Feasibility and Learning Curve of Robotic Laparoendoscopic Single-Site Surgery in Gynecology

Role of single port robotic surgery in gynecology

Robot-assisted Single-Site Laparoscopy (R-LSS) is a rapidly evolving minimally invasive technique. Although it is a very recent technology, the use of R-LSS have been increasingly report in gynecology, for both benign and malignant indications. This review aims to summarize the evolution of this innovative technique and to examine its feasibility and safety for gynecological surgical procedures. We evaluated studies dealing about R-LSS in gynecological surgery. We performed a comprehensive literature research on PubMed and the Cochrane Library in February 2024. Based on the study reviewed, R-LSS seems to be a feasible and effective alternative to other mini-invasive approach in gynecological surgery. R-LSS combine the advantages of robotics surgery with the aesthetic result of a single incision. Compare to Single-Site Laparoscopy, it restore triangulation of the instrument and improve visualization and ergonomic. R-LSS seems to be related to favourable intra-e post-operative outcomes. Although, further studies would be necessary allow us to draw any final conclusion.

Assessing the learning curve for transumbilical single-site laparoscopy for endometrial cancer

Introduction

Applying transumbilical laparoendoscopic single-site surgery to endometrial cancers is worldwide, and the depiction of the learning curve is rarely described, which leads to the vagueness of young clinical practitioners. We accumulated the data to identify the completion of the learning curve by analyzing the operative and postoperative outcomes of the patients with endometrial cancer for transumbilical laparoendoscopic single-site surgery (TU-LESS).

Methods

This was a retrospective, consecutive single-center study of patients with endometrial cancer undergoing standard endometrial cancer comprehensive staging surgery (extrafascial hysterectomy, bilateral salpingectomy, and pelvic lymphadenectomy) through TU-LESS by an experienced surgeon from December, 2017 to June, 2021 in the Department of Gynecologic Oncology, West China Second Hospital, Sichuan University, China.

Results

After applying the inclusion and exclusion criteria, 42 patients were included in the study. The learning curve for this study was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Applying CUSUM and RA-CUSUM has grouped 42 cases into three phases. The prior five cases represented the learning period. The following six cases were needed to lay a technical foundation (cases 6-11). The third phase was regarded as achieving proficiency (cases 12-42). The operative time decreased drastically with the learning curve. There were no significant differences in terms of postoperative complications and lymph node retrieval among the three phases. More difficult patients were confronted in the third phase.

Discussion

In our study, the learning curve was composed of three phases. According to the results of our study, 11 cases were required for experienced surgeons to achieve a technical foundation.

Robotic single-port hysterectomy versus robotic multisite hysterectomy in benign gynecologic diseases: A retrospective comparison of clinical and surgical outcomes

BACKGROUND

This study aimed to compare clinical and surgical outcomes of robotic single-port hysterectomy (RSPH) using the da Vinci® SP surgical system and robotic multisite hysterectomy (RMSH) with the da Vinci Xi system in benign gynecologic disease.

METHODS

The retrospective study included 134 patients who underwent RSPH or RMSH between November 2019 and December 2020. Total operation time, amount of blood loss, and the change in hemoglobin (Hb) after surgery and the weight of the removed uteri were also measured. Data on complications such as post-operative fever and length of hospitalization were also compared and analyzed.

RESULTS

There was no significant difference in the total operation time between the two groups, although the operation time was slightly longer in the RSPH group. Results in the RSPH group were superior to the RMSH group in docking time and wound incision time (1.67 ± 0.79 vs. 5.46 ± 2.25 min, p-value <0.01; 6.48 ± 4.29 vs. 9.10 ± 4.64 min, p-value <0.01, respectively). On the other hand, wound suture time took longer in the RSPH group (18.12 ± 5.66 vs. 10.69 ± 3.18 min, p-value <0.01). The weights of the removed specimens were higher in the RMSH group (302.64 ± 190.56 vs. 369.24 ± 181.70 g, p-value <0.04). The amount of blood loss during surgery and the difference in hemoglobin (Hb) before and after surgery were less in the RSPH group (97.39 ± 113.79 vs. 224.93 ± 152.29 mL, p-value <0.01, 1.51 ± 1.08 vs. 2.54 ± 1.08 g/dL, p-value <0.01). When considering the weight difference as a correction between the two surgical groups (because there were many heavier samples in the RMSH group), the blood loss of the RSPH group was also less than that of the RMSH group by 115.95 ± 23.78 mL (p-value <0.01).

