**1. Introduction**

This chapter will introduce the single port robotic system. Topics include an introduction to the robotic single site port, the trocars, and the single site instruments. Step-by-step instruction is provided on how to create the umbilical incision and properly insert the single site port and trocars. The advantages and disadvantages of single port robotic surgery compared to multiple port robotic surgery and laparoscopic single site surgery are reviewed. Surgical tips and tricks are provided throughout each section to maximize efficiency, minimize complications, and overcome the inherent limitations of the robotic single site system. The utility of the robotic single site platform for performing minor gynecologic surgery is discussed in detail. Finally, a simple method for umbilical closure is described.

### **2. Advantages of robotic single site surgery**

Single site surgery, whether laparoscopic or robotic, offers several advantages over traditional multiple port surgery. The anatomy of the umbilicus is unique. It is the only part of the anterior abdominal wall where the skin and peritoneum are

located directly adjacent to each other, without intervening fat and muscle. As a result, the umbilicus provides easy access to the abdomen, even in morbidly obese patients. Furthermore, the stalk of the umbilicus is composed primarily of fibrotic scar tissue with minimal vascularity. Consequently, most umbilical incisions are relatively bloodless [1]. In addition, single site surgery obviously eliminates the risks associated with the placement of accessory trocars, including bleeding, flank hematomas, incisional hernias, and visceral injury. The lack of additional trocars also contributes to less post-operative pain [2, 3].

the left-sided instrument, even though, externally, these instruments and trocars

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

Compared to traditional multiple port robotic surgery, there are some disadvan-

Finally, the "working space" of the robotic single site system is limited compared to traditional robotic surgery. The trocar length is fixed, and the instruments cannot be retracted back any further than the tip of the trocars. This can make surgery more difficult in the setting of big pathology such as a large fibroid uterus or large ovarian cyst. In addition, in patients of short stature, the distance from the umbilicus to the pelvis is often smaller, and this can further compromise the functional

Access by the assistant surgeon can be compromised with the robotic single site system. Lateral movements can lead to repeated collisions (often coined "sword fighting") between the instruments and camera both inside the abdomen and outside. The most unencumbered instrument movements by the assistant are those performed in an anterior to posterior direction — parallel to the camera. Despite these disadvantages, the robotic single site system can readily handle most gynecologic surgery. Various techniques for overcoming these disadvantages are discussed

The initial step in any single site operation, whether robotic or laparoscopic, is the umbilical incision. Various incisions have been proposed, but the simplest, easiest, and most cosmetic approach is a midline vertical incision right through the center of the umbilicus. Local anesthesia (with or without epinephrine) is injected into the base of the umbilicus. Toothed forceps placed at the superior and inferior edges of the umbilicus are used to elevate the skin and an incision is made vertically through the center of the umbilicus. Allis clamps are then placed laterally and used to elevate the skin edges. With the edges elevated, the stalk of the umbilicus is palpated as a horizontal band of fascia in the center of the incision. Kocher clamps are then placed laterally on this fascia band, and the Allis clamps are removed. While elevating with the Kocher clamps, an incision is then made vertically in the fascia. The fascial incision is then sharply enlarged to allow the surgeon to bluntly enter the abdomen digitally. The skin and fascial incisions are then enlarged as needed. For robotic single site surgery, a 2-3 cm incision is required. This is slightly larger than what may be required for laparoscopic single site surgery, depending on the intended operation. The fascial incision should be extended vertically in both

directions until it is slightly larger than the skin incision (**Figures 2**–**5**).

tages to the single site robotic system. The robotic single site instruments are relatively primitive. There are no advanced energy instruments such as the harmonic scalpel or bipolar transection tools built into the robotic single site system. The only unipolar tool available is the hook; the scissors do not have any unipolar power capability. In addition, the required semi-rigid flexibility of the robotic single site instruments leads to a relatively weak grasping force. This is most readily apparent when attempting to suture with the needle driver or when trying to hold tissue on tension. Furthermore, even though the needle driver is wristed, it has less

are located on the opposite side (**Figure 1**).

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

**3. Disadvantages of robotic single site surgery**

range of motion than traditional robotic instruments.

in the "Tips and Tricks" section of this chapter.

workspace.

**4. Abdominal entry**

**15**

The most obvious advantage of single site surgery, however, is cosmesis. Even a 2-3 cm incision can be hidden in the umbilicus, and it often becomes virtually invisible as it heals [4]. The poor vascularity of the umbilicus also minimizes the risk for a postoperative hematoma and virtually eliminates the risk for keloid formation [5].

The most functional advantage of single site surgery is using the umbilical incision for specimen retrieval. The lack of intervening muscle and fat provides easy access to the surgical specimen. Specimen retrieval is easy, and any morcellation required is readily accomplished by bringing the specimen bag up through the umbilical incision [6].

Robotic single site surgery offers advantages over traditional laparoscopic single site surgery. The 3-D binocular vision provided by the robotic platform allows for better depth perception and facilitates more precise surgical movements. Although the only wristed instrument is the robotic needle driver, this is also a significant advantage over all "straight stick" laparoscopic instruments. The binocular vision and wristed needle driver greatly facilitate intracorporeal suturing and knot tying. The needle driver can also be employed as a grasper and its dexterity can improve exposure for adhesiolysis or facilitate the excision of an ovarian cyst. Finally, the robotic single site platform is more ergonomic and intuitive. Intra-abdominally, the surgeon's right hand controls the right sided instrument and the left hand controls

**Figure 1.** *Surgeon's right hand controls the right instrument intra abdominally and vice versa.*

the left-sided instrument, even though, externally, these instruments and trocars are located on the opposite side (**Figure 1**).
