**Abstract**

Starting from the first robotic hysterectomy, currently, this method is widely accepted all over the world as an alternative to open or laparoscopic surgery due to the technical advantages it offers. We are currently using the DaVinci Xi platform, whose components, instruments, and accessories are described. This chapter aims to present all surgical steps of a robotically assisted hysterectomy, starting with patient positioning, uterine manipulator insertion, port insertion, pneumoperitoneum performing, and the operative technique of the total robotic hysterectomy: connective vascular disconnection, colpotomy, uterus retrieval, and colporrhaphy. A special mention belongs to radical robotic hysterectomy with sentinel node detection and pelvic lymphadenectomy. The chapter ends with a brief description of the perioperative complications.

**Keywords:** robotics, hysterectomy, surgical technique, minimally-invasive, artificial intelligence, robotically assisted hysterectomy, Da Vinci Xi platform, surgical steps

## **1. Introduction**

The idea of using robotic systems in surgery was proposed as early as 1967; it took more than 30 years of study and thorough research to complete the first fully multifunctional surgical robot. The first robotic System used was ROBODOC, used in orthopedic surgery for hip prosthesis; it was developed and used by Hap Paul and William Bargar in late 1980 [1–3]. Subsequently, systems were created and used in urology, prostate surgery, neurosurgery, otorhinolaryngology, gynecology, and cardiovascular surgery [4].

The United States Department of Defense developed the concept of robotic surgery to provide fast, high-precision surgical assistance directly on the battlefield. The prototype built contained two separate units: the surgeon's working unit and a remote-controlled surgical unit [5]. The System consisted of two video cameras that sent images from the operating field to a remote console. The surgeon could safely steer the robot's arms, thus accessing surgical instruments. This prototype has undergone several changes and improvements over time [6].

There are currently three types of robotic surgical systems: the AESOP, the Da Vinci System, and the ZEUS System. Currently, an essential multifunctional robotic surgery system approved by the FDA is the Da Vinci type from intuitive surgical Inc., which is used worldwide. The Da Vinci System comprises the surgeon's console, the video system, and the patient's cart, containing three or four robotic arms. The surgeon at the work console remotely directs the instruments attached to the robot arms [7].

In 1997, the first Da Vinci prototype was tested in humans, demonstrating the effectiveness of multiple joint instruments in abdominal and cardiovascular surgery. The FDA approved using this System in surgical practice in 2000 [8]. Since 2005, the Da Vinci System has been approved in the United States for use in gynecological procedures, both benign and malignant. The most highly-performed major surgical procedure in gynecology is a hysterectomy [9].

The first simple robotic hysterectomy was performed in 2002, and the first radical robotic hysterectomy was completed four years later, in 2006 [10]. The robotic hysterectomy is widely accepted as an alternative to open or laparoscopic surgery due to the technical advantages of robotic surgery, including 3-dimensional viewing, more precise control of instruments, and further articulation of tools, which enable surgeries to perform complex procedures more carefully. Minimally invasive robotic surgery is used today for up to 30% of benign and up to 65% of oncology cases in gynecologic surgery [11].
