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1.  Novel Port Placement and 5-mm Instrumentation for Robotic-Assisted Hysterectomy 
Background and Objectives:
The value of robotic surgery for gynecologic procedures has been critically evaluated over the past few years. Its drawbacks have been noted as larger port size, location of port placement, limited instrumentation, and cost. In this study, we describe a novel technique for robotic-assisted laparoscopic hysterectomy (RALH) with 3 important improvements: (1) more aesthetic triangular laparoscopic port configuration, (2) use of 5-mm robotic cannulas and instruments, and (3) improved access around the robotic arms for the bedside assistant with the use of pediatric-length laparoscopic instruments.
Methods:
We reviewed a series of 44 women who underwent a novel RALH technique and concomitant procedures for benign hysterectomy between January 2008 and September 2011.
Results:
The novel RALH technique and concomitant procedures were completed in all of the cases without conversion to larger ports, laparotomy, or video-assisted laparoscopy. Mean age was 49.9 years (SD 8.8, range 33–70), mean body mass index was 26.1 (SD 5.1, range 18.9–40.3), mean uterine weight was 168.2 g (SD 212.7, range 60–1405), mean estimated blood loss was 69.7 mL (SD 146.9, range 20–1000), and median length of stay was <1 day (SD 0.6, range 0–2.5). There were no major and 3 minor peri- and postoperative complications, including 2 urinary tract infections and 1 case of intravenous site thrombophlebitis. Mean follow-up time was 40.0 months (SD 13.6, range 15–59).
Conclusion:
Use of the triangular gynecology laparoscopic port placement and 5-mm robotic instruments for RALH is safe and feasible and does not impede the surgeon's ability to perform the procedures or affect patient outcomes.
doi:10.4293/108680813X13693422518399
PMCID: PMC4035625  PMID: 24960478
Robotic-assisted laparoscopic hysterectomy; 5-mm Robotic ports; Short laparoscopic instruments; Aesthetics
2.  Hybrid Single-incision Laparoscopic Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis for Ulcerative Colitis 
The Indian Journal of Surgery  2010;72(5):400-403.
Single-incision laparoscopic surgery is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery. We report one of the initial clinical experiences from India for Laparoscopic Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis (RPC IPAA) with this new technique. A SILSTM port was used through the curved intra-umbilical 25-mm incision. A 12-mm port was placed in the right iliac fossa at the ileostomy site. Another 5 mm port was placed in the left iliac fossa at the drain site. 10 mm 0 degree lens was used through the SILS port. Two 5 mm port were placed from the SILS port. Right iliac fossa port was the surgeon’s right hand port and left hand port was 5 mm SILS port. Left iliac fossa port and 5 mm SILS port were used by the assistant surgeon for retraction. The specimen was delivered through the umbilical incision by extending the incision for 1.5 cm on either side. Ileal J Pouch was created extracorporeally and then anastomosed to the anal canal with the circular stapler laparoscopically. The diverting loop ileostomy was brought out through the right iliac fossa 12 mm port. The pelvic drain was brought out through the left iliac fossa port. The procedure was completed without any perioperative complications. Operative time was 256 minutes. Postoperative follow-up did not reveal any umbilical wound complication. Till date we have performed 26 Laparoscopic RPC with IPAA and this was the first Single Incision Laparoscopic RPC with IPAA. For experienced laparoscopic colorectal surgeons, single incision laparoscopic colectomy (SILC) is feasible. Single-incision laparoscopic colectomy is a promising alternative method as minimally invasive abdominal surgery for the treatment of patients requiring colectomy.
doi:10.1007/s12262-010-0125-1
PMCID: PMC3077133  PMID: 21966141
Laparoscopic surgery; Incision; Single-incision laparoscopic colectomy; Single incision laparoscopic surgery
3.  Automated end-to-side anastomosis to the middle cerebral artery with C-Port xA: A feasibility study on human cadavers 
Asian Journal of Neurosurgery  2013;8(2):74-77.
Background:
Anastomosis to the superficial temporal artery is suitable in patients with functional and structural impairment of the middle cerebral artery (i.e., complex aneurysms and skull base tumors), as either definitive treatment or an additional safety measure. A shorter occlusion time or a non-occlusive technique is expected to reduce the risk of cerebral ischemia following the procedure. In this cadaver study, we assessed the fitness of C-Port xA® device for use in superficial temporal artery (STA)–middle cerebral artery (MCA) bypass.
Materials and Methods:
Seven fixed human head specimens were prepared through eight pterional craniotomies. The superficial temporal artery was dissected and the sylvian fissure was opened to access the MCA. The C-Port xA was tested on each of the eight exposures. We recorded the lengths of both donor and recipient vessel, the durations of the procedure and the craniotomy, and sylvian scissure opening sizes. The bypass was then assessed by pressure injection of methylene blue in the donor vessel.
Results:
C-Port xA-assisted STA–MCA anastomosis was successfully accomplished in seven dissections. A minimum STA length of 7 cm, a sylvian scissure opening larger than 5 cm, and a craniotomy size of at least 6 × 6 cm appeared to be the requisites for a safe maneuverability of the device. The MCA occlusion time lasted in all cases less than 4.5 min, and we observed a clear improvement in time performance with growing experience.
