**4.1 Tips and tricks**


#### **5. The robotic single site system**

The single site robotic system consists of three main components — the port, the individual instruments, and the various trocars.

#### **5.1 The single site port**

The robotic port is a flexible hourglass shaped device designed to sit in the umbilicus. It has a lip on each end. The inner lip is designed to sit in the peritoneal cavity and the outer lip above the skin. The port itself has four lumens for the various single site trocars and an insufflation channel with a plastic trocar embedded in it. An arrow is present on the exposed lip and the port should be oriented so that this arrow points towards the intended operative field. The two channels closest to the operative field are for the camera trocar and the assistant trocar (**Figures 6** and **7**). The two port channels furthest away for the operative field (or more cephalad in the case of gynecologic surgery) are for the single site trocars.

In preparation for port insertion, place a Kocher clamp laterally on each side of the incision, holding both the peritoneum and the fascia together. Lifting these clamps provides counter traction to facilitate port insertion and holding both the peritoneum and the fascia together prevents pre-peritoneal insertion of the port. Some surgeons alternatively prefer to use "S" shaped retractors to elevate the

anterior abdominal wall instead of Kocher clamps; however, I have found this method less effective. Two long Kelly clamps are then placed on the port as shown (**Figure 7**). With the surgeon's non-dominant hand steadying the port, the dominant hand holds the inferiorly placed Kelly clamp and inserts the port into the

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

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

*Robotic port with the camera trocar and assistant trocar in place.*

**Figure 6.** *Robotic port.*

**Figure 7.**

**19**

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

**4.1 Tips and tricks**

both the skin and fascia.

in the usual manner

**5.1 The single site port**

**18**

**5. The robotic single site system**

individual instruments, and the various trocars.

1.Aggressive incisions in the skin and fascia facilitate entry, and hesitant

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

incisions complicate entry. The base and stalk of the umbilicus is composed of thick fibrotic scar tissue, thicker than any other part of the anterior abdominal wall. A number 15 scalpel is used, as bigger blades may not reach the base of the umbilicus, especially if it is anatomically smaller. Generally, the entire length of the number 15 blade is needed to achieve proper incision depth in

2.Not infrequently a hernia is encountered in the umbilicus during initial entry. Virtually all of these are fat containing. Excision of any excess fat with unipolar cautery easily restores normal anatomy, and the operation then continues as planned. When an umbilical hernia is encountered upon entry, closure of the umbilicus at the end of surgery is done with either a permanent suture such as

0-Prolene or a significantly delayed absorbable suture such as 0-PDS.

approximated with a permanent suture such as 0-Prolene

3.Patients with a previous umbilical hernia repair require special attention. If mesh present, entry is accomplished by making an incision through the mesh just as it is performed for the fascial incision. During closure, the mesh is re-

4.Periumbilical adhesions can also complicate surgical entry. When these are encountered, the fascia is elevated with Kocher clamps and the adhesions are lysed sharply under direct visualization as far as possible. Insertion of a laparoscopic single site port with a small intra-abdominal footprint (such as the Covidien SILS port or the Gel-Point Mini) then allows for further

adhesiolysis laparoscopically under direct visualization. Once the adhesions are taken down, the robotic single site port can then be inserted without difficulty

The single site robotic system consists of three main components — the port, the

The robotic port is a flexible hourglass shaped device designed to sit in the umbilicus. It has a lip on each end. The inner lip is designed to sit in the peritoneal cavity and the outer lip above the skin. The port itself has four lumens for the various single site trocars and an insufflation channel with a plastic trocar embedded in it. An arrow is present on the exposed lip and the port should be oriented so that this arrow points towards the intended operative field. The two channels closest to the operative field are for the camera trocar and the assistant trocar (**Figures 6** and **7**). The two port channels furthest away for the operative field (or more cephalad in the case of gynecologic surgery) are for the single site trocars. In preparation for port insertion, place a Kocher clamp laterally on each side of the incision, holding both the peritoneum and the fascia together. Lifting these clamps provides counter traction to facilitate port insertion and holding both the peritoneum and the fascia together prevents pre-peritoneal insertion of the port. Some surgeons alternatively prefer to use "S" shaped retractors to elevate the

**Figure 7.** *Robotic port with the camera trocar and assistant trocar in place.*

anterior abdominal wall instead of Kocher clamps; however, I have found this method less effective. Two long Kelly clamps are then placed on the port as shown (**Figure 7**). With the surgeon's non-dominant hand steadying the port, the dominant hand holds the inferiorly placed Kelly clamp and inserts the port into the

**Figure 8.** *Kocher clamps placed on robotic port to facilitate 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 the Trendelenburg position.
