Robotic Hysterectomy Strategies for Uterine Didelphys

INTRODUCTION: Müllerian anomalies result from errors in the fusion or resorption of the paired müllerian ducts, leading to structural variants of the female reproductive tract. Uterine didelphys, representing approximately 8–11% of müllerian anomalies with a population prevalence of 0.1–0.3%, is characterized by two separate uterine cavities, often with duplicated cervices and a longitudinal vaginal septum. These anatomic distortions pose unique technical challenges during hysterectomy, including distorted pelvic anatomy, difficulty with uterine manipulation, and increased risk of injury to the ureters, bladder, and rectum. OBJECTIVE: To describe the surgical challenges and technical strategies employed during robotic-assisted hysterectomy in a patient with uterine didelphys, and to highlight key learning points for safe operative management. METHODS: We present the case of a 33-year-old G2P2 with a history of uterine didelphys and two prior cesarean deliveries, who elected to undergo hysterectomy for dysmenorrhea. The patient’s vaginal septum was asymptomatic and retained. Robotic-assisted hysterectomy was performed with sequential uterine manipulator placement, tailored dissection strategies, and intraoperative adjuncts to safely address distorted anatomy. RESULTS: Initial hysterectomy was performed on the right uterus with use of a small illuminated colpotomy cup to aid bladder dissection. The right ureter was found in close proximity to the cervicovaginal junction, requiring meticulous ureterolysis to create safe separation from the uterine artery and colpotomy site. Adhesions from prior cesarean deliveries were managed by first identifying the pubocervical fascia, allowing safe bladder flap creation. The process was repeated on the left side, with careful ureterolysis and bladder dissection. Midline adhesions between the posterior uterus and anterior rectum were safely lysed after confirming rectal integrity with an EEA sizer, which also facilitated rectal retraction. Colpotomy was completed using a colpotomy cup on the left and a spongestick on the right to delineate vaginal fornices. The vaginal septum was incorporated into the cuff closure with a running barbed suture to prevent creation of a communicating channel. The procedure was completed without intraoperative complications. CONCLUSIONS: Robotic hysterectomy in patients with uterine didelphys requires careful preoperative planning and intraoperative adaptations to address distorted anatomy. Key technical strategies include: (1) sequential placement of a uterine manipulator with small colpotomy cup, (2) identification of the pubocervical fascia to facilitate safe bladder dissection, (3) ureterolysis to separate the ureters from uterine vessels and colpotomy sites, (4) use of an EEA sizer to assist rectal adhesiolysis, and (5) incorporation of the vaginal septum during cuff closure. This case highlights the importance of anticipating anatomic variation and adapting surgical techniques to optimize patient safety.