# Surgical Outcomes and Learning Curve of Robotic Single-Port Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Hysterectomy Using the Da Vinci Single-Port System

## TL;DR

This study evaluates the safety and learning curve of a new robotic surgery method for hysterectomy through the vagina.

## Contribution

The study provides evidence that proficiency in robotic single-port vaginal surgery can be achieved after 30 cases.

## Key findings

- Median total operative time was 151 minutes with a 35-minute hysterectomy time.
- Proficiency in hysterectomy time was achieved after 30 cases, while port placement and docking stabilized after 43 and 37 cases.
- Only 1.0% of cases required conversion to another surgical approach.

## Abstract

Objective: This study aims to assess the surgical outcomes and learning curve of robotic single-port vaginal natural orifice transluminal endoscopic surgery (RSP-vNOTES) for hysterectomy in benign gynecologic conditions.

Materials and methods: A retrospective observational analysis was conducted of 97 consecutively enrolled patients who underwent RSP-vNOTES hysterectomy using the da Vinci (single-port) SP system between December 2023 and July 2025 at a single tertiary care center.

Results: Median procedural durations included a total operative time of 151 minutes, a port placement time of five minutes, a docking time of two minutes, a robotic console time of 78 minutes, and a hysterectomy time of 35 minutes. One case (1.0%) required conversion to a transumbilical single-incision robotic approach for management of diaphragmatic endometriosis after completion of the vaginal hysterectomy, rather than due to failure of the hysterectomy itself. Fourteen patients (14.4%) experienced perioperative complications. Cumulative sum analysis revealed that hysterectomy time stabilized after approximately 30 cases, while port placement and docking times plateaued after 43 and 37 cases, respectively.

Conclusions: These findings suggest that proficiency in RSP-vNOTES can be achieved with sequential case experience. RSP-vNOTES appears to be a safe and effective surgical approach for hysterectomy, including complex scenarios such as endometriosis. Proficiency is typically achieved after 30 cases, particularly among surgeons with prior experience in robotic-assisted single-site and vNOTES techniques.