vaginal hysterectomy, laparoscopic hysterectomy, and robot-assisted hysterectomy, respectively. The cost of the OR for 0-30 minutes and each additional 30 minutes were $3,693 and $1,488, $4,961 and $2,426, $5,513 and $2,756 in level 3, 4, and 5 surgeries, respectively. The median time for step 1 was 12.1 min (5.25-23.3), for step 2 was 19 (4.59-44) min, and for step 3 was 25.3 (16.45-45) min. The total median time until the actual operation began was 54.58 min (40-100). The total cost was $6948.7 when the charge was calculated according to level 4 and $7771.1 when the charge was calculated according to level 5. Robot-assisted surgery is already 'cost-expensive' in the preparation stage of a surgical procedure during anaesthesia induction and draping of the patient because of charging levels. Every effort should be made to shorten the time and reduce the number of instruments used without compromising care. (J Turk Ger Gynecol Assoc 2014; 15: 25-9).Journal of the Turkish German Gynecological Association. 03/2014; 15(1):25-29.
- [Show abstract] [Hide abstract]
ABSTRACT: Blood transfusions may be lifesaving, but they inherit their own risks. Risk of transfusion to benefit is a delicate balance. In addition, blood product transfusions purchases are one of the largest line items among the hospital and laboratory charges. In this review, we aimed to discuss the transfusion strategies and share our transfusion protocol as well as the steps for hospitals to build-up a blood management program while all these factors weight in. Moreover, we evaluate the financial burden to the health care system.The Eurasian Journal of Medicine. 02/2014; 46(1):47-49.
- [Show abstract] [Hide abstract]
ABSTRACT: Uterine fibroids (UF) are the most common gynecological tumors in premenopausal women. Hysterectomy remains the major and definitive therapeutic option. Minimally invasive surgical techniques for performing hysterectomy have many advantages over laparotomy. Current drug therapies for UF remain unsatisfactory. Unquestionably, continued investigation of novel agents is necessary. The currently used drugs for UF treatment which exclusively modulate a single target, typically either the estrogen or progesterone signaling pathways, are limited in their therapeutic effects. By contrast, multi-target drugs which simultaneously modulate multiple critical hubs in the network of the signaling pathways underlying UF pathogenesis should achieve robust and durable therapeutic effects.Journal of the Turkish German Gynecological Association. 04/2013; 14(1):40-45.
Hindawi Publishing Corporation
Obstetrics and Gynecology International
Volume 2011, Article ID 683703, 8 pages
Total Laparoscopic andRobotically Assisted Hysterectomy for
BenignPathology duringIntroduction of a RoboticProgram
Gokhan SamiKilic,GradieMoore,Ayman Elbatanony,CarmenRadecki,
John Y.Phelps, andMostafa A.Borahay
Department of Obstetrics & Gynecology, The University of Texas Medical Branch, Galveston, TX 77555-0587, USA
Correspondence should be addressed to Gokhan Sami Kilic, firstname.lastname@example.org
Received 2 June 2011; Accepted 28 July 2011
Academic Editor: Linus Chuang
Copyright © 2011 Gokhan Sami Kilic et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Study Objective. Prospectively compare outcomes of robotically assisted and laparoscopic hysterectomy in the process of imple-
hysterectomy, 25 patients underwent robotic hysterectomy, and 11 patients underwent vaginal hysterectomy at our institution.
Interventions. Outcomes of robotically assisted, laparoscopic, and vaginal complex hysterectomies performed by a single surgeon
for noncancerous indications. Measurements and Main Results. Operative times were 208.3 ± 59.01 minutes for laparoscopic,
286.2±82.87 minutes for robotic, and 163.5±61.89 minutes for vaginal (P < .0001). Estimated blood loss for patients undergoing
laparoscopic surgery was 242.7 ± 211.37cc, 137.4 ± 107.50cc for robotic surgery, and 243.2 ± 127.52cc for vaginal surgery
(P = 0.05). The mean length of stay ranged from 1.8 to 2.3 days for the 3 methods. Association was significant for uterine weight
(P = 0.0043) among surgery methods. Conclusion. Robotically assisted hysterectomy is feasible with low morbidity, a shorter
hospital stay, and less blood loss. This suggests that robotic assistance facilitates a minimally invasive approach for patients with
larger uterine size even during implementing a new robotic program.
