Introduction

It has been established that robotic-assisted laparoscopic surgery has several advantages when compared to standard laparoscopic surgery. Optics, ergonomics, dexterity, and precision are all enhanced with use of the robotic platform for a number of urologic procedures. For these reasons, it was postulated that the application of robotics to LESS could overcome some of the constraints seen with the conventional laparoscopic approach. Issues such as instrument clashing, inability to achieve effective triangulation for dissection, and difficulties with intracorporeal suturing have limited the widespread adoption of conventional LESS in urology.

Kaouk et al. [8] reported the first experience with robotic LESS (R-LESS) in 2008 (radical prostatectomy, nephrectomy, and pyeloplasty). They noted that intracorporeal suturing and dissection were easier, as compared with standard LESS. Since then there have been numerous reports and refinements in technique from the same group, for a number of different urologic procedures [9–11]. Furthermore, there have been a number of series that have compared R-LESS to either standard laparoscopy, conventional LESS, or standard robotic surgery [9, 12, 13]. While these studies have been small and retrospective in nature, they have shown that R-LESS is not inferior with regard to perioperative outcomes and may offer better cosmesis. Additionally, the surgeons found the EndoWrist technology and three-dimensional high-definition camera beneficial. However, despite the advantages of the robotic platform, R-LESS is not free of challenges, which are similar to conventional LESS. Instrument clashing remains an issue due to the bulky external profile of the current robotic system. Other issues include lack of space for the assistant at the bedside, inability to incorporate the fourth robotic arm for retraction, and difficulties with triangulation.

Although solutions for some of these issues are currently under development [14, 15], R-LESS is still very much in its infancy. Standard robotic surgery and R-LESS share numerous similarities. The setup of the operating room is identical, as well as all the instruments, drapes, sutures, etc. Docking of the robot is also identical, although the arms may be angled differently to minimize instrument clashing. With regard to the procedures, almost all of the steps of standard robotic surgery are carried out in R-LESS. That being said, there are improvisations that are made because of the limited space with R-LESS. For example, because there is no space for the fourth arm, which is often used to retract tissue, various other techniques have been employed (i.e., stay and marionette sutures). Also, other strategies are employed to minimize instrument clashing, such as moving the two arms and camera together in unison. For this reason, this chapter will focus on the equipment and aspects of each procedure that are specific to R-LESS and differ from standard robotic surgery.

Access/Port Placement

An important distinction must be made with regard to access in R-LESS, and that is single port vs. single site. Single-port access utilizes a single skin and fascial incision, through which a multichannel access platform is placed (Fig. 10.4). The endoscope and instruments are all placed through the access platform. Single-site access also utilizes a single-skin incision; however, multiple fascial incisions are made, through which the access platform and low-profile ports are placed (Fig. 10.5). The point of access can be umbilical or extraumbilical. The umbilical access point has been most commonly utilized [16] as the scar can more easily be hidden and cosmesis maximized.

Single-Port Access

A number of different access devices for single port exist, including a TriPort [8] and a GelPort [9]. Single-port access for upper- and lower-tract R-LESS procedures is similar. A 2–5-cm trans-umbilical incision is made, either directly through the umbilicus or using a semicircular incision concealed within the umbilicus. Dissection then proceeds, using a combination of blunt dissection and electrocautery, to the anterior rectus fascia. A 3–4-cm vertical incision is then made in the linea alba, access to the peritoneal cavity is gained, and the chosen multichannel access device is placed. Stay sutures can be placed in the fascia to aid with port placement and wound closure, if desired. If the GelPort is to be used, the wound protector is placed first. Next, the GelSeal cap is placed, after the port sites have been marked on its surface. Depending on the procedure/pathology, access can be transperitoneal or extraperitoneal, as both approaches have been described. Additionally, a transvesical approach has been utilized, specifically for robotic enucleation of the prostate [17].

Single-Site Access

In a similar fashion to single-port access, an incision is created intraumbilically (3–4.5 cm), and the umbilicus is released from the rectus fascia. A 2-cm incision is then made through the linea alba. The robotic ports are then placed through the same umbilical incision, but through separate fascial stab incisions. Typically, they are tunneled under the skin to the appropriate location. For example, during an R-LESS radical prostatectomy, the first 8-mm robotic port is placed at the most caudal part of the incision and tunneled as far laterally as possible. The subsequent robotic port is then placed on the opposite side of the incision, in a similar fashion. Finally, a multichannel port is inserted through the fascial incision into the peritoneal cavity (or extraperitoneal space).

Multichannel Port Selection

A number of different multichannel ports have been used for R-LESS [18, 19]; however, there have been no direct head-to-head comparisons. In Kaouk’s initial R-LESS series, the R-port (Advanced Surgical Concepts, Dublin, Ireland) was used. This port consists of one 12-mm channel, two 5-mm channels, and an insufflation cannula. The port is placed using the Hasson technique through a 2-cm umbilical incision. The authors made no specific comments with regard to the performance of the port, and there were no reported issues with pneumoperitoneum leakage or instrument crowding. White et al. [20] reported their experience with 50 patients, which included 24 renal procedures and 26 pelvic procedures. They used three different commercially available ports, including the SILS Port, the R-port, and the GelPort/GelPOINT. The authors mentioned the three multichannel ports used; they preferred the SILS Port because of its durability, the free exchange of cannulas of varying size, and the ease of passage of staplers, clip appliers, sutures, and entrapment bags through the port. However, they noted that gas leakage was experienced with three multichannel ports, which was usually caused by a fascial incision that was too large. To combat this, they placed a fascial suture or petroleum impregnated gauze along the tract of the port. Stein et al. [9] used the GelPort laparoscopic access system to perform 4 R-LESS upper tract procedures (pyeloplasty n = 2, partial nephrectomy n = 1, radical nephrectomy n = 1). They concluded that the GelPort was beneficial for R-LESS because it allowed for greater spacing and flexibility of port placement and easier access to the surgical field for the bedside assistant. Although the fascial incision used was larger so as to place the port (2–2.5 cm), they found that this facilitated specimen extraction, especially during the radical nephrectomy.

