Single-Access Robotic Surgery

Fig. 14.1

The “Chopstick” surgery technique prevents the collision of the external robotic arms

The robotic instruments cross at the abdominal wall to have the right instrument on the left side of the target and the left instrument on the right. To correct for the change in handedness, the robotic console was instructed to drive the left instrument with the right-hand effector and the right instrument with the left-hand effector. In this way, collision of the external robotic arms was prevented. A similar robotic setup was adopted by Hagen et al., who explored the feasibility of single-incision transabdominal and transvaginal surgery by crossing control-switching robotic arms to achieve an intuitive control. Allemann et al. compared the outcomes of LESS Nissen fundoplication performed with and without a robotic platform in a porcine model [18]. Sugimoto et al. performed eight robotic hepatobiliary LESS procedures, including four cholecystectomies and four lateral liver segmentectomies, in a porcine study [19]. Again, the instruments were crossed to avoid sword fighting and clashing of instruments.

Laparoscopic suturing and knot tying are considered advanced skills with a steep-learning curve. Although the multisite approach to laparoscopic surgery is the gold standard, increasingly complex operations are attempted with a minimal port approach. Suturing and intracorporeal knot tying with single-port systems pose significant difficulty, often requiring conversion to traditional multiport laparoscopy or even open surgery. In fact, while suturing with extracorporeal knot tying is described, few reports describe the learning curve of intracorporeal knot tying using LESS surgical techniques [20, 21]. A specialized robotic platform for single-site surgery can overcome the technical difficulties inherent to LESS surgery and to improve operator ergonomics [22, 23]. Furthermore, the robotic single-site platform would make more complex laparoscopic tasks easier than using more conventional single-incision laparoscopic surgical techniques.

14.3 Single-Port Devices for Robotic Surgery

As demonstrated by the high number of publications, R-LESS is a topic of interest. This is particularly true in the field of urology, general surgery, and gynecology. The analyses of the reviewed articles show that R-LESS is technically feasible and safe for patients.

Most of the publications recorded were clinical case series and only few comparative studies were found. At present, no clinical controlled study has been reported. However, the technique is new and we can expect in the future to have publications with higher levels of evidence. Nevertheless, we can hypothesize that R-LESS may share common outcomes with LESS which could be used as a surrogate. Another limitation of this review is that the reports covered a wide range of procedures in different surgical specialties (mainly urology, general surgery, and gynecology). Therefore, direct comparison was not always possible, but reviewing different approaches has identified technical difficulties and common solutions. It is evident from the literature that many access devices have been used so far for R-LESS.

14.3.1 TriPort®/QuadPort®

TriPort® is a multichannel port with three soft valves. In order to adapt the instruments and the camera, robotic ports are inserted directly in the valves of the multichannel port. Two of the three valves are used for one instrument and the camera. The third valve is left to the assistant for suction and retraction. A third robotic port for the second instrument is placed directly in the wound, in tandem with the R-port (hybrid port technique). Using a QuadPort®, Desai et al. [24] reported a similar method. However, they didn’t place any robotic port beside the multichannel port. Both instruments and the camera passed through the four valves of the QuadPort®. However, this device requires a minimal 25-mm length incision, whereas the TriPort® needs only 12 mm. Allemann et al. [18] used only three valves of QuadPort® which was positioned supraumbilically and placed an accessory port in the right hypochondrium. Hagen et al. [23] inserted both the instruments and the laparoscope through one TriPort.

14.3.2 GelPort®

The GelPort is an Alexis wound retractor/protector (Applied Medical, Rancho Santa Margarita, CA, USA) adapted with a gel seal cap. The robotic ports were directly inserted in the gel. The device rapidly became widely used for R-LESS. Ragupathy et al. [25] reported their initial experience with GelPOINT®. This platform is a kind of GelPort designed especially for single-site surgery with insufflation and venting access.

14.3.3 SILS®

Following the several attempts to use robotic technology originally designed for multiport surgery by different authors, Intuitive Surgical International (Sunnyvale, CA, USA) has recently developed a new set of instruments and accessories for robotic single-incision laparoscopy to be used with the da Vinci Si Surgical System®: the da Vinci Single-Site Instrumentation.

Since the market introduction of this new instrumentation in March 2011 in Europe and December 2011 in the USA, an increasing number of surgeons have started the clinical use of the da Vinci® Single-Site Instrumentation for different procedures.

