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The introduction of robotic technology has dramatically altered the surgical approach to hysterectomy. Following introduction of the robotic surgical system, there has been a dramatic decrease in the proportion of hysterectomies being performed via laparotomy. Furthermore, a continually growing number of hysterectomies are being performed via laparoscopy both with and without the assistance of robotic technology [1]. In order to safely and efficiently perform a robotic hysterectomy on a normal-sized or small uterus, a surgeon must be methodical in the techniques employed.

Minimal invasive techniques have become a standard approach in the management of rectal cancer surgery. The use of robotic assisted instruments seems to have further advantages in the dissection of the tissue and protection of the surrounding tissue, especially in tight regions like the pelvic floor.

Options for approach to hysterectomy include abdominal, vaginal, laparoscopic or robot-assisted laparoscopic surgery. There are well-documented benefits to minimally invasive modes of surgery compared to traditional abdominal procedures. Despite this fact, the majority of hysterectomies in the United States are still performed via laparotomy. With regard to differentiation between the various minimally invasive approaches, it has been consistently demonstrated that robotic hysterectomy procedures are associated with longer operative times and higher cost. However, the available literature is limited by the small number of randomized or prospective studies comparing surgical approach to hysterectomy.

Application of energy in minimally invasive hysterectomy creates thermal injury which may increase vaginal cuff dehiscence. The purpose of this study was to compare vaginal tissue damage in a swine model between the two power settings of ultrasonic energy. This was an IACUC-approved, prospective, single-blinded study analyzing energy-induced damage to the swine vagina during robotic hysterectomy. Multiple colpotomy transections were performed on 18 animals using robotic ultrasonic energy, the exact same platform used in human surgery. Specimens (n = 72) were analyzed by a veterinary pathologist blinded to the energy source. Thermal injury was microscopically measured. Mean thermal injury (µm) was not statistically different between Max-Setting 5 and Min-Setting 3 (1243 ± 544 vs. 1293 ± 554; 95 % CI -310 to 210, p = 0.66). Time (s) to complete transection was significantly shorter when using Setting 5 (13.00 ± 7.75 vs. 17.92 ± 9.03; 95 % CI -4.92 to -8.88, p = 0.001). The rate of injury (µm/s) for Setting 5 also trended toward being higher (118.98 ± 72.81 vs. 93.03 ± 62.34; 95 % CI -5.91 to 57.81, p = 0.053). In these swine vaginal specimens, energy-induced tissue damage was not statistically different for the two ultrasonic power settings. Max-Setting 5 was faster and trended toward a higher rate of damage; this was balanced by equivalent distance of tissue injury compared with Min-Setting 3. In larger human specimens, the use of Max-Setting 5 may be recommended to decrease surgical time as it is faster and causes an equivalent amount of injury to Min-Setting 3.

Objective: The aim of this research was to determine patient and intraoperative characteristics that may predict feasibility of same-day discharge after robotic hysterectomy. Materials and Methods: Patients undergoing robotic hysterectomy from October 2007 to April 2011 were included in the study. Patient demographics were retrospectively collected and analyzed, include: age (years), height (inches), weight (kg), body mass index (BMI, measured in kg/m2), procedure indication, number of previous abdominal procedures, and American Society of Anesthesiologists (ASA) physical classification system score. Procedure data were collected as well as transfusion status, postoperative length of hospital stay (LOS), procedure type, presence of abdominal adhesive disease, conversion to laparotomy, estimated blood loss (EBL), procedure duration, intraoperative complications, and short-term complications. Results: Patient age (p

Video Objective To demonstrate successful ureterolysis technique when the ureter is abutting the cervix. Setting A 43 year-old multiparous woman with an enlarged fibroid uterus and abnormal uterine bleeding desired definitive surgical management. Her right ureter was abutting the cervix to within less than 0.5cm and required meticulous dissection to maintain its integrity. Interventions Several factors are considered to maintain ureteral integrity during hysterectomy. These include: 1- Identification and dissection of the ureter along the medial leaflet of the broad ligament; 2- In-depth knowledge of the anatomical variations of the parametric; 3- Judicious use of monopolar and bipolar electrosurgery; 4- In-depth understanding of the various effects of electrosurgery on tissues. Conclusion Understanding the course of the ureter is crucial during hysterectomy. When abutting the cervix, judicious use of monopolar and bipolar energy is key to maintain ureteral integrity.

