**5.2 Tips and tricks**

1. Initial placement of the robotic port can be a challenge when the umbilicus is relatively deep, as it can be difficult to place the inner lip of the port past the peritoneum. To overcome this, it helps to place an extra small Alexis retractor in the umbilicus. Once the Alexis retractor is folded down, the depth of the umbilicus is reduced, and the peritoneum is pulled upward towards the skin. Using two Kocher clamps to elevate the fascia bilaterally, the robotic port can then be placed in the umbilicus inside the Alexis retractor. Some surgeons routinely use this technique to place the robotic single incision port (**Figures 9** and **10**).

2.The robotic single site port is relatively fragile. Excessive force will cause it to tear which can lead to difficulty maintaining an adequate pneumoperitoneum during surgery. If difficulty is encountered with insertion, enlarge the skin and

fascial incisions by a millimeter or two and re-attempt port placement.

*Second Kocher clamp drags the port completely into the umbilicus after removing the first clamp.*

*Initial Kocher clamp slides the robotic port into the abdomen in a "C" shaped motion.*

*Fundamentals of the Robotic Assisted Laparoscopic Single Port System and Utility in Minor…*

*DOI: http://dx.doi.org/10.5772/intechopen.96588*

**Figure 9.**

**Figure 10.**

**21**

*Fundamentals of the Robotic Assisted Laparoscopic Single Port System and Utility in Minor… DOI: http://dx.doi.org/10.5772/intechopen.96588*

**Figure 9.** *Initial Kocher clamp slides the robotic port into the abdomen in a "C" shaped motion.*

**Figure 10.** *Second Kocher clamp drags the port completely into the umbilicus after removing the first clamp.*

2.The robotic single site port is relatively fragile. Excessive force will cause it to tear which can lead to difficulty maintaining an adequate pneumoperitoneum during surgery. If difficulty is encountered with insertion, enlarge the skin and fascial incisions by a millimeter or two and re-attempt port placement.

abdomen with a "C" shaped motion. It is important to assure that the leading edge of the port is in the abdominal cavity at this time. While applying constant pressure to hold the port in place with the surgeon's non-dominant hand, the dominant hand then removes the inferior Kelly clamp and grabs the superior one. Final insertion of the port is then accomplished by pushing the second clamp in a vertical direction, essentially dragging the port into the umbilicus (**Figure 8A** and **B**). During insertion of the port, the assistant provides constant counter traction by elevating the anterior abdominal wall with the Kocher clamps. Once the port is in the umbilicus, the second clamp is then removed. Before the Kocher clamps are removed, digital pressure is applied to the center of the port to push the port as deeply into the umbilicus as possible. When properly placed, the inner lip of the port should be located in the abdominal cavity and the outer lip above the level of the skin. The port is then adjusted so that the arrow is pointed towards the operative field. This assures that, when the single site trocars are placed, they will be properly oriented to the surgical field. At this point the abdomen is inflated and the patient is placed in

1. Initial placement of the robotic port can be a challenge when the umbilicus is relatively deep, as it can be difficult to place the inner lip of the port past the

peritoneum. To overcome this, it helps to place an extra small Alexis retractor in the umbilicus. Once the Alexis retractor is folded down, the depth of the umbilicus is reduced, and the peritoneum is pulled upward towards the skin. Using two Kocher clamps to elevate the fascia bilaterally, the robotic port can then be placed in the umbilicus inside the Alexis retractor. Some surgeons routinely use this technique to place the robotic

the Trendelenburg position.

*Kocher clamps placed on robotic port to facilitate placement.*

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

single incision port (**Figures 9** and **10**).

**5.2 Tips and tricks**

**20**

**Figure 8.**

3.The key to easy port placement is to make sure that the tip of the second Kelly clamp is intra-peritoneal once the first Kelly clamp is removed. This allows the second Kelly clamp to pull the port into the abdomen rather than to push it in. Pushing it in often leads to tearing of the port. To maintain the proper location of the second Kelly clamp while removing the first one, the operator's nondominant hand needs to maintain firm and constant pressure holding the port in place. If the port slips out even slightly, the tip of the second Kelly will not be intraperitoneal.

camera trocar is introduced first. With the surgeon and assistant stabilizing the robotic port in the umbilicus, the trocar is placed through the appropriate channel in a direction parallel to the long axis of the port. Unlike multi-port robotic surgery, the robot is docked at this point, the camera trocar is attached to the appropriate robotic arm, and targeting is performed. Docking at this stage facilitates placement

*Fundamentals of the Robotic Assisted Laparoscopic Single Port System and Utility in Minor…*

To place the 5 mm curved single site trocars, the laparoscope is placed in the 30 degree up position and oriented 90 degrees from the pelvis towards the right lower quadrant of the abdomen. The intra-abdominal right sided trocar is placed first (from the left side of the patient). Using one hand to stabilize the port, the surgeon's other hand inserts the trocar through the port in a direction perpendicular to the long axis of the patient, from left to right. Once through the port and within the abdomen, the laparoscope can then visualize the tip of the trocar with the obturator in it. Under continuous laparoscopic visualization, the 5 mm trocar is then turned and advanced towards the pelvis until the thin black line on the trocar shaft reaches the robotic port. After placing the left-sided trocar into the right intra-abdominal space, the laparoscope is turned 180 degrees and oriented to visualize the left lower quadrant of the abdomen. The right-sided trocar is then placed into the left lower abdominal region using the same technique. The robotic arms are then docked to the curved trocars. Keeping the laparoscope in the 30 degree up position the assis-

1.Lubricating the trocars makes insertion easier. Surgilube lubricating jelly helps. However, in my experience, coating the trocars and obturator tip with a little blood and grease from the umbilical incision works best and makes trocar

operative field with both trocars visible on the monitor. This orients the trocars

The robotic single site instruments are all 5 mm, semi-rigid, and flexible. The semi-rigid nature of the instruments allows them to effectively manipulate tissue. The flexibility allows them to be inserted through the curved single site trocars. However, that flexibility comes at a price — the grasping power of the instruments is significantly weaker than standard robotic instruments. This makes it harder to hold tissue on tension, and it makes needles in the needle driver more likely to pivot with any lateral tension. Another drawback is that the only instruments with electrical energy are the unipolar hook and the bipolar forceps. The scissors have no electrical power. The robotic single site instruments currently

2.When attaching the robotic arms to the trocars, it helps to visualize the

of the additional trocars.

*DOI: http://dx.doi.org/10.5772/intechopen.96588*

**6.1 Tips and tricks**

insertion very smooth.

for easy docking.

**7. The instruments**

available are

**23**

• 5 mm Maryland Dissector

• 5 mm Suction Irrigator

• 5 mm Hem-o-Lok ML Clip Applier

tant trocar is then placed parallel to the camera trocar.
