**1. Introduction**

Hysterectomy is the surgical procedure to remove the uterus surgically. The word 'Hysterectomy' is invented based on Ancient Greek hustéra, "womb" and ektomía- "a cutting out of," and, thus, means the removal of the uterus. Hysterectomies can be performed by open incision, vaginally, or minimally invasively—either by laparoscopy or robotically. Around 600,000 hysterectomies are performed in the United States annually [1]. Out of them, 85% are for non-cancerous lesions [2]. The traditional open approach to perform hysterectomies involves making a large incision around 10–15 cm above the pubic bone horizontally or vertically. Studies have demonstrated that hysterectomies with open approaches have higher blood loss, increased average length of hospital stay, and more postoperative complications in comparison to minimal invasive approach, including laparoscopic and robotic. The laparoscopic approach has been used for more than three decades and has become standard of care for many gynecological procedures. In 2005, the US Food and Drug Administration approved the use of the da Vinci robotic system for gynecologic surgeries. The use of this technology has allowed surgeons to perform gynecologic procedures with improvements in visualization, including 3D stereoscopic visualization, increased range of motion with enhanced wrist movements, and improved ergonomics with excellent dexterity compared to conventional laparoscopic techniques [3, 4]. However, studies have not shown any difference in operative or postoperative outcomes for patients undergoing robotic hysterectomies

compared to laparoscopic hysterectomies [5, 6]. The robotic approach, indeed, has longer operative times [7] for certain operations and is more expensive, not exclusively limited to only operative cost (6–25% more than laparoscopy) [8] but also initial acquisition cost and maintenance cost compared to the standard laparoscopic approach [9]. The da Vinci system requires an initial investment of \$1.5 to \$2.5 million, depending on the model and configuration. Ongoing costs include annual service contracts (ranging in price from \$150 to \$170 K), instrument and accessory costs (ranging from \$700–\$3,500 per procedure).

Despite all shortcomings, surgeons still appreciate excellent visualization providing [6] more precision in surgery and better ergonomics, allowing them to do certain complex tasks, which would be very difficult with standard laparoscopic procedure. Many studies have shown the utility of the robotic platform with better outcomes and safety profiles for various benign conditions, including robotic myomectomies [10] for fibroids, robotic-assisted laparoscopic sacrocolpopexy for pelvic organ prolapse, endometriosis, benign ovarian tumors, etc. [7, 10]. The role of minimally invasive surgery for endometrial cancer has been well established by LAP 2 study [11, 12]. In addition, the role of robotic platform for other gynecological cancer including early cervical and ovarian cancer have been investigated as well [13]. In 2012, the Clinical Practice Robotics Task Force of the Society of Gynecologic Oncology stated that robotic-assisted surgery in the field of gynecology-oncology provides an advantage over traditional methods, including conventional laparoscopic approaches and laparotomies [14]. The use of robotic platform has been well established in many gynecological procedures and in other specialties like general surgery, urology, cardiothoracic surgery, etc. However, with higher acquisition and maintenance costs and with no difference in reimbursement compared to the standard laparoscopic procedure, many small community hospitals that initially acquired a robotic platform by using all cash reserves are struggling to keep it going, and many are rolling back on their decision in 1–3 years [8, 15]. In addition to a higher financial burden, many other factors are roadblocks for widespread implementation or failures of robotic programs. In this article, we would like to expand further on these roadblocks and provide reasonable, evidence-based solutions.