Conclusions:
The results suggest that the C-Port xA device is suitable for STA–MCA bypass. We experienced a shorter occlusion time and a shorter learning curve compared to conventional techniques. Further miniaturization and special adaptation of this device may allow a future application even to deeper intracranial vessels. Clinical trials will have to assess the long-term results and benefits of this minimal occlusive technique.
doi:10.4103/1793-5482.116377
PMCID: PMC3775185  PMID: 24049548
Automated end-to-side anastomosis; bypass; human cadavers; middle cerebral artery; superficial temporal artery
4.  Effectiveness of Postgraduate Training for Learning Extraperitoneal Access for Robot-Assisted Radical Prostatectomy 
Journal of Endourology  2011;25(8):1363-1369.
Abstract
Purpose
To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs.
Materials and Methods
The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes.
Results
The median setup time for EP was 26 minutes (range 15–65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001).
Conclusions
Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.
doi:10.1089/end.2011.0052
PMCID: PMC3180764  PMID: 21745117
5.  Simultaneous bilateral robotic partial nephrectomy: Case report and critical evaluation of the technique 
We report our first simultaneous bilateral robot assisted partial nephrectomy (RAPN) in order to show and critically discuss the feasibility of this procedure. Materials and methods A 69-year-old male patient visited our department due to incidental finding of bilateral mesorenal small masses (2.5 cm on the right and 3.5 cm on the left) suspicious for malignancy. We started from the right side with patient in flank position. Port placement: 12-mm periumbilical camera port, two 8-mm robotic ports in wide ‘‘V’’configuration, additional 12 mm assistant port on the midline between the umbilicus and symphysis pubis. A right unclamping RAPN with sliding clip renorrhaphy was performed. The trocars were removed and the robot undocked. Without interrupting the anesthesiological procedures, the patient was reported in supine position and, after 180 degrees rotation of the surgical bed, was newly placed in contralateral flank position. Using both the previous periumbilical and midline ports, two other 8-mm robotic trocars were placed. The robot was then redocked and RAPN was also performed on the left side using the same previously reported technique. Results Total time: 285 min. Estimated blood losses: 150 cc. Postoperative period: uneventful. Pathological examination: bilateral renal cell carcinoma, negative surgical margins. Conclusions Our experience was encouraging and confirmed the feasibility and safety of this procedure. The planning of our technique was time and cost effective with cosmetic benefit for the patient. However, we think that an appropriate selection of the patients and a skill in robotic renal surgery are advisable before approaching this type of surgery.
doi:10.12998/wjcc.v2.i6.224
PMCID: PMC4061314  PMID: 24945012
Robotics; Nephrectomy; Renal cell carcinoma; Remote operation robotics
6.  Functional Abdominal Pain Syndrome in Morbidly Obese Patients Following Laparoscopic Gastric Bypass Surgery 
Archives of Trauma Research  2014;3(1):e13110.
Background:
Roux-en-Y gastric bypass surgery (RYGBP) is one of the most common bariatric surgeries, which is being performed using various techniques like gastrojejunostomy by hand swen, linear or circular stapler. Abdominal pain is a common complaint following laparoscopic gastric bypass procedure (LGBP), which has different aetiologies, such as overeating, adhesion, internal herniation, bile reflux and many more. In this study LGBP was performed in an ante-colic ante-gastric pattern in a double loop manner and the prevalence and distribution of pain in morbidly obese patients undergoing LGBP was assessed.
Objectives:
The aim of this study was to analyze the distribution and frequency of post LGBP pain in morbidly obese patients.
Patients and Methods:
This study was performed on 190 morbidly obese patients referred to Hazrat Rasoul Hospital in Tehran. After LGBP, pain was measured in the following intervals: 24 hours, one week and one month after the operation. Before the operation onset, 2 mg Keflin and 5000 IU subcutaneous heparin were administered as prophylaxis. LGBP was performed using five ports including: one 11 mm port was placed 15-20 cm far from the xiphoid, one 12-mm port in mid-clavicular line at the level of camera port, one 5-mm port in subcostal area in ante-axillary region in the left, another 5-mm port in the right mid-clavicular area and a 5-mm port in sub-xyphoid. All operations were done by the same team. Staple was used for all anastomoses and hand sewn technique to close the staple insertion site. The mesenteric defect was left open and no effort was made to repair it.
Results:
The results of this study showed that 99.94 % of the patients had complains of pain in the first 24 hours of post operation, about 60% after one week and 29.5 % still had pain after one month. In addition, left upper quadrant (LUQ) was found to be the most prevalent site for the pain in 53.7% of the patients in the first 24 hours, 59.6% after one week and 16.8% after one month (except for obscure pain) with a significance of < 0.05.
Conclusions:
In this study, the authors analyzed the location and disturbance level of pain after LGBP, which could serve as a cornerstone for further researches. The authors suggest that long-term follow-up (for more than a year after operation) should be considered in future studies and also the relationship between the drainage site and pain should be investigated.
doi:10.5812/atr.13110
PMCID: PMC4080767  PMID: 25032167
Surgical Procedures, Minimally Invasive; Abdominal Pain; LGBP Protein; Pacifastacus Leniusculus
7.  Single-Site Robotic Cholecystectomy 
Background:
Laparoscopic single-incision surgery is fraught with significant technical drawbacks but has witnessed increased growth mainly for its presumed aesthetic advantages. Recently, a single-site robotic platform has been introduced to alleviate some of the technical challenges with laparoscopic single-site surgery, although literature on this topic is scant. The aim of this study is to analyze the experience of a single surgeon with single-site robotic cholecystectomies since the U.S. Food and Drug Administration gave its approval in December 2011, and to evaluate the robotic platform's safety and short-term surgical outcomes.