Hysterectomy is the second most commonly performed su-
rgical procedure in the United States after cesarean delivery
. The Nationwide Inpatient Sample of the Healthcare
for benign disease in 2005 . A stable rate of 5.1–5.8
hysterectomies per 1,000 female civilian US residents was
reported between 1995 and 1999 . The same recent
analysis of Healthcare Cost and Utilization Project data
showed that abdominal hysterectomy was performed in 64%
of cases, followed by the vaginal route in 22% of cases and
the laparoscopic route in 14%. Robotic-assisted hysterec-
tomy is emerging as a new technique for hysterectomy .
Improved visualization and dexterity in robotic surgery
may offer some advantages over conventional laparoscopy
[4, 5], and shorter hospital stays and decreased blood loss
may also be advantages over laparotomy [6, 7]. Overall,
minimally invasive surgical techniques for performing hys-
terectomy have been shown to reduce patient morbidity and
shorten hospital stays [8, 9]. A robotic system (da Vinci
Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA) is
designed to address many of the limitations of conventional
laparoscopy, and these benefits may allow for a minimally
invasive approach in more complex cases, demonstrating the
feasibility and safety of this technology as effective without
increasing morbidity. However, while there have been several
pilot studies on alternatives to laparoscopic hysterectomy, to
date there have only been 3 larger-scale studies of robotic-
assisted total hysterectomy specifically for benign indications
[10–12]. In addition, limited data suggest possible advan-
tagesof robotic hysterectomyover thelaparoscopic approach
2 Obstetrics and Gynecology International
in complex cases, where the use of conventional laparoscopy
is traditionally contraindicated [5, 13]. For example, one
study reported success in treating 152 patients with complex
benign pathology using robotic-assisted total hysterectomy
with good patient outcomes . Another study comparing
laparoscopic and robotic myomectomy supported the same
This prospective study will focus on the intra- and per-
ioperative outcomes of robotically assisted hysterectomy for
benign cases in comparison with total laparoscopic and vagi-
nal hysterectomy. As the only tertiary teaching institution
in the area, the benign cases that we see are often complex
ones. In this study, we sought to investigate whether robotic
assistance facilitates the surgery and results in low morbidity
with acceptable perioperative outcomes.
This prospective study was conducted based on preoperative
and perioperative characteristics for 3 operative types. From
June 2008 to December 2009, 34 patients underwent lap-
aroscopic hysterectomy (Group A), 25 patients underwent
robotic hysterectomy (Group B), and 11 patients underwent
vaginal hysterectomy (Group C) at our institution. All
of these hysterectomies were performed for noncancerous
indications, including adnexal mass, endometriosis, abnor-
mal uterine bleeding, hyperplasia, dysplasia, leiomyomas,
chronic pelvic pain, adenomyosis, and pelvic prolapse,
To eliminate surgeon bias in our study, all surgeries were
either performed by or supervised by the same surgeon. All
laparoscopic and vaginal hysterectomy cases were performed
by residents under the direct supervision of the first author,
with more than 50% of cases performed by residents as first
surgeons. In contrast, 40% of robotic cases were teaching
cases. In robotic cases, resident participation was primarily
in uterine manipulator placement, trocar placement, and
vaginal cuff closure.
For our study, hysterectomy with or without bilateral
salpingo-oophorectomy was considered to be “type 1.” Hys-
terectomies performed at the same time as additional sur-
geries were labeled as “type 2 or more.” According to this
classification, 91% of laparoscopic cases were type 1 versus
84% of robotic hysterectomy cases. Of vaginal hysterectomy
cases, 72.73% required 2 or more additional surgeries.
