ABSTRACT

PURPOSE: To present current experience using the novel robotic Single-Site platform in procedures other than cholecystectomy.

METHODS: Twenty months after initiation of the Single-Site robotic program, over 150 cholecystectomies have been performed in our department. This experience served as the basis for using the same platform for various procedures through a single incision. We present our experience from a series of Robotic Single-Site  procedures most of which were performed for the first time. These robotic procedures include: one combined Nissen Fundoplication with cholecystectomy, two varicocele repairs, one hysterectomy, one excision of bilateral ovarian endometriomas, one combined renal cyst excision with cholecystectomy and one thoracoscopic-robotic pericardial cyst excision. Modifications from Single-Site cholecystectomy as well as encountered difficulties during  the procedures are discussed together data from literature.

RESULTS: All procedures were completed successfully without conversion to multiport robotic or conventional laparoscopic or open surgery. In all cases there was minimal blood loss, uneventful post-operative recovery and excellent cosmetic result.

CONCLUSIONS: Robotic Single-Site Surgery has recently been demonstrated to be safe and feasible for cholecystectomy. The potential of this method in the hands of expert robotic teams can be great, extending the application to various procedures of the upper and lower abdomen. Yet larger clinical studies are necessary in order to identify the limits of this method.     

KEY WORDS: Robotic single-site, VESPA, Nissen fundoplication, hysterectomy, endometriosis, pericardial cyst, renal cyst.

 

BACKGROUND

It has been nearly 20 months since the 1^st  robotic single-site cholecystectomy  was performed by our team using the da Vinci SI HD system. During this time, the VESPA (Video Endoscopic Single Port Access) technique has been adopted by several institutions and results concerning cholecystectomy are encouraging.^[1,2]  However most authors agree that the applications of da Vinci single-site platform will not be restricted to cholecystectomy alone. Advances in camera and instrument design have made possible the completion of more complex surgical procedures through a single-incision approach. Single-incision surgery is an attractive option to patients because apart from its `cosmetic benefit, it  potentially decreases postoperative pain and allows for quicker recovery.^[3-5]

The Port:The Single-site  port has five lumens: four to introduce the cannulae and one lumen for the insufflation adaptor [Figure 1 - The Single - Site Port].

Figure 1 The SINGLE-SITE Port has a target anatomy arrow indicator and five lumens: four to hold cannulae and one lumen for the insufflation adapter (Intuitive Surgical Inc.).

Insertion of the port in the abdomen follows the same  principles as for robotic single-site cholecystectomy^[1] i.e. careful grasping of the port with an atramautic clump and lubrication with saline before insertion through the 2-2.5cm incision. A special indicator on the anterior surface of the port should always be directed towards target anatomy (e.g. the gallbladder for cholecystectomy, the uterus for hysterectomy and so on).

Creating the Incision: Surgical technique for cholecystectomy involves a 2.0-2.5 cm midline trans-umbilical, infraumbilical or a semilunar umbilical incision along the lower rim of the umbilicus, for optimal cosmetic result ^[1]. Port placement in single-site robotic surgery is quite simple after proper training and remains the same for every type of surgical procedure, including pelvic surgery. Furthermore, with careful preoperative design of port position it may be used  for combined procedures via the same incision. The port can be placed anywhere on the abdominal wall, according to the location of the target tissue-organ. For example, for performing  single-site  Nissen fundoplication the port was placed cranially 3cm and to the left from of the navel (same position as in multiport). The new, shorter, single-site cannulae (25 cm) facilitate pelvic surgery to be performed through a single umbilical port. Additionally, apart from using the VESPA system in abdominal surgery, it may be used in thoracic surgery as well, if the port is placed between the ribs, after adequate retraction.

