da Vinci robotic single-incision cholecystectomy and hepatectomy using single-channel GelPort access
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- Sugimoto, M., Tanaka, K., Matsuoka, Y. et al. J Hepatobiliary Pancreat Sci (2011) 18: 493. doi:10.1007/s00534-011-0387-4
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Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study.
We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot’s triangle. The instruments were crossed to avoid “sword fighting” and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles.
All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70 min (±15) and 60 min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision.
Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.
KeywordsRobotic-assisted surgerySingle-incision laparoscopic surgery (SILS)Laparoscopic cholecystectomyLaparoscopic hepatectomyReduced port laparoscopic surgery (RPLS)
Minimally invasive laparoscopic surgery has been widely adopted in the field of digestive surgery and has been extended to the hepatobiliary and pancreatic area. The public demand for even less invasive procedures will motivate surgeons, industry, and academics to explore the possibilities and refine the technology. The conventional laparoscopic procedure retains many technical limitations, especially in the complex hepato-biliary-pancreatic (HBP) area. Robotic-assisted laparoscopic surgery provides a precise surgical technique, excludes physiological hand tremor and permits minor invasiveness only. Robotic surgery was recently approved for clinical use in HBP surgery. The most complex reconstructive and extirpative HBP surgical procedures have been reported, including biliary [1–3], liver [4–11], and pancreas [12–22]. Robotic surgery provides the advantages of easy articulation and improved ergonomics. To further minimize morbidity of minimally invasive surgery and move towards scarless surgery for hepatobiliary surgery, single-incision laparoscopic surgery (SILS), single-port laparoscopic surgery (SPS), or laparoendoscopic single-site surgery (LESS) have been recently reported, affording a virtually scar-free surgery through a hidden umbilical incision [23–28]. However, even with the use of laparoscopic curved or articulating instruments, significant clashing with both the camera and other instruments can increase operating times and require significant laparoscopic skills, especially for intracorporeal suturing, for which an ideal platform has not been identified. The GelPort® laparoscopic system (Applied Medical, CA, USA) allows a surgeon to insert multiple laparoscopic ports into the operating field through a small single incision. The purpose of our study is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery in a preliminary animal study using the GelPort laparoscopic system as a minimally invasive access platform.
The committee of animal research at the Foundation for Kobe International Medical Alliance Japan approved this study. A surgeon certified by the JSES endoscopic surgical skill qualification system in Japan  who was experienced in both laparoscopic and robotic hepatobiliary surgery performed eight procedures, including four robotic cholecystectomies and four robotic hepatectomies, on pigs weighing 30–40 kg under endotracheal general anesthesia.
The da Vinci® S-HD Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) was prepared behind sterile drapes. The operating procedure was performed in the supine position. The operating surgeon sat at the surgical console located about 3 m from the operating table.
Procedure 1: Robotic cholecystectomy
Procedure 2: Robotic hepatectomy
After completion of all procedures, fascial defects were closed individually and skin was apposed.
We performed 8 procedures of robotic single-incision surgery and were able to complete all scheduled procedures (8/8, 100%).
Adequate ligation of the cystic duct and artery using the robotic EndoWrist in the appropriate place was manually successful in all procedures (4/4, 100%). The entire gallbladder and lateral segment of the liver could be removed (8/8, 100%).
The cholecystectomies and hepatectomies were safely performed in average operating times of 70 min (±15) and 60 min (±20), respectively, with minimal blood loss.
There were no conversions, re-interventions, or extension of the skin incision.
Minimally invasive laparoscopic HBP surgery has been adopted in recent years. The demand for even less invasive procedures in the HBP area will motivate surgeons, industry, and academics to explore the possibilities and refine the technology. To further minimize morbidity of minimally invasive surgery, single-incision laparoscopic surgery (SILS) or natural orifice translumenal endoscopic surgery (NOTES) has been developed toward virtually scar-free surgery through a hidden umbilical incision.
NOTES offers the aesthetic benefits of scarless surgery with potential benefits of decreased postoperative pain. We have reported NOTES in the HBP area, but there are still technical challenges due to limitations of suitable instruments and endoscopic equipment [30–33]. The clinical application of NOTES is also a technically challenging procedure and current instruments need to be further improved . SILS has been seen as a bridge between NOTES and traditional laparoscopic surgery . However, Hirano et al.  reported an overview of comparative features of single-incision laparoscopic cholecystectomy: out of 252 reported cases, there were 14 (5.6%) conversions to standard laparoscopy (due to difficult dissection, bleeding from the cystic artery, choledochoscopy, and failure in trocar insertion) and five complications (subcutaneous hematoma, hepatic injury, bile leakage, mesenteric injury, and injury of the right hepatic duct). Both conventional and SILS laparoscopic HBP procedures still need to be further improved.
