{"paper_id":"4f46875b-402d-4f67-9c2e-218f71739bb0","body_text":"Abstract\nBackground\nLarge uteri with multiple fibroids or adenomyosis present significant challenges for minimally invasive surgery due to increased vascularity, distorted pelvic anatomy, and limited working space. While robotic platforms enhance precision through improved dexterity and vision, most surgeons still rely on an additional assistant port for suction, traction, and suture introduction. Reduced-port robotic hysterectomy aims to minimise abdominal incisions without compromising safety. Evidence for assistant-port-free approaches in complex pathology remains scarce.\nAims\nTo describe the feasibility, safety, and technical nuances of a three-port, assistant-port-free robotic total hysterectomy with bilateral salpingo-oophorectomy for a large adenomyotic uterus with multiple fibroids using the da Vinci Xi robotic surgical system.\nMaterials and Methods\nA 58-year-old woman presented with post-menopausal bleeding and imaging revealing diffuse adenomyosis with multiple large fibroids. A three-port robotic approach was performed without an accessory port. A V-type uterine manipulator was used. Key operative strategies included precise port spacing, early bilateral devascularisation, retrograde dissection of obscured vascular pedicles, and colpotomy-based suture introduction for vault closure. Outcomes assessed included operative time, blood loss, complications, and recovery.\nConclusion\nAssistant-port-free three-port robotic hysterectomy is feasible and safe for large benign uteri in experienced hands. Strategic port positioning, effective uterine manipulation, meticulous vascular control, and innovative colpotomy-assisted vault suturing enable elimination of the assistant port without compromising operative efficiency or safety. This technique may reduce abdominal morbidity and resource utilisation while preserving the ergonomic and precision advantages of robotic surgery. Further studies with larger cohorts are warranted to validate reproducibility and long-term outcomes.\nSimilar content being viewed by others\nReferences\nTyan P, Klebanoff JS, Frangieh M, et al. Safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights. J Robotic Surg. 2021;15:259–64.\nSinha R, Rupa B, Mohanty G. Two arms-three instruments robot-assisted laparoscopic hysterectomy: a reproducible technique. Laparoscopic, Endoscopic and Robotic Surgery. 2021;4(2):44–7.\nLee SY, Lee SR, Song JY. Single-port versus reduced-port (1 + 1) robotic myomectomy and hysterectomy. J Clin Med. 2024;31;13(21):6563.\nAlkatout I, O’Sullivan O, Peters G, Maass N. Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System. Medicina (Kaunas). 2023;60(1):53.\nPatel R, Patel R. Robotic Surgery for Benign Hysterectomy: A Real-World Study From India. Cureus. 2024;16(12):e74932.\nAuthor information\nAuthors and Affiliations\nCorresponding author\nEthics declarations\nConflict of interest\nThere are no conflict of interest and no funding.\nInformed consent\nInformed consent was obtained from all individual participants included in the study.\nHuman participant and animal rights\nResearch involving Human Participant No.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nGaurav S. Desai is Consultant. Pramila Kukral is Consultant. Vidhee Panchal and Snehal Deshmukh are Registrar.\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nDesai, G.S., Kukral, P., Panchal, V. et al. Three-Port, Assistant-Port-Free Robotic Hysterectomy for a Large Adenomyotic Uterus with Multiple Fibroids: A Feasibility Case Report. J Obstet Gynecol India 76, 172–175 (2026). https://doi.org/10.1007/s13224-025-02323-1\nReceived:\nAccepted:\nPublished:\nVersion of record:\nIssue date:\nDOI: https://doi.org/10.1007/s13224-025-02323-1","source_license":"CC0","license_restricted":false}