Patient Outcomes with Robotic-Assisted Total Laparoscopic Hysterectomy Versus Robotic-Assisted Total Laparoscopic Hysterectomy with Minilaparotomy

Background: Minimally invasive hysterectomy, with removal of the specimen through the vagina, has minimal morbidity and superior intraoperative and postoperative outcomes compared to abdominal hysterectomy. There are times, however, when vaginal specimen removal may not be feasible and a minilaparotomy can be utilized. This study purpose was to compare outcomes of robotic-assisted total laparoscopic hysterectomies with vaginal removal of the specimen versus minilaparotomy specimen extraction. Methods: A retrospective cohort study was conducted among two groups of patients who underwent a robotic-assisted total laparoscopic hysterectomy with vaginal specimen extraction (RV) or minilaparotomy specimen extraction (RL) by the gynecologic oncology service at an academic institution. Blood loss, pain medication requirements, length of stay and surgical complications were compared between groups. Results: From January 2017 to October 2022, 1643 patients underwent a robotic hysterectomy. Sixty patients required a minilaparotomy for specimen extraction versus 1583 patients who had a vaginal extraction. RL cases had a larger blood loss (114.8mL vs 60.0mL, p<0.001), morphine milligram equivalents requirements (95.8 versus 84.2, p=0.018), and length of stay (1.5 versus 1.2 days, p<0.001) when compared to RV cases. Postoperative complications were more common in malignant RL cases compared to malignant RV extraction cases (p-value =0.028). Conclusion: Despite a statistical increase in blood loss, pain medication needs, and length of stay, these outcomes were of limited clinical significance, and overall, RL was found to be a safe option for specimen removal when vaginal extraction is not feasible.