**9. Closure of the umbilicus**

Once the port is removed, the fascia and peritoneum are closed with a single running non-locking 0 Vicryl suture. With the fascia closed, flaps are created bilaterally by undermining the skin on either side of the incision until all tension is released. This assures that the umbilicus will appear symmetric when finally closed. Several millimeters of skin are then trimmed on either side along the entire length of the vertical incision. More skin is trimmed from the center of the incision and less inferiorly or superiorly. Trimming of the skin improves blood flow to the edges. Given the generally poor blood flow to the umbilicus, freshening the edges improves healing. Additionally, trimming the skin makes the size of the incision smaller when it is ultimately closed; it tends to pull the incision into the umbilicus.

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

The base of the umbilicus is then recreated. One or two 2–0 Vicryl sutures on a non-cutting needle are then used to tack the middle of each half of the incision to the fascia. A non-cutting needle is used to avoid inadvertently cutting the fascial

#### **Figure 13.**

However, retrieval can be difficult and frustrating. Often the needle can get caught in the trocar tip, become dislodged from the grasper holding it, and fall back into the abdominal cavity. One solution is to anchor the used needles into the peritoneum in the midline of the anterior abdominal wall. Multiple needles can be stored in this manner, When the procedure is completed, the needles can be placed in a laparoscopic bag. Once the robotic port is removed, the bag

can be retrieved through the umbilicus with the needles in it.

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

with significant leakage of gas.

6.Make the umbilical incision as small as possible to allow placement of the robotic port. Too large an incision increases the risk for air leakage around the port and can lead to difficulty maintaining an adequate pneumoperitoneum during surgery. When creating the incision, keep in mind that it can always be made bigger, but it cannot be made smaller. If a 10 mm assistant trocar is not needed during the surgery, an 8 mm AirSeal trocar with a 5 mm channel (specifically made for robotic single site surgery) can be inserted through the robotic port. The AirSeal trocar will maintain the pneumoperitoneum even

7.When operating laterally the workspace can also be limited. Angling the camera way from the horizontal axis towards the lateral pelvis can overcome the obstacle. When the camera is angled, it allows for greater lateral movement of the single site instruments. Such a strategy helps access areas such as the

8.Cauterizing a vascular pedicle such as the infundibulopelvic ligament can take longer due to the weaker grasping power of the bipolar forceps. When bipolar cautery is engaged, bubbling can be seen around the forceps. The pedicle is adequately cauterized when the bubbling recedes. Cautery should continue

9.Most gynecologic surgery is performed using the shorter 5 mm curved trocars. However, the longer trocars can assist with suturing deep in the pelvis, particularly the vaginal cuff. The semi-rigid nature of the single site instruments can make it difficult to drive a needle through relatively tough tissue. The instruments tend to bend when tension is applied, and this weakens the force that can be applied to the needle in order to drive it through tissue. Exchanging the shorter 5 mm trocar for the longer one minimizes the bending of the needle driver when force is applied. This increases the driving force that

Once the port is removed, the fascia and peritoneum are closed with a single running non-locking 0 Vicryl suture. With the fascia closed, flaps are created bilaterally by undermining the skin on either side of the incision until all tension is released. This assures that the umbilicus will appear symmetric when finally closed. Several millimeters of skin are then trimmed on either side along the entire length of the vertical incision. More skin is trimmed from the center of the incision and less inferiorly or superiorly. Trimming of the skin improves blood flow to the edges. Given the generally poor blood flow to the umbilicus, freshening the edges improves healing. Additionally, trimming the skin makes the size of the incision smaller when it is ultimately closed; it tends to pull the incision into the umbilicus.

pelvic brim or the base of the infundibulopelvic ligament.

until this is seen, and only then should the pedicle be cut.

can be applied to the needle to drive it through tissue.

**9. Closure of the umbilicus**

**26**

*With the laparoscope in the 30 degree up position, the surgeon's assistant has easy access to the operative field. When the assistant places an instrument, it presents directly between both single site trocars.*

**Figure 14.** *Skin flaps are created bilaterally by sharply detaching the skin from the fascia until no tension remains.*

**Figure 15.** *Redundant skin.*

stitch. A deep bite is taken in the fascia to assure that the skin is securely attached. Interrupted inverted 3–0 Vicryl sutures on a cutting needle are then placed in the inferior and superior poles of the incision to reapproximate the skin. Care is taken to include a significant amount of subcutaneous fat with these sutures in order to bulk

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

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

*The skin of both sides of the incision is secured to the fascia with one or two absorbable sutures.*

A small amount of packing is placed in the umbilicus, and an eye patch trimmed to a 2–3 cm circle is placed over the packing. A medium Tegaderm patch is then placed over the trimmed eye patch. Using a small needle and a 10 ml syringe with reverse suction, the air under the Tegaderm is removed creating a negative pressure dressing. The needle should be placed through the Tegaderm and skin adjacent to the dressing not through the center over the eye patch, otherwise the negative

Minor gynecologic surgery generally encompasses surgery on the adnexa and excision of pelvic endometriosis. The single site robotic approach for minor gynecologic surgery offers advantages over both traditional multi-port laparoscopic and

In addition, with traditional multi-port laparoscopic or robotic surgery, specimen removal from the abdomen can be challenging. Often one of the incisions needs to be enlarged in order to extract the tissue, resulting in the potential for

robotic surgery. Compared to traditional multi-port surgery, the single site approach is more cosmetic, decreases postoperative pain, and removes the risk of

up the tissue at both poles of the incision (**Figures 13**–**17**).

**10. The utility of the single site robotic system for minor**

pressure will not be maintained.

**Figure 17.**

**gynecologic surgery**

trocar related complications.

**29**

**Figure 16.** *Redundant skin is trimmed.*

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

stitch. A deep bite is taken in the fascia to assure that the skin is securely attached. Interrupted inverted 3–0 Vicryl sutures on a cutting needle are then placed in the inferior and superior poles of the incision to reapproximate the skin. Care is taken to include a significant amount of subcutaneous fat with these sutures in order to bulk up the tissue at both poles of the incision (**Figures 13**–**17**).

A small amount of packing is placed in the umbilicus, and an eye patch trimmed to a 2–3 cm circle is placed over the packing. A medium Tegaderm patch is then placed over the trimmed eye patch. Using a small needle and a 10 ml syringe with reverse suction, the air under the Tegaderm is removed creating a negative pressure dressing. The needle should be placed through the Tegaderm and skin adjacent to the dressing not through the center over the eye patch, otherwise the negative pressure will not be maintained.