The set includes a multichannel access port with room for four cannulas and an insufflation valve. Two curved cannulas are for robotically controlled instruments, and the other two cannulas are straight; one cannula is 8.5 mm and accommodates the robotic endoscope, and the other cannula is a 5-mm bedside-assistant port. The curved cannulas are integral to the system, since their configuration allows the instruments to be positioned to achieve triangulation of the target anatomy. This triangulation is achieved by crossing the curved cannulas midway through the access port. Same-sided hand–eye control of the instruments is maintained through assignment of software of the Si system that enables the surgeon’s right hand to control the screen right instrument even though the instrument is in the left robotic arm and, reciprocally, the left hand to control the screen left instrument even though the instrument is in the right robotic arm. The second part of the platform is a set of semirigid, nonwristed instruments with standard da Vinci® instrument tips. The semirigid, flexible shaft allows for insertion down the curved cannula and triangulation of the anatomy. Robotic arm collisions are minimized externally because the curved cannulas angle the robotic arms away from each other. Internal collisions with the camera are avoided because the camera is designed to be placed into the middle of the curved cannula zone and is not in a parallel arrangement. The single-site instruments and accessories are intended to be used with the da Vinci® Si Surgical System and are of similar construction to existing EndoWrist instruments, except they do not have a wrist at the distal end of the instrument.

These accessories are of great value as their multichannel port includes four separate access ports for instruments, camera, and assistance. They easily recreate triangulation and allow better visualization of the operating field.

14.3.4 Trocars and Surgical Setting

QuadPort offers enough access for instruments, laparoscope, and assistance, but the minimum incision required is large (25 mm). With only three channels, R-port/TriPort is smaller. Authors using QuadPort or TriPort reported numerous instrument conflicts. Moreover, the TriPort’s outer ring is rigid and induced interference with the robotic port placed alongside. That’s why Stein et al. [26] changed to GelPort. This configuration avoids almost all collisions. It allows enough space to be kept between each port. According to Joseph et al. [16], 2 cm is the minimum distance required between each port to avoid “sword fighting.” Moreover, the GelPort allows resetting port placement during the operation. Another advantage of the GelPort is that it can be placed in various positions. For example, the Alexis wound retractor/protector can be partially folded so that the GelPort can lie on the edge on the abdomen [19]. This maneuver allows the instruments to have extreme angulation with the abdominal wall. However, the GelPort requires a large incision, which might be an advantage when large specimens need to be extracted (3–5 cm).

Because of its foam structure, the SILS Port seems to be very effective in maintaining pneumoperitoneum. However, it doesn’t avoid instrument clashing and offers only three accesses. As a result, a supplementary port is generally required.

Regarding the arm positioning, the “chopstick” technique is a cornerstone. As demonstrated by many authors, it is helpful in reducing crowding and instrument clashing as well as allowing more lateral range of motion. Da Vinci S and SI have a thinner arm than the standard version. This means that they are less clumsy. In order to reduce external collisions, these versions should be used preferentially. Moreover, 5-mm instruments are thinner and more adapted to R-LESS because of their design. Indeed, they are not conventionally articulated and can deflect. Their range of motion is thus more important than a classical EndoWrist instrument. Changing the level of motion scaling is another option to reduce instrument clashing. When the robot is adjusted for fine-tuning, it slows down the movements realized by the arms. Most tested surgeries needed assistance for retraction, irrigation, suction, etc. Some procedures required specific implements like a stapler, bulldog clamps, or a LigaSure®. An assistant port frequently necessitates a second access through the same wound (hybrid port) or in another place (dual-port technique).

In these cases, the technique does not formally meet the criteria of single-site surgery. Owing to technical difficulty, a second port is particularly necessary for some procedures like partial nephrectomies [27]. Nevertheless, the introduction of a third instrument complicates the position that the robotic arms need to keep to avoid collisions. Use of bariatric instruments allows the assistant to interfere less with the robot [28]. When possible, it is easier to work without any ancillary port. The marionette technique or needlescopic retractors seem to be valid options for dynamic retraction. Most surgeons use an assistant for dynamic retraction either through an assistant port or through the techniques described above. The EndoGrab system permits static retraction. It is easy to use and provides good retraction without breaching the abdomen. Of course, it is not possible to modify exposition without resetting the device placement.

