Robotic-assisted Laparoscopic Hysterectomy Research Articles

Value-based assessment of hysterectomy approaches.

AimBy evaluating operative outcomes relative to cost, we compared the value of minimally invasive hysterectomy approaches, including a technique discussed less often in the literature, laparoscopic retroperitoneal hysterectomy (LRH), which incorporates retroperitoneal dissection and ligation of the uterine arteries at their vascular origin.MethodsRetrospective chart review of all women (N = 2689) aged greater than or equal to 18 years who underwent hysterectomy for benign conditions from 2011 to 2013 at a high‐volume hospital in Maryland, USA. Procedures included: laparoscopic supracervical hysterectomy, robotic‐assisted laparoscopic hysterectomy (RALH), total laparoscopic hysterectomy, laparoscopic‐assisted vaginal hysterectomy, total vaginal hysterectomy (TVH), and LRH.ResultsTotal vaginal hysterectomy had the highest intraoperative complication rate (9.6%; P < 0.0001) but the lowest postoperative complication rate (1.8%; P < 0.0001). Robotics had the highest postoperative complication rate (11.4%; P < 0.0001). LRH had the shortest operative time (71.2 min; P < 0.0001) and the lowest intraoperative complication rates (2.1%; P < 0.0001). LRH and TVH were the least costly (averaging $4061 and $6416, respectively), while RALH was the most costly ($9354). Taking both operative outcomes and cost into account, LRH, TVH and laparoscopic‐assisted vaginal hysterectomy yielded the highest value scores; total laparoscopic hysterectomy, RALH, and laparoscopic supracervical hysterectomy yielded the lowest.ConclusionUnderstanding the value of surgical interventions requires an evaluation of both operative outcomes and direct hospital costs. Using a quality‐cost framework, the LRH approach as performed by high‐volume laparoscopic specialists emerged as having the highest calculated value.

Dual Usage of 5 mm Laparoscope for Abdominal Entry and Cystoscopy During Robotic Assisted Laparoscopic Hysterectomy: Safe Alternative to Traditional Cystoscopy

Objective: To assess whether dual usage of 5 mm laparoscope for both abdominal entry and cystoscopy during robotic assisted laparoscopic hysterectomy (RALH) affects the incidence of urinary tract infection (UTI).

Utilization of Robot Assisted Hysterectomy for Benign Disease: An Institutional Review

Objective: To examine procedural indications, pathology results, surgical risk factors, and surgical complications for patients undergoing conventional total laparoscopic hysterectomy (TLH) versus robotic-assisted laparoscopic hysterectomy (RALH) at an academic institution.

Robotic-Assisted Laparoscopic Nerve Sparing Radical Hysterectomy Improves Long-Term Bladder Function: Based on Urodynamic Assessment

Robotic-Assisted Laparoscopic Nerve Sparing Radical Hysterectomy Improves Long-Term Bladder Function: Based on Urodynamic Assessment

732 - Robotic Hysterectomy for Cesarean Scar Ectopic Pregnancy

Objective: To present a case of cesarean scar ectopic pregnancy and demonstrate techniques to prevent complications during robot-assisted total laparoscopic hysterectomy, in the face of challenging anatomy.

735 - Robotic-Assisted Laparoscopic Hysterectomy in Large Fibroid Uterus, Tips and Techniques

Objective: To demonstrate the surgical techniques in robotic-assisted laparoscopic hysterectomy for large uterus.

