**6. The trocars**

The camera trocar is straight and 8 mm in diameter. It is placed through the vertical middle channel between the plastic insufflation tube and the assistant trocar channel. The assistant trocars are also straight and either 5 mm or 10 mm in diameter. Either one can be placed through the vertical assistant channel adjacent to the camera trocar. The 5 mm single site trocars are curved and come in two sizes one shorter and one longer. They are placed through the remaining channels on the robotic port. These channels traverse the port diagonally, so that the right trocar emerges one the left side intra-abdominally, and vice versa. Once placed, the trocars criss cross each other in the port (**Figure 11**). All trocars are inserted until the thin black line on the trocars reaches the external edge of the port. All of the trocars have a blunt obturator to assist with insertion through the robotic port.

The trocars are inserted after the robotic port has been placed in the umbilicus, the abdomen insufflated, and the patient placed in Trendelenburg position. The

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

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 of the additional trocars.

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 assistant trocar is then placed parallel to the camera trocar.

### **6.1 Tips and tricks**

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

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

The camera trocar is straight and 8 mm in diameter. It is placed through the vertical middle channel between the plastic insufflation tube and the assistant trocar channel. The assistant trocars are also straight and either 5 mm or 10 mm in diameter. Either one can be placed through the vertical assistant channel adjacent to the camera trocar. The 5 mm single site trocars are curved and come in two sizes one shorter and one longer. They are placed through the remaining channels on the robotic port. These channels traverse the port diagonally, so that the right trocar emerges one the left side intra-abdominally, and vice versa. Once placed, the trocars criss cross each other in the port (**Figure 11**). All trocars are inserted until the thin black line on the trocars reaches the external edge of the port. All of the trocars have

The trocars are inserted after the robotic port has been placed in the umbilicus, the abdomen insufflated, and the patient placed in Trendelenburg position. The

*With the Alexis retractor secured to the umbilicus, and Kocher clamps attached to the fascia, the robotic port is*

a blunt obturator to assist with insertion through the robotic port.

be intraperitoneal.

**6. The trocars**

**Figure 11.**

**22**

*inserted in the usual manner.*


### **7. The instruments**

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 available are


While this appears to be a wide array of instruments, in reality, most single site surgery is performed primarily with the bipolar forceps, unipolar hook, and wristed needle driver. The bipolar forceps functions as a grasper. As a result, unless extra tension is needed for traction, most of the other graspers will be used infrequently. Without unipolar power, the scissors become less valuable. The scissors are probably most useful only when operating near bowel or other situations where unipolar energy may pose an unnecessary risk.

2.For instance, when performing a single site hysterectomy, I routinely utilize the 30 degree up positioning for most of the surgery. After isolating the uterine vessels, I grasp them with the single site instruments distally and proximally. My assistant can then easily secure the pedicle with a Ligasure device brought through the assistant trocar. The 30 degree up positioning also allows more freedom of movement for the assistant to manipulate tissue laterally and assist

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

3.The most obvious tip for facilitating the performance of single site robotic surgery is to add an 8 mm accessory robotic trocar laterally to the umbilicus. The colloquial term for this would be "single site plus one." A right-handed surgeon would likely place this on the patient's right side; the opposite placement is preferred for left-handed surgeons. All regular wristed robotic instruments are then potentially available to be placed through this port, including the Vessel Sealer, unipolar scissors, single tooth tenaculum, or needle drivers with (more wristing capability and more grasping power). Adding an 8 mm plus one port is a great way to get started with single site surgery.

4.Despite the fact that most single-site robotic gynecologic surgery is performed with the shorter curved trocars, one of the biggest difficulties to contend with is that the workspace is still limited. The trocars are fixed in length, and the instruments cannot be retracted back past the trocar tips. However, this limitation can be overcome with several strategies. First, it helps to pull the tissue to be operated on into the pelvis. This is somewhat counter-intuitive to the normal pelvic surgeon. In general, we tend to elevate tissue or push the pelvic organs cephalad with a vaginal manipulator. Retracting the tissue inferiorly pulls it into the workspace of the single site instruments. Second, a small advantage can be gained by pulling the single site trocars back slightly so

that the black line on the trocar is 1-2 cm above the robotic port. This technique can be helpful with larger pathology or if access is needed to the

5.Passing sutures and needles can only be done through the 10 mm assistant trocar. 10 mm needles tend to easily pass into the abdomen through the port.

pelvic brim or sacral promontory.

**25**

the surgeon.

*Single site trocars cross within the robotic port.*

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

**Figure 12.**

The unipolar hook is an instrument relatively unfamiliar to gynecologic surgeons. As a result, there is a learning curve associated with its use. However, most experienced surgeons readily adapt to it without much difficulty.