Video Objective Rate of placenta increta is raising in the United States due to a higher number of cesarean deliveries performed in the United States. We present a case of placenta increta diagnosed post cesarean delivery day 3. Robotic hysterectomy performed successfully on postpartum day 3. Setting community hospital medical center. Interventions Robotic Hysterectomy. Conclusion Robotic Hysterectomy provide a better option for Dissection of fine tissue planes . And less blood loss during surgery specially in anticipated difficult cases. Placenta increta in stable patient can be managed medically with methotrexate or surgically with Hysterectomy usually interval hysterectomy performed 4-6 weeks postpartum. We performed the first Robotic Hysterectomy for placenta increta Post cesarean delivery day 3. Recognizing the challenges of large postpartum uterus,placenta increta, fresh cesarean section. And difficult bladder dissection . Using the robotic platform with 3D magnification made it easier to perform a rather more challenging surgery.

Background Robotic surgery is associated with several advantages but also high costs. This study evaluates clinical outcomes and financial feasibility of outpatient robotic hysterectomy. Methods Retrospective cohort study (Class II-2) of patients who underwent robotic hysterectomy for benign conditions by the same surgeon (M.A.B.) at the University of Texas Medical Branch, Galveston, TX, USA, during November 2010–February 2013. The study only included cases considered appropriate for outpatient management. Clinical outcomes and costs for patients discharged the same day (outpatients) were compared to those electively admitted (hospitalized). Results Twenty-nine cases (14 outpatient and 15 hospitalized) were analysed. Demographic, pre-, peri- and postoperative characteristics and payer types were not different among the groups (p > 0.05). Outpatient hysterectomy was associated with $4968 hospital savings (p < 0.001), $410 payer savings (p = 0.775) and $4558 improvement in net profit/loss (p = 0.01). Conclusions In well-selected patients, adopting a well-designed programme, outpatient robotic hysterectomy seems to be safe and financially feasible. Copyright © 2014 John Wiley & Sons, Ltd.

Background The objective was to evaluate the learning curve for performing a robotic hysterectomy to treat benign gynaecological disease. Methods Thirty-six patients underwent robotic hysterectomy for benign indications. A systematic chart review of consecutive cases was conducted. The collected data included age, BMI, operating time, set-up time, docking time, uterine weight, blood loss, intraoperative complications, postoperative complications, conversions to laparotomy and length of hospital stay. Results The mean operating, set-up and docking times were 169 ± 54.5, 52.9 ± 12.4 and 7.8 ± 7.6 min, respectively. The learning curve analysis revealed a decrease in both docking and operating times, with both curves plateauing after case 9. Conclusions The learning curve analysis revealed a decrease in docking time and operating time after case 9, suggesting that there might be a fast, learning curve for experienced laparoscopic surgeons to master robotic hysterectomy, and that the docking process does not have a significant negative influence on the overall operating time. Copyright © 2013 John Wiley & Sons, Ltd.

Since the introduction of robotic technology, there have been significant changes to the field of gynecology. The number of minimally invasive procedures has drastically increased, with robotic procedures rising remarkably. To date several authors have published cost analyses demonstrating that robotic hysterectomy for benign and oncologic indications is more costly compared to the laparoscopic approach. Despite being more expensive than laparoscopy, other studies have found robotics to be less expensive and more effective than laparotomy. In this review, controversies surrounding cost-effectiveness studies are explored.

The introduction of new and improved surgical techniques for treatment of endometrial carcinoma has been shown to be associated with histological artifacts making interpretation and diagnosis a challenge for the pathologist with an impact on clinical staging. In this review, challenging artifacts associated with the use of manipulated laparoscopic hysterectomies for endometrial carcinoma are discussed with a review of the literature. Topics discussed include the artifacts of vascular pseudoinvasion; endomyometrial cleft displacement, disruption of endometrial lining, nuclear crush artefact and positive peritoneal cytology. The pathologist should be aware of these artifacts in order to prevent diagnostic errors and unwarranted therapy for some patients.

