Robotic Laparoscopic Single-Site Surgery

*Rene I. Luna*

## **Abstract**

Minimally invasive surgery has changed the landscape of women's surgical healthcare. Conventional and robotic laparoscopy are the preferred approach for many major minimally invasive gynecological procedures. However, the philosophy of minimally invasive surgery has been pushed to reduce the size and minimize the number of ports placed. Many conventional minimally invasive surgical procedures use 3–5 ports through multiple small incisions. Laparoscopic single site surgery tries to perform on that philosophy but has its limitations. Enters robotic surgery already a major force in minimally invasive surgery and now sets to remove the limitations of single site surgery. However it requires proper understanding of the instruments and the techniques for successful robotic single site surgery. It starts with patient selection. Knowing the instruments needed and the proper set up of those instruments. Then knowing how to use the instruments in operating and suturing and closing. And finish with special considerations.

**Keywords:** robotic single-site, patient selection, set up, port entry, instruments, first assist and closure, special considerations

### **1. Introduction**

Minimally invasive surgery has changed the landscape of women's surgical healthcare. Women are now able to undergo major surgeries as outpatient procedures leading to faster recoveries and more importantly, faster return to normalcy. Conventional and robotic laparoscopy are now the preferred approach for many major minimally invasive gynecological procedures. The predictable result has been a change in the overall philosophy of minimally invasive surgery in gynecology today. This philosophy constantly pushes to reduce the size of each trocar port and to minimize the number of ports placed. Currently, many conventional minimally invasive surgical procedures use 3–5 ports through multiple small incisions. Each port carries a small, but not statistically zero risk for a port site complication [1]. These port site complications may include bleeding, infection, organ injury, soft tissue trauma (leading to increased post op pain,) the risk of herniation and decreased final cosmesis [2].

Now with new instrumentation, as well as better visualization and greater surgeon dedication, procedures can be performed using a single incision port entry. This leads to often entirely concealing the incision at the umbilicus. The result is rewarding the patient and surgeon with a virtually scarless procedure [3].

This is not to say, however, that no challenges remain. Some of these new challenges Include mastering inline camera viewing, off center operating, the difficulty


#### **Table 1.**

*Instruments needed for robotic single port hysterectomy.*

of instrument crowding and a lack of instrument triangulation resulting in technically challenging laparoscopic single-site surgery. To try and improve on these challenges, the only commercially available system currently available, The Intuitive Robotic Surgical System™ comes equipped with a single-site robotic instrument set on their Si and Xi models. The Robotic single-site instruments provide and enable a broader range of instrument movement with flexible instruments which allows them to fit into curved trocars. The result is greatly improved triangulation and almost a complete elimination of instrument crowding. These changes significantly improve surgical movements allowing the surgeon to have greater motion and technical ease of operating. The surgeon has complete control of the camera and instruments and remains sitting at a comfortable surgeon console. This provides an extremely ergonomically friendly procedure, almost regardless of surgical time [4, 5]. This procedure, however, is not without its own challenges.

In the following sections, we will discuss patient evaluation, instruments needed, and some important differences between robotic multiport and robot single-site surgery. Further along we will go through the sequence of steps necessary for port placement and docking while performing a robotic single-site hysterectomy. We will then finish by discussing special considerations (**Table 1**).

#### **2. Patient evaluation**

The process of deciding the appropriate surgical route remains as recommended by the American College of Obstetricians and Gynecologists [6]. This generally means that a diligent surgeon should take into account the individual circumstances of the patient, along with the patient's medical and surgical histories, as include consideration of the particular surgeon's own skills as well as the modalities available prior to deciding on the final surgical route. However, when beginning robotic single-site surgery, patient selection is an even more important process. Patients with a body mass index (BMI) of less than 32 to 34 are going to be the best candidates due to the height of the single-site port trocar and the complex nature of laparoscopic surgery in more obese patients. An initial uterine size of 12 cm or smaller in length will also be ideal for port placement and maximize the comfortable range of instrument movements. A larger uterus will significantly

**57**

**Figure 1.**

*Intuitive Gelport(™).*

*Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

Important Differences from Multiport Robotics.

Hopefully in the future these costs will continue to decline.

and larger pathology.

**3. Set up**

port entries of the Gelport.

limit both of these aspects, requiring more advanced maneuvers to proceed. Also, a patient's surgical history, especially when indicating the likelihood of adhesive disease and/or adjacent adnexal disease may significantly raise the level of surgical difficulty and case complexity. In less experienced surgeons these cases should be initially avoided without proctorship and consideration may be given to less complex modalities such as conventional laparoscopy or laparotomy. Once comfortable and experienced, a surgeon's patient selection can then be opened to more complex

There are many important differences between robotic multiport and robotic single-site surgical platforms. There are no advanced instruments such as the Intuitive Vessel Sealer™ for use in the single-site set. The set does contain a full range of graspers, however they have no energy application available to them. As a result, with the standard set your energy comes from two instruments, a fenestrated bipolar grasper (for burning and sealing) and a monopolar hook (mainly for cutting.) Another major difference from Multiport is the loss of wristed instruments in the single-site set. In fact, only the needle driver instrument is wristed. All other single-site instruments are straight. Another major difference is that the instruments are flexible. While this maximizes triangulation, it also serves to take away from maximum instrument force and torque. This is most noticeable during suturing or "traction-counter-traction" movements. Because of these changes the single-site instruments actually cost less than the multiport instruments, which is an advantage. This cost change actually brings robotic single-site surgery closer in cost to conventional laparoscopic surgery than to multiport robotic assisted surgery [7].