Each case was evaluated for its complexity based on
preoperative diagnosis, prior pelvic or abdominal surgery,
patient’s body mass index (BMI), and uterine weight. Prior
pelvic or abdominal surgery was categorized as none, 1
previous surgery, or 2 or more previous surgeries. Patient
BMI was categorized as BMI less than 30 or BMI of 30 or
greater. Uterine weight was categorized as either <250g or
≥250g. All cases were further categorized as being teaching
or nonteaching cases.
Before the initiation of this prospective study, insti-
tutional review board approval was obtained from The
University of Texas Medical Branch at Galveston for data
collection on patients who consented for surgery. All the
cases were performed by a single surgeon with 7 years of
experience in vaginal and laparoscopic hysterectomy, while
the robotic cases were the first 25 cases in his medical career.
Residents were involved in all laparoscopic and vaginal
hysterectomy cases, performing more than 50% of any given
case with supervision. Robotic cases were considered to
be teaching cases, and resident involvement included only
vaginal cuff closing.
Patients with a uterine size not greater than 14 weeks
requiring pelvic prolapse surgeries or Grade 2 Baden-
Walker uterine descensus in addition to their hysterectomies
were selected for the vaginal hysterectomy group. After
the decision of minimally invasive hysterectomy was made,
the choice between laparoscopy and robotic approach was
left solely to the patient’s discretion. All cases were per-
formed under general endotracheal anesthesia. Antibiotics
were given just before surgery. Patients were placed in the
dorsal lithotomy position with Allen stirrups (Allen Medical
Systems, Acton MA) for lower extremity positioning.
2.1. Robotic Hysterectomy. A Rumi System uterine manip-
ulator with balloon tip (Cooper Surgical) was placed after
appropriate preparation and draping. Patients were placed
in a steep Trendelenburg position, with arms tucked at
the sides and shoulder blocks placed to limit shift on the
beginning of the case was assured to prevent trauma to the
stomach. All cases with previous abdominopelvic surgeries
were started using a Veress needle to the left upper quadrant
for insufflation of CO2and followed by a 12-mm bladeless
trocar introduced from the same location under direct visu-
alization. In cases of no previous abdominopelvic surgeries,
the Veress needle was placed in the umbilicus to obtain
the necessary insufflation of CO2, and this was followed by
introducing a 12-mm bladeless trocar for the camera at the
umbilicus. Two additional 8-mm robotic trocars were placed
on the patients’ abdomens where additional retraction was
necessary. The left upper quadrant 12-mm trocar was used
on this group as well to allow the bedside surgical assistant
to use a grasper or suction irrigation device. The robotic
system was then docked at a 45◦angle from the patient’s
left foot side. All cases were performed using monopolar
EndoWrist scissors (Intuitive Surgical, Inc.) combined with
a PK grasper. Hysterectomies were classified as American
Association of Gynecologic Laparoscopists type IVE, defined
as total laparoscopic removal of the uterus and cervix
Colpotomizer System (Cooper Surgical).
All pathologic specimens were removed using 1 of the 3
following methods: direct removal through the vaginal cuff
opening, morcellation of the specimen using an endoscopic
morcellator, or sectioning of the uterine specimen with the
robot using an EndoWrist monopolar cautery instrument
(Institutive Surgical, Inc.) to create portions small enough to
be delivered vaginally. The vaginal cuff was closed robotically
using 0 polyglactin (Vicryl, Ethicon Endo-Surgery, Inc.,
Cincinnati, OH) on a CT-1 needle in a single separate suture
Obstetrics and Gynecology International3
Sutures were instrument-tied using the robotic instru-
ments. Patients were desufflated, and pedicles were checked
at half desufflation for homeostasis. The robotic system was
then undocked, and all trocars were removed under direct
visualization. The 12-mm trocar sites received a single deep
0-polyglactin suture, and all skin incisions were closed with
4-0 polyglactin subcuticular sutures. Adhesive skin closures
(Steri-Strips, 3M, St. Paul, MN) were placed as dressing.