Objective To compare outcomes and cost for patients with endometrial cancer undergoing vaginal hysterectomy (VH) or robotic hysterectomy (RH), with or without lymphadenectomy (LND). Methods Patients undergoing planned VH (and laparoscopic LND) or RH (and robotic LND) between January 2007 and November 2012 were reviewed. Patients with stage IV disease, synchronous cancer, synchronous surgery, or treated with palliative intent were excluded. Patients were objectively triaged to LND per institutional protocol based on frozen section. Outcomes were compared between VH and RH groups matched 1:1 on propensity scores. Results VH was planned in 153 patients; 60 (39%) had concurrent LND while 93 (61%) were low risk and did not require LND. RH was planned in 398 patients; 225 (56%) required concurrent LND and 173 (44%) did not. Among 50 PS-matched pairs without LND, there was no significant difference in complications, length of stay, readmission, or progression free survival. However, median operative time was 1.3h longer and median 30-day cost $3150 higher for RH compared to VH (both p Among patients requiring LND, 42 PS-matched pairs were identified. Median operative time was not different when pelvic and para-aortic LND was performed, and 12min longer in the VH group for pelvic LND alone (p=0.03). Median 30-day cost was $921 higher for RH compared to VH when LND was required (p=0.08). Conclusion Utilization of vaginal hysterectomy for endometrial cancer results in similar surgical and oncologic outcomes and lower costs compared to RH and should be considered for appropriate patients with a low risk of requiring LND.

Robotic hysterectomy for very large uteri requires longer operative times but results in shorter hospital stays and decreased intraoperative blood loss., Background and Objectives: We sought to examine the outcomes of patients with myomatous uteri weighing >1000 g who underwent hysterectomy by one of two modalities, either with a robotic system or by laparotomy. Methods: All patients who underwent robotic hysterectomy for uteri weighing >1000 g at our institution between May 2007 and January 2011 were identified, and a retrospective chart review was performed. These patients were matched to a laparotomy control group by body mass index and uterine weight, and the postoperative outcomes in both groups were analyzed and compared. Results: Sixty patients with uteri weighing >1000 g underwent hysterectomy, 30 with the robotic system and 30 by laparotomy. The median body mass index was 31.8 kg/m2 (range, 18.5–56.3 kg/m2) and the median uterine weight was 1259 g (range, 1000–3543 g) in the robotic group versus 30.2 kg/m2 (range, 18–48 kg/m2) and 1509 g (range, 1000–3570 g), respectively, in the laparotomy group (P = .31). The median operating time was 255 minutes (range, 180–372 minutes) in the robotic group versus 150 minutes (range, 100–285 minutes) in the laparotomy group (P < .001). There were no conversions to laparotomy. In both groups the operative time was not increased with increasing specimen weight. The median blood loss was 150 mL in the robotic group versus 425 mL in the laparotomy group. Of 30 patients in the robotic group, 23 (76.6%) were discharged from the hospital on postoperative day 1. The median hospital stay for the robotic group was 1 day, and for the laparotomy group, it was 2.5 days (P < .01). Conclusion: Robotic surgeries for very large myomatous uteri are feasible and have minimal morbidity even in morbidly obese patients. The robotic surgery requires a longer operative time but results in a shorter hospital stay and decreased intraoperative blood loss.

The objective of this article is to reflect the current stand on robotic vs laparoscopic hysterectomy. There are only few recent studies comparing robotic with laparoscopic hysterectomy and most are retrospective. Early studies found prolonged operating times (e.g. 150.8 vs 114.4 minutes, p = 0.001) for robotic assisted than laparoscopic hysterectomy,1,2 but this appears to have been the result of a lack of experience with this new technology; the learning curve to reduce the robotic surgical time had median of 29 cases per surgeon.10 Subsequent studies reported operative durations which are comparable to conventional total laparoscopic hysterectomy, approximately 2 hours.13,14 A minority of studies have reported that roboticassisted is superior to conventional laparoscopic hysterectomy, with reports of shorter operative duration, decreased blood loss, decreased rate of conversion to laparotomy, decreased use of postoperative narcotic analgesia, and shorter hospital stay.1,2,12 Materials and methods: This involved the review of related articles to robotic vs laparoscopic hysterectomy. The scope of this review covered Medline, UpToDate, PubMed, Highwire press, Da Vinci community, Google search engine.12,13 Summary: Recent comparative studies have found that robotic and conventional laparoscopic hysterectomy are essentially equivalent regarding surgical and clinical outcome. Operating times are slightly higher and costs are significantly higher for the robotic hysterectomy.