The incidence, causes, and management of lower urinary tract injury during total laparoscopic hysterectomy

ObjectivesDetermining the incidence and causes of lower urinary tract injury in patients undergoing total laparoscopic hysterectomy and examining the procedures applied for management. MethodsPatients who underwent total laparoscopic hysterectomy in a large referral center between 1 January 2015 and 31 October 2017 for benign gynecological reasons were included in the study. Patients who underwent laparoscopic supracervical hysterectomy, laparoscopy-assisted vaginal hysterectomy and robot-assisted laparoscopic hysterectomy were not included in this study. The hospital records of all patients included in the study were examined and the incidence, causes and management of lower urinary tract injuries were reviewed. ResultsTotal lower urinary tract injury rate was found as 2.01%, and these injuries were evaluated separately as bladder and ureter injuries. All the bladder injuries had occurred on the posterior wall of the bladder during vesicouterine dissection; six cases were intraoperatively detected and one case was detected on the first postoperative day. Most of ureteral injury cases were detected in the early postoperative period (75%). The rates of previous cesarean section and endometriosis were significantly higher in patients with injury to the bladder and ureter than in the control group (p<0,001). There was no significant difference between the patients with lower urinary tract injury and the control group regarding uterine weight, estimated blood loss, bilateral salpingo-oophorectomy, the presence and location of fibroids, and laparoscopic or vaginal closure of the vaginal cuff. ConclusionLaparoscopic hysterectomy may be a good option in appropriate patients, but in case of previous cesarean section and endometriosis cases, patients should be informed about the possible complications in detail before the operation and care should be taken during dissection.

The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for the large uterus

There are currently sparse data on the relationship between surgeon- and patient-related factors and perioperative morbidity in the setting of elective hysterectomy for the larger uterus. We sought to evaluate the impact of surgeon case volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for uteri >250 g. This is a retrospective cohort study of all women who underwent total vaginal, total laparoscopic, laparoscopic-assisted vaginal, or robotic-assisted total laparoscopic hysterectomy from January 2014 through July 2016. Hysterectomy was performed for: fibroids, pelvic pain, abnormal uterine bleeding, or prolapse. Patients were identified by Current Procedural Terminology codes and the systemwide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon case volume was defined as the mean number of minimally invasive hysterectomy cases performed per month by each surgeon during the study period. In all, 763 patients met inclusion criteria: 416 (54.5%) total laparoscopic hysterectomy, 196 (25.7%) robotic-assisted total laparoscopic hysterectomy, 90 (11.8%) total vaginal hysterectomy, and 61 (8%) laparoscopic-assisted vaginal hysterectomy. Mean (±SD) age was 47.3 ± 6.1 years, and body mass index was 31.1 ± 7.4 kg/m2. In all, 66 surgeons performed minimally invasive hysterectomy for uteri >250 g during the study period, and the median rate of minimally invasive hysterectomy cases for large uteri per month was 3.4 (0.4-3.7) cases/month. The median (IQR) uterine weight was 409 (308-606.5) g. The rate of postoperative adverse events Dindo grade >2 was 17.8% (95% confidence interval, 15.2-20.7). The overall rate of intraoperative adverse events was 4.2% (95% confidence interval, 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% confidence interval, 4.0-7.4). There was no significant difference in adverse event rates between the routes of minimally invasive hysterectomy cases (25.6% vs 17.5% vs 18.0% vs 14.8% for total laparoscopic hysterectomy, robotic-assisted laparoscopic hysterectomy, total vaginal hysterectomy, and laparoscopic-assisted vaginal hysterectomy, respectively, P= .2). In a logistic regression model controlling for age, body mass index, uterine weight, operating time, and history of laparotomy, higher monthly minimally invasive hysterectomy volume was significantly associated with the likelihood that a patient would experience a postoperative adverse event (adjusted odds ratio, 1.1 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.0-1.3). When controlling for the same variables, a higher incidence of intraoperative complications was significantly associated with monthly minimally invasive hysterectomy case volume (adjusted odds ratio, 1.5 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 1.20-2.08). Increasing age was associated with a lower incidence of complications (adjusted odds ratio, 0.9 for each additional year; 95% confidence interval, 0.8-0.9). Higher monthly minimally invasive hysterectomy volume was associated with a lower rate of conversion from a minimally invasive approach to laparotomy (adjusted odds ratio, 0.4 for each additional minimally invasive hysterectomy case for large uteri per month; 95% confidence interval, 0.2-0.5). The overall rate of serious adverse events associated with minimally invasive hysterectomy for uteri >250 g was low. Higher monthly minimally invasive hysterectomy case volume was associated with a higher rate of intraoperative and postoperative adverse events but was associated with a lower rate of conversion to laparotomy.

