Robotic laparoendoscopic single-site surgery by da Vinci Xi system in gynecology: a retrospective series of 721 cases.

This retrospective study was approved by the Institutional Review Board of West China Second University Hospital (IRB number: 2023331, 2023332). Between April 28, 2021 and September 30, 2023, patients eligible for MIS were provided with the option of R-LESS and fully consulted about its benefits, costs, and possible risks. Regarding MIS for cervical cancer, we performed preoperative and postoperative staging based on FIGO 2018 guidelines. Patients meeting the following criteria were eligible for R-LESS procedures: (1) Cervical cancer confirmed by preoperative biopsy; (2) Clinical stage IA1 to IIA1; (3) Cervical lesions < 4 cm; (4) No evidence of suspected parametrial involvement, lymph node metastasis, or distant metastasis on imaging. Final decisions were at the discretion of patients themselves, and written informed consent were provided. Patients’ demographic data and perioperative outcomes were retrospectively collected from the electronic medical records. Demographic parameters included age, body mass index (BMI), prior abdominal surgery, comorbidity, and surgical indication. Perioperative outcomes including procedure type, operative time (OT), estimated blood loss (EBL), conversion, requirement of additional port, intraoperative complication, postoperative hospital stay, catheter indwelling time, drainage time, exhaust time, pain assessment and postoperative complication were evaluated. OT was calculated from the skin incision to closure. EBL was estimated by the main surgeon according to intraoperative conditions. Any bladder, ureteral, bowel, and vascular injuries were defined as intraoperative complications. Patients received either patient-controlled intravenous analgesia or transversus abdominis plane block as analgesic protocols and underwent standardized pain assessments with Visual Analog Scale (VAS), ranging from 0 to 10 with verbal description of “no pain” to “agonizing pain” at 12 h, 24 h, 36 h after surgery. Any adverse event occurred within 3 months was recorded as postoperative complications. The Clavien-Dindo classification system was incorporated to standardize postoperative complication grading. For malignant diseases, the number of removed lymph nodes was also retrieved from the pathologic report. All surgeries were performed by experienced gynecologic oncologists using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, USA, Fig. 1 ) following the standard procedures. The operating surgeons had variable levels of experience with conventional LESS, ranging from extensive to none. The role of bedside assistant was assigned to a gynecologic fellow or a senior resident. Fig. 1 Da Vinci Xi surgical system ( a ) Patient cart; ( b ) Vision cart; ( c ) Surgeon’s console; ( d ) Camera and instruments Da Vinci Xi surgical system ( a ) Patient cart; ( b ) Vision cart; ( c ) Surgeon’s console; ( d ) Camera and instruments The patients were placed in Trendelenburg position after induction of general anesthesia. A Foley catheter and a uterine manipulator if needed were placed prior to skin incision. For transumbilical approach, a 2.5–3.0 cm vertical umbilical incision was made, through which a single-port multi-channel device with 4 identical 10-mm channels (Kangji Medical, Hangzhou, China, Fig. 2 a) was inserted into the peritoneal cavity. For transvaginal approach, the port was inserted after dissecting the vesicovaginal and rectovaginal spaces, and cutting off bilateral cardinal and sacral ligaments. In one case of vulva cancer who needed left inguinal lymphadenectomy, a 3.0 cm incision was made above and parallel to the left groin followed by inserting the port into subcutaneous space. Fig. 2 R-LESS preparation ( a ) Single-site multi-channel port for R-LESS; ( b ) Robotic docking; ( c ) Port arrangement R-LESS preparation ( a ) Single-site multi-channel port for R-LESS; ( b ) Robotic docking; ( c ) Port arrangement The patient cart was driven to the right side of the operating table. A 30-degree, high-definition, three-dimensional (3D) robotic camera was introduced through channel 2 and