System Set-up: Although it follows similar principles, docking of the Single-Site daVinci differs from the classic multiport robotic docking; therefore it requires additional training. Positioning of the patient, the robot and proper placement of the operating table are equally important. The surgical team should be extensively trained on docking, cannulae insertion, abdominal wall lift maneuver  and abdominal exploration procedures that take place before every main procedure.^[1,2]

In our department we have performed 153 robotic single-site cholecystectomies using the VESPA platform. This experience served as the basis for applying this platform to other types of procedures. The single-site robotic procedures performed include one combined Nissen Fundoplication with cholecystectomy, two varicocele repairs, one hysterectomy, one excision of bilateral ovarian endometriomas, one combined renal cyst excision & cholecystectomy and one intrathoracic thoracoscopic-robotic pericardial cyst excision. In all cases, training and experience from single-site robotic cholecystectomy proved to be of high importance. In the following paragraphs each of these procedures is presented, along with the modifications during setup and all encountered challenges during surgery.

SINGLE-SITE ROBOTIC VARICOCELE REPAIR

The laparoscopic varicocele repair is a relatively simple procedure and was chosen as the first operation to be performed with the VESPA technique, beyond cholecystectomy. Two young men 31 and 32 years old, presented with symptomatic left varicoceles. After discussing the therapeutic options it was decided to perform the operation in a robotic Single-Site approach for optimal cosmetic result. Informed consent was obtained in both cases. In both cases a semilunar incision of 2cm, was made at the lower rim of umbilicus and the port was placed  with the guiding guiding arrow on top of the port oriented towards the left iliac fossa. The robotic system was placed to the left of the patient. Introduction of cannulae and docking were performed under direct vision following the protocol used for cholecystectomy.  A robotic Single-Site monopolar hook and a Maryland dissector were used for dissection and identification of the spermatic vessels. The monopolar hook was used for opening the peritoneum and dissection of the vessels. Ligation of the vein and collateral branches was performed robotically using the Single-Site clip applier and Hem-o-lok clips (Weck, Medium-Large Polymer Clips). This phase was performed cautiously in order to preserve the spermatic arteries. No assistance was necessary from the accessory port. Both procedures were completed without any blood loss and operative times were 24’ and 32’ respectively. Recovery was uneventful and overall hospitalization did not exceed 24 hours. Up to now there is no recurrence or longterm complications such as wound infection, hydrocele, or incision site herniation.

ROBOTIC SINGLE-SITE  NISSEN FUNDOPLICATION WITH CHOLECYSTECTOMY

In our department we have a large experience with laparoscopic fundoplication since 1994, and with the robotic technique since 2006. Using the multiport robotic technique we have over 83 cases. The first robotic Single-SiteNissen fundoplication was performed on a 41 year old female, which presented with severe gastroesophageal reflux and hiatal hernia, along with symptomatic cholelithiasis. A combined procedure of Nissen fundoplication with cholecystectomy was planned and the patient gave a written informed consent for a robotic Single-Site approach. The patient was placed in a supine anti-Trendelenburg position with a 30 degree shift to the left. The Single-Site port was not placed in the umbilicus as it was routinely done for cholecystectomy. The incision was made 3cm cranially from the umbilicus and 2cm to the left of the midline in order to facilitate the fundoplication. The indicator on the port was turned further to the left (at 10 o’clock position) and the robotic cart was positioned over the right shoulder. Pneumoperitoneum was established at a pressure of 12mmHg. As a first step the long curved cannulae (30cm) of the VESPA system were introduced to the abdominal cavity under direct vision. Although the introduction of cannulae and system docking were relatively simple, visualization of the critical view from a different position was influenced because of a large left hepatic lobe and the round ligament. The right cannula was used for retraction of the left hepatic lobe. The instruments used at this phase were mainly the Single-Site  monopolar hook and the Crocodile grasper. Cholecystectomy was performed in routine fashion as described ^[1]. The gallbladder was placed in an endobag, the cannulae were removed and the system was undocked. The pneumoperitoneum was released and the endobag retrieved from the port incision. Then the port was reinserted and pneumoperitoneum reestablished.

