Leading article

Single-port robotically assisted laparoscopic surgery G. Spinoglio and L. M. Lenti Department of General and Oncological Surgery, Santissimi Antonio e Biagio Hospital, Via Venezia 16, 15121, Alessandria, Italy (e-mail: [email protected])

Published online 20 November 2013 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9291

In the past 20 years surgical techniques have moved towards a less invasive approach from open to laparoscopic to single-incision laparoscopic surgery (SILS). This last technique was developed to reduce body wall trauma and improve cosmesis1,2 . In doing so, this was at the risk of losing some of the advantages of multiport surgery, notably triangulation and ergonomic acceptability. The da Vinci Single-Site Robotic Platform (Intuitive Surgical, Sunnyvale, California, USA) appears to overcome many of the intrinsic limitations of SILS3 , permitting more precise surgical actions, by increasing freedom of movement and restoring intuitive control of the instruments. The main innovations are the use of flexible instruments introduced through curved cannulas, crossed at the level of the abdominal wall, restoring the triangulation and the correct hand–instrument correlation through the da Vinci software. The curvature of the cannulas, crossing inside the port, increases the distance between instrument tips, allowing each to reach the target anatomy in a convergent way. The intra-abdominal instrument position is reversed: the instrument that enters the abdomen from the left, reaches the operative field on the right, and vice versa. The da Vinci software automatically associates the surgeon’s hands with the ipsilateral instrument tips, restoring the intuitive control. Although the Single-Site platform was designed primarily to work in a confined operative field with a specific anatomical target, such as the  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

gallbladder, the system has also been used for colonic surgery. During single-incision laparoscopic cholecystectomy (SILC), because of the parallelism of the instruments, lateral traction demands crossing the instruments inside the abdomen and the surgeon’s hands outside. The robotic Single-Site platform allows perfect triangulation to display Calot’s triangle, as in four-trocar laparoscopic cholecystectomy, with the added benefits of a stable threedimensional high-definition view, precision, dexterity, ease and safety in changing instruments4 . The recent introduction of a nearinfrared fluorescent vision system into the Single-Site platform should increase safety during cholecystectomy. After an intravenous injection of indocyanine green during patient preparation, the surgeon can quickly switch between normal viewing mode to fluorescence in order to obtain an intraoperative dynamic fluorescent cholangiogram5 . Although current literature includes only some 70 patients who have undergone single-site robotic cholecystectomy (SSRC), this is probably only a small proportion of the actual population that has had this type of surgery. At the authors’ own centre, 130 fully robotic SSRCs have now been performed, without conversion6,7 . Mean (range) operating, docking and console times were 68 (35–125), 3·8 (3–8) and 23·4 (10–61) min respectively. Most patients were discharged within 24 h of the surgical procedure. At 2month follow-up, two patients (1·5 per cent) had developed an incisional hernia.

A comparison of operating times between the first 25 SSRC and the first 25 SILC procedures performed by the same surgeon was used to assess learning curve differences6 . With SILC, operating time decreased with increasing number of procedures. In contrast, SSRC operating times were lower than those of SILC from the outset, with no evidence of a specific learning curve. The close analogy of the singlesite robotic approach with four-port laparoscopic cholecystectomy suggests that a surgeon who is proficient in the latter procedure might need only a very short training period in SSRC to achieve acceptable operating times without major complications8 . In colonic surgery, the literature suggests that the SILS approach is safe and feasible in selected patients, the most frequently reported procedure being right hemicolectomy with umbilical access9 . Problems of triangulation, internal and external instrument collision, and display of key anatomical features are raised regularly. Following local experience with SSRC, the robotic Single-Site platform has been used to test its feasibility and safety in colonic surgery, with the same technical steps as in the conventional minimally invasive multiport approach (either laparoscopic or robotic). During multiport right colectomy, the telescope is placed in the middle of a line joining the umbilicus and anterior superior iliac spine10 , in order to visualize clearly the mesenteric root and perform en bloc lymphadenectomy, exposing the anterior surface of the mesenteric vessels. To BJS 2014; 101: 3–4

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replicate this kind of view in singlesite robotic right colectomy, the port is placed through a left-sided suprapubic incision that is enlarged toward the right side like a Pfannenstiel incision for specimen extraction at the end of the operation. It seems likely that, at least in patients with a low body mass index and small tumours, the robotic SingleSite platform might be easier, and enable a more accurate lymphadenectomy to be performed compared with SILS, as a result of stable threedimensional vision, absence of tremor, and lack of internal and external conflicts. Many of the inherent limitations of SILS can be overcome by SSRC. Evidence gained from cholecystectomy suggests that wider evaluation in the context of colonic surgery is reasonable. As with the introduction of other novel surgical applications, detailed registries and full accountability within nationally agreed frameworks should be fundamental elements, to safeguard patients and establish whether or not there are real benefits from this type of surgery. Disclosure

G. Spinoglio and L. M. Lenti

References 1 Mutter D, Callari C, Diana M, Dallemagne B, Leroy J, Marescaux J. Single port laparoscopic cholecystectomy: which technique, which surgeon, for which patient? A study of the implementation in a teaching hospital. J Hepatobiliary Pancreat Sci 2011; 18: 453–457. 2 Prasad A, Mukherjee KA, Kaul S, Kaur M. Postoperative pain after cholecystectomy: conventional laparoscopy versus single-incision laparoscopic surgery. J Minim Access Surg 2011; 7: 24–27. 3 Kroh M, El-Hayek K, Rosenblatt S, Chand B, Escobar P, Kaouk J et al. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc 2011; 25: 3566–3573. 4 Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, Georgiou M. Cholecystectomy using a novel Single-Site robotic platform: early experience from 45 consecutive cases. Surg Endosc 2012; 26: 2687–2694. 5 Ishizawa T, Tamura S, Masuda K, Aoki T, Hasegawa K, Imamura H et al. Intraoperative fluorescent cholangiography using indocyanine green: a biliary road map for safe

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surgery. J Am Coll Surg 2009; 208: e1–e4. Spinoglio G, Lenti LM, Maglione V, Lucido FS, Priora F, Bianchi PP et al. Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience. Surg Endosc 2012; 26: 1648–1655. Spinoglio G, Priora F, Bianchi PP, Lucido FS, Licciardello A, Maglione V et al. Real-time near-infrared (NIR) fluorescent cholangiography in single-site robotic cholecystectomy (SSRC): a single-institutional prospective study. Surg Endosc 2013; 27: 2156–2162. Pietrabissa A, Sbrana F, Morelli L, Badessi F, Pugliese L, Vinci A et al. Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology. Arch Surg 2012; 147: 709–714. Ostrowitz MB, Eschete D, Zemon H, DeNoto G. Robotic-assisted single-incision right colectomy: early experience. Int J Med Robot 2009; 5: 465–470. Spinoglio G, Summa M, Priora F, Quarati R, Testa S. Robotic colorectal surgery: first 50 cases experience. Dis Colon Rectum 2008; 51: 1627–1632.

The authors declare no conflict of interest.

 2013 BJS Society Ltd Published by John Wiley & Sons Ltd

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Single-port robotically assisted laparoscopic surgery.

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