International expert consensus-driven surgical process model for robot-assisted hysterectomy: Delphi study results

Krystel Nyangoh Timoh¹, Soline Galuret², Thomas Hébert³, Henri Azaïs⁴, Marc Barahona⁵, Sven Becker⁶, Pierre Adrien Bolze⁷, Thomas Boisramé⁸, Bruno Borghese⁹, Marie Carbonnel¹⁰, Vito Cela¹¹, Céline Chauleur¹², Tony Chalhoub¹³, Tak Hong Cheung¹⁴, François Closon¹⁵, Patrice Crochet¹⁶, Yohann Dabi¹⁷, Laurent De Landsheere¹⁵, Emilie Faller¹⁸, Francesco Fanfani¹⁹, Tristan Gauthier²⁰, Walter Gotlieb²¹, Manuel Maria Ianieri²², Thomas Ind²³, Tae Joong Kim²⁴, Martin Koskas²⁵, Joseph Ng²⁶, Benjamin Merlot²⁷, Jiheum Paek²⁸, Charles-André Philip²⁹, Diego Raimondo³⁰, Horace Roman²⁷, Maria Rosendal³¹, Renato Seracchioli³⁰, Tommaso Simoncini³², Phuong Lien Tran³³, Claire Marie Tourette³⁴, Arnaud Huaulmé², Pierre Jannin²

Affiliations

¹ Department of Obstetrics and Gynecology, Rennes University Hospital, INSERM U1099, Laboratoire Traitement du Signal Et de L'Image (LTSI), Service de Gynécologie Et Obstétrique, CHU de Rennes, Rennes University, INSERM, LTSI-UMR 1099, 16 Boulevard de Bulgarie, 35000, Rennes, France. Krystel.NYANGOH.TIMOH@chu-rennes.fr.
² INSERM, Rennes University, LTSI-UMR 1099, Rennes, France.
³ University Hospital of Tours, Tours, France.
⁴ Department of Gynecological Oncological and Breast Surgery, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Européen Georges-Pompidou, Paris, France.
⁵ Department of Gynecology, Bellvitge University Hospital, University of Barcelona (UB), IDIBELL, Barcelona, Spain.
⁶ Department of Gynecology and Obstetrics, University Hospital of Frankfurt, Frankfurt, Germany.
⁷ Department of Gynecological Surgery and Oncology-Obstetrics, Pierre Bénite, Université Lyon 1, CICLY EA3738, Hospices Civils de Lyon, University Hospital Lyon Sud, Lyon, France.
⁸ Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France.
⁹ Department of Obstetrics and Gynecology II and Reproductive Medicine, Cochin Hospital, AP-HP, Paris Cité University, Paris, France.
¹⁰ Department of Gynecology and Obstetrics, Foch Hospital, University of Versailles Saint Quentin en Yvelines-Paris Saclay, Suresnes, France.
¹¹ Azienda Ospedalero Universitaria Pisana, Pisa, Italy.
¹² INSERM, Department of Gynecology and Obstetrics, North Hospital, Saint-Etienne University, Saint Priest en Jarez, U1059, Saint-Étienne, France.
¹³ St George's University Hospital NHS Foundation Trust, London, UK.
¹⁴ Departement of Obstetrics and Gynecology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China.
¹⁵ Department of Obstetrics and Gynecology, University of Liège, Hôpital de La Citadelle, Liège, Belgium.
¹⁶ INSERM NORDIC UMR 1239 Team Adrenal and Gonadal Physiopathology (AGoPath), Department of Obstetrics and Gynecology, Charles Nicolle Hospital, University of Rouen, Rouen, France.
¹⁷ Department of Gynecology, Obstetrics and Reproductive Medicine, Sorbonne University - Tenon Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France.
¹⁸ Institut de Santé Pelvienne Des Deux Rives, Maison Médicale Des Deux Rives, Clinique Rhena, Strasbourg, France.
¹⁹ Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
²⁰ Department of Gynecology, University Hospital of Limoges, Mother and Child Hospital, Limoges, France.
²¹ Division of Gynecologic Oncology, McGill University - Jewish General Hospital, Montreal, Canada.
²² Unit of Gynecology and Obstetrics, Policlinico Abano Terme, Abano Terme, Italy.
²³ Department of Gynecological Oncology, Royal United Hospitals, Bath, UK.
²⁴ Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
²⁵ Department of Obstetrics and Gynecology, Hospital Bichat, Paris Cité University, Paris, France.
²⁶ Department of Obstetrics and Gynecology, National University Hospital of Singapore, Singapore, Singapore.
²⁷ IFEMEndo, Clinique Tivoli-Ducos, Bordeaux, France.
²⁸ Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea.
²⁹ Department of Obstetrics and Gynecological Surgery, Femme Mère Enfant University Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France.
³⁰ IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
³¹ Department of Gynecology and Obstetrics, Kolding Hospital, Kolding, Denmark.
³² Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
³³ Department of Obstetrics and Gynecology, University Hospital of South Reunion, Saint Pierre Réunion, France.
³⁴ Departement of Obstetrics and Gynecology, Centre Hospitalier Universitaire La Conception Assistance Publique Des Hôpitaux de Marseille (APHM), Marseille, France.