Operative cost and outcomes between robotic and laparoscopic hysterectomy across different uterine weights. Retrospective cohort study including patients undergoing robotic and laparoscopic hysterectomy for benign disease at an Academic university hospital. One hundred and ninety six hysterectomies were identified (101 robotic versus 95 laparoscopic). Demographic and surgical characteristics were statistically equivalent. Robotic group had a higher body mass index (±SD) (32.9 ± 6.5 versus 30.4 ± 7.1, p 0.012) and more frequent history of adnexal surgery (12.9 versus 4.2%, p 0.031). Laparoscopic group had a higher number of concurrent salpingectomy (81 versus 66.3%, p 0.02). Estimated blood loss did not differ between procedures. Compared to robotic hysterectomies, laparoscopic procedures added 47 min (CI: 31-63 min; p 0.001) of operative time, costed $1648 more (CI: 500-2797; p = 0. 005) and had triple the odds of having an overnight admission (OR = 2.94 CI: 1.34-6.44; p = 0.007). After stratification of cases by uterine weight, the mean operative time difference between the two groups in uteri between 750 and 1000 g and in uteri1000 g was 81.3 min (CI: 51.3-111.3, p 0.0001) and 70 min (CI: 26-114, p 0.005), respectively, in favor of the robotic group. Mean direct cost difference in uteri between 750 and 1000 g and uteri1000 g was 1859$ (CI: 629-3090, p 0.006) and 4509$ (CI: 377-8641, p 0.004), respectively, also in favor of the robotic group. In expert hands, robotic hysterectomy for uteri weighing more than 750 g may be associated with shorter operative time and improved cost profile.

Objectives To demonstrate the initial experience of robotic hysterectomy to treat benign uterine disease at a university hospital in Brazil. Methods A cross-sectional study was conducted to review data from the first twenty patients undergoing robotic hysterectomy at our hospital. The surgeries were performed from November 2013 to August 2014, all of them by the same surgeon. The patients were reviewed for preoperative characteristics, including age, body mass index (BMI), indications for the hysterectomy and previous surgeries. Data of operative times, complications, postoperative pain and length of hospital stay were also collected. Results The total operating room time was 252.9 minutes, while the operative time was 180.7 minutes and the console time was 136.6 minutes. Docking time was 4.2 minutes, and the average undocking time was 1.9 minutes. There was a strong correlation between the operative time and the patient's BMI (r = 0.670 ; p = 0.001). The console time had significant correlation with the uterine weight and the patient's BMI (r = 0.468; p = 0.037). A learning curve was observed during docking and undocking times. Conclusion Despite its high cost, the robotic surgery is gaining more space in gynecological surgery. By the results obtained in our hospital, this surgical proposal proved to be feasible and safe. Our initial experience demonstrated a learning curve in some ways. Resumo Objetivos O presente projeto visa à documentação da experiência inicial do Hospital de Clínicas de Porto Alegre na realização da histerectomia robótica. Métodos Um estudo transversal foi realizado a fim de revisar dados das primeiras vinte pacientes submetidas à histerectomia robótica em nosso hospital. As cirurgias foram realizadas no período de novembro de 2013 a agosto de 2014, e todas tiveram o mesmo cirurgião. Foram analisadas características pré-operatórias, incluindo idade, índice de massa corporal, cirurgias prévias abdominais, paridade, indicação da histerectomia. Dados referentes aos tempos operatórios, complicações, dor pósoperatória e tempo de internação pós-operatória também foram coletados. Resultados O tempo de sala total foi de 252,9 minutos, enquanto o tempo cirúrgico total foi 180,7 minutos, e o tempo de console foi 136,6 minutos. O tempo médio de docking foi 4,2 minutos; e o tempo médio de undocking foi 1,9 minutos. Foi observada forte correlação entre o tempo cirúrgico total e o índice de massa corporal da paciente (r = 0,670; p = 0,001). O tempo de console teve correlação significativa com o peso uterino e com o índice de massa corporal das pacientes (r = 0,468; p = 0,037). Foi observada curva de aprendizado nos tempos de docking e undocking. Conclusão Apesar do alto custo, a robótica vem ganhando espaço na cirurgia ginecológica. Pelos resultados obtidos no nosso hospital, a proposta provou ser factível e segura. Nossa experiência inicial demonstrou curva de aprendizado em alguns aspectos.

