What is the step‑by‑step technique for performing a robotic‑assisted vaginal hysterectomy in an adult woman with benign uterine disease whose uterus fits through the vagina, has adequate vaginal access, no severe pelvic adhesions, and no contraindications to laparoscopy?

Robotic-Assisted Vaginal Hysterectomy: Step-by-Step Technique

For a woman with benign uterine disease and adequate vaginal access, perform a robotic vaginal natural orifice transluminal endoscopic surgery (robotic vNOTES) hysterectomy using either the da Vinci Single-Port (SP) system or standard multi-arm configuration with vaginal port placement. This approach combines the minimally invasive benefits of vaginal surgery with robotic precision, particularly valuable for larger uteri or complex pathology 1, 2.

Patient Positioning and Initial Access

Position the patient in dorsal lithotomy with steep Trendelenburg (20 degrees) 3. Begin with vaginal access:

• Perform anterior and posterior colpotomy to enter the peritoneal cavity vaginally
• Detach bilateral uterosacral ligaments through the vaginal approach
• Insert an Alexis ring retractor into the vaginal opening to maintain access 1
• Place GelPoint trocars in a diamond configuration on the GelSeal cap and secure to the ring
• Establish pneumoperitoneum at 12 mmHg through the vaginal port 1, 3

Port Configuration and Robot Docking

For da Vinci SP system (preferred for confined vaginal space):

• Insert the SP access port directly through the vaginal opening after colpotomy 2
• This single-port approach is particularly effective for large uteri (median 370g, up to 800g successfully completed) 2
• Median operative time: 74 minutes 2

For standard multi-arm robotic system:

• Insert camera trocar first through the vaginal port
• Add two additional instrument trocars with appropriate spacing to avoid arm collision 1
• Arrange trocars to optimize triangulation while working through the vaginal access point

Surgical Steps

1. Camera insertion and visualization: Establish three-dimensional cephalic-to-caudal view through the vaginal approach 1

2. Uterine mobilization: Use wristed robotic instruments to:

   • Secure and elevate the uterus with vaginal traction 3
   • Identify and protect ureters bilaterally
   • Coagulate and divide uterine vessels

3. Adnexal management:

   • Perform bilateral salpingectomy as indicated
   • Address ovarian pathology (cystectomy) if present 1
   • Preserve ovaries unless specific indication for removal exists 4

4. Uterine extraction: Remove specimen through vaginal opening (no abdominal incisions required)

5. Vaginal cuff closure: Close using robotic suturing with enhanced precision

Key Technical Advantages

The robotic approach overcomes traditional vNOTES limitations:

• Three-dimensional visualization replaces challenging two-dimensional laparoscopic view 1
• Wristed instrumentation provides enhanced dexterity in confined space 1, 2
• Surgeon-controlled camera eliminates assistant-dependent visualization 1
• Elimination of hand tremor improves precision 5

Expected Outcomes

Based on the most recent high-quality evidence 2:

• Same-day discharge: 94.1% of patients
• Minimal blood loss with no conversions or intraoperative complications
• Low postoperative pain: Median VAS score of 0 at 4 hours
• No 30-day complications in reported series

Critical Considerations

Patient selection factors that predict success 6:

• History of vaginal delivery (strongly favorable)
• Lower BMI improves outcomes
• Uterine weight is the sole independent predictor of technique failure 7
• Previous cesarean delivery does not preclude vaginal approach (96% success rate) 7

Common pitfall: Transient intraoperative hematuria occurs in 12.3% of robotic vaginal cases versus 0.6% in standard robotic hysterectomy 6. This is typically self-limited but requires awareness.

Conversion strategy: If vaginal completion fails, the established algorithm is: pure vaginal → robotic vNOTES → laparoscopy/laparotomy 7. This stepped approach achieves 95.2% vaginal completion rates without abdominal incision 7.

Practical Setup Tips

• Insert nasogastric tube through umbilical incision for suction/irrigation access 3
• Use GelSeal cap with diamond trocar configuration for optimal instrument spacing 1
• Maintain steep Trendelenburg throughout to optimize pelvic visualization 3

The robotic vNOTES approach represents the current evolution in minimally invasive hysterectomy, particularly valuable when uterine size or complexity would traditionally require abdominal approach 4, 2. The da Vinci SP system specifically addresses the anatomical constraints of vaginal surgery while maintaining robotic advantages 2.