Methods:
From February 1st 2012 to February 28th 2013, patients who underwent single-site cholecystectomy at an academic institution in the United States were retrospectively reviewed from a prospectively maintained database. The following variables were analyzed: age, sex, body mass index, previous surgeries, total operative time, port insertion time, docking time, console time, estimated blood loss, closure time, conversion to open or multiport approach, postoperative outcomes for wound infection, bile leak, biliary ductal injury, right hepatic artery injury, reoperations, readmission, and mortality. Indication for cholecystectomy was symptomatic gallbladder disease. No exclusion criteria were used and no cost analysis was performed.
Results:
During the study period, 31 patients were enrolled. The mean patient age, body mass index, weight, and operative time was 33.6 years, 32.2 kg/m2, 86.3 kg, and 81.4 minutes, respectively. There were no conversions to the open or traditional multiport approach, and no major complications of biliary ductal or hepatic artery injury, bile leak, reoperations, or mortality occurred. There was 1 case of superficial wound infection.
Conclusions:
Single-site robotic cholecystectomy is feasible and safe and requires a minimal learning curve to transition from traditional multiport to single-port robotic cholecystectomy.
doi:10.4293/JSLS.2014.00266
PMCID: PMC4154417  PMID: 25392627
Robotic cholecystectomy; Single site
8.  Early Outcomes of Single-Port Video-Assisted Thoracic Surgery for Primary Spontaneous Pneumothorax 
Background
Recently, single-port video-assisted thoracic surgery (VATS) has been proposed as an alternative to the conventional three-port VATS for primary spontaneous pneumothorax (PSP). The aim of this study is to evaluate the early outcomes of the single-port VATS for PSP.
Methods
VATS was performed for PSP in 52 patients from March 2012 to March 2013. We reviewed the medical records of these 52 patients, retrospectively. Nineteen patients underwent the conventional three-port VATS (three-port group) and 33 patients underwent the single-port VATS (single-port group). Both groups were compared according to the operation time, number of wedge resections, amount of chest tube drainage during the first 24 hours after surgery, length of chest tube drainage, length of hospital stay, postoperative pain score, and postoperative paresthesia.
Results
There was no difference in patient characteristics between the two groups. There was no difference in the number of wedge resections, operation time, or amount of drainage between the two groups. The mean lengths of chest tube drainage and hospital stay were shorter in the single-port group than in the three-port group. Further, there was less postoperative pain and paresthesia in the single-port group than in the three-port group. These differences were statistically significant. The mean size of the surgical wound was 2.10 cm (range, 1.6 to 3.0 cm) in the single-port group.
Conclusion
Single-port VATS for PSP had many advantages in terms of the lengths of chest tube drainage and hospital stay, postoperative pain, and paresthesia. Single-port VATS is a feasible technique for PSP as an alternative to the conventional three-port VATS in well-selected patients.
doi:10.5090/kjtcs.2014.47.4.384
PMCID: PMC4157502  PMID: 25207248
Video-assisted thoracic surgery (VATS); Pneumothorax; Postoperative pain; Paresthesia
9.  Robotic single-port transumbilical total hysterectomy: a pilot study 
Journal of Gynecologic Oncology  2011;22(2):120-126.
Objective
To evaluate the feasibility of robotic single-port transumbilical total hysterectomy using a home-made surgical glove port system.
Methods
We retrospectively reviewed the medical records of patients who underwent robotic single-port transumbilical total hysterectomy between January 2010 and July 2010. All surgical procedures were performed through a single 3-4-cm umbilical incision, with a multi-channel system consisting of a wound retractor, a surgical glove, and two 10/12-mm and two 8 mm trocars.
Results
Seven patients were treated with robotic single-port transumbilical total hysterectomy. Procedures included total hysterectomy due to benign gynecological disease (n=5), extra-fascial hysterectomy due to carcinoma in situ of the cervix (n=1), and radical hysterectomy due to cervical cancer IB1 (n=1). The median total operative time was 109 minutes (range, 105 to 311 minutes), the median blood loss was 100 mL (range, 10 to 750 mL), and the median weight of the resected uteri was 200 g (range, 40 to 310 g). One benign case was converted to 3-port robotic surgery due to severe pelvic adhesions, and no post-operative complications occurred.
Conclusion
Robotic single-port transumbilical total hysterectomy is technically feasible in selected patients with gynecological disease. Robotics may enhance surgical skills during single-port transumbilical hysterectomy, especially in patients with gynecologic cancers.
doi:10.3802/jgo.2011.22.2.120
PMCID: PMC3152752  PMID: 21860738
Robotic surgery; Single-port; Laparoscopic; Hysterectomy; Gynecology
10.  Single Port Access (SPA) Cholecystectomy: Two Year Follow-up 
The authors conclude that single port access cholecystectomy is a viable alternative to multi-port cholecystectomy.
Introduction:
Laparoscopy is a constantly evolving field of surgery. New technology, applications, and benefits prompt continual improvement. We have developed a Single Port Access (SPA) surgical technique that allows for the entire cholecystectomy to be performed through a single incision within the umbilicus while maintaining safe standard dissection and retraction techniques of currently performed multi-port laparoscopic cholecystectomy.