PMID: 41152527
DOI: 10.1007/s00464-025-12339-3

International expert consensus-driven surgical process model for robot-assisted hysterectomy: Delphi study results

Krystel Nyangoh Timoh et al. Surg Endosc. 2025.

. 2025 Oct 28.

doi: 10.1007/s00464-025-12339-3. Online ahead of print.

Authors

Affiliations

¹ Department of Obstetrics and Gynecology, Rennes University Hospital, INSERM U1099, Laboratoire Traitement du Signal Et de L'Image (LTSI), Service de Gynécologie Et Obstétrique, CHU de Rennes, Rennes University, INSERM, LTSI-UMR 1099, 16 Boulevard de Bulgarie, 35000, Rennes, France. Krystel.NYANGOH.TIMOH@chu-rennes.fr.
² INSERM, Rennes University, LTSI-UMR 1099, Rennes, France.
³ University Hospital of Tours, Tours, France.
⁴ Department of Gynecological Oncological and Breast Surgery, AP-HP (Assistance Publique des Hôpitaux de Paris), Hôpital Européen Georges-Pompidou, Paris, France.
⁵ Department of Gynecology, Bellvitge University Hospital, University of Barcelona (UB), IDIBELL, Barcelona, Spain.
⁶ Department of Gynecology and Obstetrics, University Hospital of Frankfurt, Frankfurt, Germany.
⁷ Department of Gynecological Surgery and Oncology-Obstetrics, Pierre Bénite, Université Lyon 1, CICLY EA3738, Hospices Civils de Lyon, University Hospital Lyon Sud, Lyon, France.
⁸ Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France.
⁹ Department of Obstetrics and Gynecology II and Reproductive Medicine, Cochin Hospital, AP-HP, Paris Cité University, Paris, France.
¹⁰ Department of Gynecology and Obstetrics, Foch Hospital, University of Versailles Saint Quentin en Yvelines-Paris Saclay, Suresnes, France.
¹¹ Azienda Ospedalero Universitaria Pisana, Pisa, Italy.
¹² INSERM, Department of Gynecology and Obstetrics, North Hospital, Saint-Etienne University, Saint Priest en Jarez, U1059, Saint-Étienne, France.
¹³ St George's University Hospital NHS Foundation Trust, London, UK.
¹⁴ Departement of Obstetrics and Gynecology, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong, China.
¹⁵ Department of Obstetrics and Gynecology, University of Liège, Hôpital de La Citadelle, Liège, Belgium.
¹⁶ INSERM NORDIC UMR 1239 Team Adrenal and Gonadal Physiopathology (AGoPath), Department of Obstetrics and Gynecology, Charles Nicolle Hospital, University of Rouen, Rouen, France.
¹⁷ Department of Gynecology, Obstetrics and Reproductive Medicine, Sorbonne University - Tenon Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France.
¹⁸ Institut de Santé Pelvienne Des Deux Rives, Maison Médicale Des Deux Rives, Clinique Rhena, Strasbourg, France.
¹⁹ Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.
²⁰ Department of Gynecology, University Hospital of Limoges, Mother and Child Hospital, Limoges, France.
²¹ Division of Gynecologic Oncology, McGill University - Jewish General Hospital, Montreal, Canada.
²² Unit of Gynecology and Obstetrics, Policlinico Abano Terme, Abano Terme, Italy.
²³ Department of Gynecological Oncology, Royal United Hospitals, Bath, UK.
²⁴ Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
²⁵ Department of Obstetrics and Gynecology, Hospital Bichat, Paris Cité University, Paris, France.
²⁶ Department of Obstetrics and Gynecology, National University Hospital of Singapore, Singapore, Singapore.
²⁷ IFEMEndo, Clinique Tivoli-Ducos, Bordeaux, France.
²⁸ Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea.
²⁹ Department of Obstetrics and Gynecological Surgery, Femme Mère Enfant University Hospital, Hospices Civils de Lyon, University of Lyon, Lyon, France.
³⁰ IRCCS Azienda Ospedaliero-Universitaria Di Bologna, Bologna, Italy.
³¹ Department of Gynecology and Obstetrics, Kolding Hospital, Kolding, Denmark.
³² Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
³³ Department of Obstetrics and Gynecology, University Hospital of South Reunion, Saint Pierre Réunion, France.
³⁴ Departement of Obstetrics and Gynecology, Centre Hospitalier Universitaire La Conception Assistance Publique Des Hôpitaux de Marseille (APHM), Marseille, France.