CONCLUSIONS

On the basis of our data, the robotic hysterectomy using the da Vinci SP surgical system might be feasible and safe, even if the hysterectomy is complex, and comparable to robotic multisite surgery by the da Vinci Xi system.

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC)

OBJECTIVE

To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP).

METHODS

A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented.

RESULTS

A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review.

CONCLUSION

SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved.

Single-port robotic surgery using the EDGE SP1000 surgical system in gynaecology: Initial experience of a single institution

BACKGROUND

The EDGE SP1000 is a newly developed single-port (SP) robotic surgical system whose clinical evaluation in gynaecology has not yet been addressed.

METHODS

This is a single-arm clinical trial evaluating the perioperative outcomes of patients receiving EDGE SP1000 assisted surgeries. Patients with either benign or malignant gynaecological diseases suitable for robotic surgery were included, and their data were prospectively collected.

RESULTS

Eighteen patients were included and 8 of them had malignant conditions. The total operative time was 190.1 ± 83.3 min for benign diseases and 254.4 ± 59.4 min for malignant diseases. The mean estimated blood loss was 25 mL (range, 5-100). No assistant ports or conversions were required. No perioperative complications occurred. Overall satisfaction with the umbilical wounds was expressed at the 1-month follow-up.

CONCLUSION

EDGE SP1000 SP robotic surgical system is technically feasible and safe in various gynaecological surgeries with good cosmetic effects.

ROBOTIC SURGERY IMPLEMENTATION IN AN ISOLATED OVERSEAS TERRITORY – THE CASE OF REUNION ISLAND

INTRODUCTION

In February 2020, robotic surgery was introduced in University Hospital of St Pierre in Reunion Island. The aim of this study was to evaluate the implementation of robotic assisted surgery in the hospital and its impact on operating times and patient outcomes.

METHODS

Date was prospectively collected on patients undergoing laparoscopic robotic assisted surgery between February 2020 and February 2022. Information included patient demographics, type of surgery, operating times and length of stay.

RESULTS

Over the two-year study period, 137 patients underwent laparoscopic robotic assisted surgery performed by 6 different surgeons. 89 of the surgeries were in gynecology, including 58 hysterectomies, 37 were in digestive surgery, and 11 in urology. The installation and docking times decreased across all specialties and were found to be significantly reduced when comparing the first and last 15 hysterectomies: mean installation time decreased from 18.7 to 14.5 minutes (p=0.048), mean docking time decreased from 11.3 to 7.1 minutes (p = 0.009).

CONCLUSIONS

The implementation of robotic assisted surgery in an isolated territory such as Reunion Island was slow due to a lack of trained surgeons, supply difficulties and Covid crisis. Despite these challenges, the use of robotic surgery allowed for technically more challenging surgeries and demonstrated similar learning curves to other centers.

Ascertaining the Effects of Tissue Sealers on Minor Laparoscopic Procedures between Obstetrics and Gynecology Residents: A Prospective Cohort Study

