**5. Operating**

Begin by placing your preferred uterine manipulator. At our institution we commonly use the Delineator™ from CooperSurgical™. Following this, your attention turns to the abdomen to identify the best position for the 2.5 cm incision that will be placed. This incision can be directly within the umbilicus or directly above or below the umbilicus. Typically, the lines of the umbilicus are used, and a vertical incision is most commonly made directly through the umbilicus. This allows for concealment of the incision line creating a superior cosmetic effect. Another common incision is a "U" incision cut either inferior or superiorly made. Great care should be taken while performing this step and again at the time of skin closure to ensure careful reconstruction. This will ensure the best cosmetic results. At times the umbilical stalk can be detached during entry. If this occurs, it should be reattached to the fascia for best cosmetic effect, preserving the depth of the umbilicus. Typically, a 2.5 cm–3 cm incision is required to install the Intuitive Gelport(™). If the incision is made too small, a visible dark, purplish ring can be seen on the skin around the umbilicus resulting from pressure necrosis. Although we have found that this usually heals over time without complication, this can simply be prevented by creating an appropriately sized incision in the first place.

Next, the fascia is identified and incised to the same length. The intuitive Gelport is then clamped at the base with long tissue forceps. Be careful not to grasp the small bronze sphere on the bottom of the port as this is part of the insufflation mechanism on the Gelport, and could be damaged by the forceps (**Figures 5** and **6**).

An army/navy retractor is then used to lift the inferior opening of the incision and the clamped gelport is inserted with downward pressure through the incision until the port is buried to the upper base. Traction and counter traction are used to perform this. Once inserted, the army/navy is again used, this time in a circular motion to sink the port into place beyond its initial ring.

Once the port is in place, gas is attached to the Gelport and insufflation begins. The single-site camera trocar is then inserted into the appropriate space in the Gelport. The trocar should be moistened with saline. Do not use gel as it will cause the trocar to slip from position during the procedure.

The patient can now be placed into Trendelenburg and the camera inserted to survey the surgical field. A 30-degree angled scope is recommended. The robot can then be moved into position and the camera docked into the trocar.

Insertion of the trocars begins with the left curved trocar first, and then the right curved trocar. While holding the port with the left hand, the right hand guides the curved trocar which starts parallel with the patient abdomen and is moved until the marked arrow passes through the Gelport. The trocar is then moved vertically and advanced to the solid line on the trocar (**Figure 7**).

#### **Figure 5.**

*A red arrow shows the small bronze sphere on the bottom of the Gelport. This is part of the insufflation mechanism on the Gelport, and could be damaged if inadvertently grasped by the forceps.*

**61**

right side.

**Figure 6.**

site side.

*Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

At the same time the trocar tip can be seen on the screen entering the patient's

The same procedure is then repeated with the right trocar. Again, it enters from

The camera port is then brought to a 90-degree angle, with the skin of the abdomen, and the assistant port is inserted until the pre-marked area is reached. A 5 mm or 10 mm assist port can be used. At our institution, I prefer an 8 mm AirSeal™ port. The camera is then brought back to center with the trocar tips in view. All trocars are then docked and positioned. The trocars should be clearly visible on the right and left sides of the camera view. Remember all trocars are moistened with saline prior to positioning in the Gelport. Again we do not recommend using gel to

Once the robot is docked, the left sided instrument clutch is pressed. This will reassign the right and left arms making the right internal arm now controlled by your right joystick, and the left internal arm now controlled by your left joystick. This switch allows the surgeon sitting at the console to have traditional right and left control. The instruments most commonly used for hysterectomy will be the Monopolar Hook and the Fenestrated Bipolar grasper. With the trocars crossed the monopolar hook is commonly placed in the left trocar and becomes your right arm. The fenestrated bipolar grasper is placed in the right trocar and becomes the left arm. Many authors have described constant camera and instrument movement as well as frequent clutch control as factors most associated with success [8, 9]. Constant centering of instruments allows for maximum traction and counter traction movement.

The 30-degree scope can be rotated to opposite sides to visualize the trocars

Note that as the trocar passes into the abdomen it crosses over to the oppo-

the right side and passes to the left side of the patient (**Figure 8**).

safely entering the abdomen (**Figure 9**).

*Proper grasping of the base of the Gelport with forceps is shown.*

avoid slippage during the procedure.