Methods:
Fifteen consecutive patients underwent SPA cholecystectomy. Indications were cholelithiasis, cholecystitis, CBD stones, and biliary akinesia. The entire procedure was performed through a single umbilical incision measuring <1.8 cm within the umbilicus. Three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision. The cholecystectomy procedures are then performed in the standard fashion described in multi-port cholecystectomy.
Results:
Fifteen patients successfully underwent Single Port Access cholecystectomy. One patient required a second 5-mm port site secondary to difficulty with retraction of a large liver. Operative times averaged 107 minutes. Blood loss, patient recovery, and outcomes have been comparable to those of standard multi-port procedures. No umbilical hernias have been seen at 2 years of follow-up.
Conclusion:
We present the SPA cholecystectomy as an alternative to multi-port cholecystectomy. In the first 2 years, SPA surgery has evolved into a technique easily taught and performed without the restrictions of new equipment or added cost.
doi:10.4293/108680809X12589998404245
PMCID: PMC3030787  PMID: 20202394
Laparoscopy; Cholecystectomy; Single port access surgery; Minimal access surgery; SPA surgery
11.  Virtual modeling of robot-assisted manipulations in abdominal surgery 
AIM: To determine the effectiveness of using multidetector computed tomography (MDCT) data in preoperative planning of robot-assisted surgery.
METHODS: Fourteen patients indicated for surgery underwent MDCT using 64 and 256-slice MDCT. Before the examination, a specially constructed navigation net was placed on the patient’s anterior abdominal wall. Processing of MDCT data was performed on a Brilliance Workspace 4 (Philips). Virtual vectors that imitate robotic and assistant ports were placed on the anterior abdominal wall of the 3D model of the patient, considering the individual anatomy of the patient and the technical capabilities of robotic arms. Sites for location of the ports were directed by projection on the roentgen-positive tags of the navigation net.
RESULTS: There were no complications observed during surgery or in the post-operative period. We were able to reduce robotic arm interference during surgery. The surgical area was optimal for robotic and assistant manipulators without any need for reinstallation of the trocars.
CONCLUSION: This method allows modeling of the main steps in robot-assisted intervention, optimizing operation of the manipulator and lowering the risk of injuries to internal organs.
doi:10.4240/wjgs.v4.i6.141
PMCID: PMC3400042  PMID: 22816028
Virtual modeling; Robotic surgery; Multidetector computed tomography; Abdominal surgery; Virtual surgery
12.  Three-Port Versus Standard Four-Port Laparoscopic Cholecystectomy: a Randomized Controlled Clinical Trial in a Community-Based Teaching Hospital in Eastern Nepal 
Objectives:
With increasing surgeon experience, laparoscopic cholecystectomy has undergone many refinements including reduction in port number and size. Three-port laparoscopic cholecystectomy has been reported to be safe and feasible in various clinical trials. However, whether it offers any additional advantages remains controversial. This study reports a randomized trial that compared the clinical outcomes of 3-port laparoscopic cholecystectomy versus conventional 4-port laparoscopic cholecystectomy.
Methods:
Seventy-five consecutive patients who underwent elective laparoscopic cholecystectomy were randomized to undergo either the 3-port or the 4-port technique. Four surgical tapes were applied to standard 4-port sites in both groups at the end of the operation. All dressings were kept intact until the first follow-up 1 week after surgery. Postoperative pain at the 4 sites was assessed on the first day after surgery by using a 10-cm unscaled visual analog scale (VAS). Other outcome measures included analgesia requirements, length of the operation, postoperative stay, and patient satisfaction score on surgery and scars.
Results:
Demographic data were comparable for both groups. Patients in the 3-port group had shorter mean operative time (47.3±29.8 min vs 60.8±32.3 min) for the 4-port group (P=0.04) and less pain at port sites (mean score using 10-cm unscaled VAS: 2.19±1.06 vs 2.91±1.20 (P=0.02). Overall pain score, analgesia requirements, hospital stay, and patient satisfaction score (mean score using 10-cm unscaled VAS: 8.2±1.7 vs 7.8±1.7, P=0.24) on surgery and scars were similar between the 2 groups.
Conclusion:
Three-port laparoscopic cholecystectomy resulted in less individual port-site pain and similar clinical outcomes with fewer surgical scars and without any increased risk of bile duct injury compared with 4-port laparoscopic cholecystectomy. Thus, it can be recommended as a safe alternative procedure in elective laparoscopic cholecystectomy.
PMCID: PMC3015828  PMID: 17931519
Laparoscopic cholecystectomy
13.  Laparoscopic Assisted Two Port Open Appendicectomy 
Oman Medical Journal  2008;23(3):166-169.
Objectives
The laparoscopic appendicectomy can be performed using one to several ports. We present our experience of two port laparoscopic assisted open appendicectomy. The objective was to assess the results retrospectively in terms of complications and its limitations.
Methods
Between years 1998-2007, a two port laparoscopic assisted appendectomy was attempted in 2380 adult patients with suspected appendicitis. The patients with localized or generalized peritonitis were included. The appendicectomy was performed via an assisted two port method using 10 mm umbilical optical port and another 10 mm port in right iliac fossa. The children aged 12 and below and pregnant patients were excluded. All patients had their laparoscopic appendicectomy within 48 hours of admission.
Results
Two port laparoscopic assisted appendicectomy was successful in 86.9% of cases. Acute appendicitis was the cause of acute abdomen in 88.9% of the patients. The accessory port was required in 8.5% of patients to complete the appendicectomy and the conversion rate to open was 4.6%. The mean operation time was 25 minutes and the mean hospital stay was 1.5 days. The port site infection was seen in 14, bleeding in 20, parietal wall abscess in three cases and intra-abdominal abscesses in 4 patients.