The objective of this study was to determine whether routine preoperative type and screen blood testing is cost effective and medically warranted for benign diagnosis in healthy patients undergoing robotic hysterectomy. The study was designed as a cross sectional retrospective descriptive study. Four hundred and twenty-two medical records of American Society of Anesthesiologists (ASA) Classifications I and II patients undergoing robotically-assisted laparoscopic hysterectomy between 1 June 2011 and 31 May 2014 at a 211 bed regional medical center were analysed. The results from this study paralleled the findings of other published research. Preoperative type and screen testing was performed on 249 (59%) of the patients in the study. Ten patients (2.4% of the group) converted to open laparotomy. Mean estimated blood loss was 59.59ml. No perioperative transfusions were required. The results indicate that preoperative type and screen testing is not warranted for patients meeting the inclusion criteria.

Objective: The purpose of this study was to evaluate the operative outcomes associated with robotically assisted vaginal hysterectomy (RAVH). Methods: This study was designed as a cohort study using databases from two separate institutions: one where RAVH is used and the other where robotic hysterectomy (RH) is used. In the RAVH group, the surgery was converted to the vaginal approach just prior to uterine vessel coagulation. The main outcome variables were time to complete hysterectomy, blood loss, and complications. Results: RAVH (n=21) and RH (n=62) groups were comparable in terms of age, parity, body mass index (BMI), and uterine weight. There were no statistically significant differences between the vaginally completed operation and robotic performance of the same steps for operative time, blood loss, and operative complications. Conclusions: RAVH and RH have similar intraoperative characteristics. (J GYNECOL SURG 28:1)

This study suggests that robotic-assisted hysterectomy has comparable outcomes and possibly fewer complications than other methods of minimally invasive hysterectomy., Objective: To compare surgical outcomes for robotic-assisted total laparoscopic hysterectomy (RH) to other minimally invasive hysterectomy (MIH) types, including total laparoscopic hysterectomy (TLH), laparoscopic-assisted vaginal hysterectomy (LAVH), and vaginal hysterectomy (VH). Methods: Retrospective cohort study of all patients who underwent RH or MIH for benign indications between January 2007 and May 2010 at 2 Henry Ford Health System teaching hospitals. Age, race, body mass index (BMI), procedure duration, estimated blood loss (EBL), peri-operative hemoglobin change, uterine weight, length of hospital stay (LOS), and complications were collected from electronic medical records and were compared between RH and MIH groups. Results: Included in the analysis were 135 RH and 162 MIH cases (n = 34 VH, n = 82 LAVH, n = 46 TLH). There were no differences in age, race, or BMI between groups, but RH patients had significantly larger uteri (P = .007; RH, 13.5%>500g; MIH 4.0%>500g). MIH patients had significantly greater EBL (P < .001) and drop in hemoglobin (P = .02) than RH patients with a 150 mL difference in median EBL (200 mL versus 50 mL) between groups. RH had longer procedure durations than MIH (P = .0002) overall, but not compared to the TLH subgroup. RH patients had a shorter LOS than MIH patients had (P = .02) who had a longer LOS for LAVH patients. Although readmission and major complication rates were similar in both groups, minor adverse events occurred more frequently in the MIH group (21.6%) than the RH group (8.9%) (P = .003). Conclusion: RH has comparable surgical outcomes, and possibly decreased blood loss, shorter length of stay, and fewer minor complications than other methods of MIH.

It is suggested that robotic hysterectomy can be performed safely in obese and morbidly obese patients, with surgical outcomes and complications similar to those of nonobese patients., Objective: To describe patient characteristics and perioperative outcomes among women undergoing robotic-assisted laparoscopic hysterectomy and to evaluate the characteristics of nonobese, obese, and morbidly obese patients. Methods: A retrospective review was conducted of 442 cases of women who underwent robotic-assisted laparoscopic hysterectomy for benign and malignant conditions over a 4-y period at an academic and community teaching hospital. Patient demographics, surgical indications, operative outcomes, and complications were evaluated for patients with a body mass index (BMI)

Background The purpose of this study was to evaluate the benefits and morbidity associated with a novel technique for a hysterectomy designed specifically for a robotic-assisted laparoscopic procedure. Recent studies have compared robotic-assisted laparoscopic hysterectomy vs. open hysterectomy. We have developed a surgical technique that has enabled us to efficiently decrease the standard operative time. Methods All patients (55) underwent a robotic-assisted hysterectomy utilizing a novel surgical technique with four specific components, inclusive of the Hem-o-lok® locking clip. Results This surgical technique has enabled us to efficiently decrease the standard operative time to an average of 80.9 ± 3.44 min with an estimated blood loss of 63.5 ± 3.76 ml and a hospital stay of 1.3 ± 0.15 days, with minimal complications during surgery (1.8%). Conclusion We have provided an efficient technique that is safe, easily reproducible and comparable to open hysterectomy operation times. Copyright © 2011 John Wiley & Sons, Ltd.