In order to approach the hiatus for the fundoplication using VESPA, the port was reinserted with the arrow indicator facing cranially (12 o’clock), while the robotic cart was brought over the patient’s head. The surgical table was placed into steep anti-Trendelenburg position. Retraction of the left lobe of the liver was a major challenge, but the long rigid shaft of theleft cannula was found to be useful. Dissection of the lesser omentum and the peri-esophageal space was performed with the monopolar hook. Hepatic vagal branch was identified and preserved along the ventral and dorsal esophageal surfaces. Another major challenge of the Single-Sitewas the phase of ligation of the short gastric vessels since a robotic bipolar cautery is not yet available for Single-Site. Initially an attempt to ligate the short gastrics was made using a conventional laparoscopic bipolar cautery through the accessory lumen of the port. However, the accessory instrument was on the same axis with the camera, and its movement along the horizontal axis was influenced by the camera position. Furthermore, the instrument was not aligned correctly with the plane of dissection. An accessory 5mm trocar was inserted along the left anterior axillary line in order to introduce the Ultracision Harmonic ACE scalpel (Ethicon™). This greatly facilitated dissection and ligation of the short gastrics and complete mobilization of the fundus. A penrose encircled the lower part of the esophagus and was used for mobilization and traction through the 5mm assistant port.

Closure of the esophageal hiatus around the lower esophagus was easily accomplished with the large Suturecut needle drivers for Single Site. The Single Site platform offers intuitive suturing capability comparable to multiport robotic surgery despite the fact that the single site instruments lack the wrist-effect. A non-absorbable coated polyester suture (e.g. Ti-Cron 2-0, Covidien's SynetureTM) was used for both the esophageal hiatus closure and fixation of the fundoplication.  Care was taken so that the fundoplication would be short in length and floppy [Figure 2C - Single-site roboticNissen fundoplication].

Figure 2-C The robotic cannula on the left  (cannula #2) applies traction to the liver, while the second robotic instrument ensures a loose fundoplication.

The skin-to-skin time for the combined cholecystectomy and Nissen fundoplication was 179’ and there was no blood loss. Post-operative period was free of complications and patient was discharged within 48h. Our patient was satisfied not only with the surgical outcome, but also with the appearance of the surgical incision. 

ROBOTIC SINGLE-SITE SUPRACERVICAL HYSTERECTOMY

A multiport robotic hysterectomy is a procedure we regularly perform in our department with the robotic cart positioned on the patient’s side (side-docking). We present a 52 year old woman, with a myomatous uterus and a history of irregular bleeding. Patient gave informed consent to undergo a robotic single site hysterectomy. A modified dorsal lithotomy position was utilized (patient’s legs separated and knees flexed using adjustable leg stirrups with boots), with steep Trendelenburg position. A Pelosi™ type uterine manipulator (Cooper-Surgical, Inc, USA) was introduced from the vagina. In Single-Sitesurgery, side-docking cannot be used since the robotic cart should be aligned with the port and target organ; therefore the robotic cart was placed between the patient legs (central docking). The Single-Site port was placed through a 2cm wide incision along the midline and 3cm over the umbilicus. The original Single-Site cannulae were 30cm in length, ie too long for pelvic surgery if the port was placed in the umbilicus. Recently however, our department was equipped with newer and shorter single-site cannulae (25cm) with which pelvic procedures are feasible through the umbilicus.

Another modification from cholecystectomy, performed during this procedure was that the insufflation tube was removed from the corresponding Single-Site port lumen. Instead, the camera trocar was used for insufflation. In this way, there were two available accessory lumina on the single port instead of one. Through these, the bedside assistant was able to insert the conventional 5mm bipolar cautery for ligation of the suspensory ligaments and uterine vessels bilaterally. In this phase the Single-Site monopolar hook and Maryland dissector were used. As mentioned before, a robotic bipolar cautery is not available for VESPA single site robotic surgery yet. Additionally the camera position, directly influenced the accessory instrument’s position. As a result,  a good coordination between the console surgeon and the bedside assistant was necessary at this phase because the console surgeon had to lead the bedside assistant to the “proper plane” for dissection and ligation of the suspensory ligament of the ovary using the bipolar cautery [Figure 2A Single-site robotic Hysterectomy]. 