Conclusion
This approach is simple, can be converted to total intracorporeal by inserting accessory port or to open appendicectomy when required and has advantage of full laparoscopy of abdomen. It has its limitations in cases of extreme obesity, thick mesentery, gangrenous appendix, very large and thick appendix, and difficulty in finding the appendix, control of bleeding, division of adhesions and to deal with other associated pathology. Cost was minimized by using non-disposable port. The overall morbidity was low. There were no specific complications related to this technique and incidence of port site infection was similar to other approaches of laparoscopic appendicectomy.
PMCID: PMC3282326  PMID: 22359707
Laparoscopy; Acute abdomen; Appendicitis; Two port
14.  Single-Port Laparoscopic Right Hemicolectomy: The Learning Curve 
This report suggests that the learning curve for a surgeon with advanced laparoscopic skills may be short, requiring approximately 10 cases to decrease operative times to baseline.
Background and Objectives:
Single-port laparoscopic colectomy is described as a new technique in colorectal surgery. The initial case reports show the safety and feasibility, but the learning curve for this technique is unknown.
Methods:
Between July 2009 and September 2010, 20 consecutive patients with an indication for right hemicolectomy underwent a single-port laparoscopic approach without bias in selection. The only exclusion criterion was a prior midline laparotomy. The patients were followed up for 30 days. Chart review was completed for up to 35 months to assess long-term morbidity and mortality rates.
Results:
The median age was 65 years (range, 59–88 years). Ninety percent of patients were men. The median body mass index was 28 kg/m2 (range, 20–35 kg/m2). Seventy-five percent of patients had significant comorbidities with an American Society of Anesthesiologists class of 3 or 4. The estimated blood loss was 25 mL (range, 25–250 mL). The median number of pathologic lymph nodes for patients diagnosed with adenocarcinoma was 16 (range, 8–23). There was one conversion to hand-assisted laparoscopic (case 6) and one to open colectomy (case 9) because of the inability to achieve safe vessel ligation. The median hospital stay was 4.5 days (range, 3–7 days). The length of stay for the first 10 patients was 5.1 days, and it was 3.9 days for the last 10 patients (P = .045). There were no significant postoperative complications within 30 days. The mean operative time for the first 10 cases was 198 minutes (range, 148–272 minutes), and it was 123 minutes (range, 98–150 minutes) for the subsequent 10 cases (P = .0001). All intraoperative complications (minor bleeding) occurred within the first 10 patients, with no significant bleeding recorded for the last 10 cases.
Conclusion:
Single-port laparoscopic right hemicolectomy can be safely performed in patients who are candidates for conventional or hand-assisted right hemicolectomy with very low intraoperative and postoperative complication rates. The 30-day morbidity rate remained low with this technique. The higher technical difficulty compared with conventional laparoscopy is reflected in the longer initial operative times. The learning curve for a surgeon with advanced laparoscopic skills and adequate procedure numbers seems to be short, requiring approximately 10 cases to decrease operative times to baseline. The role and feasibility of broad adaptation for single-incision laparoscopy in colorectal surgery need to be further evaluated in larger case series and trials.
doi:10.4293/108680813X13654754534558
PMCID: PMC3771784  PMID: 23925011
Single port; Single incision; Laparoscopic; Right hemicolectomy; Learning curve
15.  Incidence of trocar site herniation following robotic gynecologic surgery 
Gynecologic oncology  2013;131(2):400-403.
Objective
Trocar site herniation is a recognized complication of minimally invasive surgery, but published data on trocar site herniation after robotic surgery are scarce. We sought to determine the incidence of trocar site herniation in women undergoing robotic surgery for gynecologic disease.
Methods
A retrospective review of robotic surgeries performed from January 1, 2006, through December 31, 2012, was conducted. Postoperative trocar site herniations were identified, along with time to presentation, location of herniation, and management. Patients were excluded if surgery was converted to laparotomy or traditional laparoscopy. The Wilcoxon rank-sum test was used to compare patients with and without herniation with respect to continuous variables, and Fisher's exact test was used to compare these 2 groups with respect to categorical variables.
Results
The study included 500 patients, 3 of whom experienced herniation at a single trocar site. The patients with and without herniation did not differ with respect to age, body mass index, smoking status, medical comorbidities, operating time, or estimated blood loss. All 3 herniations occurred at 12-mm trocar sites. Two herniations occurred at assistant port sites, and 1 occurred at the umbilical camera port site. The median time to herniation was 21 days (range, 8-38 days). One patient required immediate surgical intervention; the other 2 patients had conservative management.
Conclusions
Trocar site herniation is a rare complication following robotic surgery. The most important risk factor for trocar site herniation appears to be larger trocar size, as all herniations occurred at 12-mm port sites.
doi:10.1016/j.ygyno.2013.08.021
PMCID: PMC4158736  PMID: 23988416
16.  Port-Site Metastases After Robotic Surgery for Gynecologic Malignancy 
The rate of port site metastasis in patients undergoing robot-assisted laparoscopic surgery for gynecologic malignancy is similar to the rate of port site metastasis for traditional laparoscopic surgery.
Background and Objectives:
Robotic-assisted laparoscopic surgery is increasingly used for the management of patients with gynecologic malignancies. The rate of port-site metastases in patients undergoing these procedures is unknown.