#### **Figure 6.**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

by creating an appropriately sized incision in the first place.

motion to sink the port into place beyond its initial ring.

the trocar to slip from position during the procedure.

and advanced to the solid line on the trocar (**Figure 7**).

(**Figures 5** and **6**).

should be taken while performing this step and again at the time of skin closure to ensure careful reconstruction. This will ensure the best cosmetic results. At times the umbilical stalk can be detached during entry. If this occurs, it should be reattached to the fascia for best cosmetic effect, preserving the depth of the umbilicus. Typically, a 2.5 cm–3 cm incision is required to install the Intuitive Gelport(™). If the incision is made too small, a visible dark, purplish ring can be seen on the skin around the umbilicus resulting from pressure necrosis. Although we have found that this usually heals over time without complication, this can simply be prevented

Next, the fascia is identified and incised to the same length. The intuitive Gelport is then clamped at the base with long tissue forceps. Be careful not to grasp the small bronze sphere on the bottom of the port as this is part of the insufflation mechanism on the Gelport, and could be damaged by the forceps

An army/navy retractor is then used to lift the inferior opening of the incision and the clamped gelport is inserted with downward pressure through the incision until the port is buried to the upper base. Traction and counter traction are used to perform this. Once inserted, the army/navy is again used, this time in a circular

Once the port is in place, gas is attached to the Gelport and insufflation begins.

The patient can now be placed into Trendelenburg and the camera inserted to survey the surgical field. A 30-degree angled scope is recommended. The robot can

Insertion of the trocars begins with the left curved trocar first, and then the right curved trocar. While holding the port with the left hand, the right hand guides the curved trocar which starts parallel with the patient abdomen and is moved until the marked arrow passes through the Gelport. The trocar is then moved vertically

*A red arrow shows the small bronze sphere on the bottom of the Gelport. This is part of the insufflation* 

*mechanism on the Gelport, and could be damaged if inadvertently grasped by the forceps.*

The single-site camera trocar is then inserted into the appropriate space in the Gelport. The trocar should be moistened with saline. Do not use gel as it will cause

then be moved into position and the camera docked into the trocar.

**60**

**Figure 5.**

*Proper grasping of the base of the Gelport with forceps is shown.*

At the same time the trocar tip can be seen on the screen entering the patient's right side.

Note that as the trocar passes into the abdomen it crosses over to the opposite side.

The same procedure is then repeated with the right trocar. Again, it enters from the right side and passes to the left side of the patient (**Figure 8**).

The 30-degree scope can be rotated to opposite sides to visualize the trocars safely entering the abdomen (**Figure 9**).

The camera port is then brought to a 90-degree angle, with the skin of the abdomen, and the assistant port is inserted until the pre-marked area is reached. A 5 mm or 10 mm assist port can be used. At our institution, I prefer an 8 mm AirSeal™ port. The camera is then brought back to center with the trocar tips in view. All trocars are then docked and positioned. The trocars should be clearly visible on the right and left sides of the camera view. Remember all trocars are moistened with saline prior to positioning in the Gelport. Again we do not recommend using gel to avoid slippage during the procedure.

Once the robot is docked, the left sided instrument clutch is pressed. This will reassign the right and left arms making the right internal arm now controlled by your right joystick, and the left internal arm now controlled by your left joystick. This switch allows the surgeon sitting at the console to have traditional right and left control. The instruments most commonly used for hysterectomy will be the Monopolar Hook and the Fenestrated Bipolar grasper. With the trocars crossed the monopolar hook is commonly placed in the left trocar and becomes your right arm. The fenestrated bipolar grasper is placed in the right trocar and becomes the left arm. Many authors have described constant camera and instrument movement as well as frequent clutch control as factors most associated with success [8, 9]. Constant centering of instruments allows for maximum traction and counter traction movement.

**Figure 7.** *The left curved trocar is inserted first, as shown in this picture.*

**Figure 8.** *A 30-degree scope is ideal for visualizing the insertion of the lateral trocars.*

Another factor that plays a large role in successful robotic single-site surgery is the uterine manipulating device (and the assistant controlling it). Their strategic movements of the uterus help bring the tissue to the instruments and are crucial to procedure success [10].

