**2.1 Patient positioning and the uterine manipulator insertion**

The uterine manipulator allows to move the uterus up and down or in a lateral position. To facilitate the insertion of a uterine manipulator, the patient must be placed in a lithotomy position with legs in stirrups and spread apart in slight ventral flexion. The buttocks must be placed slightly over the edge of the operating table, a position that allows movements of the uterine manipulator.

A bladder catheter is inserted before the uterine manipulator placement.

The patient arms must be placed along the body to avoid injury to the brachial plexus.

We use the Koh manipulator with three different cups according to the dimensions of the cervix and vagina. For robotic surgery, we need a prominent Trendelenburg position (25–30°). The shoulder braces are mandatory to avoid slipping.

#### **2.2 Abdominal access. First port insertion. Pneumoperitoneum**

In most cases, the access for the vision port is done transumbilical. The umbilical area is the thinnest abdominal wall area, where aponeurosis detaches difficult from the peritoneum.

We anchor the umbilicus with two forceps, and a small incision of the skin is made to allow the insertion of the Veress needle. The correct positioning of the Veress needle inside the peritoneum is checked using known tests: suction, drop, or pressure tests. For abdominal placement of the vision port, the surgical table must be placed in a neutral position to avoid the risk of vascular injury of great vessels.

The pneumoperitoneum, for gynecological surgeries, is done to a pressure of 12–15 mmHg. To allow the insertion of an 8 mm trochar, the umbilical incision will be extended. The trochar is inserted perpendicular to the abdominal wall with the shutter mounted. When removed the shutter, a gas jet under pressure is heard, a sign that the instrument is correctly placed. Connect the cannula tap to the CO2 insufflation system and insert the camera [11, 12].

Other methods of making pneumoperitoneum, the Henson trochar approach, the visiport trochar, or the Veress optical needle, are rarely used [12].

#### **2.3 Ancillary trochars placement**

The working trochars are inserted under visual control. The incision in the skin will be about 8 mm to allow the tight insertion of the trocar. We use, for gynecological surgery, 3 or 4 Da Vinci trochars and one assistant's trochar placed in line. In the case of a simple robotic hysterectomy, we put four trochars in the umbilical cord. The distance between the trochars should be about 8–10 cm to avoid crossing the instruments during surgery. For fragile patients, the holes can be placed at distances of up to 4 cm without exceeding this value. The Da Vinci system trochars, marked with three black lines, are inserted so that the midline is placed at the level of the peritoneum.

The assistant surgeon uses a 12 mm trochar to couple the Air Seal system. It is placed on the right or left side, either on the umbilical line or triangular and cranial, between the optical and Da Vinci 2 or 3 ports.

The distance between the assistant and Da Vinci ports must exceed 7 cm.

Place the patient in the Trendelenburg position at 25– 30°. In the case of the adjoining syndrome, under visual control, adhesiolysis is performed. Remove the small intestine and epiploon from the visual field with an atraumatic pen. Place the surgical table in the lowest position possible. Dock arm 2 of the Da Vinci System at the endoscopic port. Insert the 8 mm 30 degrees endoscope and target the pubic symphysis. Arms 2 and 3 are docked.

The work tools are inserted as follows: on arm 2, the bipolar or vessel sealer extends is mounted, and on arm three is mounted monopolar curved scissors. Arm 4 will remain stowed (**Figure 11**).

## **3. The robotic hysterectomy**

Hysterectomy is one of the most common non-pregnancy-related gynecological surgeries. There are three main types of hysterectomy [13]: *Total hysterectomy, Supracervical* hysterectomy, and *Radical hysterectomy.* The uni- or bilateral adnexectomy or salpingectomy can be associated with any type of hysterectomy.
