Robotic Single-Incision Laparoscopic Surgery for the Management of Endometriosis: First Experience Via the Da Vinci SP Platform

All authors contributed to the study of conception and design. Material preparation, data collection and analysis were performed by Qiannan Yang, Daniel Y Lovell, and Xiaoming Guan. The first draft of the manuscript was written by Qiannan Yang and all authors commented on previous versions of the manuscript. All authors have read and approved the final manuscript.

Patient consent was waived due to the retrospective nature of the study by an Institutional Review Board (IRB). This study was IRB‐approved from Baylor College of Medicine on March 8, 2022, under the approval number H‐51429.

The authors have nothing to report. Statement of prior presentation or publications and/or abstract/poster presentation: None.

A total of 50 patients underwent RSP‐SILS between November 2023 and July 2025, all of whom were diagnosed with endometriosis based on pathological findings. Table  1 provides a detailed account of the characteristics of these patients. The median age was 34 years with an IQR of 27–38 years. The median BMI was 26 kg/m 2 with an IQR of 22–33 kg/m 2 . Self‐reported race and ethnicity distribution was Caucasian (60.0%), Hispanic (18%), African American (10.0%), and Asian (8%). Thirty‐one patients (62%) have a history of abdominal surgery. Endometriosis staging was graded according to the revised American Society for Reproductive Medicine (rASRM) endometriosis classification, showing 7 (14%) patients with stage I, 15 (30%) patients with stage II, 13 (26%) patients with stage III, 15 (30%) patients with stage IV. Patients' characteristics ( N  = 50). Note: rASRM: the revised American Society for Reproductive Medicine (rASRM) classification. Figure  1 provides an overview of the additional procedures performed alongside endometriosis excision and routine cystoscopy. Table  2 provides perioperative surgical results. With a port placement time of 1 min [IQR 1–2 min], a robot dock time of 3 min [IQR 2–3 min], and a robot console time of 99 min [IQR 70–146 min], the median total operative time was 142 min [IQR 115–204 min]. Median estimated blood loss was 25 mL [IQR 15–50 mL]. In addition, 86% of patients were discharged on the same day. Additional surgical procedures were performed. IUD: Intrauterine Device. Perioperative surgical outcomes ( N  = 50). The pain scores from 50 patients before and after surgery are shown in Table  3 . Patients exhibited a significant decrease in pain in weeks 1, 2, 3, and 6 post‐surgery, when compared with their self‐reported preoperative scores (all p  < 0.05). Preoperative and postoperative pain scales ( N  = 50). At mid‐term follow‐up (Table  4 ), postoperative complications were observed in 3 patients (6%). One patient developed a presacral pelvic haematoma 3 weeks postoperatively following bowel resection with primary colo‐anal anastomosis; this was managed with CT‐guided drainage catheter placement by Interventional Radiology. In another case, a patient who underwent a combined procedure involving colorectal and thoracic surgeons was diagnosed with Clostridioides difficile infection by the colorectal surgeon and was successfully treated with antibiotics. Additionally, one case of umbilical surgical site infection occurred 5 months postoperatively and was managed conservatively. Recurrent pelvic pain was reported in 3 patients (6%). Mid‐term clinical and functional outcomes ( N  = 50). CUSUM analysis was applied to assess trends in robot docking time, and total operative time (Figure  2 ). Based on the CUSUM analysis, robot docking time showed substantial improvement after approximately 18 cases, while total operative time plateaued after around 27 cases, equating to proficiency after this number of cases. Cumulative sum analysis of robot docking time and total operative time.