The following times were recorded: docking time,
defined as the time from first incision to placement of the
robotic instruments into the patient, morcellation time, and
total operative time, defined as time from when the patient
was brought into the OR until she left the room. In addition,
uterine weight, blood loss, conversions, and intraoperative
and postoperative complications requiring intervention, as
well as length of hospital stay, were monitored and recorded.
Cases were stratified based on the level of complexity using
BMI, uterine weight, presence of prior pelvic or abdominal
surgeries, and preoperative diagnosis. We also reported
outcomes for subgroups of patients with uterine weight
of ≥250g or BMI ≥ 30.
2.2. Laparoscopic Hysterectomy. Laparoscopic hysterectomy
cases were done with the same trocar placement technique
and locations applied in robotic cases, but, instead of an 8-
mm robotic port, 25-mm bladeless trocars were used. Other
than docking time, the same parameters were recorded as for
2.3. Vaginal Hysterectomy. The cervix was grasped with a
tenaculum, and the cervicovaginal junction was circumfer-
entially injected with a vasoconstrictive agent. A circumfer-
ential incision was made at the cervicovaginal junction, and
Careful entry into the anterior and posterior cul-de-sacs
was done using sharp dissection. Retraction of the bladder
was entered anteriorly and posteriorly, the uterosacral and
cardinal ligament complex was detached from the uterus
bilaterally. Downward traction on the cervix brought the
uterus and its remaining attachments closer to the operator,
where they too could be seen, clamped, and transected under
A McCall’s culdoplasty or simple peritoneal closure
and intraperitoneal uterosacral ligament plication were per-
formed after a vaginal hysterectomy to prevent vaginal vault
prolapse. The vaginal cuff was closed by using 0-polyglactin
CT-1 needle in a running suture closure.
acteristics were summarized using means, standard devi-
ations and 95% confidence interval for the continuous
variables, and proportions for discrete variables among the
3 surgery groups (laparoscopic, robotic, and vaginal). The 1-
way analysis of variance (ANOVA) was used to compare the
means of continuous variables among the surgery groups.
The chi-square test was used to investigate the association
between category variable and the surgery groups, and the
normality of continuous variables was tested. The tests
were assessed at the 0.05 level of significance. Statistical
computations were carried out using statistical software, SAS
A total of 70 consecutive patients underwent hysterectomy
indications in 12 months. Patient characteristics and surgical
indications are listed in Table 1. The average age for the
patients was 42.5 ±8.78 years for laparoscopic hysterectomy,
46.6 ± 7.54 years for robotic hysterectomy, and 44.1 ±
10.72 for vaginal hysterectomy. Overall, 58.82% of patients
had a BMI equal to or exceeding 30, and percentages
for robotic and vaginal hysterectomy were 64.0% and
36.36%, respectively. Cervical dysplasia and leiomyomas
were the main indication (67.6%) for laparoscopic hys-
terectomy patients. Adenomyosis and leiomyomas were the
main indications (84%) for robotic hysterectomy patients.
Pelvic prolapse and SUI were the only reasons for vaginal
hysterectomy (100%). The racial composition of patients
included 61.76% white, 20.59% African American, and
17.65% Hispanic for laparoscopic hysterectomy; 40% white,
48% African American, and 12% Hispanic for robotic
hysterectomy; 72.73% white, 18.18% African American, and
9.09% Hispanic for vaginal hysterectomy. The majority of
laparoscopic hysterectomy patients (76%) had a history of
prior abdominal/pelvic surgery. In the same group, 35.29%
had undergone 2 or more prior abdominal/pelvic surgeries.
Among robotic hysterectomy patients, 76% had a history
of prior abdominal/pelvic surgery. Of these women, 32%
had undergone multiple prior abdominal/pelvic surgeries.