Background and Objectives: The type of instrumentation used during laparoscopic surgery might impact on the learning curve of resident surgeons. The aim of this study was to investigate differences in operator satisfaction and surgical outcomes between tissue sealers and classic bipolar instruments during gynecological laparoscopies performed by residents. Materials and Methods: A prospective cohort study conducted at two tertiary university hospitals between March 2019 and March 2021, on consecutive procedures: salpingo-oophorectomies (Group 1) and salpingectomies (Group 2), subdivided according to the utilized device: radiofrequency tissue sealers (Groups A1 and A2) or bipolar forceps (Groups B1 and B2). Results: 80 procedures were included. Concerning salpingo-oophorectomies, better visibility (8.4 ± 0.8 vs. 7.3 ± 0.9; p = 0.03), reduced difficulty (5.4 ± 1.2 vs. 7.0 ± 1.4; p = 0.02), improved overall satisfaction (9.2 ± 0.4 vs. 7.6 ± 1.0; p = 0.02) and reduced procedure time (7.8 ± 3.4 vs. 12.6 ± 3.1; p = 0.01) were reported by residents using tissue sealers. Intraoperative blood loss (12.2 ± 4.7 mL vs. 33.2 ± 9.7 mL; p = 0.01) and 24 h postoperative pain (4.5 ± 1.1 vs. 5.7 ± 1.8; p = 0.03) were lower in group A1 than B1. For salpingectomies, a significant reduction in duration was found in A2 compared to B2 (7.2 ± 3.4 min vs. 13.8 ± 2.2 min; p = 0.02). Tissue sealers enhanced visibility (8.1 ± 1.1 vs. 6.7 ± 1.4; p = 0.01), difficulty (6.5 ± 1.1 vs. 7.5 ± 0.9; p = 0.04) and improved satisfaction (9.3 ± 0.5 vs. 7.5 ± 0.6; p = 0.01). Moreover, hemoglobin loss and postoperative pain were reduced in A2 relative to B2 [(8.1 ± 4.2 % vs. 4.5 ± 1.1%; p = 0.02) and (5.1 ± 0.9 vs. 4.1 ± 0.8; p = 0.03), respectively] Conclusions: The use of sealing devices by residents was related to reduced difficulty as well improved visibility and overall satisfaction, with improved surgical outcomes.

Learning Curve Analysis of Single-Site Robot-Assisted Hysterectomy

We aim to analyze the surgical outcomes and learning curve of single-site robot-assisted hysterectomy. This was a retrospective cohort study from a single academic medical center. A total of 123 patients who underwent single-site robotic surgery for gynecologic disease were enrolled. Gynecologic surgeries were performed by a single surgeon using single-site robot-assisted hysterectomy. The median age of enrolled patients was 49 years (range: 30–74 years). The median operation time was 131 min (range: 59–502 min) and the median docking time was 3 min (range: 1–10 min). In addition, the median console time was 76 min (range: 29–465 min). The cumulative sum (CUSUM) graph for total operation time indicated an initial decrease at case 41, generating 3 distinct performance phases: learning (n = 41 initial cases), competence (n = 54 middle cases), and mastery (n = 28 final cases). There was one case conversion to open surgery due to the difficulty in securing the field of view because of a 16-cm bulky mass protruding from the left pelvic wall. No patients required a transfusion and two complications including vaginal cuff dehiscence were identified. The single-site robot-assisted hysterectomy is a safe and feasible procedure. The learning curve consisted of 41 cases to significantly decrease the total operation time.

Single-Incision versus Multiport Robotic Myomectomy: A Propensity Score Matched Analysis of Surgical Outcomes and Surgical Tips

We aimed to compare the perioperative outcomes of single-incision robotic myomectomy (SIRM) and multiport robotic myomectomy (MPRM) and provide surgical tips. We retrospectively analyzed the medical records of 462 patients with symptomatic leiomyoma who underwent MPRM or SIRM between March 2019 and April 2021. Demographic characteristics and surgical outcomes, including the total operative time (OT), estimated blood loss (EBL), and surgical complication rate, were compared between the two groups. Patients in the SIRM group had lower a body mass index and rate of previous pelvic surgery and were younger than those in the MPRM group. The myoma type was not different between groups; however, the MPRM group had larger, and more myomas than the SIRM group. After propensity score matching, these variables were not significantly different between the groups. The total OT, EBL, difference in hemoglobin levels, transfusion rate, and postoperative fever were not different between the groups. No postoperative complications occurred in the SIRM group. In the MPRM group, one patient needed conversion to laparotomy, and two patients had postoperative complications (umbilical incisional hernia and acute kidney injury). In conclusion, both MPRM and SIRM are feasible and effective surgical options for symptomatic myomas with cosmetic benefits and minimal risk of laparotomy conversion.