**63**

**Figure 9.**

*Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

The initial steps in a robotic single-site hysterectomy largely depend on if the ovaries are to be removed or remain, as this will determine the plane of dissection. The round ligament is coagulated with the fenestrated Bipolar and transected with the Monopolar hook. The anterior and posterior peritoneal planes are separated with traction and counter traction and Monopolar Hook to skeletonize the uterine vasculature down to the uterine artery. A bladder flap is then created by dividing the vesico-uterine fascia, and the bladder is bluntly pushed out of the operating field. Traction and counter traction are again used for dissecting and opening the bladder flap. Once the flap is created, the ring or cup of the uterine manipulator must be identified. The colpotomy is begun in the anterior portion and is made with the hook cautery. This acts to further isolate the uterine arteries. Surgeon's preference may dictate coagulating the uterine arteries before the colotomy is made or as they are identified while creating the colpotomy. The arteries are coagulated and sealed using the fenestrated bipolar grasper and transected with the monopolar hook. The colpotomy can then be completed using the hook. Once the uterus is detached and removed, our next step will be the closure of the vaginal cuff.

*Installation is complete with the camera and both trocars in position.*

Robotic single-site suturing has great advantages over laparoscopic suturing because of the availability of wristed instruments. The wristed needle driver is, in fact, the only wristed instrument in the set. When closing the vaginal cuff, the fenestrated arm can remain on the left arm to allow for grasping of the vaginal cuff. The monopolar hook is replaced with the wristed needle driver. The wristed singlesite needle driver's movements are slightly more encumbered in comparison to the multiport version, however it is still wristed and allows for increased articulation

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

*The left curved trocar is inserted first, as shown in this picture.*

Another factor that plays a large role in successful robotic single-site surgery is the uterine manipulating device (and the assistant controlling it). Their strategic movements of the uterus help bring the tissue to the instruments and are crucial to

*A 30-degree scope is ideal for visualizing the insertion of the lateral trocars.*

**62**

**Figure 8.**

**Figure 7.**

procedure success [10].

**Figure 9.** *Installation is complete with the camera and both trocars in position.*

The initial steps in a robotic single-site hysterectomy largely depend on if the ovaries are to be removed or remain, as this will determine the plane of dissection. The round ligament is coagulated with the fenestrated Bipolar and transected with the Monopolar hook. The anterior and posterior peritoneal planes are separated with traction and counter traction and Monopolar Hook to skeletonize the uterine vasculature down to the uterine artery. A bladder flap is then created by dividing the vesico-uterine fascia, and the bladder is bluntly pushed out of the operating field. Traction and counter traction are again used for dissecting and opening the bladder flap. Once the flap is created, the ring or cup of the uterine manipulator must be identified. The colpotomy is begun in the anterior portion and is made with the hook cautery. This acts to further isolate the uterine arteries. Surgeon's preference may dictate coagulating the uterine arteries before the colotomy is made or as they are identified while creating the colpotomy. The arteries are coagulated and sealed using the fenestrated bipolar grasper and transected with the monopolar hook. The colpotomy can then be completed using the hook. Once the uterus is detached and removed, our next step will be the closure of the vaginal cuff.

Robotic single-site suturing has great advantages over laparoscopic suturing because of the availability of wristed instruments. The wristed needle driver is, in fact, the only wristed instrument in the set. When closing the vaginal cuff, the fenestrated arm can remain on the left arm to allow for grasping of the vaginal cuff. The monopolar hook is replaced with the wristed needle driver. The wristed singlesite needle driver's movements are slightly more encumbered in comparison to the multiport version, however it is still wristed and allows for increased articulation

for driving a needle. Another difference is the loss of strength or torque in using the single-site needle driver due to its curved flexible nature. My preferred suture and needle is a barbed 2.0 trimethylene carbonate suture on a P14 reverse cutting needle V-Loc™. Many authors have recommended this system for cuff closure when performing a robotic single-site hysterectomy [11]. This allows for an easier drive of the needle through the cuff for suturing. Another way to help with instrument torque or force if having trouble driving the needle, is to advance the trocars slightly inward to decrease the flexibility of the instruments. In my experience, mastery of traction and counter traction are the keys to successful closure. The needle is small enough to pass through the 8 mm air seal port for entry and removal. I recommend 1–2 redundant throws of the V-Loc™ stitch device in order to secure the suture line after completing the vaginal closure.