docked towards the pelvic cavity in a scope-up or scope-down setting according to the main surgeon’s preference. Routinely used fenestrated bipolar forceps and unipolar scissors were introduced through channel 1 and 3, while the Maryland grasper or Vessel Sealer was adopted occasionally. The unipolar scissors would be switched to a wristed needle driver for oophoroplasty, uterine wall suture and vaginal cuff closure. The bed-side assistant standing on the left or cephalic side of the operating table played an important role by inserting a long straight laparoscopic instrument from channel 4 in the posterior part of the port to assist with retraction, irrigation, delivering sutures and gauzes, and specimen extraction (Fig. 2 b, 2 c). When performing radical hysterectomy for cervical cancer, the MIS had controversy due to worse survival rate compared with laparotomy, which speculatively ascribed to direct squeezing and damage to the cervical lesion by the uterine manipulator, open colpotomy, and insufflation gas that promoted tumor cell growth and spread [ 10 ]. Based on that, we made technical improvements including Zheng’s 4C suspension method [ 11 ] or Ma’s banding method (Fig. 3 ) to replace the uterine manipulator, along with closed colpotomy. Fig. 3 R-LESS radical hysterectomy with Ma’s banding method ( a ) Pelvic lymphadenectomy; ( b ) Uterine manipulation by Ma’s cerclage band; ( c ) Rectovaginal space dissection; ( d ) Exposure of paravesical fossa; ( e ) Vaginal sealing by barbed suture; ( f ) Closed colpotomy R-LESS radical hysterectomy with Ma’s banding method ( a ) Pelvic lymphadenectomy; ( b ) Uterine manipulation by Ma’s cerclage band; ( c ) Rectovaginal space dissection; ( d ) Exposure of paravesical fossa; ( e ) Vaginal sealing by barbed suture; ( f ) Closed colpotomy As for lymph node dissection (LND) in malignant cases, when sentinel lymph node (SLN) dissection was planned, all mapped nodes with black stain or green fluorescence were identified and resected. If no SLN was detected, pelvic LND should be performed ipsilaterally. When comprehensive pelvic LND was planned, after the common, external, internal iliac lymph nodes were resected successively, the atresia vessel at the distal end of internal iliac artery was identified and pulled medially by the bed-side assistant to expose obturator regions for obturator nodes dissection. In high-risk cases requiring a high-level para-aortic LND, da Vinci Xi system was dual docked towards the upper abdominal cavity by rotating the arm beam for 180 degrees without changing the cart’s position or rearranging the ports [ 12 ]. Procedures including omentectomy and cytoreduction could be performed simultaneously at dual-docking (Fig. 4 ). Fig. 4 R-LESS procedures at dual-docking ( a ) Rearrangement of robotic arms; ( b ) Para-aortic lymphadenectomy up to the left renal vein; ( c ) Omentectomy R-LESS procedures at dual-docking ( a ) Rearrangement of robotic arms; ( b ) Para-aortic lymphadenectomy up to the left renal vein; ( c ) Omentectomy Resected tissues were bagged and extracted either through vagina or umbilical incision, based on whether a hysterectomy was performed and the size of the uterus. The umbilical incision was cosmetically repaired by Zheng’s anchor suturing technique [ 13 ]. Patients’ demographic data and perioperative outcomes were retrospectively collected from the electronic medical records. Statistical analysis was performed using SPSS 26.0. Continuous data with normal or abnormal distribution were presented as mean ± standard deviation (SD) or median (P 25 , P 75 ), respectively. Categorical data were reported as an absolute number with a percentage. Patients were categorized by benign and malignant indications to demonstrate perioperative outcomes, and one representative procedure in each category was divided into three stages by calendar year to explore the impact of robotic system on OT. Comparisons among stages were conducted by Kruskal-Wallis analysis. Univariate and multivariate logistic regression analyses were conducted to identify relevant risk factors for conversions and complications. P  < 0.05 was interpreted as statistically significant.