Robotic-assisted hysterectomy in a community hospital after seven years of experience

BackgroundThe da Vinci robotic-assisted laparoscopic hysterectomy is being widely adopted by healthcare institutions and constitutes the highest percentage of the robotic-assisted surgeries. By now da Vinci robotic-assisted hysterectomy (RAH) is used worldwide, and even so, different aspects of this relatively new surgical technique remain under evaluation. There are contradicting reports in the literature about the superiority of RAH versus conventional laparoscopic hysterectomy (CLH) in terms of patient outcomes and costs. The purpose of this small size study was to contribute to this open question by analyzing patient records in a community hospital with extensive seven years of experience in RAH. The analysis of the data compares the surgical outcomes and patient costs of RAH (n = 23) versus CLH (n = 23). MethodA retrospective study using the electronic chart review was performed. ResultsThere were no statistically significant differences between the two groups for estimated blood loss, duration of surgery, length of stay, 30-day readmission, and patient costs; however, the average cost of RAH was $3116 less than CLH, if not considering the cost and maintenance of the surgical robot indicating surgical team approaching proficiency and maturity in RAH. A strong correlation between uterus weight, blood loss, duration of surgery, and patient cost within only the RAH group was observed, suggesting a more precise surgical technique. ConclusionRAH and CLH had similar surgical outcomes. RAH can be a more precise surgical technique, and potentially less costly when the cost and maintenance of the robot are not considered.

Mesh Exposure After Robot-Assisted Laparoscopic Pelvic Floor Surgery: A Prospective Cohort Study

To prospectively evaluate the mesh exposure rate after robot-assisted laparoscopic pelvic floor surgery for the treatment of female pelvic organ prolapse (POP) in a large cohort. Prospective observational cohort study (Canadian Task Force classification II-2). Two large teaching hospitals with a tertiary referral function for pelvic floor disorders. Patients with symptomatic POP and simplified POP quantification (S-POP) stage ≥2. Patients with a history of mesh repair or concomitant insertion of a tension-free vaginal tape were excluded. Robot-assisted laparoscopic sacrocolpopexy or robot-assisted laparoscopic supracervical hysterectomy with a sacrocervicopexy. A blinded vaginal examination with the aid of a transparent speculum was performed to look for mesh-related complications. Mesh exposures were described following the International Urogynecological Association/International Continence Society classification system. One hundred and ninety-two patients were included, of whom 166 (86.5%) were seen for follow-up examination. The median duration of follow-up was 15.7 months (range, 8.2-44.4 months). Two vaginal mesh exposures (1.2%) were detected, both of which were treated in the outpatient clinic. One patient without any complaints had a suture exposure, which was removed in the outpatient clinic. The safety of the use of mesh in pelvic floor surgery is a matter of debate owing to the occurrence of mesh-related complications. Based on the current literature, mesh-related complications seem to be lower in transabdominal mesh surgery than in transvaginal mesh surgery. In this study, a low mesh exposure rate was observed in robot-assisted abdominal pelvic floor surgery for POP.

Two-port robotic hysterectomy: a novel approach.