This study is a retrospective case series involving 50 patients who underwent RSP‐SILS for the surgical management of endometriosis at Baylor St. Luke's Hospital, affiliated with Baylor College of Medicine, between November 2023 and July 2025. All surgical procedures were performed by a single fellowship‐trained minimally invasive gynaecologic surgeon (X.G.), who is affiliated with a tertiary endometriosis referral centre. Patients were identified via medical records for those who underwent surgery with the primary surgeon. Patients were filtered for the terms “Robotic Da Vinci SP single‐incision laparoscopic surgery” and “endometriosis” via a secure, password‐protected network. Inclusion criteria included all patients who underwent RSP‐SILS for endometriosis. There were no exclusion criteria. Additional patient characteristics were collected and included age, body mass index (BMI), race and ethnicity, history of vaginal delivery, abdominal surgery, endometriosis staging, total operative time, port placement time, robot docking time, robot console time, estimated blood loss, same‐day discharge rate, conversion rate, pain levels before or after surgery, and mid‐term follow‐up. Mid‐term follow‐up was defined as a postoperative interval of 6–12 months. This study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (IRB) of Baylor College of Medicine on March 8, 2022, under the approval number H‐51429. Patient consent was waived due to the retrospective nature of the study by the IRB of Baylor College of Medicine. The patient was placed in the dorsal lithotomy position, prepped and draped in the normal sterile fashion with her arms tucked. A Rumi uterine manipulator and a Foley were placed. A 15 mm skin incision was made in the umbilicus, and the incision was carried down in layers until intraperitoneal. A specially designed Da Vinci SP single‐site retaining port‐ring was inserted into the incision and secured down to the level of the skin. The Da Vinci SP globe was snapped onto the port. The AirSeal iFS insufflator [ConMed, Largo, Florida] trocar is then placed into the assistant port of the Da Vinci SP globe, with the AirSeal then activated. Following insufflation and achieving pneumoperitoneum, the Da Vinci SP robotic system was docked for the procedure. The downward limit of the robotic arm was set, and the robotic instruments were placed onto the robotic arm and advanced into the Da Vinci SP globe before the surgeon took control of the instruments. From here, the indicated procedures, such as endometriosis excision, were performed. Data analysis was performed using SPSS software [version 25.0; SPSS Inc., Chicago, Illinois]. Descriptive statistics were generated. Continuous variables were tested for normality using the Kolmogorov‐Smirnov test. As primary outcomes did not follow a normal distribution, continuous data were summarised as medians with interquartile ranges (IQR), and group differences were evaluated using the Mann‐Whitney U ‐test. Categorical variables were reported as proportions. The learning curve for RSP‐SILS was assessed using cumulative sum (CUSUM) analysis. The CUSUM was calculated as CUSUM =  ∑ i = 1 n ( X i − μ ) , where Xi represents the individual time, and μ denotes the mean overall individual time. Statistical significance was set at p  < 0.05.

This pilot study demonstrates the mid‐term feasibility and safety of robot‐assisted endometriosis‐related procedures using the Da Vinci SP platform. Overall, the operative times were comparable, no conversions to laparoscopic or open surgery were made, and there was acceptable blood loss, minimal complications, and shorter time to discharge. Based on the learning curve analysis, the robotic docking time stabilised after approximately 18 cases, suggesting progressive technical familiarisation with the RSP‐SILS platform. However, further research is needed to confirm these findings and establish long‐term efficacy and safety.