Finally, there have been a number of centers that have had experience using a homemade port, both for conventional LESS and R-LESS. Lee et al. [18] reported the largest series of R-LESS procedures using a homemade port, which consisted of an Alexis wound retractor (Applied Medical, Rancho Santa Margarita, California) and a standard size 7 surgical glove stretched over top. They utilized a 5–6-cm fascial incision to place the wound retractor. Four trocars were placed through the fingers of the glove, including two 8-mm robotic trocars and two 12-mm optical trocars. They performed 68 upper tract procedures, including 51 partial nephrectomies, 12 nephroureterectomies, 2 adrenalectomies, 2 radical nephrectomies, and 1 simple nephrectomy. The authors felt that the homemade port offered greater flexibility of port placement than any of the commercially available multichannel devices, as well as is extremely cost-effective. Limitations included the susceptibility of the glove to tearing with the insertion of the robotic instruments, the larger fascial incision required to place the wound retractor, and ballooning of the glove under higher pneumoperitoneum pressures (>20 mmHg). However, the authors concluded that their homemade port was a safe, effective, low-cost alternative to commercially available multichannel ports.

Docking the Robot

There are only a few subtle differences between docking the robot for standard robotic surgery and R-LESS. The DaVinci Si model has been preferred over the S model because of its enhanced visualization, ability to customize the console settings ergonomically, and smaller external profile, which helps to minimize clashing of the robotic arms [20, 21]. Otherwise, the robot is brought into the surgical field in a standard fashion, which is from behind the patient and over the shoulder for upper-tract procedures and in between the patient’s legs for lower-tract procedures.

Additionally, because of the limited working space, the majority of R-LESS procedures employ a two-arm approach. There have been a number of strategies employed in order to minimize clashing of the robotic arms, which is a limitation that is encountered with the current robotic platforms. Joseph et al. [14, 22] developed a “chopstick” technique, whereby the robotic instruments are crossed at the abdominal wall to reduce instrument clashing and improve triangulation. This concept had already been used in conventional LESS; however, the crossing of instruments and resultant “reverse handedness” made the cases very challenging. However, with the DaVinci system, the inputs to the left- and right-hand effectors can be switched electronically, which eliminates the reverse handedness and restores intuitive control of the instruments as they appear on the screen.

Instrumentation

The vast majority of the R-LESS procedures to date have been performed with standard instruments as task-specific tools have remained mostly under development and testing. Two of the larger clinical series report the use of standard 8- and 5-mm instruments for a wide range of R-LESS procedures [18, 20]. White et al. [11] described using an 8-mm instrument in the right hand and a 5-mm pediatric instrument in the left hand for their R-LESS prostatectomy series of 20 patients. The authors felt that this configuration maximized the benefit of each instrument. The 5-mm instruments do not articulate but instead deflect, which greatly increased their range of motion.

Conversely, the authors found that the EndoWrist action of the standard 8-mm instruments greatly facilitated complex tasks, such as suturing. Furthermore, they reported that the 8-mm robotic Hem-o-lok clip applier was beneficial during nerve sparing as clip placement was in the surgeon’s hands and clashing with the bedside assistant’s instruments was minimized.

Intuitive Surgical Inc. has also addressed the problem of instrument collision and developed a set of R-LESS-specific instruments (Fig. 10.6). The set consists of a multichannel access platform with channels for four ports and an insufflation valve. The ports themselves consist of two with curved cannulas for the robotic instruments and two with straight cannulas for the endoscope and assistant instruments. The robotic instruments are also curved and are designed to cross at the abdominal wall, effectively separating the arms in space extracorporeally. Furthermore, the design of the system also minimizes internal instrument collision with the camera as they are not arranged in parallel. We described the first urologic applications in the laboratory at our center [15, 23]. Both the porcine model and human cadavers were used to perform a number of upper tract procedures (i.e., pyeloplasty, partial nephrectomy, etc.). Setup and docking times were comparable with the standard robotic system, and there were no significant complications. All procedures were completed successfully without the need for completion. Major limitations included collision with the assistant instruments, which at times limited suction and retraction, and lack of articulation of the robotic instruments, which made suturing difficult when required. The majority of clinical experience with the single-site instruments has been with cholecystectomy [24, 25]; however, Cestari et al. [26] reported their experience in a highly selected group of nine patients with a UPJO. Exclusion criteria included BMI >30 kg/m², a large renal pelvis, previous abdominal/renal surgery, and concomitant stone disease. All procedures were performed successfully without the need for conversion or additional ports. Mean OR time was 166 min. A number of different lens configurations have been used with the 12-mm robotic camera during R-LESS procedures. For their R-LESS prostatectomy series, White et al. [11] attempted to use the 0° lens for all procedures but found that the 30° upward lens was beneficial in instances where instrument clashing occurred by positioning the scope out of the path of the instruments. For upper tract procedures, all lens configurations have been used, with no clear advantage favoring one particular choice. It seems that when choosing a lens, one must tailor it to the particular situation and consider port placement, the degree of instrument clashing, and the pathology at hand.

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