The issue is cost. For a simple total hyst, a vaginal approach is cheapest and the least invasive method of treatment. Nothing is less invasive than a vag hyst period. Lap and dV are equivalent in terms of invasiveness, but a lap hyst is cheaper. The instruments are cheaper and doing a TLH doesn't require purchasing a $2m piece of capital. If the patient looks like it's going to be a chip shot, the surgeon should start lap and the robot can be docked if needed. The problem is ISI couldn't care less about cost, so they use the guise of patient safety to leverage hospitals and surgeons into doing BSOs with the robot (part of the clinical pathway after all!), which is totally ridiculous. ISI's greed will be their undoing. If they pushed the robot for use in appropriate procedures, I guarantee we wouldn't be having this discussion (look at urology and dVLAR). However, because of their hostile sales tactics that are grounded in a greed driven culture that says the robot should be used in simple procedures like hysts and choles, societies and hospital systems are starting to push back on the exbortitant and unnecessary costs of attempting to do every procedure that way.