Figure 2-A The bed-side assistant using bipolar cautery (center) dissects the right ovary while the console surgeon provides the proper plane

Dissection of the vesicouterine pouch, the broad ligament of uterus and division of the cervix were accomplished with the robotic monopolar hook without difficulty. Later on, the uterus was placed in a simple endobag anchored with a Mersilk no-2 (W936, Ethicon™) suture and brought to the surface after removal of all robotic instruments and release of pneumoperitoneum. The endobag was removed from the main incision with a small dilatation of the fascia without extending the skin incision. To prevent post-surgical abdominal wall hernias, the fascia was closed with two continuous PDS II no1 (W9237, Ethicon™) sutures. There were no intraoperative or postoperative complications. Patient was discharged within less than 24 hours after surgery.

ROBOTIC SINGLE-SITE BILATERAL ENDOMETRIOMAS EXCISION

Single-Siteindications in our institution continued with endometrioma excision. Patient was a 41 year-old nulliparous, diagnosed during regular pelvic sonographic examination without any symptoms of endometriosis, neither history of prior pelvic surgery.  Three endometriotic cysts were identified, a 3cm cyst within the left ovary and two cysts (4cm and 7cm) within the right ovary. Patient signed an informed consent for a robotic single site approach of her pathology. The Single-Site port was placed through a 2cm wide, midline infra-umbilical incision. Second generation, shorter Single-Site cannulae (25cm long) were used, which are easier to handle during docking and may facilitate pelvic procedures when the port is located at the umbilicus.

The patient was placed in a modified dorsal lithotomy position, with steep Trendelenburg position. A Pelosi™ type uterine manipulator (Cooper-Surgical, Inc, USA) was inserted through the vagina. The robotic instruments involved Single-Site monopolar hook, Crocodile grasper, Maryland dissector and Single-Site  suction-irrigation. Initially the monopolar hook was used to dissect through the ovarian surface and identify the plane of the ovarian cyst. For the removal of the cyst from the normal ovarian epithelium a combined traction using Maryland and Crocodile grasper were initially used [Figure 2B Single-site robotic Endometriomas].

Figure 2-B The Crocodile grasper and Maryland dissector perform blunt dissection of the cyst from the ovary.

However, blunt dissection was causing bleeding at the plane of dissection; therefore a monopolar hook was used for both dissection and hemostasis. The 3cm endometrioma in the left ovary, was removed intact. At times the robotic Single-Site Suction-irrigation was used manually from the bed-side assistant through the accessory port, to absorb smoke or clean the surgical field. The suction-irrigation tip may be ‘driven’ by the surgeons instruments, and make suction possible at places that the assistant cannot reach (limited degrees of freedom).

Dissection of the endometriomas from the right side was much more difficult, due to the endometriomas been impacted in pelvis, with multiple dense inflammatory adhesions and leaking  chocolate-like material. The content of the endometrioma was suctioned and the sac of the cyst was detached from the internal surface of the ovary. To improve ergonomics, our instruments were oriented in the same manner as in cholecystectomy. More specifically, the assistant laparoscopic grasper run over the camera and held the ovary from the top, while the console surgeon was dissecting the cyst. This way, the ovary was stabilized and the assistant’s instruments did not interfere with the surgeon’s field. Robotic suction-irrigation was useful to help identify minor sites of bleeding. Hemostasis in the internal ovarian surface was accomplished with the monopolar cautery.

All cysts were carefully placed in a simple endobag tied with a Mersilk no-2 (W936, Ethicon™), and brought to the surface from the initial port incision. There were no intraoperative and postoperative complications. Patient had an uneventful recovery and was discharged within 24 hours. Histology, confirmed that the specimens were endometriotic cysts.    

ROBOTIC SINGLE-SITE RENAL CYST EXCISION AND CHOLECYSTECTOMY

In this case, a 64-year female patient presented with symptomatic cholelithiasis and a history of a right renal cyst which enlarged 6cm over the past 6 months. Computerized tomography revealed a cortical cyst 12cm in diameter in the superior pole of the right kidney. A combined procedure of a single-site cholecystectomy and removal of the renal cyst through the same port was suggested to the patient, who gave an informed consent.

