In Dr Paraiso’s article, “A randomized trial comparing conventional and robotically assisted total laparascopic hysterectomy,” the authors appear to demonstrate that robotically assisted total laparoscopic hysterectomy requires significantly longer operative times when compared with conventional total laparoscopic hysterectomy. Although we agree with the final conclusion that both laparoscopic and robotic-assisted hysterectomies are safe, we must disagree with the general conclusion that all operative times are increased with robotic-assisted hysterectomies.

In the trial by Paraiso et al, the minimum number of completed robotic cases to be an eligible surgeon for the study was set at 20 cases. In addition, the authors did not indicate over what time period those 20 cases were accumulated. Not having inclusion/exclusion criteria for the robotic experience level similar to those of conventional laparoscopic experience creates a flaw in the conclusions. The conclusions are misleading in that they are comparing surgical outcomes between expert laparoscopic surgeons and surgeons who may have not attained minimum competency in the use of the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA).

Specifically, Lenihan et al published their experience with the learning curve for robotic surgery and indicated 50 cases were necessary to stabilize operative times at 95 minutes. Bell et al established that a similar number of cases were necessary to stabilize operative times between 80 and 85 minutes. In 2013, Woelk et al published the results indicating that 91 cases are necessary when looking at intraoperative complications and 44 when looking at all complications from surgery. It has been acknowledged that operative times, although important, may not be a fully encompassing measure of proficiency.

Since the inception of our robotics program, we have improved operative times and developed a novel setup for improving robotic surgery outcomes. An experienced robotic surgeon is able to do the following: (1) select port placements to reduce arm collisions; (2) adjust port sites based on uterine size and expected pathology; and (3) remove and reinstall malfunctioning instruments, which rarely occurs, in a timely manner, all cited as limitations to robotic-assisted surgery in the trial by Paraiso et al when compared with laparoscopy.

Ultimately, the experience of the surgeon is the key component to a successful surgery, which was not mentioned as a limitation. We would argue that future studies compare their data with expert robotic surgeons who have completed a case series with volumes equal to their expert laparoscopic surgeons.