Hugo™ robotically assisted surgery versus laparoscopic hysterectomy for benign gynecological diseases: a secondary data analysis of clinical records in Panama.

The preoperative characteristics of the study population included age (years), body mass index (BMI, kg/m²), and hysterectomy indications (uterine myomatosis/fibromatosis, endometriosis, adenomyosis, abnormal uterine bleeding, and others). We also collected information on the uterus weight (g) registered in the health record. Surgery-related variables included the type of surgical procedure (Hugo™ RAS system or conventional laparoscopy), total surgical time defined as the interval from the first skin incision to the closure of the last skin incision, estimated intraoperative blood loss (ml), conversion to open surgery, intraoperative and postoperative complications, and length of hospital stay (days). Intraoperative complications were defined as bowel, bladder, ureteral, or vascular injuries that could have occurred during the surgery. Postoperative clinical data were collected until the patient’s discharge. Postoperative complications were classified according to the Clavien-Dindo classification [ 24 ]. The length of hospital stay was calculated from the day of hospital admission to discharge. Before conducting the statistical analysis, an anonymized electronic database was created, containing clinical and surgical information collected from the patient’s clinical records, but without any personally identifiable details. We conducted a descriptive analysis of patients’ sociodemographic and surgery-related characteristics. We used percentages for categorical variables and the median with range (minimum and maximum values) for numerical variables with non-normal data, as verified by the Shapiro-Wilk test. We compared patient and surgery characteristics using the Chi-square test for categorical variables and the Wilcoxon rank sum test for numerical variables, due to their non-normal distribution. We used linear regression analysis with robust standard errors to determine if the type of surgery was associated with surgical time, independent of other patient characteristics. Since the residuals of the dependent variable (surgery time) were not normally distributed, we performed a logarithmic transformation to meet the residuals’ normality requirements for multiple linear regression. We used robust standard errors to control for heteroskedasticity. The p-value < 0.05 was considered statistically significant. The analysis was performed using Stata V.14.0 statistical software.

The analysis included 122 records of women who underwent total hysterectomy. The preoperative characteristics of the study population are presented in Table  1 . Compared to the women who underwent conventional laparoscopy, the women in the Hugo™ RAS group were older (LS median age 45 years vs. Hugo™ RAS 48 years, p  = 0.018) and had a lower body mass index (LS 31 kg/m2 vs. Hugo™ RAS 29 kg/m2, p  = 0.018). There were no statistically significant differences between the two groups of women regarding hysterectomy indications and uterus weight. Myomatosis, fibromatosis, leiomyomas, and abnormal uterine bleeding were the most common preoperative indications for elective hysterectomy. Table 1 Comparison of general and clinical characteristics of women who underwent robotic-assisted and conventional laparoscopic total hysterectomy Conventional total laparoscopic hysterectomy n  = 59 median (min-max) Robotic-assisted hysterectomy n  = 63 median (min-max) P Patients’ preoperative characteristics  Age (years) 45 (25–68) 48 (31–70) 0.018  Body mass index (kg/m 2 ) 31 (22–48) 29 (20–52) 0.018  Hysterectomy indications Ω n (%) n (%)  Uterine myomatosis/fibromatosis/leiomyomas 49 (83.1) 57 (90.5) 0.225  Endometriosis 10 (16.9) 6 (9.5) 0.225  Adenomyosis 10 (16.9) 17 (27.0) 0.182  Abnormal uterine bleeding 47 (79.7) 51 (80.9) 0.858  Other 7 (11.9) 4 (6.4) 0.288  Other characteristics median (min-max) median (min-max)  Uterine weight (grams) 210 (68–1700) 161 (65–1400) 0.136 Surgery characteristics  Total surgical time, skin to skin (minutes) 117 (40–270) 76 (46–298) < 0.001  Conversion, n (%) 2 (0.4) 0 0.150  Blood loss during surgery (ml) 200 (20–600) 30 (0–120) < 0.001  Blood loss, n (%) <250 ml ≥250 ≤ 499 ml ≥500 ml 41 (69.5) 13 (20.0) 5 (8.5) 63 (100) 0 0 < 0.001 Hospital Stay (day) 2 (1–4) 2 (1–3) 0.012 1 day, n (%) 2 days 3–4 days 1 (1.7) 52 (88.1) 6 (10.2) 7 (11.1) 54(85.7) 2 (3.2) 0.040 Ω The majority of patients had more than one preoperative diagnosis Comparison of general and clinical characteristics of women who underwent robotic-assisted and conventional laparoscopic total hysterectomy Blood loss, n (%) <250 ml ≥250 ≤ 499 ml ≥500 ml 41 (69.5) 13 (20.0) 5 (8.5) 63 (100) 0 0 1 day, n (%) 2 days 3–4 days 1 (1.7) 52 (88.1) 6 (10.2) 7 (11.1) 54(85.7) 2 (3.2) Ω The majority of patients had more than one preoperative diagnosis Operative and postoperative outcomes: The total surgery time and blood loss were significantly lower in the Hugo™ RAS group compared to the LS group (76 min vs. 117 min and 30 mL vs. 200 mL, respectively, p  < 0.001). No intraoperative and postoperative complications were registered in either group, yet there were two conversions to open surgery in the conventional laparoscopy group. Finally, the hospital stay was slightly shorter in the Hugo™ RAS group ( p  = 0.012). Table  2 provides information on the results of the linear regression analysis, showing that the Hugo™ RAS system was associated with a 22% decrease in surgical time compared to laparoscopy (95% Confidence intervals: −0.38; −0.07, p  = 0.005) after controlling for the patient’s age, BMI, preoperative diagnoses, uterine weight, and blood loss during surgery. Table 2 Association of robotic surgery with total surgery time Adjusted Coef. Robust Std. Err. [95% Conf. Interval] P Robotic-assisted hysterectomy Ω −0.22 0.08 −0.38; −0.07 0.005 Age −0.003 0.003 −0.01; 0.004 0.401 Body mass index 0.006 0.005 −0.004; 0.02 0.239 Uterine weight (grams) 0.001 0.0001 0.0004; 0.001 < 0.001 Hysterectomy indications:  Uterine myomatosis −0.08 0.08 −0.22; 0.07 0.314  Endometriosis 0.06 0.08 −0.10; 0.23 0.450  Adenomyosis 0.04 0.06 −0.08; 0.16 0.515  Abnormal uterine bleeding −0.03 0.09 −0.20; 0.14 0.723  Other 0.02 0.12 −0.22; 0.26 0.873  Blood loss during surgery (ml) 0.0005 0.0003 −0.00005; 0.001 0.074 R-squared = 0.5559. Robust standard errors (to control for heteroskedasticity) The dependent variable was the logarithmic transformation of total surgery time Ω Reference value: conventional laparoscopic hysterectomy Association of robotic surgery with total surgery time R-squared = 0.5559. Robust standard errors (to control for heteroskedasticity) The dependent variable was the logarithmic transformation of total surgery time Ω Reference value: conventional laparoscopic hysterectomy

We conducted a retrospective analysis of secondary data of clinical records of patients who underwent a benign total hysterectomy in two hospitals in Panama City from July 1, 2022, to June 29, 2023. The study analyzed clinical records of all women aged > 18 and < 70 who underwent a benign total hysterectomy during the study period with Hugo™ RAS System at the Pacifica Salud hospital in Panama City ( n  = 63) and those with conventional laparoscopy at the Complejo Hospitalario Doctor Arnulfo Arias Madrid (CHDrAAM) ( n  = 59). In each hospital, surgeries were performed by experienced gynecology surgeons trained in either robotic ( n  = 5 at Pacifica Salud hospital) or laparoscopic gynecological surgeries ( n  = 6 at CHDrAAM). Specifically, in the robotic surgery group, all surgeons held certifications in robotic surgery after completing 6 h of theoretical training and 52 h of simulation-based and robotic console training at the University of Illinois Simulation Center. They previously performed 8 to 15 robotic surgeries and had at least 2 years of experience with robotic surgery. In the laparoscopic surgery group, all surgeons held certification and had a minimum of 10 years of experience in laparoscopic surgery. The sample consisted of clinical records from 122 women, which was sufficient for conducting a multivariable regression analysis based on the rule of thumb that recommends having ten participants for each variable included in the regression [ 23 ]. This study included ten variables; therefore, the minimum required sample size was 100 women.

