Evaluation of the Safe Implementation and Proficiency of Four-Port Solo Robot-Assisted Total Laparoscopic Hysterectomy Based on Uterine Size

<title>Abstract</title> <p>Objective To evaluate proficiency in four-port robot-assisted total laparoscopic hysterectomy (RA-TLH) performed without an assistant, based on the surgeon’s number of procedures, console time, and weight of retrieved tissue. Materials and Methods The 486 cases of RA-TLH were classified by retrieved tissue weight into Group S (&lt; 250 g), Group M (≥ 250 g but &lt; 500 g), Group L (≥ 500 g but &lt; 750 g), Group H (≥ 750 g but &lt; 1,000 g), and Group G (≥ 1,000g but &lt; 3000g). Proficiency was assessed based on the number of cases performed and the cumulative sum (CUSUM). This study is a single-center retrospective case–control study. Results Group A (surgeons with ≤ 20 cases) demonstrated a significantly longer console time than Group B (21–40 cases) only for cases with a retrieved weight of ≤ 500 g. Groups B, C (≥ 41 cases), and D (experienced surgeons) showed no significant differences. A significant difference in blood loss was observed only between Groups A and C within the M group. The learning curves of the four novice surgeons exhibited a biphasic pattern, with turning points occurring at the 15th, 17th, 18th, and 37th cases. Conclusion We estimate that proficiency in this procedure is achieved following approximately 20 cases involving uteri weighing ≤ 500 g. Furthermore, the results suggest that skilled surgeons can perform even high-difficulty cases involving uteri weighing ≥ 1,000 g in a minimally invasive and safe manner.</p>