PMID: 41152527
DOI: 10.1007/s00464-025-12339-3

Abstract

Background: Despite the widespread use of robot-assisted total laparoscopic hysterectomy (rTLH), there is still significant variability in how the procedure is performed, leading to inconsistencies in surgical outcomes and challenges in training. While existing curricula focus on technical skills, they lack formal models that capture procedural logic and variability. An expert-validated, standardized SPM is essential for improving reproducibility, enhancing surgical education, and enabling integration with artificial intelligence (AI)-driven systems. We sought to develop the first consensus-based surgical process model (SPM) for standard rTLH SPM (e.g., normal BMI, non-enlarged uterus) using a Delphi methodology involving international experts.

Methods: A five-round Delphi study was conducted from November 2023 to October 2024 with 35 expert robotic gynecologic surgeons from 10 countries. Panelists iteratively reviewed, refined, and reached consensus on the phases, steps, and SPM paths of rTLH. Consensus was defined as ≥ 75% agreement on Likert scale responses.

Results: The final SPM comprises 7 phases and 34 surgical steps, each precisely defined through expert consensus. Seven validated SPM paths were identified, reflecting real-world procedural variability while preserving a common surgical practice centered on uterine pedicle dissection.

Conclusions: This study provides the first internationally validated SPM for rTLH, offering a formal, adaptable representation of the procedure. The model supports improved training and objective performance assessment, and serves as a foundational tool for surgical data science and AI applications in robotic gynecologic surgery.

Keywords: Delphi; Expert consensus; Hysterectomy; Laparoscopy; Robot-assisted surgery; Surgical process model.