Hysterectomy is a widely performed surgical intervention for benign gynecological conditions aimed at relieving symptoms, reducing the risk of advancing to more severe health problems, and enhancing quality of life [ 1 ]. In high-income countries, about 20 to 45% of women have had a hysterectomy by age 60 to 75 [ 2 – 5 ]. Although hysterectomies are common in low- and middle-income countries, there is a lack of information on this topic, particularly for Latin American countries [ 6 – 9 ]. The techniques for performing hysterectomies have significantly changed during the past decades, shifting from open surgeries to minimally invasive methods. In the United States, the rate of minimally invasive hysterectomy rose from 20.2% in 2000 to 65.7% in 2018 [ 10 ]. Nowadays, laparoscopic and robot-assisted surgeries are among the predominant minimally invasive techniques used in gynecology. Both methods offer considerable benefits over traditional open surgery; yet each has advantages and drawbacks that can affect surgical precision, clinical outcomes, and recovery time. Laparoscopic surgery (LS) is the standard approach to gynecological surgeries that uses small incisions to minimize tissue damage [ 11 ]. Compared to open laparotomy, LS leads to less intraoperative and postoperative complications, resulting in shorter hospital stays [ 12 , 13 ]. Consequently, from a health services perspective, LS is more cost-effective than open gynecological procedure [ 12 , 13 ]. In the past three decades, robotically assisted surgery (RAS) has been increasingly adopted as an alternative to LS, with its uptake varying across medical specialties. By 2025, RAS is projected to exceed LS in colectomies, prostatectomies, pancreatectomies, and esophagectomies [ 14 ]. In gynecology, RAS hysterectomies are as effective as LS hysterectomies, leading to shorter hospital stays [ 15 ] and lower readmission rates [ 16 ]. In addition, compared to LS, RAS offers better precision and improved comfort for surgeons, leading to better outcomes [ 17 , 18 ]. However, most evidence about RAS comes from high-income countries, while experiences from low- and middle-income countries, like those in Latin America, are incipient. RAS is expanding slowly in Latin America due to constraints related to healthcare policies, funding, and infrastructure [ 14 ]. According to Global Health Intelligence [ 19 ], in 2021, about 150 robotic systems were used across 130 medical institutions in Latin America, primarily in Brazil, Mexico, Chile, Colombia, and Panama. The Medtronic Hugo™ RAS system was introduced in 2019. The first surgery with this RAS was performed in Chile in 2021 for prostatectomy [ 20 ]. In 2022, the Pacífica Salud Hospital in Panama City began using this system for gynecological surgery. The Hugo™ RAS system has numerous improvements over the previously existing robotic platforms, including independent robotic arms, enhanced flexibility, an open console with diverse gripping techniques, and an artificial intelligence system for surgical feedback and optimization [ 21 ]. Additionally, this system is safe for patients with and without risk factors for developing major surgical complications [ 22 ]. However, due to its novelty, there is a need for more information on the Hugo™ RAS system’s use in gynecology. Comparing the Hugo™ RAS system to LS is justified for understanding the advantages and disadvantages of both approaches, including the required operative time and the associated operative and postoperative complications. Therefore, the present study aimed to compare the general and clinical characteristics of women who have undergone Hugo™ RAS and laparoscopic benign total hysterectomy at two hospitals in Panama and to analyze which type of surgery is associated with a shorter operating time after controlling for patients’ characteristics.

The present study found that Hugo™ robotically assisted surgery was associated with a 22% decrease in operating time for benign hysterectomies compared to laparoscopy, regardless of patient age, BMI, preoperative diagnoses, uterine weight, and blood loss during surgery. Additionally, blood loss and hospital stays were slightly lower in women who underwent hysterectomy with the Hugo™ RAS, while no intraoperative or postoperative complications were reported in either group. This study applied surgical performance criteria to evaluate the Hugo™ RAS group in comparison to laparoscopy. Operative time represents a complex interaction of patients’ and providers’ characteristics, including surgical skills, surgeon experience, and patient comorbidity [ 25 ]. The shorter operative time represents benefits for surgeons and patients. For patients, it helps minimize the risks associated with prolonged anesthesia surgery complications, speeding patient recovery and increasing satisfaction [ 26 ]. For surgeons, it helps to reduce muscular fatigue [ 27 ] and hand tremors [ 28 ]. Other studies have shown lower self-reported surgeon discomfort in robotic procedures than in laparoscopy and open surgery [ 18 ]. This is especially important since up to 74% of laparoscopic surgeons have reported physical complaints [ 29 ]. In our study, a shorter operative time was observed in the RAS group, even though the LS surgeons had more experience. This finding remained significant after controlling for patient characteristics in multivariable regression analysis. This result contrasts positively with previous research comparing laparoscopic versus robotic abdominal and pelvic surgery, which indicated longer RAS durations [ 30 ]. Our findings may reflect the intrinsic advantages of robotic technology, such as enhanced instrument dexterity, three-dimensional visualization, ergonomic precision, and reduced operator fatigue, all of which can shorten critical steps of the surgery, even for surgeons who are still in the learning