For vaginal hysterectomy patients, more than 45% had
undergone prior abdominal/pelvic surgery. Only 18.18%
uterine weight, 14.71% of patients in the laparoscopy group
had a uterine weight greater than 250g versus 44% for
the robotic group. All vaginal hysterectomy cases revealed a
uterine weight less than 250g.
Total operative time was, on average, 216.3 minutes,
which included morcellation time when applicable for la-
paroscopic patients (Table 2), 298.8 minutes for robotic
patients, and 163.5 minutes for vaginal hysterectomy. When
morcellation of the uterus was taken out of the operative
time, the mean values were as follows: 208.3 minutes
for laparoscopic, 286.2 minutes for robotic, and 163.5
minutes for vaginal cases. Room time was documented
independently of operative time, and the mean values
were 281.4 minutes for laparoscopic, 378.1 minutes for
robotic, and 218.5 minutes for vaginal cases. Uniquely,
the docking time was only applicable for robotic cases,
and its mean value was 21.5 minutes. Average blood loss
for laparoscopic hysterectomy patients in this study was
calculated to be 242.7mL (50mL–1000mL), compared to
robotic hysterectomy patients with average blood loss of
4Obstetrics and Gynecology International
Table 1: Preoperative characteristics.
Group A, laparoscopic
(n = 34)
Group B, robotic
(n = 25)
Group C, vaginal
(n = 11)
Body mass index
More than 30
Less than 30
Uterine weight (g)
Less than 250g
More than 250g
Prior pelvic or abdominal surgery
2 and more occurrences
Type of surgery
2 and more
Indication for surgery
Abnormal uterine bleeding
Chronic pelvic pain
137.4mL (20mL–400mL) and 243.2mL (50mL–500mL)
for vaginal hysterectomy patients.
Laparoscopic patients had an average length of stay of
2.3 ± 1.06 days (range 1–5 days). Robotic patients had an
average length of stay of 1.8 ± 0.88 days (range 1–4 days).
Vaginal hysterectomy patients had an average length of stay
of 2.00 ±1.00 days (range 1–4 days).
In the robotic and laparoscopic groups, there was 1
serious intraoperative complication in each group. This
included 1 ureteral injury and 1 bowel injury. Also, there
were 4 cases in the laparoscopic group and 3 in the
robotic group who had mild intraoperative complications.
These included uterine artery bleeding, vaginal laceration,
IV infiltration, incorrect count, serosal bowel injury, and
serosal bladder injury. There was no complication in the
vaginal hysterectomy cases. Among the laparoscopic cases,
the uterine artery bleeding and bowel injury cases were
converted to minilaparotomy. Among the robotic cases, 1
case with severe adhesions led to a ureteral injury that was
corrected by minilaparotomy. Another case was converted to
open due to intolerance of the Trendelenburg position. Two
patients from each of the robotic and laparoscopic groups
received 2 units of packed RBCs intraoperatively. Among
these 4 patients, only 1 required blood due to intraoperative
excessive bleeding while the remaining 3 were due to severe
preoperative anemia, which was treated by transfusion at the
time of surgery.
There were 10 laparoscopic hysterectomy patients with
postoperative complications, including urinary retention,
irregular blood pressure, deep venous thrombosis, trocar
Obstetrics and Gynecology International5
Table 2: Operative characteristics.
Group A, laparoscopic
(n = 34)
Group B, robotic
(n = 25)
Group C, vaginal
(n = 11)
Docking time (min)
Room time (min)
Operative time (min)
Operative time not including
Type of cases
Estimated blood loss (cc)
Length of stay (days)
34 25 11
34 (100%) 10 (40.00%)
23 (92.00%)11 (100%)
11 (44.00%)11 (100%)
6 Obstetrics and Gynecology International
Table 3: Regression model: the effects of preoperative characteristics on operative time.