Vajinal kubbe açılması ve eşlik eden barsak eviserasyonu histerektomi operasyonları sonrası nadir görülen bir komplikasyondur. Laparoskopik cerrahinin günümüzde giderek yaygınlaşan kullanımı ile birlikte özellikle robotik cerrahinin kullanım sıklığında artışa paralel olarak bu komplikasyonun görülme sıklığında da olası bir artış izlenmektedir. Bu olgu sunumu ile vajinal kubbe açılması sıklığındaki artış için olası risk faktörleri ve tedavi yaklaşımı değerlendirilecektir. J Turk Soc Obstet Gynecol 2014;4:249-51, Vaginal cuff dehisence with bowel evisceration after hysterectomy is a very rare complication. However, the incidance of this complication appears to be increased with the widely used techniques of laparoscopic surgery especially with robotic hysterectomy. In this case report we aimed to evaluate the risk factors and treatment methods for this complication. J Turk Soc Obstet Gynecol 2014;4:249-51

Background: Gynecologic cancer and treatment related morbidities adversely affect the quality of life (QOL) and overall outcome. QOL assessment and focus on QOL improvement still lag behind in the priority list of cancer management in Indian women. Aim: To assess the quality of life in India gynecologic cancer patients and possible tools for its improvement. Methods: This review is based on PubMed literature search of all the studies related to QOL in gynecologic cancer patients in India. The studies were categorized into those assessing QOL and improving QOL. Results: Unlike the abundant literature on QOL of patients with breast and oral cancers, the studies on QOL of women with gynecologic cancers are scarce. Nonetheless, twenty-five articles could be retrieved that directed efforts to identify parameters and tools assessing QOL as well as to modify treatment strategies for better QOL. The principal of nerve sparing technique and easily reproducible steps of laparoscopy and robotic hysterectomy has been recently used in Indian patients. It helped in improving QOL of operable cervical cancer patients. Ayurveda holds an important place in Indian medicine and has effective remedies for many diseases. Studies on the use of Ayurvedic drugs during chemotherapy and radiotherapy have shown reduction in treatment related toxicities. Conclusion: Improvement in 'quality of life' should be considered as important as increment in overall survival while managing women with gynecologic cancers. Better QOL would boost the patient's and family's compliance to treatment and improve disease specific outcome. Simpler QOL assessment tools and refined multimodal therapy techniques suitable for Indian population need to be integrated in national cancer treatment guidelines.

Training residents to perform robotic surgery poses several challenges. We describe a comprehensive method, beginning with a dry lab, and progressing through bedside assisting, then segmental involvement, to full participation, for residents to train and obtain credentials in robotic hysterectomy. From August 1, 2006 through July 31, 2009 a training method was developed at the University of South Alabama on the Gynecologic Oncology service. A dry lab which closely simulates specific tasks performed in a robotic hysterectomy was accompanied by resident observation of robotic surgery, and followed with progressive involvement in the robotic console. This culminated in their completion of dozens of complete robotic hysterectomies. Sixteen residents completed the dry lab and 228 robotic cases were performed, 190 of which were hysterectomy; 161/190 (84.7%) included resident participation, 103/190 (54.2%) included resident participation in the console, and in 65/190 (34.2%) residents completed the hysterectomy procedure. The mean time for resident robotic hysterectomy was 45.08 min (range = 13-92 min), and the mean time to tie a single figure-of-eight suture in the vaginal cuff was 4.41 min (range = 2.25-9.25). Complications were similar for resident and attending surgeon cases. Using a dry lab as well as graded introduction to robotic surgery which begins with observation, progresses through bedside assisting, and culminates in complete hysterectomy by residents, we have demonstrated a method to train and credential Ob/Gyn residents in robotic hysterectomy.

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.

INTRODUCTION:The number of opioid-related deaths has quadrupled in the United States since 1999, and the opioid crisis is well-defined. The purpose of this study is to identify demographic predictors of increased inpatient and post-discharge opioid use in order to tailor postoperative opioid dispens