Methods:
We conducted a retrospective cohort analysis of a prospective database. A total of 220 women underwent robotic-assisted surgery from 2007 through 2011. Malignancy was detected in 145 cases, and 142 met the inclusion criteria with histologically proven cancer and robotically completed surgery. All women who underwent surgical treatment for their malignancies were followed up at the study site for oncology treatments.
Results:
There were 710 potential port sites for metastasis. We found that 2 of 142 patients each had a single port-site metastasis, for an overall rate of 1.41%, or 0.28% per trocar site. Recurrent disease was not isolated in the two patients found to have port-site metastases because both had concurrent sites of pelvic recurrence.
Conclusion:
The rate of port-site metastases in patients undergoing robotic-assisted laparoscopic surgery for gynecologic malignancies is similar to the published rate in the literature for traditional laparoscopic oncology.
doi:10.4293/108680813X13693422519271
PMCID: PMC3939345  PMID: 24680146
Port-site metastases; Robotics; Gynecologic oncology
17.  Is Fourth Port Really Required in Laparoscopic Cholecystectomy? 
The Indian Journal of Surgery  2010;72(5):373-376.
Since the advent of four-port laparoscopic cholecystectomy, many modifications regarding port number and size have been tried. The feasibility of three-port technique has been found comparable to the conventional four-port laparoscopic cholecystectomy. To assess the feasibility and safety of three-port laparoscopic cholecystectomy in a prospective study. Between March 2007 and March 2009, fifty patients with cholelithiasis aged between 15 and 56 years underwent three-port cholecystectomy in a prospective study in Government medical college, Srinagar. A single surgeon did all the cases and there was no criterion for the patient selection. These were consecutive fifty surgeries done by the surgeon. The outcome was assessed in terms of intra-operative and post-operative parameters. The mean (range) age was 45 (15–56) years and there were thirty-nine females and eleven males in the study. All the procedures were completed successfully without any conversions to open or any major complications; though three patients needed the addition of a fourth port as in conventional laparoscopic cholecystectomy. The mean (range) operative time was 55 (30–90) min and the average blood loss was 30 ml. The mean (range) hospital stay was 1 (1–3) days. All patients returned to routine work within 1 week of surgery. The mean follow-up was 5 (2–7) months. We conclude, from the results above, that three-port laparoscopic cholecystectomy is safe and feasible. There are only two visible surgical scars, better cosmetic appearance with no increased risk of bile duct injury. It reduces the manpower in the form of a second assistant. Thus, it can be recommended as a safe alternative procedure to conventional four-port laparoscopic cholecystectomy.
doi:10.1007/s12262-010-0154-9
PMCID: PMC3077134  PMID: 21966135
Laparoscopic cholecystectomy; Three ports; Feasibility
18.  Long-Term Study of Port-Site Incisional Hernia After Laparoscopic Procedures 
Background:
Laparoscopic surgery is widely practiced and offers realistic benefits over conventional surgery. There is considerable variation in results between surgeons, concerning port-site complications. The aim of this study was to evaluate the laparoscopic port closure technique and to explore the factors associated with port-site incisional hernia.
Methods:
Between January 2000 and January 2007, 5541 laparoscopic operations were performed by a single consultant surgeon for different indications. The ports were closed by the classical method using a J-shaped needle after release of pneumoperitoneum. The incidence of port-site incisional hernias was calculated. All patients were followed up by outpatient clinic visits and by their general practitioners.
Results:
During a 6-year period, 5541 laparoscopic operations were performed. Eight patients (0.14%) developed port-site hernia during a mean follow-up period of 43 months (range, 25 to 96) and required elective surgery to repair their hernias. No major complications or mortality was reported.
Conclusion:
Laparoscopic port closure using the classical method was associated with an acceptable incidence of port-site hernia. Modification of the current methods of closure may lead to a new technique to prevent or reduce the incidence of port-site incisional hernias.
PMCID: PMC3015977  PMID: 19793475
Port-site incisional hernia; Pneumoperitoneum; Port closure
19.  Port site and peritoneal metastases after robot-assisted radical prostatectomy☆ 
INTRODUCTION
Port site metastasis after minimally invasive urologic surgery is a rare event despite the widespread utility of laparoscopic techniques in the management of urologic malignancies. Herein, we report a case of port site metastasis after robot-assisted radical prostatectomy.
PRESENTATION OF CASE
A currently 77-year-old male patient, who was diagnosed with cT2c, Gleason 7 (4 + 3) prostate adenocarcinoma in our clinic back in 2009, had undergone robot-assisted radical prostatectomy elsewhere. Histopathological examination revealed pT3a, Gleason 9 (4 + 5) disease. Lymph nodes were negative, however surgical margins were positive on the right side. PSA recurred after 9 months and maximal androgen blockade was initiated. Despite antiandrogenic manipulations, PSA reached 0.83 ng/ml, 33 months postoperatively. Concurrently, we noticed a palpable anterior abdominal mass which demonstrated metabolic hyperactivity on PET scanning. Percutaneous biopsy of the lesion confirmed the presence of metastatic adenocarcinoma. PSA did not normalize after the complete excision of the metastatic focus. Repeated PET scan revealed multiple implants on the peritoneal surfaces of various organs.
DISCUSSION
Port site and peritoneal metastasis of prostate cancer after robot-assisted radical prostatectomy has not been reported so far. This peculiar dissemination pattern is most probably the result of tumor biology and perioperative factors.