We started the procedure with the cholecystectomy first. The single-site port was introduced through a 2-cm, midline, infraumbilical incision and pneumoperitoneum was established. Robotic single-site cholecystectomy was carried out in a routine fashion. Minor modifications from the standard procedure were necessary to overcome challenges of the single incision approach. The assisting grasper was used through the accessory lumen of the port without the 5mm trocar. In this way we noticed that freedom of the accessory instruments was slightly increased. Also, the assistant’s instruments were independent from the camera position. In this way their contribution to exposure of the field was quite significant. Surprisingly enough, introduction of instruments directly through the Single site port without using a trocar, does not result in air leakage as one would expect. On the other hand, extra care must be paid to avoid damage to the port. Cholecystectomy was completed successfully and the procedure continued with the right renal cyst without releasing the pneumoperitoneum, nor undocking the system.

In order to proceed with exposure of the right retrohepatic area, the laparoscopic 5mm flexible snake liver retractor was introduced (without the 5mm trocar), through the accessory port. The flexible retractor was  gently used to retract the right hepatic lobe towards the midline, revealing adhesions of the liver to the diaphragm and posterior peritoneum. These were released with a robotic monopolar hook. Dissection of the renal cyst was carried out  after aspiration of 750ml of serous fluid. Using the single-site monopolar hook the cyst was unroofed [Figure 2D Single-site roboticRenal Cyst]

Figure 2-D Exposure  and unroofing of the renal cyst, while the 5mm snake retractor pushes the liver medially. 

A drainage tube was inserted through a small right lateral wall incision and pushed behind the liver with the robotic grasper.  The liver retractor was carefully unfolded and removed. A 10mm Trocar was inserted through the accessory lumen, and a laparoscopic endobag tied with a Mersilk no-2 (W936, Ethicon™) was introduced through it. The gallbladder and the renal cyst were placed in the endobag and removed through the umbilical incision during removal of the Single Site port. Post-operative period was uneventful and patient was discharged within less than 48 hours after drainage was removed.  

 

 ROBOTIC SINGLE-SITE  PERICARDIAL CYST EXCISION 

 

We present a 31-year old female with a pericardial cystic mass, 10cm in diameter in the right hemithorax, confirmed by a thin-sliced CT scan [Figure 3A Single-Site Robotic Pericardial cyst excision]

Figure 3-A Magnetic resonance imaging (sagittal plane). The cyst is visualized above the liver extending posteriorly.

robotic single-site thoracoscopic approach was planned and consent was signed by the patient.  To our knowledge this is the first publication for single site robotic thoracoscopic procedure using this method. Under general anesthesia with double-lumen endotracheal intubation and the right lung collapsed in the left lateral decubitus position, a 2cm length-incision was made parallel to the ribs, in the 5th intercostal space, at the level of the right mid-axillary line [Figure 3B Single-Site Robotic Pericardial cyst excision]

Figure 3-B Incision location in relation to intercostal spaces.

 Incision was dilated with rib retractors and the single-site port was introduced in the same manner as for abdominal surgery [Figure 3C Single-Site Robotic Pericardial cyst excision].

Figure 3-C The single-site port in position

Although port insertion was relatively easy, the pressure exerted from the ribs, initially affected the shape of the elastic port. Eventually, repositioning of the trocars and cannulae restored the shape of the port and allowed the normal motion range of the robotic arms without collisions. An 8.5mm robotic scope 0^o was introduced, followed by the short (25cm) curved non-flexible single-site cannulae under direct vision. A 5mm assistant trocar was also inserted within the accessory lumen of the port.  The robotic instruments used were monopolar hook and Crocodile grasper.  Although insufflation was not mandatory for this case, low pressure levels (5mmHg) were found useful to allow for  air circulation and cleaning of the smoke that was produced from electrocautery. Despite this measure, the bedside assistant had to clean the robotic camera oftentimes during the procedure. Soon after access in the right thoracic cavity, the pericardial cyst was easily identified, and its wall was cauterized and opened; the content absorbed (serous fluid) [Figure 3D Single-Site Robotic Pericardial cyst excision ].

Figure 3-D The pericardial cyst is incised and its content is absorbed using a robotic single-site suction.

