What are the steps involved in a robot-assisted total hysterectomy (RAT-H) procedure?

Robot-Assisted Total Hysterectomy: Surgical Steps and Procedure Overview

Robot-assisted total hysterectomy is a minimally invasive surgical approach that offers advantages including less blood loss, shorter hospital stays, and faster recovery compared to traditional open surgery, while maintaining similar operative outcomes to conventional laparoscopy. 1

Pre-operative Setup and Positioning

• Patient is placed in dorsal lithotomy position with steep Trendelenburg positioning
• General anesthesia is administered
• Pneumoperitoneum is established using Veress needle or open Hasson technique
• Robot is docked between the patient's legs
• Standard port placement includes:
  • Camera port at umbilicus
  • Two to three robotic instrument ports
  • One to two assistant ports for suction/irrigation and tissue retrieval

Step 1: Initial Assessment and Adhesiolysis

• Thorough inspection of the abdominal cavity for metastatic disease or other pathology 1
• Careful lysis of any adhesions to improve visualization and access
• Identification of key anatomical landmarks including ureters, bladder, and bowel

Step 2: Development of the Paravesical and Pararectal Spaces

• Identification and development of the paravesical space
• Development of the pararectal space
• Identification and preservation of the ureter on each side
• Careful dissection to expose the uterine arteries

Step 3: Securing the Infundibulopelvic Ligaments or Utero-Ovarian Ligaments

• If ovaries are to be removed: Skeletonization and securing of the infundibulopelvic ligaments
• If ovaries are to be preserved: Division of the utero-ovarian ligaments
• Careful sealing and division using bipolar energy or vessel sealing devices

Step 4: Bladder Flap Development

• Creation of a bladder flap by dissecting the vesicouterine peritoneum
• Careful dissection of the bladder from the anterior cervix and upper vagina
• Identification and preservation of the ureteral course

Step 5: Securing the Uterine Vessels

• Skeletonization and securing of the uterine arteries at their origin
• Careful sealing and division using bipolar energy or vessel sealing devices
• Preservation of the ureter during this critical step

Step 6: Cardinal and Uterosacral Ligament Division

• Identification and division of the cardinal ligaments
• Division of the uterosacral ligaments
• Careful dissection down to the level of the vagina

Step 7: Colpotomy and Specimen Removal

• Placement of a vaginal manipulator to delineate the vaginal fornices
• Circumferential colpotomy to separate the uterus and cervix from the vagina
• Removal of the specimen through the vagina
• Specimen may be placed in an endoscopic bag if morcellation is needed for large specimens (though morcellation is generally avoided in cancer cases) 1

Step 8: Vaginal Cuff Closure

• Closure of the vaginal cuff using interrupted or continuous sutures
• Ensuring hemostasis at the vaginal cuff
• Reinforcement of the vaginal cuff with incorporation of the uterosacral ligaments if needed

Step 9: Final Inspection and Closure

• Thorough inspection for hemostasis
• Irrigation of the pelvis
• Removal of all instruments under direct visualization
• Closure of port sites with appropriate sutures

Special Considerations

• Lymphadenectomy: If indicated (particularly for endometrial cancer), pelvic and/or para-aortic lymphadenectomy may be performed robotically during the same procedure 1
• Obesity: Robotic approach offers particular advantages in obese patients due to improved visualization and instrument dexterity 1, 2
• Complex Cases: High-volume surgeons may achieve shorter operative times using robotic approach for complex cases 3

Potential Complications and Their Prevention

• Urinary Tract Injury: Careful identification and preservation of ureters and bladder throughout the procedure 4
• Bowel Injury: Meticulous dissection and careful use of energy devices near bowel 2
• Vascular Injury: Proper identification of vascular structures before division 2
• Vaginal Cuff Complications: Proper closure technique to prevent dehiscence 1

Advantages of Robotic Approach

• Enhanced visualization with 3D magnified view
• Improved dexterity with wristed instruments
• Reduced blood loss compared to open surgery
• Shorter hospital stay (average 1.6 days vs 3.9 days for open surgery) 5
• Faster return to normal activities 1
• Lower conversion rates to open surgery compared to conventional laparoscopy 1
• Particularly beneficial for complex cases and obese patients 2, 3

Robot-assisted total hysterectomy offers a safe and effective approach for hysterectomy with outcomes similar to conventional laparoscopy but with potential advantages in visualization and instrument control, particularly in complex cases.