Totally, 721 patients undergoing R-LESS procedures were included in this study (Table  1 ). The mean age was 45.8 ± 11.6 years old, and the mean BMI was 22.9 ± 3.5 kg/m 2 . 44.7% of the patients had prior abdominal surgeries. Hypertension was the most common comorbidity. Uterine myoma/adenomyosis and cervical cancer accounted for the largest proportions of benign and malignant indications, respectively. Table 1 Patients’ demographic characteristics and surgical indications ( n  = 721) Variables Mean ± SD/Median ( P 25 , P 75 )/ n (%) Age, years 45.8 ± 11.6 BMI, kg/m 2 22.9 ± 3.5 Prior abdominal surgeries  Yes 344 (47.7)  No 377 (52.3) Comorbidities ( n  = 199, 27.6%)  Hypertension 87 (12.1)  Diabetes 35 (4.9)  Chronic pulmonary diseases 16 (2.2)  Moderate and severe anemia 16 (2.2)  Cardiovascular diseases 13 (1.8)  Thyroid dysfunction 29 (4.0)  Prior cancer histories 23 (3.2)  Others^ 39 (5.4) Surgical indications  Benign Adnexal mass 117 (16.2) Uterine myoma/Adenomyosis 164 (22.7) Cervical intraepithelial neoplasia/Carcinoma in situ 98 (13.6) Endometrial hyperplasia 17 (2.4) BRAC genes mutation 1 (0.1) Uterine prolapse 2 (0.3)  Malignant Cervical cancer 170 (23.6) Vaginal cancer 1 (0.1) Endometrial cancer 113 (15.7) Uterine sarcoma 9 (1.2) Ovarian/Fallopian cancer 28 (3.9) Vulva cancer 1 (0.1) Patients’ demographic characteristics and surgical indications ( n  = 721) In 400 benign procedures, 97.3% utilized the transumbilical approach, while 2.7% were completed transvaginally. Among the surgeries performed, total hysterectomy was the most common procedure type (Table  2 ). Table 2 Surgical types and approaches of R-LESS benign procedures ( n  = 400) Surgical types and approaches n (%) Ovarian cystectomy  Unilateral 66 (16.5)  Bilateral 38 (9.5) Adnexectomy  Unilateral 2 (0.5)  Bilateral 10 (2.5) Myomectomy 42 (10.5) Total hysterectomy with or without adnexectomy 239 (59.8) Subtotal hysterectomy with or without adnexectomy 3 (0.8) Surgical approaches  Transumbilical single-site approach 389 (97.3)  V-NOTES 11 (2.7) V-NOTES, Transvaginal Natural Orifice Transluminal Endoscopic Surgery Surgical types and approaches of R-LESS benign procedures ( n  = 400) V-NOTES, Transvaginal Natural Orifice Transluminal Endoscopic Surgery The median operative time (OT) was 145.0 min and the median estimated blood loss (EBL) was 45.0 mL. There were 4 (1.0%) intraoperative complications. Of these, 1 transmural bowel injury required laparotomic repair due to extensive adhesions, while the other 3 injuries were successfully managed via R-LESS. During the initial two myomectomies, surgeons required an additional port to address huge myomas when they had not yet fully mastered R-LESS techniques. The median exhaust time was 2.0 days. Catheters and drainage tubes were removed at a median of 2.0 days in 348 patients and 3.0 days in 54 patients, respectively. The median postoperative hospital stay was 4.0 days. The mean VAS scores were 2.0 ± 0.8 at 24 h postoperatively. Postoperative complications occurred in 2.4% of patients. Five incisional complications and 3 pulmonary embolisms resolved with conservative management, while 1 vaginal stump hemorrhage required readmission for transvaginal repair 30 days after surgery (Table  4 ). In 321 malignant procedures, 99.7% were completed through transumbilical approach. The most common surgical type was radical hysterectomy with pelvic LND for cervical cancer (Table  3 ). Table 3 Surgical types and approaches of R-LESS malignant procedures ( n  = 321) Surgical types and approaches n (%) Cervical cancer  Extrafascial hysterectomy + bilateral adnexectomy ± PLND 40 (12.5)  Modified radical hysterectomy + bilateral adnexectomy + PLND 9 (2.8)  Radical hysterectomy + bilateral adnexectomy + PLND 112 (34.9)  Radical parametrectomy + upper vaginectomy + PLND 1 (0.3)  Radical trachelectomy + PLND 1 (0.3)  PLND/PALND ± bilateral adnexectomy 7 (2.2) Endometrial cancer  Comprehensive staging surgery 93 (30.0)  Maximal tumor debulking surgery 18 (5.6)  PALND 1 (0.3)  PLND/PALND + omentectomy 1 (0.3) Ovarian/Fallopian tube cancer  Comprehensive staging surgery 10 (3.1)  Fertility-sparing staging surgery 7 (2.2)  Primary debulking surgery 7 (2.2)  Interval debulking surgery 2 (0.6)  Bilateral adnexectomy 1 (0.3)  PALND 1 (0.3) Uterine sarcoma  Total hysterectomy + bilateral adnexectomy ± LND ± peritoneal biopsy 7 (2.2)  Bilateral oophorectomy + LND + omentectomy + peritoneal biopsy 1 (0.3) Vulva cancer Radical vulvectomy + left inguinal LND 1 (0.3) Vaginal cancer  Radical hysterectomy + bilateral adnexectomy + partial vaginectomy 1 (0.3) LND 276 (86.0)  Sentinel lymph node mapping and dissection  Enlarged or metastatic LND  Comprehensive PLND ± PALND Surgical