We present the first gynecologic study using a dedicated robotic single-site platform. Our laboratory animal data indicate that single-port robotic surgery using the novel single-site platform is feasible and safe for a variety of gynecologic procedures. No difference in mean operating times was noted between the sides of the procedure (ie, right oophorectomy vs. left oophorectomy). Complex procedures such as lymph node dissections and anastomosis were feasible without the addition of extra trocars, or marionette techniques, or both of these together. Finally, our data demonstrated that after proper training of surgeons (didactics and dry laboratory), robotic single-port insertion and docking times in the animal model decreases with the number of procedures performed.
In the last decade, numerous studies have demonstrated that laparoscopic approaches to various gynecologic conditions including oncology is feasible and results in shorter hospital stays, improved quality of life and comparable surgical outcomes to those of laparotomy.3–6
Single-port laparoscopic surgery has been introduced as a further development of laparoscopy. The concept of multiple instruments and optics operating through a single incision give rise to specific challenges and unique ergonomic problems not previously encountered with conventional laparoscopy.
For instance, triangulation is needed for proper dissection while providing effective traction and countertraction during surgery; a task that is easily achievable with conventional laparoscopy is by far more difficult with single-port laparoscopy. External and internal conflicts also represent an important challenge. Instrument crowding is perhaps the most frustrating aspect of this new modality. This has improved somewhat with the development of streamlined profile flexible camera systems and by using instruments of different lengths and articulation.
Robotics may overcome some of the technical limitations of single-port laparoscopy. The da Vinci robotic surgical system (Intuitive Surgical, Inc.) has gained tremendous popularity among gynecologists as an adjunctive tool for minimally invasive gynecologic surgery. Robotic-assisted surgery offers advantages, such as 3-dimensional visualization, scaling of movement, and range of motion superior to that with conventional laparoscopy.
Initial experience with robotic LESS was reported by Haber et al.7
Subsequently, Kaouk et al8
reported the first robotic single-port transumbilical surgery in urology by performing a successful radical prostatectomy and nephrectomy. Our group reported the first experience with robotic-assisted single-port surgery utilizing the da Vinci-S platform.9,10
Advantages like 3-dimensional visualization of the operative field, decreasing tension tremor of the surgeon, and added wrist motion for improved dexterity and greater surgical precision allowed the completion of multiple gynecologic procedures including hysterectomy, oophorectomy, and lymph node dissections. However, we believe there are several factors and limitations intrinsic to using the da Vinci-S or Si platform for single-port surgery that merit further discussion.
First, although the capabilities of the da Vinci S and Si platforms to dock at different positions and target different organs is well established, it follows the aforementioned classical surgical concepts (ie, triangulation of target anatomy by placement of multiple robotic trocars at different angles, etc). Second, hardware (robotic trocars, cannulas, instrumentation, optics) and software were not designed for single-incision surgery. Inverting controls of the robotic systems (right to left and vice versa) may allow the surgeon to operate without crossing the hands at the console; however, the robotic arms are crossed internally. This internal crossing presents a limitation of movement during pelvic surgery especially when working laterally (ie, side wall) or with large uteri. Finally, commercially available port systems were not designed for single-port robotics. Docking and advancing cross-rigid robotic instruments is inherently dangerous and may cause disruption of the port system.
Clearly, several objections can be raised to the arguments we have presented. Surgeons proficient in single-port operative laparoscopy performed all of the cases. However, as with most technology, a learning curve is required to become proficient. There are no published data for single-port operative laparoscopy, but it is expected that robotics will enable more surgeons to adopt this approach to surgery. This article demonstrates the potential for this new technology. Although the robotic single-site platform clearly offers advantages over conventional single-port laparoscopy in terms of 3-dimensional visualization of the operative field, and decreasing tension tremor of the surgeon, it lacks wrist motion for improved dexterity and surgical precision. This major limitation is akin to conventional laparoscopy or single-port surgery. Whether this platform would be superior in terms of performance and surgical outcomes to conventional single-port laparoscopy remains to be seen in clinical trials.
Benefits beyond cosmesis of single-port laparoscopy over conventional laparoscopy are beginning to emerge. Recent data demonstrated improved blood loss, hospital stay, and pain scores in women who underwent single-port hysterectomy.11,12
Nevertheless, initial learning curve studies suggest that the learning curve for complex single-port procedures is similar to that of conventional laparoscopic cases.13
Further prospective studies will be required to confirm these results.