Laparoendoscopic Single Site Hysterectomy: Literature Review and Procedure Description

Laparoendoscopic single site surgery (LESS) refers to a spectrum of surgical techniques that allow the performance of laparoscopic surgery through consolidation of all ports into one surgical incision. LESS has emerged as a potentially less invasive alternative to multiport laparoscopy and in the last year in gynecology; hence, this approach has been largely applied for selective indications to perform total hysterectomy. We performed a literature review on single site hysterectomy and described indications and technique, highlighting practical problems, pointers, limitations and recent technical development as robotic assistance.

Efficacy and utility of robotic single-access bilateral nephrectomy (r-SABN) in end-stage renal disease patients

PURPOSE

Bilateral native nephrectomies are needed in ESRD patients with select indications in a pre-transplant setting. Yet, the perioperative morbidity is significant in this population. Herein we evaluate the efficacy and utility of r-SABN.

METHOD

A total of 12 patients were consented at a single center. Of 12 patients, 3 patients did not meet study criteria and were excluded. Preoperative, perioperative, and postoperative data were prospectively collected from 9 patients from electronic health records and administered postoperative surveys. Patients were assessed at 30-180 days postoperatively for follow-up.

RESULTS

Mean operative time was 204.3 ± 59.7 min (142.0-314.0) and estimated blood loss during operation was 94.4 ± 87.3 ml (25.0-300.0). The mean length of hospital stay was 2 ± 0.7 days (1-3) for all patients. Total post-operative opioid usage was normalized to morphine dose equivalents (MDE) and calculated to be 56.1 ± 30.4 mg (30.8-101.8). Patients experienced a fourfold and tenfold respective increase in weekly structural and incidental physical activity from 30 to 180 days postoperatively. There were no procedure related intraoperative or postoperative complications reported in the cohort.

CONCLUSION

Overall, r-SABN afforded the patients low morbidity. Longitudinal studies are in progress to further assess the efficacy and outcome of this procedure. In a single-center study, we demonstrate r-SABN is viable and provides a novel tool for treatment of ESRD patients requiring this procedure.

Robotic single-site surgery in benign gynecologic diseases: Experiences and learning curve based on 626 robotic cases at a single institute

AIM

The purpose of this study was to report on 626 cases of successful robotic single-site (RSS) surgeries to address various types of gynecologic disease and to evaluate the outcomes and learning curve inherent to RSS surgery in the gynecology field.

METHODS

A total of 626 cases of RSS surgeries were performed by 3 gynecologic surgeons at Ewha Womans University Medical Center, Robot Surgery Center from November 2014 to January 2018 were collected retrospectively. All of the patients' charts were reviewed, and the clinical characteristics and surgical variables were analyzed.

RESULTS

Among the total of 626 cases, there were 220 cases of RSS myomectomy (RSSM), 182 cases of RSS hysterectomy (RSSH), 195 of RSS adnexectomy, 24 of RSS sacrocolpopexy (RSS SCP) and 5 were classified as other RSS surgeries. The patient's mean age was 38.98 ± 10.07 years. There was 3.99 ± 2.15 min of mean docking time and 117.78 ± 51.18 min of mean operating time. The surgical variables were analyzed annually. The total operating time was seen to decrease significantly according to each period. The docking time declined significantly and gradually after 1 year. We also analyzed each of the surgical types by time. The operating time of RSSH, RSSM, RSS adnexectomy and RSS SCP fell over time. The tendency found was for operating time to decline sharply following the first 10 cases. When we analyzed the data at annual intervals, the operating time was most significantly less and stable following the first year. There were a few intraoperative or perioperative complications in 16 cases (2.6%).