approach  Transumbilical single-site approach 321 (99.7)  Skin incision above the left groin 1 (0.3) PLND pelvic lymph node dissection, PALND para-aortic lymph node dissection, LND  lymph node dissection Surgical types and approaches of R-LESS malignant procedures ( n  = 321) PLND pelvic lymph node dissection, PALND para-aortic lymph node dissection, LND  lymph node dissection The median OT was 218.0 min, and the median EBL was 50.0 mL. Intraoperative complications occurred in 9 patients (2.8%), totaling 10 events, with most successfully managed by R-LESS. However, one external iliac vein injury required conversion to conventional LESS for hemostasis. Two patients with endometrial cancer converted to laparotomy for intact removal of enlarged uteri, while three patients with advanced ovarian cancer underwent conversion to laparotomy, robotic multi-port surgery, and traditional multi-port surgery respectively for optimal upper abdominal cytoreduction after intraoperative assessment by a general surgeon. The overall conversion rate for malignant procedures was 1.9%. The median exhaust time was 3.0 days. For patients undergoing radical parametrectomy, the median catheter indwelling time was 21.0 days, compared to 3.0 days for others. Drainage tubes were removed at a median of 4.0 days postoperatively in 155 patients. The median postoperative hospital stay was 5.0 days. Postoperative VAS scores were rated as 2.0 ± 0.7 at 24 h. Among 154 patients receiving comprehensive LND, the median number of resected nodes was 28.0. Forty-three patients experienced a total of 51 postoperative complications, in which 14 cases of urinary retention required recatheterization after catheter removal, 3 urogenital fistulas were managed with ureteral reimplantation, and 1 infected intra-abdominal hematoma necessitated reoperation for evacuation (Table  4 ). Table 4 Perioperative outcomes of patients with benign and malignant indications Benign indications ( n  = 400) Malignant indications ( n  = 321) Operative time, min 145.0 (115.0, 180.8) 218.0 (170.0, 282.0) Estimated blood loss, mL 45.0 (20.0, 60.0) 50.0 (50.0, 100.0) Conversion, n (%)  Laparotomy 1 (0.3) 3 (0.9)  Traditional laparoscopy 0 (0) 2 (0.6)  Robotic multi-port surgery 0 (0) 1 (0.3) Additional port, n (%) 2 (0.5) 0 (0) Intraoperative complications, n (%)  Ureteral injury 1 (0.3) 3 (0.9)  Bladder injury 1 (0.3) 2 (0.6)  Bowel injury 2 (0.5) 2 (0.6)  Vascular injury 0 (0) 3 (0.9) Exhaust time, days 2.0 (2.0, 3.0) 3.0 (2.0, 3.0) Catheter indwelling time, days  After radical parametrectomy NA 21.0 (21.0, 22.3)  Others 2.0 (1.0, 3.0) 3.0 (2.0, 4.0) Drainage time, days 3.0 (2.0, 3.0) 4.0 (3.0, 5.0) Postoperative hospital stay, days 4.0 (3.0, 5.0) 5.0 (4.0, 6.0) Postoperative VAS score  12 h 2.3 ± 0.8 2.1 ± 0.7  24 h 2.0 ± 0.8 2.0 ± 0.7  36 h 1.6 ± 0.9 1.6 ± 0.7 Number of resected nodes in comprehensive lymphadenectomy NA 28.0 (22.0, 33.0) Postoperative complication, n (%) *  Grade I 5 (1.3) 19 (5.9)  Grade II 3 (0.8) 28 (8.7)  Grade III 1 (0.3) 4 (1.2) * Clavien-Dindo classification Perioperative outcomes of patients with benign and malignant indications * Clavien-Dindo classification Potential risk factors for R-LESS conversions and complications including age, BMI, prior abdominal surgery, comorbidity, surgical indications, and the surgeon’s LESS experience were analyzed using logistic regression. The results demonstrated that prior abdominal surgery was an independent risk factor for intraoperative complications. Malignant surgical indication was identified as an independent risk factor for both intraoperative and postoperative complications. In contrast, age, BMI, and the surgeon’s LESS experience did not significantly affect the incidence of conversions or complications (Supplementary Table S1-S3). The median OT for R-LESS total hysterectomy in benign cases decreased significantly in the second year compared to the first (172.5 vs. 146.5 min, p  = 0.006), but slightly prolonged in the third year (146.5 vs. 160.0 min, p  = 0.245). For R-LESS radical hysterectomy in cervical cancer, the median OT also decreased significantly in the second year (313.0 vs. 251.0 min, p  = 0.007) and stabilized in the third year (251.0 vs. 220.0, p  = 0.280), with a continued downtrend (Fig. 5 ). Fig. 5 The median operative time of R-LESS total hysterectomy and radical hysterectomy by year The median operative time of R-LESS total hysterectomy and radical hysterectomy by year