The objective of the study was to demonstrate a novel technique for two-port robotic hysterectomy with a particular focus on the challenging portions of the procedure. The study is designed as a technical video, showing step-by-step a two-port robotic hysterectomy approach (Canadian Task Force classification level III). IRB approval was not required for this study. The benefits of minimally invasive surgery for gynecological pathology have been clearly documented in multiple studies. Patients had fewer medical and surgical complications postoperatively, better cosmesis and quality of life. Most gynecological surgeons require 3-5 ports for the standard gynecological procedure. Even though the minimally invasive multiport system provides an excellent safety profile, multiple incisions are associated with a greater risk for morbidity including infection, pain, and hernia. In the past decade, various new methods have emerged to minimize the number of ports used in gynecological surgery. The interventions employed were a two-port robotic hysterectomy, using a camera port plus one robotic arm, with a focus on salpingectomy and cuff closure. We describe a transvaginal and a transabdominal approach for salpingectomy and a novel method for cuff closure. The transvaginal and transabdominal techniques for salpingectomy for two-port robotic-assisted hysterectomy provide excellent tension and exposure for a safe procedure without the need for an extra port. We also describe a transvaginal technique to place the vaginal cuff on tension during closure. With the necessary set of skills on a carefully chosen patient, two-port robotic-assisted total laparoscopic hysterectomy is a feasible procedure.

Dermatologic Manifestations of Laparoscopic Port Site Vascular Injuries

Vascular injuries are a rare but serious complication associated with laparoscopic surgery. We encountered an unrecognized port site vascular injury in a 36-year-old woman, gravida 4 para 3, who presented 11 days after undergoing robotic-assisted laparoscopic hysterectomy with extreme ecchymosis extending from the right umbilicus to the vulva and knees (Fig A).

Combined Oocyte Retrieval and Robot-assisted Hysterectomy in a Super Morbidly Obese Patient with Endometrial Carcinoma

To report on the unique, innovative management of a super morbidly obese patient presenting for fertility preservation in the setting of Grade 2 endometrioid endometrial adenocarcinoma. A back-to-back oocyte retrieval and robot-assisted total laparoscopic hysterectomy (RA-TLH) with bilateral salpingo-oophorectomy (BSO) was performed in a 37-year-old nulligravid woman with super morbid obesity (BMI 63 kg/m2) with endometrial cancer. the successful retrieval of oocytes for fertility preservation and oncologic intervention via RA-TLH with BSO in the same operative and anesthetic episode. This combined procedure strategy was successful in our case and is a feasible option for similar high-risk patients in the future. Identifying safe and effective approaches for oocyte retrieval in morbidly obese patients represents a pressing need as obesity rates rise among reproductive-aged women. Back-to-back oocyte retrieval and RA-TLH with BSO are not only feasible, but could also decrease significant anesthetic risks for morbidly obese patients.

12: The impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy for large uteri

To evaluate the impact of surgeon volume on perioperative adverse events in women undergoing minimally invasive hysterectomy (MIH) for uteri >250 grams. This is a retrospective cohort study of all women who underwent vaginal (VH), laparoscopic (TLH), laparoscopic-assisted vaginal (LAVH), or robotic-assisted laparoscopic hysterectomy (RH) between January 2014 and July 2016 at a tertiary care referral center. Hysterectomy was performed for the following indications: fibroids, pelvic pain, abnormal uterine bleeding, and prolapse. Women were excluded if there was a preoperative diagnosis of malignancy. Patients were identified by Current Procedural Terminology codes and the system-wide electronic medical record was queried for demographic and perioperative data. Perioperative adverse events were defined a priori and classified using the Clavien-Dindo scale. Surgeon volume was defined as the mean number of MIH cases performed per month by each surgeon during the study period. Seven hundred sixty-three patients met inclusion criteria: 416 (54.5%) TLH, 196 (25.7%) RH, 90 (11.8%) TVH, and 61 (8%) LAVH. Mean (±SD) age was 47 ± 6 years, and body mass index (BMI) was 31.1 ± 7.4 kg/m2. Sixty-six surgeons performed MIH for uteri >250 grams during the study period. The mean monthly case volume was 16.4 ± 7.2 cases, and the median MIH volume was 23 cases (range: 1–147 cases). The mean uterine weight was 522.8 ± 322.7 grams. The rate of postoperative adverse events >Dindo grade 2 was 17.8% (95% CI = 15.2-20.7); 2.2% (95% CI = 1.4-3.6) were grade 3 and 0.5% (95% CI = 0.7-1.4) grade 4; there were no grade 5 adverse events. The overall rate of intraoperative adverse events was 4.2% (95% CI = 2.9-5.9). The rate of conversion to laparotomy was 5.5% (95% CI = 4.0-7.4). There was no difference in adverse event rates between the routes of MIH cases (25.6% vs. 17.5% vs. 18.0% vs. 14.8%, p = 0.2). Women who experienced any adverse event compared to those who did not were more likely to be of Hispanic, Asian or “other” ethnicity, had higher intraoperative blood loss (EBL) and longer operating case time. In a logistic regression model controlling for age, BMI, uterine weight, operating time, history of laparotomy and parity, higher monthly MIH volume remained significantly associated with adverse events (adjOR = 1.14, 95% CI = 1.0-1.3, p = 0.01), as did higher EBL (adjOR = 1.4, 95% CI = 1.1-1.8, p = 0.006). When controlling for the same variables, higher monthly MIH case volume remained significantly associated with intraoperative complications (adjOR = 1.30, 95% CI = 1.0-1.6, p = 0.02) as well as higher EBL (adjOR = 3.1, 95% CI = 2.0-4.9, p < 0.001). Conversion from a minimally invasive approach to laparotomy was not associated with monthly MIH case volume; however, conversion was associated with higher EBL (adjOR = 2.9, 95% CI = 1.8-4.9) and heavier uteri (adjOR = 9.7, 95% CI = 3.9-23). The overall rate of serious adverse events associated with MIH for uteri >250 grams was low. Higher EBL and longer operative times were associated with higher perioperative adverse event rates. Higher monthly MIH case volume was associated with a higher rate of intra- and postoperative adverse events but was not associated with conversion to laparotomy.