14.4 Single-Port Robotic Surgery: Current Clinical Applications

Desai et al. [24] were the first to report an R-LESS experiment conducted in 2008 on a cadaveric model. The procedure was a transvesical radical prostatectomy. At the same time, Kaouk et al. [13] published the first R-LESS clinical case report. The authors performed three different kinds of urologic procedures: an intraperitoneal radical prostatectomy, a pyeloplasty, and a radical nephrectomy. The same group also reported the first human R-LESS partial nephrectomy in a further publication [29]. At the beginning of 2009, Barret et al. [22] from French Institut Montsouris reported initial clinical experiences with R-LESS extraperitoneal radical prostatectomy. The first R-LESS clinical case in gynecology was described by Escobar et al. [30]. They realized a prophylactic bilateral hysterosalpingo-oophorectomy for a patient with a history of familial breast cancer (BRCA). They subsequently reported two bilateral hysterosalpingo-oophorectomies and two bilateral salpingo-oophorectomies [31]. In July 2009, White et al. [32] mentioned the first and sole cases of R-LESS ureteral reimplant and sacral colpopexy. Ostrowitz et al. [21] were the first authors to report the use of R-LESS in digestive surgery. They performed right hemicolectomies for two villous tumors of the cecum and one ascendo-cecal adenocarcinoma. Romanelli et al. [33] mentioned the first R-LESS cholecystectomy. They used three separated fascia access in the same wound, but because of loss of pneumoperitoneum, the technique was abandoned and the procedure completed with LESS. Allemann et al. [18] performed Nissen fundoplication on 18 pigs with either R-LESS or LESS. They recorded external but also internal clashing by the means of an observer and a second laparoscope inserted in the left iliac fossa for this purpose. A unique case of partial colectomy for malignancy was performed by Ragupathy et al. [25].

Haber et al. [34] reported their initial wet laboratory experience with the da Vinci Single-Site Instrumentation in October 2010. Using a cadaveric model, Escobar et al. [35] performed the first modified radical hysterectomy with this device. Wren and Curet [28] and Kroh et al. [36] in the USA and Morel et al. [37] in Europe performed the first human cholecystectomies by means of Intuitive’s new platform. The first case control survey was published by White et al. [38]. They matched 10 R-LESS radical nephrectomies with ten CL controls. Sugimoto et al. [19] published their experiences with R-LESS hepatic surgery. They performed four lateral segmentectomies on laboratory pigs. The first multicentric study was published in June 2011 and analyzes retrospectively registries’ raw data.

Even if a wide range of surgical operations have been performed with the single-site robotic technology, only few operations have shown to have those features needed to be part of clinical routine.

14.4.1 Experience in Urologic Surgery

The volume of available clinical outcomes of robotic LESS (R-LESS) has considerably grown since the pioneering description of the first successful clinical series of single-port robotic procedures [13]. So far, roughly 150 robotic urologic LESS cases have been reported by different institutions across the globe, with a variety of techniques and port configurations.

14.4.1.1 Upper Urinary Tract Surgery

Further expanding the application of robotics to LESS, Kaouk and Goel [29] reported an initial experience with partial nephrectomy in two patients. Pediatric instruments, including graspers, electrocautery hook, and harmonic scalpel, were used for tumor exposure and excision. A 30° robotic lens was placed in the upward configuration. A 2.8-cm left lower pole anterior medial tumor and a 1.1-cm right lateral lower pole tumor were excised without renal hilar clamping. Both patients had confirmed renal cell carcinoma with negative margins, and there were no intraoperative complications. In another study from the Cleveland Clinic, Stein et al. [26] reported R-LESS using a GelPort as the access platform. Four procedures were successfully performed, including two pyeloplasties, one radical nephrectomy, and one partial nephrectomy. The GelPort provided adequate spacing and flexibility of port placement as well as acceptable access to the surgical field for the assistant. Nephrectomy—simple, radical, or living donor—is one of the most commonly performed procedures in the field of LESS, and different groups have reported their techniques and early comparative outcomes [39–41]. White et al. detailed the technique of R-LESS radical nephrectomy and reported the outcomes compared with the current gold standard laparoscopic procedure [38]. Two single-port devices, the SILS Port and the GelPort/GelPoint, were used equally, and the da Vinci S or Si Surgical System in a three-arm approach was used. There was no difference between R-LESS and conventional laparoscopy in terms of operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission and a shorter length of stay. Study limitations included the small sample size, short follow-up period, and retrospective study design.