CONCLUSION

Robotic single-site surgery is a feasible and safe procedure for treating various kinds of gynecologic diseases. The learning curve was approximately 10 cases of RSS surgery in gynecologic disease, having a greater amount of experience at performing RSS surgery was revealed to be key to achieving better surgical outcomes.

The robotic single-port platform for gynecologic surgery: a systematic review of the literature and meta-analysis

Since the first robotic single-site hysterectomy was performed, the research focused on the use of robotic single-site surgery (RSSS) for all gynecological conditions. This review aims to examine the studies available in the literature on RSSS in gynecology both for benign and malignant indications. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). All the articles were grouped into three sets based on the surgical indication (Group 1, 2, and 3 for benign, malignant, and mixed diseases, respectively). Two hundred and fifty total studies were analyzed, and 27 articles were included in the review. A total of 1065 patients were included in the analysis. Of these, 605 patients were included in group 1, 260 in group 2, and 200 in group 3. Ten (1.7%) patients with benign pathology, 16 (6.2%) patients with malignant disease, and 5 (2.5%) patients with both diseases developed major complications. Two (0.3%) patients in group 1, 3 (1.2%) patients in group 2 and 5 (2.5%) in group 3 were converted to a different type of surgery. No significant differences were found between groups for BMI (p = 0.235), operative time (p = 0.723), estimated blood loss (EBL) (p = 0.342), and hospital stay (p = 0.146). The complications and conversions incidence through pooled analysis showed a higher general conversion rate (p = 0.012) in group 3 (3.0%) and higher complications rate (p = 0.001) in group 2 (5.3%) compared to the other groups. RSSS seems to be a feasible and safe procedure for all gynecological surgical procedures. A long-term analysis would be necessary before considering the RSSS oncologically safe for patients with malignant disease.

Transition from multiport to single-site surgery: A single institution experience in robotic supracervical hysterectomy for benign gynecological diseases

OBJECTIVE

To share our experience of transition from multiport to single-site robotic surgery for benign gynecological conditions as well as to assess the selection criteria of candidates for robotic single-site supracervical hysterectomy (RSSH).

MATERIALS AND METHODS

A retrospective review was conducted on patients undergoing robotic supracervical hysterectomy by a single surgeon in a single institute between June 2014 and December 2017. Patients who underwent additional procedures along with supracervical hysterectomy and who had unexpectant corpus malignancy proved pathologically were excluded from comparisons between patients undergoing RSSH and robotic multiport supracervical hysterectomy (RMSH).

RESULTS

Between June 2014 and December 2017, we accomplished 26 RSSH and 57 RMSH. There were no conversions, intraoperative complications, and readmissions within 30 days after surgery. In the RSSH group, the mean uterine weight was 264.6 ± 140.9 g with mean docking time of 15.8 ± 5.5 min, mean console time of 61.1 ± 35.6 min and mean operative time of 140.3 ± 34.4 min. In comparison to the RMSH group, the percentage of overweight/obese patients was lower (p = 0.018) and the uterine size was smaller (p < 0.001) with adenomyosis diagnosed more frequently (p = 0.002) in the RSSH group. While the operative time in the RSSH group was significantly shorter (p = 0.002), the RSSH group took longer time in docking (p < 0.001) and comparable time in console (p = 0.254). In view of chronological change, docking time and console time in the RMSH group remained steady, whereas steep decreases were observed in the RSSH group. The intraoperative blood loss and hemoglobin drop were comparable. The length of hospital stay was significantly shorter in the RSSH group (p = 0.005).

CONCLUSION

Transition from multiport to single-site surgery can be smooth for a surgical team experienced in the conventional multiport robotic system. RSSH is safe and feasible in properly selected patients.