phase. The median BMI was slightly higher in the laparoscopic surgery group compared to the Hugo™ RAS group (BMI 31 vs. 29 kg/m²). Obesity presents extra challenges for surgeons, including difficulties with airway and venous access, an increased risk of complications related to surgery and anesthesia, such as peripheral nerve damage, and a higher incidence of surgical site infections, among other issues [ 31 ]. To mitigate the confounding impact of BMI on operating time, we adjusted the relationship between the independent variable (type of surgery) and the dependent variable (operating time) by accounting for BMI and other potential confounding factors. The adjustment for confounders in multiple regression is a commonly accepted method for deriving an unbiased estimate of the relationship between independent and dependent variables. There are fewer adverse surgery outcomes with the Hugo™ RAS group. The present study found that blood loss and hospital stays were slightly lower in women who underwent hysterectomy with the Hugo™ RAS compared to laparoscopy. This finding is consistent with the results of systematic reviews and meta-analyses of randomized controlled trials comparing gynecologic laparoscopic procedures with and without robotic assistance, which revealed that RAS was associated with lower estimated blood loss and shorter postoperative hospital length of stay compared to laparoscopic procedures [ 32 ]. No intraoperative and postoperative complications were registered in either group. This finding supports the safety of both surgery types. Other studies reported similar intraoperative and postoperative complications risks for Hugo™ RAS and laparoscopic gynecologic surgeries [ 32 ]. Our research has several limitations. First, the retrospective design may introduce selection bias due to the non-random allocation of patients between the Hugo™ RAS and laparoscopic surgery groups and restricts our ability to establish causal relationships. To minimize selection bias, we analyzed all women aged 18 to 70 who underwent benign total hysterectomy at two hospitals—one exclusively offered robotic surgery, and another provided only laparoscopic surgeries. This approach ensured that women received the same type of surgery at each hospital, regardless of their characteristics. We also compared patient characteristics in both groups and adjusted study outcome for confounding variables. Second, although all patients had complete information on the analyzed variables, we were unable to assess postoperative hemoglobin decreases or long-term health impacts, such as pelvic adhesions or changes in pelvic organ function, or patient-centered outcomes like quality of life and satisfaction, as these variables are typically not recorded in health records. Future studies should focus on incorporating these measures to inform health providers and decision-makers about the possible benefits of Hugo™ RAS on patients’ well-being. Third, differences in surgeons experience among those performing robotic-assisted surgery compared to traditional laparoscopic surgery may have introduced a performance bias, as more experienced surgeons tend to perform better. In the present study, while all surgeons in the robotic group were certified and trained, their cumulative experience ranged from 8 to 15 procedures. This suggests that some surgeons may still be within the learning curve, which could adversely affect their operative time. However, despite the relatively less experience of the RAS surgeons, the surgery time was shorter in the RAS group. It is possible that with more experience, the operative time for RAS could further improve. It is recommended that future studies analyzing real clinical practice data should collect detailed information on each surgeon’s experience and control for this variable in their statistical analysis. Third, this study also did not assess the cost implications of robotic versus laparoscopic surgery, which are crucial factors to consider when implementing new technology. Therefore, we recommend conducting studies on the cost-effectiveness and cost-benefit of Hugo™ RAS within a Panamanian context. Finally, the lack of random sampling may limit the extent to which the study’s findings can be generalized. Nevertheless, the women analyzed were real-world patients with a variety of ages, body mass indices, and indications for hysterectomy, which improves the study’s external validity. Furthermore, we provided comprehensive descriptions of the context and the types of hysterectomy procedures performed (robotic and laparoscopic). This information enables others to assess the relevance of our results to their own settings and populations. In conclusion, our findings support that Hugo™ RAS system is associated with a 22% decrease in operating time for benign hysterectomy compared to laparoscopy, regardless of patient characteristics. Both robotic-assisted surgery and laparoscopic hysterectomy showed a good safety profile, with lower blood loss and shorter hospital stays in the robotic surgery group.

According to the clinical records, laparoscopic hysterectomies were performed through four abdominal ports (12 mm umbilical, right, and left ports, and 5 mm accessory), and the instruments used were a 30º lens, an advanced bipolar for dissection and vessel sealing, laparoscopic scissors, and a needle holder. Robotic hysterectomies with the Hugo™ RAS system were performed through four abdominal ports: an 11 mm umbilical port, 8 mm auxiliary ports on the right and left, and an 11 mm auxiliary port. The robotic arms were coupled using the systematized 7-step technique. A 0º optical lens with two lenses was used for the umbilical port; monopolar scissors for dissection in the right-side accessory port; fenestrated bipolar forceps for vessel sealing in the left accessory trocar; and a needle holder for suturing.