LESS adrenal surgery has been effectively performed for a number of indications using a wide variety of approaches. Park et al. were the first to report a case of retroperitoneoscopic R-LESS adrenalectomy for an adrenal cortical adenoma [42]. A 3-cm transverse skin incision was made just below the lowest tip of the 12th rib, and after exposing the retroperitoneal space, a glove port was applied to the skin incision. A 10-mm robotic camera with a 30° up view and three 5-mm robotic ports were inserted through the glove port. The total operation time was 188 min, and the patient recovered uneventfully. LESS pyeloplasty is technically demanding, largely because of the difficulty associated with intracorporeal suturing through a single abdominal incision. By adopting the principle of the chopstick technique for R-LESS, Olweny et al. used a setup including a GelPoint access device, a 30° up robotic scope, and the da Vinci Si surgical robot to enhance the applicability of the robotic platform to LESS pyeloplasty and reduce its learning curve. The authors compared their initial ten cases of R-LESS pyeloplasty with the last ten cases of conventional LESS pyeloplasty done by a single surgeon. Mean operative time was significantly longer for R-LESS but was probably related to the stent insertion time. Two conversions to standard laparoscopy and two postoperative complications occurred in 30 % of LESS patients, whereas there were no conversions and one postoperative complication in the R-LESS group.

14.4.1.2 Pelvic Urologic Surgery

When first reporting an initial feasibility study of LESS radical prostatectomy in humans, Kaouk et al. acknowledged the limitation of this procedure because of challenges related to ergonomics and intracorporeal suturing, and they claimed a potential application of robotics [43]. Within the first clinical series of R-LESS from the same group, a case of radical prostatectomy was reported, and the benefits of the robotic platform were soon noticed [13]. After a preliminary experience in a cadaver model and a case completed with an additional 5-mm port [44], Barret et al. also reported a complete case of R-LESS radical prostatectomy. They used a single umbilical incision and placed a 12-mm port for the robotic scope, a 5-mm port for the assistant, and two 8-mm ports for the robotic arms arranged in a rhomboid fashion. Significant external robotic arm collisions were experienced, as well as a reduced space for the assistant to work [45]. White et al. detailed the surgical technique and reported the outcomes of 20 R-LESS radical prostatectomies [46]. Most of the study population was represented by low-/intermediate-risk patients with baseline erectile dysfunction. An incision of 3.0–4.5 cm was created intraumbilically. The initial robotic 8-mm port was placed at the most caudal portion of the incision on the right side and directed as far laterally as possible; this procedure was repeated on the opposite side with a 5-mm pediatric or standard 8-mm robotic port. A SILS Port was inserted and the patient placed in a steep Trendelenburg position. The da Vinci S or Si System in a three-arm approach was docked, and the robotic 12-mm scope introduced through the SILS Port, with a 5-mm channel free for the suction or sutures to be passed. Steps of the procedures resembled those of the standard robotic procedure. During the bladder neck dissection, a suture was placed through the abdominal wall and then through the distal bladder neck or prostatic base; it was then exited out of the abdominal wall to serve as a retractor in a “marionette” fashion. Prostatic dissection was obtained using a 5-mm harmonic scalpel in a non-nerve-sparing procedure. Otherwise, an interfascial nerve-sparing approach was accomplished with a combination of sharp dissection and robotically applied Hem-o-Lok clips. A standard lymph node dissection was performed, and vesicourethral anastomosis was done with two sutures in a semicircular running fashion. A positive margin was found in four cases, two of the margins in the first three cases. The limited follow-up did not allow a reliable oncologic assessment. Within the field of prostate surgery, single-port transvesical enucleation of the prostate (STEP) was demonstrated to be technically feasible but still challenging by Desai et al. [47]. Recently, Fareed et al. reported the perioperative and short-term outcomes of their initial series of robotic STEP [48]. Nine patients with symptomatic benign prostatic hyperplasia were scheduled for the procedure. A 3-cm lower midline incision was made, a cystotomy created, and a GelPort positioned in the bladder. The da Vinci Si operating system was docked. There was significant postoperative improvement in the flow rates, but a high-grade complication was observed in three patients (37.5 %). The authors concluded that despite providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications, and its role remains to be determined.

14.4.2 Gynecologic Surgery

The introduction of single-site robotic surgery in gynecology is a recent event. The first worldwide case of robotically assisted single-port hysterectomy was performed by Cela et al. in 2011 [49]. From these experiences, few studies with limited case series or case reports were reported in literature regarding principally the single-site robotic hysterectomy [50–53].

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