Prior pelvic surgery
Teaching case (NT)
Type of surgery
Body mass index (less than 30)
Estimated blood loss
site pain, cuff cellulitis, and urinary tract infection. Among
the laparoscopic cases, 1 patient had both cuff cellulitis
and anemia, while the remaining 9 cases comprised the
rest of the previous complications. In the robotic cases, 5
patients experienced postoperative complications. One of
the robotic patients had both cuff cellulitis and trocar site
pain. The remaining 4 patients had complications, such as
irregular blood pressure, urinary tract infection, and trocar
site pain. Among the vaginal hysterectomy cases, 3 patients
had postoperative complications. Two of them had urinary
tract infections, and 1 had urinary retention. None of our
postoperative patients required blood transfusion, and no
patient needed to go to the operative room for a second time
related to the initial surgery.
The percentage of cases with intraoperative challenges
was 35.29% for laparoscopic, 56% for robotic, and 0%
for vaginal procedures. Intraoperative challenges included
dense pelviabdominal adhesions, lower uterine segment
fibroids extending to the uterine artery, morcellated cases,
adnexal masses requiring lateral pelvic wall dissection, an
inability to obtain an appropriate Trendelenburg position,
and malfunction of the instruments.
A multiple regression model was used to determine the
factors influencing operative time. Prior pelvic surgery, clas-
sification as a teaching case, and BMI did not affect operative
time. The variables that were significantly associated with
increased operative time were inclusion in the laparoscopic
or robotic groups (Groups A and B), type of surgery, and
estimated blood loss (Table 3).
This prospective study presents our initial experience with
robotic-assisted total hysterectomies for benign indications
in 25 consecutive cases compared to 34 laparoscopic and
11 vaginal hysterectomies, also for benign indications. The
inclusion criteria for vaginal hysterectomies were Baden-
Walker Grade 2 or higher symptomatic uterine, bladder,
or rectum prolapse; required additional vaginal surgeries;
and a uterus not greater than 14 weeks in size. Due to
this relative selection bias, we could not randomize the
used for certain perioperative outcomes, such as recovery
time. To prevent surgeon selection bias, the decision to have
robotic versus laparoscopic surgery was left to the patients
after risks, benefits, and exact procedures were explained in
Robotic gynecologic procedures were FDA approved
in March 2005 . Published average times for robotic
hysterectomies vary from 122.9 minutes to 242 minutes in
mainstream journals [10, 11, 15–17]. The operative time in
our study, 286.2 minutes—slightly longer than average—was
affected by multiple factors. In our study, operative time
was reported from “skin to skin,” which is defined as from
when the surgeon started to perform the vaginal exam under
general anesthesia until the last suture was placed to close
the trocar sites, instead of starting from uterine manipulator
or skin incision. The single interrupted suture technique
used to close the vaginal cuff versus the continuous running
suture may have an impact on operating time. Additionally,
technical intraoperative problems required changing the
camera, cord, and light source, and a visualization problem
in the robotic system was included in our operative time.
The robotic cases, reported to explore the learning curve,
were the first 25 performed by the surgeon, residents, and
the OR team. One observation about the learning curve is
that the first 15 cases averaged 308.5 minutes, while the next
10 cases averaged only 252.8 minutes. Room time, used as
an indicator of ancillary team efficiency, dropped from 407.8
minutes in thefirst 15 casesto 333.6 minutes in the following
10 cases. Our data revealed that after the first 15 cases of
robotic surgery, operating time was not statistically different
from our laparoscopic cases (P
suggests the learning curve to be between 20 and 100 cases,
[11, 15, 18] and our study supports the lower side of the
Our experience indicates that initiating a new robotic
program requires more team training than any other proce-
dures. This includes technical personnel, scrub nurses, and
circulating nurses available in the operating room. The team
should be doubled to be able to substitute when needed.