[Robotic surgery program in gynecology: Lessons from the first 100 procedures]

INTRODUCTION

The objective of this work is to report the first 6 months of a robotic program in a surgical gynecological team, trained in advanced laparoscopy, in terms of operating times, complication rate, analgesic consumption and average duration of hospitalization.

METHODS

This is a prospective observational study, intended to treat.

RESULTS

During the study period, 98 women underwent laparoscopic robot assisted surgery. The average BMI was 27.2kg/m² (±7). Malignant diseases accounted for 41% of operative indications. Comparing the first 30 procedures to the last 30 procedures, there is a significant decrease in docking times: 14.7min (±7.0) vs 8.9min (±5.0), P=0.009. There is also a trend towards a decrease in operative times for hysterectomy: 151.9min (±56.2) vs 113min (±51.4), P=0.08. The rates of complications were not significantly different at the beginning and end of inclusion during the study (10.0% vs 16.7%).

CONCLUSION

The implementation of a robotic surgery program in a gynecological surgery department does not lead to an increase in complications for the patients, including for the first procedures. The learning curve mainly allows a reduction in the robot's installation time.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Robotic laparoendoscopic single-site surgery in gynecology: A systematic review

Robotic laparoendoscopic single-site (R-LESS) seems to be the next route in advancing minimal invasive surgery, with the potential for better cosmetic results and reduced patient morbidity compared with multi-port surgery. This review describes the history and development of (R-LESS) gynecologic surgery and outlines the latest advancements in the realm of gynecology. The review was conducted according to the PRISMA guidelines. Pubmed and ClinicalTrials.gov (www.clinicaltrials.gov) were the main search engines utilized for retrieval of study data (1990 - present). The following subject headings and keywords were searched: "robotic laparoscopic single incision", "robotic laparoendoscopic single site", "single incision robotic surgery" and "single-port robotic surgery". All original research articles including randomized, non-randomized controlled trials, cohort studies, patient series, and case reports were included. The search produced a total of 1127 results. After duplicate removal, 452 remained, and each title and abstract was reviewed by 2 reviewers. Subsequently, 56 full texts were selected for full review and an additional 20 excluded, leaving 36 studies that were included in the final review. Based on the data gathered we reached the conclusion that R-LESS surgery is feasible, safe and has equivalent surgical outcomes as conventional LESS surgery; in addition to shorter recovery times, less postoperative pain and better cosmetic outcomes than robotic multi-port surgery. To conclude, R-LESS is a feasible approach with low complication rates, minimal blood loss and postsurgical pain, fast recovery, and virtually scar-free results. However, the lack of large comparative prospective randomized controlled studies prevents drawing absolute conclusions.

Single-site port robotic-assisted hysterectomy: an update

Single-incision approach in robotic gynecology is a relatively new concept. The role of single-port systems in robotic hysterectomy, their advantages and disadvantages, as well as the technical challenges, are still under investigation. A systematic review was performed by searching in PubMed and Scopus databases. In 810 out of 1225 patients, hysterectomy was performed for non-neoplastic disease. Single-Site^® was the most common port system. Duration of the procedure and relative blood loss ranged from 60 to 311 min and 7 to 750 ml, respectively. The weight of the removed uteri ranged from 39 to 520 g. 4.9% of the included patients presented complications, among which bleeding, vaginal haematoma, laceration and dehiscence, umbilical hernia, and visceral injuries. Conversion rate to laparotomy reached 2.8%. Although some technical difficulties are still described in the literature, the single-port approach is becoming more standardized nowadays and performed by more surgeons. The initial phase of the learning curve can be achieved after five cases, while a proficiency in intracorporeal cuff suturing after 14 cases. Uterus weight and previous abdominal surgical history can still be limitations of the technique. Compared to our previous study, we can see that the technique has been used in more elderly or obese patients. The complication rate can reach 4.9% while the conversion rate can reach 2.8%. However, we consider that complication and conversion rates as well as surgical time could be improved with experience. Regarding post-operative pain and cosmetic outcomes, the lack of information do not allow us to draw any safe conclusions.