Various multichannel ports exist for performing RLESS (Table 33.1). No studies exist to directly compare outcomes between each device, though many studies have described their individual use, noting their advantages and disadvantages. In the initial RLESS series, Kaouk et al. employed the R-Port device (Advanced Surgical Concepts, Bray, Ireland) [1]. This device is comprised of an insufflation cannula, two 5 mm ports, and one 12 mm channel to accommodate a laparoscopic lens. This port accommodates a 12–25 mm fascial incision and is placed using the open Hasson technique. It is designed to expand both radially and length wise in order to adjust to a larger abdominal wall thickness of up to 10 cm and to decrease the risk of gas leakage during insufflation. Stein et al described the use of the GelPort for four cases of RLESS upper tract procedures and reported flexibility with port placement, an easy access for the bedside assistant and facilitation with specimen removal, especially in cases of RLESS nephrectomy [2]. White et al. reported a series of 50 cases using the SILS port (Covidien, Minneapolis, MN), R-Port, and GelPoint devices [11]. They reported a preference for the SILS port due to the ability to freely exchange the cannulas allowing placement of various sized trocars, ease of passage for clips, suture and stapling devices by the assistant and finally, for its durability. The authors also noted that gas leakage was experienced with use of all the devices, usually secondary to fascial incisions that were made to large during initial placement of the multichannel device. Lee et al. have published the largest series of RLESS procedures using a homemade multichannel device fashioned from an Alexis retractor (Applied Medical) and a sterile surgical glove, size 7 [12]. The wound retractor is placed and the sterile glove is stretched over the opening. Up to four trocars may be placed through the glove fingers. The main advantage for this homemade multichannel port is decreased cost and availability of components, but it is limited in the fact that the surgical glove is easily torn, especially with high insufflation pressures.

Subtle differences exist when comparing traditional robotic docking with docking used for RLESS procedures. In regards to the robotic platform, the da Vinci Si or Xi models are preferred over the S model secondary to enhanced visualization, improved ergonomic control at the surgeon console, and, most importantly, a more-compact, sleeker bedside profile which assists with minimizing external clashing of the robotic arms [11, 13]. For RLESS procedures, typically only two robotic instrument arms are used due to limited working space.

Other tactics have been described in order to minimize external clashing of robotic arms. The “chopstick” technique popularized by Joseph et al. minimizes external instrument clashing by crossing the instruments at the level of the fascia in order to create more space between the robotic arms outside of the body [7, 14]. This technique was previously employed during single-site laparoscopic surgery but proves to be very challenging secondary to the crossing of instruments resulting in “reverse handedness.” This benefit of using the robotic platform is that the robotic instruments are controlled electronically, allowing the left- and right-hand joystick hand effectors to be interchanged, thus removing this challenge. The main drawback of this method is intra-abdominal arm clashing. The surgeon must always remain cognizant as to the position of each instrument to avoid clashing and counter-springing.

The standard selection of robotic instruments has been the most commonly utilized tool for performing RLESS procedures , as only a limited quantity of RLESS-specific appliances have been developed [4, 11, 12]. The benefit for using the existing 8 mm da Vinci robotic instruments is familiarity and employment of EndoWrist technology. Five millimeter instruments can also be deployed, but it is important to note that 5 mm instruments deflect rather than articulate, which maintains their range of motion.

Intuitive surgical has developed various tools specific for RLESS , including a multichannel platform specialized for their robotic platform (Fig. 33.3), which includes two curved cannulas, two straight cannulas, and a valve to allow insufflation. The curve of the lateral cannulas allows for institution of intracorporeal triangulation. Similar to the “chopstick” technique, the instruments are crossed at the level of the fascia, necessitating electronic reversal of the effector controls between the surgeon console and patient-side cart. This platform was utilized by Cestari et al. in performing RLESS pyeloplasty in nine patients [15]. All nine cases were performed with a mean OR time of 166 min, no need for additional ports or need for operative conversion.

Various lens arrangements have been described for RLESS procedures. In their series of RLESS prostatectomy, White et al. primary employed the use of a 0° scope but found that the utilization of a 30° has the advantage of positioning the camera out of the path of the robotic instruments potentially decreasing the degree of instrument clashing [4]. Various arrangements have been used for upper tract RLESS procedures. When considering which lens to use during RLESS, the surgeon must take into account port placement and potential for clashing. Having both 30° and 0° lenses available during an early experience may be beneficial in assessing which configuration is preferred for a specific procedure.