Interdepartmental collaboration in the related specialties for
combined surgeries and intraoperative consultation needs
to be developed simultaneously. Administrative support is
also essential to create robotic programs. These are all
independent factors that affect operative time and quality of
care in robotic surgeries.
= 0.1179). Current data
Obstetrics and Gynecology International7
In laparoscopy and robotic cases, BMIs higher than 30
were predominant (58% and 64%, resp.), in contrast to
vaginal hysterectomies (36%). Uterine weight more than
250g was more common in the robotic group (44%).
Estimated blood loss was least in robotic cases, with 137mL.
Previous abdominopelvic surgery was more common in
robotic and laparoscopic cases compared to vaginal cases
(76% and 76.4%, resp., versus 45.4%). Length of hospital
stay was least with robotic cases (robotics 1.8 days, vaginal
2.0 days, and laparoscopic 2.3 days). While recognizing
that our study included only a limited number of cases,
we found that robotic hysterectomy seems to be a good
approach for patients with high BMI, a larger uterus, or
a history of previous abdominopelvic surgeries. Robotic
surgery provides a safe and fast recovery as well.
Robotic hysterectomy has only recently emerged in the
gynecology field. Gynecologists need more scientific data
to address specific indications, advantages, and disadvan-
tages of different surgical approaches during the informed
consent process. Our study is the first to compare robotic,
laparoscopic, and vaginal hysterectomies using multiple
perioperative criteria performed by a single surgeon. We
on the vaginal approach since additional vaginal surgeries
were required. However, our preoperative characteristics
other than uterine weight were not statistically different
among the 3 groups. Surgery time was shorter in vaginal
hysterectomies, even with the additional pelvic surgeries
with Falcone, whose review compared laparoscopic, vaginal
surgeries, and abdominal hysterectomies. Minimally invasive
laparoscopic hysterectomy not only had a longer operation
time but also had faster recovery, shorter hospital stays,
and lower EBL compared to the abdominal method .
Based on these criteria, it is clear to see the superiority of
laparoscopic and vaginal hysterectomies over the abdominal
approach. Vaginal hysterectomy should be the first choice
in selected patients, especially when cost effectiveness is
brought into the equation. However, minimally invasive
surgeries are increasing their presence nationwide, and there
are strong indications to predict that the trend will continue.
Laparoscopic versus robotic approaches still require more
exploration to identify the patient’s characteristics to offer
the more suitable surgery between these 2 hysterectomy
This study has been presented at the following confer-
ences: Oral Presentation—Second European Symposium in
Robotic Gynecological Surgery, Lund, Sweden, September
9–11, 2010, and Scientific Virtual Poster Presentation—The
39th Global Congress of Minimally Invasive Gynecology,
AAGL, Las Vegas, Nevada, November 8–12, 2010. None of
the authors have financial interest in any aspect of this
work, and this prospective study was not supported by grant
 T. Falcone and M. D. Walters, “Hysterectomy for benign
disease,” Obstetrics and Gynecology, vol. 111, no. 3, pp. 753–
 V. L. Jacoby, A. Autry, G. Jacobson, R. Domush, S. Nakagawa,
and A. Jacoby, “Nationwide use of laparoscopic hysterectomy
compared with abdominal and vaginal approaches,”Obstetrics
and Gynecology, vol. 114, no. 5, pp. 1041–1048, 2009.
 H. Keshavarz, S. D. Hillis, B. A. Kieke, and P. A. March-
banks, “Hysterectomy Surveillance—United States, 1994–
1999,” Morbidity and Mortality Weekly Report, vol. 51, no.
SS05, pp. 1–8, 2002.
 D. S. Veljovich, P. J. Paley, C. W. Drescher, E. N. Everett,
C. Shah, and W. A. Peters, “Robotic surgery in gynecologic
oncology: program initiation and outcomes after the first
staging,” American Journal of Obstetrics and Gynecology, vol.
198, no. 6, pp. 679.e1–679.e10, 2008.