Its supplying arterial branch was identified and ligated with hem-o-lock clips (Medium-Large Polymer Clips). Eventually the cystic wall was removed in one piece. During completion of the removal, a conventional bipolar cautery was used through the accessory port to achieve complete hemostasis. A thoracic tube was inserted through a small incision in the 5^th intercostal space. The specimen was grasped with a laparoscopic grasper from the accessory lumen and retrieved from the main incision, after removal of the port. 

DISCUSSION

Laparoendoscopic single-site (LESS) surgery has gained increased acceptance among surgeons in various specialties and yet has been successfully applied to a number of common minimally invasive surgery procedures including cholecystectomy, hysterectomy, colectomy, bariatric and even anti-reflux surgery. However, Instrument crowding, diminished triangulations and very steep learning curve are considered major limiting factors.  Robotic single-site was specifically designed to overcome ergonomic difficulties frequently encountered during LESS. The automatic reversion of the crossed instruments allows far greater maneuverability and ergonomics, while the improved 3-dimensional image significantly improves surgeon’s skill. The semi-flexible, curved instrumentation offers a stable and secure platform with lack of instrument collisions in which more complex procedures can be performed. However, there is very little published data on the application of Robotic single-site technique for these procedures.

Single-Site varicocele ligation has been performed successfully with LESS in several institutions, and surgeons have already published satisfactory results, in comparison to multiport laparoscopy.^[6-8] Data regarding robotic single-site varicocele ligation is unavailable. In our department this procedure was selected for reasons of technical simplicity and because the port would be located in umbilicus, i.e. a familiar location to our team since that had been used regularly for single-site cholecystectomy. Results of the robotic approach with respect to skin-to-skin surgical time, duration of hospitalization, post-operative recovery and cosmetic result are comparable to those of LESS technique.

There are few reports concerning single-site surgery in anti-reflux surgery. Various methods of liver retraction and suturing techniques including extracorporeal knots are used.^[9,10] Ross S. et al reported an extensive experience of 130 cases of LESS Nissen fundoplication, in which results were comparable to those of conventional laparoscopy. Furthermore, patient underwent LESS approach were more satisfied with their surgical scar during follow up. ^[4]  Yet, however there is no publication concerning robotic single-site approach for anti-reflux surgery. In our experience, the da Vinci platform may serve well this type of surgery, but improvements are to be made in the fields of liver retraction and the availability of integrated bipolar cautery or ultrasonic scissors.

Single-site hysterectomy has become very popular mostly because it is welcomed by patients who are more concerned about cosmetic outcomes. A number of studies have concluded that hysterectomy is both safe and feasible with LESS technique, all of which however involved a relatively short number of patients. ^[3,11,12] There are very few studies concerning Robotic Single-site hysterectomy. Escobar et al. performed a series of pelvic procedures in porcine models and reported that single-site robotic platform allows performing technically challenging procedures,^[13] although more recently he assessed specific technical requirements and limitations including  anthropometrical, docking and robotic arms placement considerations, in which he concluded that further work is needed in the development and advance of single-site robotic platforms.^[14] In our point of view, robotic single-site hysterectomy is feasible but also very challenging with the current equipment. The lack of single-site integrated bipolar cautery is a major limitation. Good coordination between the console surgeon and the bedside assistant applying conventional bipolar cautery can overcome this difficulty, although this method may not be applicable in more complex cases. 

A similar issue occurs for other gynecologic procedures, such as treating endometriomas. Manipulation of the ovaries and blunt dissection of ovarian cysts is efficient with the current single-site graspers (Crocodile grasper and Maryland dissector), but the lack of bipolar cautery can prove of great significance during bleeding near critical structures such as the external iliac vessels or the ureter. On the other hand, console surgeon’s expertise may counterbalance this problem and preserve hemostasis by either preserving a bloodless plane during cyst removal, or by applying with caution the monopolar diathermy where necessary. Studies involving single-site laparoscopy (LESS) used in the treatment of adnexal masses, have reported the safety and feasibility of this method for ovaries up to 10cm in diameter, however there is always the possibility of conversion, in cases with suspected malignancy.^[15,16]

Transumbilical LESS technique in urology has evolved and already there are reports for performing complex urologic procedures such as partial or total nephrectomy with this method.^[5] Robotic single-site surgery in urology has not yet been reported. Our case was a combined cholecystectomy and renal cyst excision. Performing concomitant procedures via single incision is always a surgical challenge.

