Three-Port, Assistant-Port-Free Robotic Hysterectomy for a Large Adenomyotic Uterus with Multiple Fibroids: A Feasibility Case Report.

Abstract

Background: Large 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.

Aims: To 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.

Materials and methods: A 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.

Conclusion: Assistant-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.