 A. P. Advincula and R. K. Reynolds, “The use of robot-assisted
laparoscopic hysterectomy in the patient with a scarred or
obliterated anterior cul-de-sac,” Journal of the Society of
Laparoendoscopic Surgeons, vol. 9, no. 3, pp. 287–291, 2005.
 E. J. Geller, N. Y. Siddiqui, J. M. Wu, and A. G. Visco,
“Short-term outcomes of robotic sacrocolpopexy compared
with abdominal sacrocolpopexy,” Obstetrics and Gynecology,
vol. 112, no. 6, pp. 1201–1206, 2008.
 J. F. Magrina, R. M. Kho, A. L. Weaver, R. P. Montero, and P.
laparoscopy and laparotomy,” Gynecologic Oncology, vol. 109,
no. 1, pp. 86–91, 2008.
 D. J. Bonilla, L. Mains, R. Whitaker, B. Crawford, M. Finan,
and M. Magnus, “Uterine weight as a predictor of morbidity
after a benign abdominal and total laparoscopic hysterec-
tomy,” Journal of Reproductive Medicine for the Obstetrician
and Gynecologist, vol. 52, no. 6, pp. 490–498, 2007.
 F. Claerhout and J. Deprest, “Laparoscopic hysterectomy for
benign diseases,” Best Practice and Research, vol. 19, no. 3, pp.
 R. M. Kho, W. S. Hilger, J. G. Hentz, P. M. Magtibay, and
J. F. Magrina, “Robotic hysterectomy: technique and initial
outcomes,” AmericanJournal of Obstetricsand Gynecology, vol.
197, no. 1, pp. 113.e1–113.e4, 2007.
 T. N. Payne and F. R. Dauterive, “A comparison of total
laparoscopic hysterectomy to robotically assisted hysterec-
tomy: surgical outcomes in a community practice,” Journal
of Minimally Invasive Gynecology, vol. 15, no. 3, pp. 286–291,
 J. F. Boggess, P. A. Gehrig, L. Cantrell et al., “Perioperative
outcomes of robotically assisted hysterectomy for benign cases
with complex pathology,” Obstetrics and Gynecology, vol. 114,
no. 3, pp. 585–593, 2009.
 I. Zapardiel, V. Zanagnolo, J. F. Magrina, and P. M. Magtibay,
“Robotic radical parametrectomy in benign disease: report of
two cases,” Acta Obstetricia et Gynecologica Scandinavica, vol.
89, no. 8, pp. 1108–1110, 2010.
 C. E. Bedient, J. F. Magrina, B. N. Noble, and R. M. Kho,
“Comparison of robotic and laparoscopic myomectomy,”
American Journal of Obstetrics and Gynecology, vol. 201, no.
6, pp. 566.e1–566.e5, 2009.
 A. R. Shashoua, D. Gill, and S. R. Locher, “Robotic-assisted
total laparoscopic hysterectomy versus conventional total
laparoscopic hysterectomy,” Journal of the Society of Laparoen-
doscopic Surgeons, vol. 13, no. 3, pp. 364–369, 2009.
8Obstetrics and Gynecology International
 R. K. Reynolds and A. P. Advincula, “Robot-assisted laparo-
scopic hysterectomy: technique and initial experience,” Amer-
ican Journal of Surgery, vol. 191, no. 4, pp. 555–560, 2006.
 R. P. Fiorentino, M. A. Zepeda, B. H. Goldstein, C. R.
John, and M. A. Rettenmaier, “Pilot study assessing robotic
laparoscopic hysterectomy and patient outcomes,” Journal of
Minimally Invasive Gynecology, vol. 13, no. 1, pp. 60–63, 2006.
 J. L. Ferguson, T. M. Beste, K. H. Nelson, and J. A.
Daucher, “Making the transition from standard gynecologic
laparoscopy to robotic laparoscopy,” Journal of the Society of
Laparoendoscopic Surgeons, vol. 8, no. 4, pp. 326–328, 2004.