**Figure 11.**

*Ancilliary trochars placement for Xi platform.*

• *Total robotic hysterectomy* can be indicated for benign disease of the uterus or the early stages of endometrial cancer.

The specific indications for robotic assistance are:


For benign and malignant conditions robotic hysterectomy is equivalent to a type A hysterectomy in the Querleu Morrow classification. It represents an extra fascial hysterectomy in which all the uterine pedicles are resected as close to the uterus as possible. The area of the cut of the vagina is <10 mm. Ureterolysis is not necessary, but ureters must only be identified. The main advantage of this type of hysterectomy consists of the possibilities of uterus extraction in a natural way, through the vagina.

• *Supracervical hysterectomy*- involves the removal only of the uterine body. The cervix is preserved. The main indication for supracervical hysterectomy is the express desire of the patient to keep the cervix for benign uterine conditions such as dysfunctional bleeding resistant to treatment, uterine leiomyomatosis, and uterine adenomyosis. Supravaginal hysterectomy can be performed in cases when technically the cervix cannot be extracted. After a supravaginal

hysterectomy, the uterine body cannot be extracted vaginally. The alternatives are in-bag morcellation and morcellation by mini-laparotomy.

• *Radical hysterectomy* remains the standard surgical treatment for the different early types of cervical cancer and endometrial cancer. If for early cervical cancer, the lymphadenectomy is mandatory for endometrial cancer stage, I or II it must respect the molecular classification and degree of risk. The real radical hysterectomy is represented by Types B and C from Querleu Morrow's classification.

Current guidelines from NCCN and ESGO indicated that both open surgery and minimally invasive surgery performed by conventional (laparoscopy) or robotic techniques are acceptable approaches to radical hysterectomy with pelvic lymphadenectomy in patients with early-stage cervical cancer and endometrial cancer [14–17]. The retrospective study showed that robot-assisted radical hysterectomy was associated with better perioperative outcomes than the open approach, and the recurrence rates and survival rates do not differ significantly between these two ways of performing radical hysterectomies [14, 17].

## **3.1 Total robotic hysterectomy-operative technique**

The robotic hysterectomy starts with an abdominal cavity inspection. Once the pneumoperitoneum was created, we checked the trochar's placement and the presence of possible intestinal or vascular trochar insertion injuries.

All four quadrants of the abdominal cavity must be inspected, including the liver and diaphragm.

The whole pelvis will be exposed after we mobilize the small bowel and sigmoid and perform adhesiolysis if it is necessary. Uterine and adnexa inspection aim to check the adequate uterine manipulator insertion and anatomy of the adnexa, the position of ureters, and the vascular axes of the pelvis.

The technique of total hysterectomy requires *disconnecting of the uterus* and cervix from vascular and connective elements of the supporting System, *section of the vagina*, *extraction* of the uterus, and *closing of* the vaginal cuff.

#### **3.2 Connective vascular disconnection**

The uterus is kept in anatomical position at three levels of connective vascular pedicles: *the superior pedicle* consisting of round ligaments and utero-adnexal or infundibulopelvic ligaments, the *medium vascular pedicle* represented by leading uterine vessels and the *inferior pedicle* consisting of cervicovaginal vessels. Only the superior pedicle is intraperitoneal, the medium and inferior being between the two folds of large ligaments. The disconnection will be done by both sides of the uterus.

### *3.2.1 Superior pedicle disconnection*

• Starts with coagulation and sectioning of *the round ligament* at the level of the avascular triangle of the broad ligament. The triangle is limited by adnexal vessels medially, extern iliac vessels laterally, and round ligament caudally (**Figure 12**).

**Figure 12.** *Coagulation and section of the right round ligament.*

**Figure 13.** *Sectioning of the anterior fold of broad ligament.*


**Figure 14.** *Coagulating and division of the infundibulopelvic ligament.*

the level of the gray triangle. This maneuver allows to check the position of the ureter in the dissection area (**Figure 14**).