03: Surgical site infection prevention bundle for hysterectomy: Effect on costs of surgical admission and 30-day readmissions

Although surgical site infection (SSI) prevention bundles for hysterectomy are becoming standard at many institutions to improve patient care and experience, there are scant data available about how SSI prevention bundles affect cost of care. This study aimed to evaluate the effect of an SSI prevention bundle initiated at our institution on costs of initial surgical admission and subsequent re-admission for SSI-related causes. Data on hysterectomies performed from April 1, 2013, to December 31, 2015, were prospectively collected. There were 1303 cases in the 20-month period prior to full bundle implementation (April 1, 2013 to November 30, 2014) and 703 cases in the 13-month post-full bundle implementation period (December 1, 2014 to December 31, 2015). We used ICD-9/10 diagnosis codes to determine causes of readmissions within 30 days of hysterectomy, and focused on readmissions related to SSI. Total costs of care during hysterectomy hospitalization and SSI-related readmissions were obtained from our institution’s financial database, and included hospital facility costs of operating room supplies, laboratory fees, imaging, medications, room and board, and nursing care. All costs are reported in inflation adjusted 2015 US dollars. Patients’ clinical characteristics were collected via medical record review. Wilcoxon rank-sum tests and generalized linear regression analysis were used to compare costs in the pre- and post-full bundle implementation periods. Costs of hysterectomy hospitalization were significantly higher in the post-full bundle implementation period than in the pre-full bundle implementation period ($5,513 vs. $4,919, p < 0.001). When stratified by route of hysterectomy and presence or absence of gynecologic cancer, there was a statistically significant increase in cost of hysterectomy between the pre-full bundle and post-full bundle intervention periods for all routes except straight-stick laparoscopies for benign indications. The costs of hysterectomy admissions in pre-full bundle compared to post-full bundle implementation periods were, for benign disease: total abdominal hysterectomy (TAH): $4,801 versus $5,173 (p = 0.005), total laparoscopic hysterectomy (TLH): $4,186 versus $4,314 (p = 0.61), and robot-assisted total laparoscopic hysterectomy (raTLH): $4,666 versus $5,027 (p = 0.02). For malignancy: TAH: $6,602 versus $9,407 (p < 0.001), TLH: $4,408 versus $6,671 (p = 0.002), and raTLH: $4,469 versus $6,107 (p < 0.001). Multivariable regression analysis adjusting for patient age, comorbid conditions, BMI, and surgical route also suggested higher cost of hysterectomy hospitalizations during the period after full bundle implementation (adjusted cost ratio = 1.11, p < 0.001). The median cost of SSI-related hospital re-admissions were $3,527 pre-full bundle and $3,797 post-full bundle implementation (p = 0.65). The mean cost of all SSI related re-admissions was $5,795 ± 1,903. In our institution’s experience, SSI prevention bundles did not reduce hospital costs of surgical admissions over time, despite a significant decrease in SSI rate during the study period. Although there are cost savings in preventing readmission, there may be increasing hospital costs, particularly for open and robot-assisted laparoscopic cases, that warrant further assessment.