CONCLUSION
Although encountered extremely rarely, surgeons should be aware of the possibility of port site and/or peritoneal metastases after minimally invasive radical prostatectomy.
doi:10.1016/j.ijscr.2014.01.010
PMCID: PMC3955239  PMID: 24531016
Port-site; Metastasis; Robot; Radical prostatectomy
20.  Comparison of Outcomes After Single-Port Laparoscopic Cholecystectomy in Relation to Patient Body Mass Index 
Background and Objectives:
Single-port laparoscopic cholecystectomy may contribute to a paradigm shift in the field of laparoscopic cholecystectomy surgery by providing patients with benefits beyond those observed after other surgical procedures. This study was designed to evaluate clinically meaningful differences in operative outcomes between obese and nonobese patients after single-port laparoscopic cholecystectomy.
Methods:
Data were collected retrospectively from 172 patients who had undergone single-port laparoscopic cholecystectomy performed by the same surgeon at a single medical center between January and December 2011. For the outcome analysis, patients were divided into nonobese and obese patient groups according to their body mass index (<25 kg/m2 vs ≥25 kg/m2).
Results:
Demographic and clinical data did not differ significantly between obese patients (n = 65) and nonobese patients (n = 107). In addition, statistically significant differences pertaining to most measured surgical outcomes including postoperative hospital stay, bile spillage, additional port use, and open conversion were not detected between the groups. However, the two groups differed significantly regarding operative time such that nonobese patients had shorter operative times than obese patients (P < .05).
Conclusion:
The results of this study showed that operative time for single-port laparoscopic cholecystectomy was the only difference between obese and nonobese patients. Given this result, body mass index may not be as relevant a factor in patient selection for single-port laparoscopic cholecystectomy as previously thought.
doi:10.4293/JSLS.2014.00048
PMCID: PMC4266224  PMID: 25516701
Laparoscopic cholecystectomy; Single port; Body mass index (BMI)
21.  Two-port vs. three-port laparoscopic appendicectomy: A bridge to least invasive surgery 
INTRODUCTION:
The conventional three-port technique for laparoscopic appendicectomy has proven its worth in the management of appendicular pathologies. From a cosmetic viewpoint, the umbilical and suprapubic port-sites are hidden by natural camouflages, the right Iliac fossa (RIF) port is the only visible external sign of surgery. The two-port technique avoids even this marker of abdominal invasion. In this study, we describe the technique of two-port laparoscopic appendicectomy (TPA) and compare it with conventional laparoscopic appendicectomy (CLA).
MATERIALS AND METHODS:
All patients studied underwent operation for acute appendicitis during a 6-month period. Data were collected prospectively for the TPA and retrospectively for the CLA. The TPA was performed with one 10 mm umbilical working port and one 5 mm suprapubic camera port. A hypodermic needle was introduced in the RIF to retract the appendix. The appendicular artery was controlled with diathermy or ultrasonic shears. The base was ligated with a loop knotted extracorporeally. CLA was performed via the conventional 10 mm umbilical, 5 mm suprapubic and 5 mm RIF ports. The appendicular stump was ligated with an endoloop or an intracorporeal knot.
RESULTS:
A total of 146 patients underwent surgery over the 6-month period for appendicitis. Out of 62 cases attempted, the TPA was successful in 51 cases, with conversion to the three-port technique in 11. The operative time, complication rates, return to work were comparable between the two groups. Patients who had TPA had a shorter postoperative stay.
CONCLUSION:
This is an initial experience with TPA. There is little difference in the operative time, postoperative stay and complications rates between this technique and the conventional three-port one. There is hence little to be lost and a likely benefit to be gained by performing the TPA although a randomised study is necessary.
doi:10.4103/0972-9941.103121
PMCID: PMC3523451  PMID: 23248441
Laparoscopic appendicectomy; two-port appendicectomy; two port vs. three port
22.  One, two or three port appendectomy – a rational approach 
Introduction
Laparoscopic appendectomy is a safe and feasible technique accepted by many surgeons as the gold standard approach for the treatment of acute appendicitis in children. Traditionally laparoscopic appendectomy requires the use of three ports. However, surgical techniques with fewer ports have been reported.
Aim
To evaluate the efficacy of laparoscopic appendectomy in children according to the proposed 3-step protocol using one, two or three ports.
Material and methods
A total of 100 children with the diagnosis of acute appendicitis underwent laparoscopic appendectomy. Patients were treated according to the following protocol: transumbilical access with one 10 mm port using the laparoscope with working channel. The appendix was mobilized and delivered through the umbilical port and tied extracorporeally and removed. If the appendix was placed retrocecally or had adhesions, a second port was introduced. The appendix was mobilized and finally retrieved from the abdominal cavity through the camera port, and resected extracorporeally. In the cases of very short and gangrenous appendix and immobile colon, a third port was introduced and totally intra-abdominal appendectomy was performed. Patients were evaluated regarding the duration of the operation, and operative and postoperative complications.
Results
During the study period 100 children (58 males, 42 females) had laparoscopic appendectomy: 48 children by one-port technique (group I), 27 children by two-port technique (group II) and 25 children by three-port technique (group III). The mean operative time was 33 min (20-55 min) in group I, 39 min in group II (23-60 min), and 49 min (30-75 min) in group III. There were no intraoperative complications. Wound infections were recorded in 4 (8.3%) patients in group I, three (11.1%) in group II and four (16.0%) in group III. One patient in group III developed an abdominal abscess managed conservatively.