A single-trocar technique has been used in the management of multiple noncomplex thoracic diseases including a mediastinal mass, management of pneumothorax and even lobectomy.^[17-19] The majority of pericardial cysts are asymptomatic and are found incidentally. Symptomatic pericardial cysts present with dyspnoea, chest pain, or persistent cough. Video-assisted  thoracoscopic removal of pericardial cysts is an excellent surgical intervention without serious morbidity and mortality. A robotic thoracoscopic surgical procedure does not differ significantly from the single-incision thoracoscopic surgery, especially if the surgical team is well trained for single-site procedures. If the port is properly placed in an intercostal space, the robotic system functions efficiently without collisions. The lack of the integrated bipolar cautery and intergrated robotic stapler is a limiting factor in performing more complex intrathoracic procedures.

CONCLUSIONS

Robotic Single-Incision surgery is proven feasible for cholecystectomy but the limits of the robotic single-site platform yet remain uncertain. The system was applied over a set of surgical procedures of different medical specialties including general surgery, urology, gynecology and thoracic surgery and the outcomes where satisfying. This is not experimental surgery, since the whole surgical team had been extensively trained in a series of robotic single-site cholecystectomies. VESPA platform can be safely used for different target organs with the prerequisite of close adherence to the safety guidelines given from Intuitive Surgical Inc. for cholecystectomy.

Improvements in robotic single-site instrumentation including the shorter cannulae, play significant role in widening its applications. Yet the unavailability of integrated single-site bipolar cautery and stapler ultimately is a strong limitation. We anticipate that the intergration of the wrist effect on the robotic single site instruments, will make maneuverability of the instruments easier and might enhance the variety of procedures that we can undertake with the VESPA platform.  Single-incision surgery is welcomed by patients who are more concerned about cosmetic outcomes and faster recovery, but the true benefit of the technique will be shown by further randomized controlled trials.

- Available Videos - 

All previously discussed procedures are available on-line. The corresponding links are provided below:

• Robotic Single-Site  Nissen Fundoplication: http://www.youtube.com/watch?v=VGvsJVzy-zU

• Robotic Single-Site   Varicocele ligation: http://www.youtube.com/watch?v=6RHbEajngDQ&feature=channel&list=UL

• Robotic Single-Site   Supracervical Hysterectomy: http://www.youtube.com/watch?v=G7T399JlRjE

• Robotic Single-Site   Endometriomas excision: http://www.youtube.com/watch?v=BhtTJuUXnHw

• Robotic Single-Site   Renal Cyst excision: http://www.youtube.com/watch?v=j2vUknLBiek

• Robotic Single-Site   Pericardial Cyst excision: http://www.youtube.com/watch?v=kN7u6wVAS7w

REFERENCES

1. Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, Georgiou M. Cholecystectomy using a novel Single-Site robotic platform: early experience from 45 consecutive cases. Surg Endosc. 2012 Sep;26(9):2687-94. Epub 2012 Apr 5.

2. Pietrabissa A, Sbrana F, Morelli L, Badessi F, Pugliese L, Vinci A, Klersy C, Spinoglio G. Overcoming the Challenges of Single-Incision Cholecystectomy With Robotic Single-SiteTechnology. Arch Surg. 2012 Apr 16. [Epub ahead of print].

3. Fanfani F, Fagotti A, Rossitto C, Gagliardi ML, Ercoli A, Gallotta V, GueliAlletti S, Monterossi G, Turco LC, Scambia G. Laparoscopic, minilaparoscopic and single-port hysterectomy: perioperative outcomes. SurgEndosc. 2012 Jun 8. [Epub ahead of print].