PubMed Disclaimer

Conflict of interest statement

Declarations. Disclosures: Krystel Nyangoh Timoh has received grants from: Gedeon, Medtronic, and Intuitive Surgical; has played a leadership or fiduciary role in: SCGP and CNGOF. Thomas Hébert has received grants from: Intuitive Surgical; has received consulting fees from: Intuitive Surgical; has received honoraria for lectures from: Intuitive Surgical; has played a leadership or fiduciary role in: SCGP. Henri Azaïs has received grants from: Intuitive Surgical; has received honoraria for lectures from: GSK and IQVIA; has received support for attending meetings from: MSD. Céline Chauleur has received grants from: Medtronic and Intuitive Surgical; has received consulting fees from: Intuitive Surgical and Leopharma; has received honoraria for lectures from: Medtronic and Intuitive Surgical; has played a leadership or fiduciary role in: SCGP and CNGOF. François Closon has received honoraria for lectures from: Theramex. Yohann Dabi has received support for attending meetings from: Intuitive Surgical. Laurent De Landsheere has received honoraria for lectures from: Intuitive Surgical. Francesco Fanfani has received honoraria for lectures from: Medtronic; has participated on a Data Safety Monitoring Board for: Medtronic. Tristan Gauthier has received grants from: Intuitive Surgical. Walter Gotlieb has received honoraria for lectures from: Merck, GSK, and Intuitive Surgical; has received payment for expert testimony from: Canadian Medical Protective Association; has played a leadership or fiduciary role in: ICRF Montreal. Thomas Ind has played a leadership or fiduciary role in: Society of European Robotic Gynecological Surgeons and British Gynecological Cancer Society; has stock in: Intuitive Surgical, Hospital Corporation of America, and Chelsea Outpatients. Martin Koskas has received consulting fees from: Intuitive Surgical; has received honoraria for lectures from: Intuitive Surgical. Joseph Ng has played a leadership or fiduciary role in: Asian Society for Gynecologic Robotic Surgery and Robotic Surgery Society of Singapore. Benjamin Merlot has received grants from: Intuitive Surgical. Charles-André Philip has received grants from: Gedeon-Richter; has received consulting fees from: Provepharm; has received honoraria for lectures from: Vatris Pharma. Horace Roman has received honoraria for lectures from: Intuitive Surgical, Karl Storz, Medtronic, Johnson&Johnson, Olympus, Gedeon-Richter, and IBSA. Tommaso Simoncini has received consulting fees from: Intuitive Surgical, Medtronic, and Applied Medical; has received honoraria for lectures from: Intuitive Surgical and Applied Medical. Phuong Lien Tran has received support for attending meetings from: Intuitive Surgical. Marc Barahona, Sven Becker, Thomas Boisramé, Bruno Borghese, Pierre Adrien Bolze, Marie Carbonnel, Vito Cela, Tony Chalhoub, Tak Hong Cheung, Patrice Crochet, Emilie Faller, Manuel Maria Ianieri, Tae Joong Kim, Jiheum Paek, Diego Raimondo, Renato Seracchioli, Claire Marie Tourette, Maria Rosendhal, Pierre Jannin, Arnaud Huaulmé, and Soline Galuret have no conflicts of interest or financial ties to disclose.

References

1. Mistry K, Fingar KR, Elixhauser A (2006) Variation in the rate of cesarean section across U.S. hospitals, 2013. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs, Rockville, MD
1. Frederick PJ, Szender JB, Hussein AA, Kesterson JP, Shelton JA, Anderson TL, Barnabei VM, Guru K (2017) Surgical competency for robot-assisted hysterectomy: development and validation of a robotic hysterectomy assessment score (RHAS). J Minim Invasive Gynecol 24:55–61 - DOI - PubMed
1. Knight S, Aggarwal R, Agostini A, Loundou A, Berdah S, Crochet P (2018) Development of an objective assessment tool for total laparoscopic hysterectomy: a Delphi method among experts and evaluation on a virtual reality simulator. PLoS ONE 13:e0190580 - DOI - PubMed - PMC
1. Meeuwsen FC, van Luyn F, Blikkendaal MD, Jansen FW, van den Dobbelsteen JJ (2019) Surgical phase modelling in minimal invasive surgery. Surg Endosc 33:1426–1432 - DOI - PubMed
1. Working group of E (2019) Surgical steps of total laparoscopic hysterectomy: Part 1: Benign disease by the European Society for Gynaecological Endoscopy (ESGE)(1). Facts Views Vis Obgyn 11:103–110

LinkOut - more resources

Full Text Sources
- Springer

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

International expert consensus-driven surgical process model for robot-assisted hysterectomy: Delphi study results

Affiliations

International expert consensus-driven surgical process model for robot-assisted hysterectomy: Delphi study results

Authors

Affiliations

Abstract

Conflict of interest statement

References

LinkOut - more resources

Full Text Sources