Conclusions
One-port laparoscopic appendectomy is a feasible technique in children. It allows 48% of children to have the operation. The addition of a second port allows one to mobilize the appendix and perform extracorporeal resection in an additional 27% of cases. These approaches have shorter operative time compared to 3-port technique. Laparoscopic extracorporeal appendectomy, especially one-port, is found to be cost effective and have excellent cosmetic results.
doi:10.5114/wiitm.2011.33991
PMCID: PMC3796724  PMID: 24130637
laparoscopy; appendectomy; one port; transumbilical
23.  Robotic Mitral Valve Repair 
Texas Heart Institute Journal  2005;32(2):143-146.
Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings.
All mitral and tricuspid valve repairs were performed by the same surgeon. Cardiopulmonary bypass was performed with femoral cannulation, antegrade cardioplegia, and transthoracic aortic cross-clamping. Multiple valve repair techniques were used, including quadrant resection, cord replacement, Alfieri leaflet coaptation, and ring annuloplasty. Access was by 2 ports and a 5-cm right anterolateral thoracotomy. All annuloplasty rings were secured using surgical clips.
From October 2003 through September 2004, 32 patients underwent robotically assisted mitral valve repair. The mean age of our population was 67.6 years (range, 43–82 years). Four patients also underwent the 1st tricuspid valve repair using the da Vinci robot in the United States. There were 3 conversions for irreparable valves, 1 stroke, and 2 deaths. The average procedure time, cardiopulmonary bypass time, and aortic cross-clamp time were all reduced, when the first 20 patients were compared with the last 12. Length-of-stay also improved. One patient required early mitral valve replacement for recurrent regurgitation. Two patients required late (>3 month) mitral valve replacement for recurrent regurgitation.
We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount.
PMCID: PMC1163458  PMID: 16107102
Annuloplasty; mitral valve/surgery; robotics; surgery, computer-assisted; surgical procedures, minimally invasive/methods; tricuspid valve/surgery; thoracic surgery, video-assisted
24.  Robotic Single-Port Hernia Surgery 
This study suggests that robotic single-port inguinal hernia surgery is feasible, safe, and efficient.
Background and Objectives:
Since the introduction of single-incision laparoscopic surgery in 2009, an increasing number of surgical procedures including hernia repair are being performed using this technique. However, its large-scale adoption awaits results of prospective randomized controlled studies confirming its potential benefits. Parallel with single-port surgery development, the issue of the chronic lack of good camera assistants is being addressed by the robotic Freehand® camera controller, which has the potential to replace camera assistants in a large percentage of routine laparoscopic surgery. Although the robotic Freehand has been used in certain operations in urology and gynecology, there have been no published reports in robotic (single-port) hernia surgery.
Methods:
This study reports the first case and a series of 16 patients who underwent robotic single-port total extraperitoneal inguinal hernia repair compared to 16 consecutive cases of conventional single-port inguinal hernia repair. Patients were matched for age, sex, body mass index, American Society of Anesthesiologists classification, and types of hernia.
Results:
Although operation time was comparable in both, the time wasted for scope cleaning was 8.5 minutes for conventional compared to 1.5 minutes for robotic surgery.
Conclusion:
Robotic single-port inguinal hernia repair is feasible and efficient. This represents a further milestone in laparoscopic surgery.
doi:10.4293/108680811X13125733356198
PMCID: PMC3183567  PMID: 21985715
Inguinal hernia; Total extraperitoneal; Robotic Freehand®; Tri-port™
25.  Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass? 
Background
The aim of this retrospective study was to evaluate the clinical outcome of three different minimally invasive surgical techniques for left anterior descending (LAD) coronary artery bypass grafting (CABG): Port-Access surgery (PA-CABG), minimally invasive direct CABG (MIDCAB) and off-pump totally endoscopic CABG (TECAB).
Methods
Over a decade, 160 eligible patients for elective LAD bypass were referred to one of the three techniques: 48 PA-CABG, 53 MIDCAB and 59 TECAB. In MIDCAB group, Euroscore was higher and target vessel quality was worse. In TECAB group, early patency was systematically evaluated using coronary CT scan. During follow-up (mean 2.7 ± 0.1 years, cumulated 438 years) symptom-based angiography was performed.
Results
There was no conversion from off-pump to on-pump procedure or to sternotomy approach. In TECAB group, there was one hospital cardiac death (1.7%), reoperation for bleeding was higher (8.5% vs 3.7% in MIDCAB and 2% in PA-CABG) and 3-month LAD reintervention was significantly higher (10% vs 1.8% in MIDCAB and 0% in PA-CABG). There was no difference between MIDCAB and PA-CABG groups. During follow-up, symptom-based angiography (n = 12) demonstrated a good patency of LAD bypass in all groups and 4 patients underwent a no LAD reintervention. At 3 years, there was no difference in survival; 3-year angina-free survival and reintervention-free survival were significantly lower in TECAB group (TECAB, 85 ± 12%, 88 ± 8%; MIDCAB, 100%, 98 ± 5%; PA-CABG, 94 ± 8%, 100%; respectively).
Conclusions
Our study confirmed that minimally invasive LAD grafting was safe and effective. TECAB is associated with a higher rate of early bypass failure and reintervention. MIDCAB is still the most reliable surgical technique for isolated LAD grafting and the least cost effective.
doi:10.1186/1749-8090-6-37
PMCID: PMC3076235  PMID: 21439055

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