This retrospective, single‐institution study presents our initial experience with 50 cases using the Da Vinci SP platform for endometriosis surgery performed by an experienced robotic surgeon. To the best of our knowledge, this is the first study to assess the surgical outcomes associated with the Da Vinci SP system in the treatment of endometriosis. There are many benefits afforded by the Da Vinci SP system. It enhances surgical mobility by incorporating elbowed and wristed instruments. This allows for movements that better mimic natural hand movements while taking benefit of the tremor reduction, precision, and the enhanced camera optics. With a new design on the camera, a “cobra” feature enables the vantage point to be altered, providing more space between the robotic instruments and the camera. Gynaecologic surgeries typically take place in several different arenas of the pelvis. Instead of moving each individual instrument to a different arena, the Custom Remote Centre (CRC) function allows all the instruments to move to a different locale in tandem by setting a new fulcrum. Lastly, the Da Vinci SP Globe can be compressed by the surgical assistant to allow an additional 8–10 cm of reach into the abdomen, if needed. At times, the Globe also allows for an area for specimens to be kept so that the robot does not have to be undocked for specimen removal. There are some downsides to the Da Vinci SP, including limitations on smoke evacuation due to the distance between the AirSeal and the surgical arena. A laparoscopic suction irrigator can assist with this, but can still be cumbersome due to the number of instruments, which is also true with laparoscopic instruments being used for tissue extraction. As the Da Vinci SP is used for fine dissection, procedures such as performing a myomectomy can be challenging due to the lack of rigidity and strength of robotic instruments. In a similar vein, cautery can be time consuming due to the smaller bipolar graspers. However, this limitation has been identified and there is a possible development of a new cautery device. With the aforementioned, the Da Vinci SP platform is specifically designed for single‐port access. The robotic docking features a simplified setup due to the use of a single robotic arm attached to a single dock. This design requires fewer calibration steps and minimises the need for instrument alignment, with collision avoidance integrated into the platform. This significantly reduces robot docking time compared to multi‐port robot‐assisted surgery. As this is a novel use of a robotic platform in gynaecology, the learning curve in robot docking proficiency was achieved after 18 cases, with a median docking time of 3 min. This is substantially shorter than the 5–15 min reported in previous studies involving a multi‐port robotic platform [ 23 , 24 , 25 ]. Although learning curve analysis suggested that total operative time for endometriosis surgery plateaued after approximately 27 cases, procedure‐specific operative times were not emphasised, as variability in surgical complexity may limit their reliability as indicators of surgeon proficiency. The total operative time was 142 min, which is comparable to, or shorter than, the median times reported in prior studies, ranging from 148 to 250.5 min [ 26 , 27 , 28 ]. Lastly, the median estimated blood loss was 25 mL, notably lower than the 50–100 mL reported in prior studies [ 26 , 27 , 28 ]. For newly emerging surgical approaches such as RSP‐SILS, conversion and complication rates are key indicators in assessing the feasibility and safety of any new approach. The findings reveal that RSP‐SILS was successfully performed in this cohort, with no conversion to either robotic multiport or open surgery. This is a significant achievement as it demonstrates the potential of RSP‐SILS to handle challenging cases without sacrificing safety. Choi JDW et al. reported a Clavien‐Dindo grade II and III complication rate of 5.17% in robot‐assisted endometriosis surgery using the Da Vinci Xi platform [ 26 ]. In our cohort, 2 Clavien–Dindo grade II complications and 1 grade III complication were observed, corresponding to a low mid‐term postoperative complication rate of 6%, which is comparable to previously reported outcomes. Recurrent pelvic pain was reported in 6% of patients at mid‐term follow‐up, a rate that compares favourably with previously published outcomes following surgical treatment for endometriosis. Given the chronic inflammatory nature of the disease and the possibility of microscopic residual lesions, some degree of symptom recurrence is anticipated and should not be interpreted solely as a limitation of the surgical approach. Notably, two of the three affected patients had coexisting adenomyosis, a condition independently associated with pelvic pain, while imaging in another patient suggested features of pelvic congestion syndrome. Although these findings may represent alternative contributors to postoperative pain, the multifactorial aetiology of pelvic pain warrants cautious interpretation. Longer‐term follow‐up is therefore necessary to better characterise symptom trajectories and determine the durability of pain relief following RSP‐SILS. Our experience demonstrates that various advanced endometriosis‐related procedures, including bowel resection and diaphragm endometriosis excision, can be successfully performed transumbilically using the Da Vinci SP platform. Several notable cases were observed in this study. One patient required lysis of obliterative pelvic adhesions and an ultra‐low anterior resection with primary colo‐anal anastomosis and diverting loop ileostomy, performed by colorectal surgery. The patient had complete posterior cul‐de‐sac obliteration with the rectum densely adherent to the uterus. A rectal nodule measuring eight by 3 cm was identified and excised following dissection of the posterior cul‐de‐sac. Additionally, three cases involved combined procedures with thoracic surgery for thoracic endometriosis. Two patients underwent right video‐assisted thoracoscopic surgery (VATS) with argon ablation of endometrial implants with a partial pleurectomy, while the other received diagnostic right thoracoscopy with flexible bronchoscopy followed by a pleurectomy. In the pelvis, radical excision of all visible endometriotic lesions is recommended to ensure thorough disease management. The “butterfly” excision of the pelvic peritoneum enables comprehensive removal of endometriotic tissue while maintaining a low complication rate [ 29 ]. Previous studies have also suggested that the peritoneal butterfly excision is particularly appropriate in cases of extensive disease involvement [ 30 ]. In the present study, en‐bloc excision of the butterfly area was performed in 47 of 50 patients (94%). Remarkably, one patient's pathology report revealed a “leiomyosarcoma” in a specimen labelled as a “right round ligament adhesion biopsy”. This unexpected finding highlights the critical importance of radical excision for all endometriotic or suspicious lesions. The pathology was confirmed by multiple pathologists, and the patient was referred to Gynaecologic Oncology. After a hysterectomy was performed, pathology did not show cancer in the uterus, and it was believed that the cancer was caught in its infancy. However, while the mid‐term outcomes are promising, there are several limitations to this study. First, as a single‐institution retrospective case series, the findings may not be generalisable to all settings or surgeons. Additionally, the relatively small sample size and focus on mid‐term outcomes limit our ability to assess long‐term efficacy and safety. Further prospective, multi‐centre studies with larger sample sizes and extended follow‐up periods are needed to evaluate the long‐term outcomes of RSP‐SILS for endometriosis management.