Laser Angiography to Assess the Vaginal Cuff During Robotic Hysterectomy.

Background and Objectives:Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH.Methods:This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion.Results:Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175).Conclusion:Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.

Outcomes in women undergoing robotic-assisted laparoscopic hysterectomy compared to conventional laparoscopic hysterectomy at a tertiary hospital in Western Australia.

Robotic-assisted laparoscopic hysterectomy (RALH) is associated with improved outcomes compared to open surgery in patients with endometrial cancer but data are conflicting when comparing RALH to conventional total laparoscopic hysterectomy (TLH). In October 2014, a RALH program was established in Perth, Western Australia. To compare outcomes in patients undergoing RALH with a matched cohort undergoing TLH. A retrospective matched cohort study compared outcomes in 45 patients who underwent RALH with 45 controls who were patients treated with TLH. Mean operating time was longer in the RALH group compared to controls (75.42min vs 53.18min, mean difference 22.24min, P <0.001, 95% Cl, 11.07-33.42). No differences were observed in mean pain scores (RALH 1.47 vs TLH 1.84 P=0.31), mean parenteral and oral opioid use (RALH 14.3mg and 42.4mg vs TLH 17.5mg and 52.57mg, P= 0.42 and 0.42, respectively), and mean length of stay (RALH 1.51 vs TLH 1.67days, P=0.49). Two patients in the RALH group and one patient in the TLH group sustained iatrogenic bladder injuries (P=0.62). The establishment of the RALH program at our institution appeared to be associated with equivalent morbidity, post-operative pain, opioid use and length of stay compared to conventional laparoscopy. A surgical learning curve for RALH was observed. Well-designed prospective studies are needed to further evaluate short- and long-term patient function, morbidity, quality of life and oncologic outcomes.

Case of Psoas Abscess after Robotic-Assisted Laparoscopic Hysterectomy and Pelvic Lymphadenectomy

Iliopsoas abscess (IPA) is a rare condition seen in a variety of specialties that presents with nonspecific complaints. Presented herein is the development of an IPA after robotic staging with sentinel lymphadenectomy for endometrial carcinoma. The patient was a 61-year-old woman with history of prolonged immunosuppressive therapy due to psoriasis. She presented with an IPA 8 weeks after a robotic-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and sentinel lymph node dissection. The patient was treated and cured with empiric antibiotics and drainage by interventional radiology. Although infrequent, one must keep IPA as a possible diagnosis in immunosuppressed patients who have undergone dissection of the retroperitoneal space during gynecologic surgery.

476 - Robotic-Assisted Hysterectomy for Endometrial Cancer: Comparing Outcomes of Two Methods for Intact Uterine Extraction

Study Objective: The objective of this study was to compare peri-operative outcomes among patients with endometrial cancer undergoing robotic-assisted laparoscopic hysterectomy (RALH) with either vaginal extraction of the uterine specimen or RALH with uterine extraction via extended incision secondary to large uteri.

122 - Evaluating the Impact of Surgical Complexity on Operative Times During Total Laparoscopic Hysterectomy

Study Objective: To objectively quantify the impact of factors contributing to the complexity of conventional (TLH) versus robotic-assisted (RATLH) total laparoscopic hysterectomy as a function of operative time.