4. Ross S, Roddenbery A, Luberice K, Paul H, Farrior T, Vice M, Patel K, Rosemurgy A. Laparoendoscopic single site (LESS) vs. conventional laparoscopic fundoplication for GASTROESOPHAGEAL REFLUX: is there a difference? SurgEndosc. 2012 Jul 18. [Epub ahead of print]

5. Bazzi WM, Stroup SP, Kopp RP, Cohen SA, Sakamoto K, Derweesh IH. Comparison of Laparoendoscopic Single-site and Multiport Laparoscopic Radical and Partial Nephrectomy: A Prospective, Nonrandomized Study. Urology. 2012 Sep 15.pii: S0090-4295(12)00794-7. doi: 10.1016/j.urology.2012.07.018. [Epub ahead of print]

6. Barone JG, Johnson K, Sterling M, Ankem MK. Laparoendoscopic single-site varicocele repair in adolescents-initial experience at a single institution. J Endourol. 2011 Oct;25(10):1605-8. Epub 2011 Aug 8.

7. Lee SW, Lee JY, Kim KH, Ha US. Laparoendoscopic single-site surgery versus conventional laparoscopic varicocele ligation in men with palpable varicocele: a randomized, clinical study. SurgEndosc. 2012 Apr;26(4):1056-62. Epub 2011 Nov 15.

8. Kaouk JH, Palmer JS. Single-port laparoscopic surgery: initial experience in children for varicocelectomy. BJU Int. 2008 Jul;102(1):97-9. Epub 2008 Mar 5.

9. Muensterer OJ, Perger L, Hansen EN, Lacher M, Harmon CM. Single-incision pediatric endosurgical Nissen fundoplication.J Laparoendosc Adv Surg Tech A. 2011 Sep;21(7):641-5. Epub 2011 Mar 28.

10.Padilla BE, Dominguez G, Millan C, Martinez-Ferro M. The use of magnets with single-site umbilical laparoscopic surgery. Semin Pediatr Surg. 2011 Nov;20(4):224-31.

11.Li M, Han Y, Feng YC. Transumbilical single-port laparoscopic hysterectomy using traditional laparoscopic instruments: a report of 20 cases. ClinExpObstet Gynecol. 2012;39(2):218-21.

12. Li M, Han Y, Feng YC. Single-port laparoscopic hysterectomy versus conventional laparoscopic hysterectomy: a prospective randomized trial. J Int Med Res. 2012;40(2):701-8.

13. Escobar PF, Haber GP, Kaouk J, Kroh M, Chalikonda S, Falcone T.  Single-port surgery: laboratory experience with the daVinci single-site platform. JSLS. 2011 Apr-Jun;15(2):136-41.

14. Escobar PF, Knight J, Rao S, Weinberg L. da Vinci  single-site platform: anthropometri-cal, docking and suturing considerations for hysterectomy in the cadaver model. Int J Med Robot. 2012 Jun;8(2):191-5. doi: 10.1002/rcs.448. Epub 2012 Feb 28.

15. Kim WC, Lee JE, Kwon YS, Koo YJ, Lee IH, Lim KT. Laparoendoscopic single-site surgery (LESS) for adnexal tumors: one surgeon's initial experience over a one-year period. Eur J ObstetGynecolReprod Biol. 2011 Oct;158(2):265-8. Epub 2011 May 26.

16. Escobar PF, Bedaiwy MA, Fader AN, Falcone T. Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease. FertilSteril. 2010 Apr;93(6):2074.e7-10. Epub 2010 Jan 25.

17. Migliore M. Efficacy and safety of single-trocar technique for minimally invasive surgery of the chest in the treatment of noncomplex pleural disease. J Thorac Cardiovasc Surg. 2003 Nov;126(5):1618-23.

18. Berlanga LA, Gigirey O. Uniportal video-assisted thoracic surgery for primary spontaneous pneumothorax using a single-incision laparoscopic surgery port: a feasible and safe procedure. Surg Endosc. 2011 Jun;25(6):2044-7. Epub 2010 Dec 7.

19. Gonzalez-Rivas D, Paradela M, Fieira E, Velasco C. Single-incision video-assisted thoracoscopic lobectomy: initial results.J Thorac Cardiovasc Surg. 2012 Mar;143(3):745-7. Epub 2011 Aug 25.

 

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