The authors have nothing to report.

Endometriosis is a benign, chronic, inflammatory disease defined by the presence of endometrial‐like tissue outside the uterine cavity, with patients typically presenting with pelvic pain or infertility. It is most frequently found on the pelvic peritoneum, ovaries, and rectovaginal septum [ 1 ]. A global study by the World Health Organisation (WHO) showed that endometriosis affects approximately 10 percent, or approximately 190 million, reproductive age women and girls worldwide. This carries a substantial social, public health, and economic impact [ 2 ]. To date, there is no cure for endometriosis, and management strategies vary depending on symptom severity and the patient's desire for future pregnancy. First‐line treatment is medical management with hormonal therapies, while pain is managed using non‐steroidal anti‐inflammatory drugs (NSAIDs) and, in more severe cases, opioids. With the aforementioned, many studies agree that surgical resection of endometriosis improves pain, fertility, and quality of life [ 3 , 4 , 5 ]. Minimally invasive surgery (MIS) has become the standard approach in the surgical management of endometriosis and offers several advantages. These include enhanced visualisation, shorter hospital stays, reduced complication and infection rates, and improved cosmesis. These benefits are amplified with the use of robot‐assisted laparoscopic surgery (RAS) [ 6 , 7 ]. The Da Vinci Single Port (SP) platform represents a significant advancement in MIS, offering exceptional precision, manoeuvrability, and control for complex procedures. Developed by Intuitive Surgical [Sunnyvale, CA] and specifically designed for single‐incision surgeries, the SP system enables surgeons to access the surgical site through a single port, thereby minimising scarring, reducing recovery time, and improving cosmesis. With its advanced articulating instruments (elbow and wristed joints), high‐definition 3D visualisation, and intuitive ergonomic controls, the Da Vinci SP platform empowers surgeons to perform challenging procedures with greater confidence and efficiency. Recent reports indicate that the Da Vinci SP platform has been employed in a wide variety of surgical procedures including radical prostatectomy, nephrectomy, colorectal surgery, cholecystectomy, pancreatic surgery, and total gastrectomy [ 8 , 9 , 10 , 11 , 12 , 13 ]. The Da Vinci Single Port (SP) platform has also been increasingly applied in gynaecologic surgery, including procedures such as hysterectomy, myomectomy, sacrocolpopexy, and ovarian cystectomy [ 14 , 15 , 16 , 17 ]. A handful of studies have evaluated the use of the Da Vinci SP platform in endometriosis, with four case reports describing its application in ureteroneocystostomy for ureteral endometriosis, segmental bowel resection for rectal endometriosis, nerve‐sparing eradication of deep endometriosis, and nerve‐sparing surgery with rectal discoid resection [ 18 , 19 , 20 , 21 ]. Additionally, one retrospective case series reported the use of vaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomies performed with or without endometriosis excision using the Da Vinci SP platform. However, this study did not specifically focus on the management of endometriosis [ 22 ]. The aim of this case series was to evaluate the feasibility, learning curve to proficiency, and the utility of the Da Vinci SP platform for endometriosis excision performed via single‐incision laparoscopic surgery.

The authors declare no conflicts of interest.