A combination of SILS technology and robotic surgery may play a key role in the next generation of minimally invasive endoscopic surgery. At present, the introduction of robotic SILS is limited by the problem of conflicting large and multiple robotic arms. A combination of robotic articulating and bent EndoWrist instruments can allow the surgeon to partially overcome the loss of triangulation and clashing of instruments.
Robotic surgery was recently approved for clinical use in HBP surgery. The most complex reconstructive and extirpative HBP surgical procedures have been reported, including biliary [1–3], liver [4–11], and pancreas [12–22]. The robotic-assisted surgical system enables the performance of such delicate operations with breakthrough precision, vision, dexterity, and improved access to the affected area. It may offer several potential benefits over traditional surgery, including short hospital stay, low risk of complications, and low blood loss, by overcoming the limits of both traditional open and laparoscopic surgery. Robotic SILS using available access ports allows the surgeon the freedom of using the robotic instruments. The cited advantages of reducing the number of incisions include better cosmesis, lowered wound complications, and reduced morbidity of bleeding, incisional hernia and organ damage.
In this study we have used the GelPort as a device giving multiple port access in a single incision because of its ease of use, reliable maintenance of pneumoperitoneum, wide range of working space for the robotic arms, and ability to rapidly switch over to conversion if necessary (Figs. 1, 2). The GelPort consists of a wound-protecting sheath, wound retractor and unique gel seal cap. The wound-protecting sheath is designed to protect incisions and soft tissues from malignant and infectious exposure. The wound retractor facilitates extracorporeal resection and organ removal while minimizing the incision size. The GelPort is latched onto the gel seal cap (Alexis Wound Retractor ring; Applied Medical). It allows unlimited insertion of instruments including the videoscope at any given time with a flexible pivot to ease multiplanar motions while maintaining pneumoperitoneum (Fig. 1). Also, the possibility of conversion to an open procedure and the need for extension of this mini-laparotomy incision to a full laparotomy incision should be kept in mind. It was important to plan the placement of the single port based on the organ being targeted at surgery. It was better to place the single port some distance away from the target area, following the principle of triangulation of the ports, so that there was enough working space.
The Mini Loop Retractor was a useful tool for handling the gallbladder, as a retractor or holding forceps. The gallbladder was grasped by tightening a built-in wire loop in this needle loop retractor. The loop at the distal end of the gallbladder was easily and freely adjustable in the appropriate directions and was also used to retract the gallbladder upwards and outwards for distal traction to expose Calot’s triangle. It could also minimize invasiveness and reduce the number of ports because it could be inserted into the abdominal cavity through a 2-mm diameter skin puncture (Fig. 3).
In this study we were able to complete all procedures without significant procedure-related complications and successfully removed the gallbladder and the liver. The learning curve is acceptable, and procedures improved toward the end of the study, which reached times similar to laparoscopic surgery. The procedure can be considered safe because there were no deaths and no unusual complications. It should be emphasized that robotic surgery and SILS require specific training and dedicated technology. It was felt that a more flexible robot arm would be required to perform single-incision surgery more comfortably. Additional platform and instrumentation development will likely simplify robotic SILS procedures further as experience grows. A study with a larger number of procedures would be required to test whether the postoperative pain reduces significantly with increasing experience and reduction in operating time.
Robotic hepatobiliary SILS is technically feasible and safe by using GelPort as a single-incision access platform. It provides adequate spacing and flexibility of robotic and assistant port placement and allows unlimited insertion of instruments at any given time with a flexible pivot to ease multiplanar motions while maintaining pneumoperitoneum. Robotic SILS is becoming established and is enormously advantageous to the patient.
This study was partially supported by a Grant-in-Aid for Scientific Research funded by the Japan Society for the Promotion of Science (JSPS), the project “Computational Anatomy for Computer-aided Diagnosis and Therapy: Frontiers of Medical Image Sciences” funded by Grant-in-Aid for Scientific Research on Innovative Areas, The Ministry of Education, Culture, Sports, Science and Technology (MEXT) Japan, Japan NOTES Research Grant, Hyogo Science and Technology Association, and JFE Grant from the Japanese Foundation for Research and Promotion of Endoscopy.