Correctly completing the set-up process is extremely important to a successful surgery, as it allows instruments to be in their proper place to allow for maximum movement. When using the Intuitive Gelport™, there will be an arrow which needs to point towards the target anatomy when placed in the abdomen. This aligns the

#### *Robotic Laparoscopic Single-Site Surgery DOI: http://dx.doi.org/10.5772/intechopen.96226*

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

Instruments Needed for Robotic Single Port Hysterectomy

Uterine manipulator (surgeon's preference on type used)

*Instruments needed for robotic single port hysterectomy.*

30-degree robotic scope in downward position

Intuitive right and left curved trocars

Fenestrated Bipolar grasper

Single site wristed needle driver

Intuitive Gelport™

Monopolar hook

**Table 1.**

AirSeal™ insufflator 8 mm AirSeal™ port Bariatric suction tip

procedure, however, is not without its own challenges.

of instrument crowding and a lack of instrument triangulation resulting in technically challenging laparoscopic single-site surgery. To try and improve on these challenges, the only commercially available system currently available, The Intuitive Robotic Surgical System™ comes equipped with a single-site robotic instrument set on their Si and Xi models. The Robotic single-site instruments provide and enable a broader range of instrument movement with flexible instruments which allows them to fit into curved trocars. The result is greatly improved triangulation and almost a complete elimination of instrument crowding. These changes significantly improve surgical movements allowing the surgeon to have greater motion and technical ease of operating. The surgeon has complete control of the camera and instruments and remains sitting at a comfortable surgeon console. This provides an extremely ergonomically friendly procedure, almost regardless of surgical time [4, 5]. This

Barbed 2.0 trimethylene carbonate suture on a P14 reverse cutting needle V-Loc™

In the following sections, we will discuss patient evaluation, instruments needed, and some important differences between robotic multiport and robot single-site surgery. Further along we will go through the sequence of steps necessary for port placement and docking while performing a robotic single-site hyster-

The process of deciding the appropriate surgical route remains as recommended by the American College of Obstetricians and Gynecologists [6]. This generally means that a diligent surgeon should take into account the individual circumstances of the patient, along with the patient's medical and surgical histories, as include consideration of the particular surgeon's own skills as well as the modalities available prior to deciding on the final surgical route. However, when beginning robotic single-site surgery, patient selection is an even more important process. Patients with a body mass index (BMI) of less than 32 to 34 are going to be the best candidates due to the height of the single-site port trocar and the complex nature of laparoscopic surgery in more obese patients. An initial uterine size of 12 cm or smaller in length will also be ideal for port placement and maximize the comfortable range of instrument movements. A larger uterus will significantly

ectomy. We will then finish by discussing special considerations (**Table 1**).

**56**

**2. Patient evaluation**

limit both of these aspects, requiring more advanced maneuvers to proceed. Also, a patient's surgical history, especially when indicating the likelihood of adhesive disease and/or adjacent adnexal disease may significantly raise the level of surgical difficulty and case complexity. In less experienced surgeons these cases should be initially avoided without proctorship and consideration may be given to less complex modalities such as conventional laparoscopy or laparotomy. Once comfortable and experienced, a surgeon's patient selection can then be opened to more complex and larger pathology.

Important Differences from Multiport Robotics.

There are many important differences between robotic multiport and robotic single-site surgical platforms. There are no advanced instruments such as the Intuitive Vessel Sealer™ for use in the single-site set. The set does contain a full range of graspers, however they have no energy application available to them. As a result, with the standard set your energy comes from two instruments, a fenestrated bipolar grasper (for burning and sealing) and a monopolar hook (mainly for cutting.) Another major difference from Multiport is the loss of wristed instruments in the single-site set. In fact, only the needle driver instrument is wristed. All other single-site instruments are straight. Another major difference is that the instruments are flexible. While this maximizes triangulation, it also serves to take away from maximum instrument force and torque. This is most noticeable during suturing or "traction-counter-traction" movements. Because of these changes the single-site instruments actually cost less than the multiport instruments, which is an advantage. This cost change actually brings robotic single-site surgery closer in cost to conventional laparoscopic surgery than to multiport robotic assisted surgery [7]. Hopefully in the future these costs will continue to decline.