## **6. Closing the fascia**

Once the surgery has been safely completed, remove all trocars so that only the camera and assistant trocars remain and evacuate the gas. Next, grasp the gel port and place a lap sponge over the Gelport to prevent splashing and gently remove the port. To close the fascial opening, I recommend grasping the fascial edge with a kocher clamp and securing each edge with a figure-of-eight stitch using a 0 vicryl on a UR6 needle, and then holding the tissue with hemostat clamps. Next, with an army/navy, I recommend grasping the lateral edges and displacing them outward and then upward using the hemostats. This will bring the fascia away from the underlying bowel. Finally, finish closing the fascia with several more figure-ofeight sutures. Generally, approximately 4–5 figure-of-eight sutures are needed to complete the closure. Lastely, I recommend reapproximating the subcutaneous tissues with 3–0 vicryl and performing skin closure with 4–0 monocryl followed by Dermabond™ adhesive.

### **7. Special considerations**

There are surgical considerations when performing robotic single-site laparoscopic surgery.

Visually the surgeon will be operating from the midline or a slightly off center position. In these situations, a 30-degree scope can be very helpful. Camera movements and instrument movements are all occurring in a very confined space within the center of the screen. Surgical instruments cannot cross or move to as far as their multiport versions can. They cannot reach opposite ends of the screen. As the instruments follow camera movement, camera clutching and instrument movements are frequently needed in order to move around the surgical field and operate safely and effectively. Instrument tips are typically working side by side.

In addition, the surgical assistant controlling the assistant port may have a challenging task. They will have limited freedom of movement and need to keep their instrument in the view of the camera at all times. The assistant must carefully control the movement of their instrument, such as a suction irrigator or a grasper. One technique to give the accessory port some additional freedom is to occasionally pull back on the camera and attempt to visualize the operative area from under the assistant's instrument. This technique resembles diving downward in practice. Generally, this will create some freedom of operation to avoid collision with your assistant's instrument. Care and vigilance must be taken, however, because too

**65**

**8. In conclusion**

**Table 2.**

Superior cosmetic incision Suturing is made easier

Competitive surgical cost

*Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

much movement may still move the assistant which can lead to unintended tissue trauma. As a result, constant coordination between the movements of the surgeon

If during a robotic single-site case, the surgeon encounters complex pathology and the case becomes too difficult to complete through single-site technique, the surgeon then has several options. The operator is able to utilize the 4th arm of the DaVinci robot and add an extra lateral single multiport trocar. This allows for utilization of an extra multiport surgical arm and the use of a full wristed surgical instrument such as a Vessel Sealer or Monopolar Scissors. This conversion makes it a robotic single-site plus one surgery. If the surgeon continues to have difficulty safely completing the surgery, then the robotic single-site surgery can be fully converted to traditional robotic multiport by removing the curved trocars and adding both right and left lateral abdominal multiport trocars. The gelport with the camera trocar can remain along with the assistant port or the assistant port can be moved to a more traditional site. This allows the surgery to remain a minimally invasive

Once the surgeon operates consistently and becomes more comfortable and confident another port option is the GelPoint™ or GelPoint Mini™ from Applied Medical. The GelPoint and Gelpoint mini allows for a smaller 2.0–2.5 cm incision and an increased range of motion with your single-site instruments. We do not recommend starting single site training with these ports because of the increased range of the instruments can lead to sudden slippage. This can lead to uncontrolled movements and possible surgical complications. Instrument control must be mastered prior to attempting these modifications. Also, the gel interface of the Gelpoint™ is known to be more prone to leaking gas due to tearing than it's Gelport™ counterpart. To negate this loss of gas, an AirSeal™ port can be used to

High Definition 3D immersed vision console The loss of instrument strength and torque

No instrument clashing Surgical assist movements are limited

Minimally invasive surgery continues to evolve providing dedicated surgeons with the instruments and confidence to bring less invasive procedures to patients. I have enjoyed learning and mastering these skills over the years. I have experienced great patient satisfaction as well and personal satisfaction in my surgical journey. I look forward along with many of my colleagues to the future and the continued

advancements of minimally invasive surgery and robotics.

and the surgical assistant is critical for safe, effective surgery.

approach before needing to convert to laparotomy.

hold the pneumoperitoneum (**Table 2**).

Port incision allows for large tissue extraction

*Advantages and disadvantages of single port robotic surgery.*

**Advantages Disadvantages**

Complete instrument and camera control Loss of wristed instruments Superior instrument movement Limited range of motion

#### *Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

after completing the vaginal closure.

**6. Closing the fascia**

Dermabond™ adhesive.

scopic surgery.