Minimally invasive surgery (MIS) is a recommended approach for most gynecologic surgeries with benefits including shorter hospitalization, reduced pain, and fewer complications [ 1 ]. Laparoendoscopic single-site surgery (LESS) has emerged as a technique that permits access to the abdominal cavity through a single small incision, typically at the umbilicus. It enables quick and safe specimen extraction through a relatively larger incision compared to multi-port laparoscopy without using power morcellation, thereby adhering to the tumor-free principle. This establishes its superiority for resecting huge masses and performing fertility-sparing surgery for malignancies. However, technical obstacles in LESS, such as instrumental collision, loss of triangulation, poor visual stability, lack of assistance, and poor ergonomics, necessitate an extensive learning curve to achieve great proficiency [ 2 ]. Since the U.S. Food and Drug Administration approved the da Vinci surgical system for gynecologic surgery in 2005, numerous studies have confirmed the feasibility and safety of robotic surgery in gynecology. The robotic system significantly enhances surgical dexterity, precision, visualization, and ergonomics through articulating instruments, tremor filtering systems, and three-dimensional camera. However, robotic multi-port surgery is associated with increased costs, higher incisional complication rates, and poorer cosmetic outcomes due to greater port numbers and sizes compared to traditional laparoscopy [ 3 , 4 ]. Integrating robotic systems with LESS (R-LESS) represents a promising concept that not only allows gynecologists to overcome technical challenges while improving accessibility to single-site surgery, but also offers inherent advantages to patients, potentially enhancing the acceptability of robotic surgery. Literature reports indicate that R-LESS achieves comparable or even superior operative outcomes with a short learning curve [ 5 – 7 ], yet few studies describe its application with the fourth generation da Vinci Xi system. Compared with the former Si system, Xi has several upgrades and modifications such as overhead docking, narrow arms and a greater range of motion without external collision, enhancing anatomic access. Although the latest da Vinci SP system, specifically designed for single-site surgery, has been reported in hysterectomy, myomectomy, cystectomy, sacrocolpopexy, and early-stage malignant surgeries [ 8 , 9 ], it remains unavailable in China. We aimed to present a large retrospective cohort to describe perioperative outcomes of R-LESS procedures using the da Vinci Xi system, demonstrating its feasibility, safety, and efficacy across diverse gynecological conditions.

Major technical defects of LESS hinder its widespread application in gynecology that introduce both physical and psychological challenges to surgeons. The robotic system overcomes these surgical difficulties through enhanced 3D visualization, superior dexterity and precision, and autonomous camera control. Ergonomic challenges are comprehensively addressed as the surgeon operates from the console, avoiding prolonged standing with torso twisting or arms elevated in strained positions. The da Vinci Xi system features smaller and thinner arms with newly designed FLEX joints, enabling closer instrumental placement and eliminating external collisions. This restores operative triangulation comparable to multi-port laparoscopy. Consequently, surgeons with different levels of experience can overcome technical and psychological barriers to mastering R-LESS. This study retrospectively reviews the application of the da Vinci Xi-assisted R-LESS in gynecology across a large series which preliminarily proves its feasibility, safety, and efficacy for diverse gynecological conditions. R-LESS significantly reduced OT and EBL in malignant procedures [ 14 , 15 ], despite having implemented a high proportion of comprehensive LND, the no-manipulation technique for cervical cancer, and multidisciplinary surgery for advanced ovarian cancer. In addition to significantly reducing the difficulty of LESS through da Vinci Xi system, its high-definition 3D vision enabled surgeons to clearly distinguish blood vessels from surrounding tissues, and the tremor filtration system greatly ensured operational stability, thereby avoiding vascular injuries caused by excessive traction and tearing. Laparotomy was historically recommended for advanced-stage malignancies. However, since da Vinci Xi system enables four-quadrant surgeries with its magnified 3D visualization significantly aiding in detecting tiny, deep metastatic lesions, we propose that ovarian cancer patients characterized by limited intraperitoneal dissemination and retroperitoneal lymphatic metastasis may still achieve satisfactory cytoreduction via R-LESS after thorough preoperative assessment. This approach facilitates fast recovery and early onset of chemotherapy, ensuring treatment efficacy and improved survival [ 12 ]. The median number of retrieved nodes for comprehensive LND was 28.0, higher than some reported ranges of 9.0–22.0[ 16 , 17 ]. Boundaries of vessels, nerves, and lymphatic tissues were difficult to clearly distinguish in a 2D view of traditional laparoscopy. Moreover, in traditional LESS, the primary surgeon had to use one instrument for exposure and another for operation without assistance, potentially resulting in incomplete LND. The robotic system’s advantages provide greater confidence for surgeons to perform LND safely, effectively, and thoroughly [ 18 ]. The total intraoperative complication rate of 1.9% was lower than those reported rates of 2.4%−6.25%[ 15 , 19 , 20 ]. Except for 2 cases that experienced conversion, most complications were successfully repaired by R-LESS or required insertion of ureteral stents. Our conversion rate of 1.0% was also significantly lower than previous reports of 5.7%−7.5%[ 19 , 21 ], and these conversions clustered in the early phase of the study period, coinciding with the surgeons’ learning curve in R-LESS technique mastery. Intraoperative complications were mainly attributed to prior abdominal surgery and malignant indication. To prevent accidental injuries, surgeons should comprehensively expose the targets, keep instruments in the central view, operate as gently as possible, and take full advantage of stereo vision to compensate for the absence of tactile feedback. Our findings demonstrated that regardless of prior LESS experience, surgeons could successfully implement R-LESS without increasing conversion or complication rates. Additionally, the median OT for both R-LESS hysterectomy and radical hysterectomy significantly improved in the second year and stabilized in the third year, despite the inclusion of more complex cases and junior surgeons. Studies reported that surgeons could achieve proficiency after 6–16 cases for R-LESS [ 22 , 23 ], compared to 17–40 cases for LESS [ 24 , 25 ], supporting that robotic assistance facilitates earlier proficiency attainment. The umbilical incision required for R-LESS is larger than that for traditional LESS or multi-port laparoscopy, which is associated with higher risks of herniation and severe pain. The reported incidence of incisional hernia after LESS varies widely (1.8%–6.35%), with advanced age and BMI identified as significant predictors [ 26 , 27 ]. However, by employing Zheng’s anchor suturing technique to reinforce fascial closure, no umbilical hernias and minimal incisional complications were observed in our study. Moreover, since the robotic cannulas were relatively fixed on the port, instruments could perform articulated movements intracorporeally without excessive umbilical distortion, potentially mitigating pain from the larger incision. As discussed in previous studies, vaginal natural orifice transluminal endoscopic surgery (vNOTES) demonstrates superior outcomes in reducing operative time, alleviating pain, and enhancing postoperative recovery compared to transumbilical LESS [ 28 – 30 ]. However, vNOTES presents unique challenges due to its “inverted” pelvic anatomy and limited instrument maneuverability, restricting its application in managing severe pelvic adhesions, huge pelvic masses, or advanced malignancies. During the study period, the case selection criteria for R-vNOTES included benign indications, no history of multiple prior pelvic surgeries, adequate uterine mobility, and absence of significant vaginal atrophy or pathological stenosis. Future advancements in surgeons’ proficiency and instrument improvements may expand R-vNOTES applications, warranting further exploration of its surgical indications and technical advantages. The greatest strength of this study is that it represents the largest known series of R-LESS by da Vinci Xi system for treating a multitude of gynecologic diseases. A significant disadvantage of robotic surgery is the high cost of equipment and consumables. Emerging robotic surgical platforms with reduced pricing, alongside novel technologies such as single-arm surgical robots, tactile feedback systems, 5G telemedicine, and multidisciplinary surgery, will advance the application of R-LESS in gynecology, allowing more patients to benefit from it.

This study preliminarily proved the feasibility, safety and efficacy of R-LESS for completing various gynecological procedures, even in complex conditions such as obesity, severe adhesions, huge masses and oncological cases with demonstrated ability to reduce surgical difficulties. Future comparative data focusing on specific diseases and procedures are expected to further elucidate the advantages of R-LESS over other surgical approaches.

Supplementary Material 1. Supplementary Material 1.