**7. Special considerations**

for driving a needle. Another difference is the loss of strength or torque in using the single-site needle driver due to its curved flexible nature. My preferred suture and needle is a barbed 2.0 trimethylene carbonate suture on a P14 reverse cutting needle V-Loc™. Many authors have recommended this system for cuff closure when performing a robotic single-site hysterectomy [11]. This allows for an easier drive of the needle through the cuff for suturing. Another way to help with instrument torque or force if having trouble driving the needle, is to advance the trocars slightly inward to decrease the flexibility of the instruments. In my experience, mastery of traction and counter traction are the keys to successful closure. The needle is small enough to pass through the 8 mm air seal port for entry and removal. I recommend 1–2 redundant throws of the V-Loc™ stitch device in order to secure the suture line

Once the surgery has been safely completed, remove all trocars so that only the camera and assistant trocars remain and evacuate the gas. Next, grasp the gel port and place a lap sponge over the Gelport to prevent splashing and gently remove the port. To close the fascial opening, I recommend grasping the fascial edge with a kocher clamp and securing each edge with a figure-of-eight stitch using a 0 vicryl on a UR6 needle, and then holding the tissue with hemostat clamps. Next, with an army/navy, I recommend grasping the lateral edges and displacing them outward and then upward using the hemostats. This will bring the fascia away from the underlying bowel. Finally, finish closing the fascia with several more figure-ofeight sutures. Generally, approximately 4–5 figure-of-eight sutures are needed to complete the closure. Lastely, I recommend reapproximating the subcutaneous tissues with 3–0 vicryl and performing skin closure with 4–0 monocryl followed by

There are surgical considerations when performing robotic single-site laparo-

Visually the surgeon will be operating from the midline or a slightly off center position. In these situations, a 30-degree scope can be very helpful. Camera movements and instrument movements are all occurring in a very confined space within the center of the screen. Surgical instruments cannot cross or move to as far as their multiport versions can. They cannot reach opposite ends of the screen. As the instruments follow camera movement, camera clutching and instrument movements are frequently needed in order to move around the surgical field and operate

safely and effectively. Instrument tips are typically working side by side.

In addition, the surgical assistant controlling the assistant port may have a challenging task. They will have limited freedom of movement and need to keep their instrument in the view of the camera at all times. The assistant must carefully control the movement of their instrument, such as a suction irrigator or a grasper. One technique to give the accessory port some additional freedom is to occasionally pull back on the camera and attempt to visualize the operative area from under the assistant's instrument. This technique resembles diving downward in practice. Generally, this will create some freedom of operation to avoid collision with your assistant's instrument. Care and vigilance must be taken, however, because too

**64**

much movement may still move the assistant which can lead to unintended tissue trauma. As a result, constant coordination between the movements of the surgeon and the surgical assistant is critical for safe, effective surgery.

If during a robotic single-site case, the surgeon encounters complex pathology and the case becomes too difficult to complete through single-site technique, the surgeon then has several options. The operator is able to utilize the 4th arm of the DaVinci robot and add an extra lateral single multiport trocar. This allows for utilization of an extra multiport surgical arm and the use of a full wristed surgical instrument such as a Vessel Sealer or Monopolar Scissors. This conversion makes it a robotic single-site plus one surgery. If the surgeon continues to have difficulty safely completing the surgery, then the robotic single-site surgery can be fully converted to traditional robotic multiport by removing the curved trocars and adding both right and left lateral abdominal multiport trocars. The gelport with the camera trocar can remain along with the assistant port or the assistant port can be moved to a more traditional site. This allows the surgery to remain a minimally invasive approach before needing to convert to laparotomy.

Once the surgeon operates consistently and becomes more comfortable and confident another port option is the GelPoint™ or GelPoint Mini™ from Applied Medical. The GelPoint and Gelpoint mini allows for a smaller 2.0–2.5 cm incision and an increased range of motion with your single-site instruments. We do not recommend starting single site training with these ports because of the increased range of the instruments can lead to sudden slippage. This can lead to uncontrolled movements and possible surgical complications. Instrument control must be mastered prior to attempting these modifications. Also, the gel interface of the Gelpoint™ is known to be more prone to leaking gas due to tearing than it's Gelport™ counterpart. To negate this loss of gas, an AirSeal™ port can be used to hold the pneumoperitoneum (**Table 2**).


**Table 2.**

*Advantages and disadvantages of single port robotic surgery.*
