Single-Site Robotic Cholecystectomy

This study aims to introduce an alternative technique for effective single-site robotic cholecystectomy (SSRC) using a reverse port. Proper exposure of Calot’s triangle is critical for safe laparoscopic cholecystectomy. Current robotic surgical systems are useful for singlesite cholecystectomy. However, in exposing Calot’s triangle, the gallbladder is usually retracted in a medial and upward direction, resulting in a narrow triangle. This intraoperative view is a major obstacle to safe laparoscopic cholecystectomy. From October 2013 to October 2014, 55 consecutive patients underwent SSRC by a single surgeon at Yonsei University Severance Hospital. Initially, 5 patients underwent the original robotic single site cholecystectomy technique, and the remaining 50 patients underwent robotic single site cholecystectomy using our reverse port technique. There were no differences between the SSRC-O (original port) group and the SSRC-R (reverse port) group in terms of patient age (P1⁄4 0.244), body mass index (P1⁄4 0.503), and pathologic conditions of the gallbladder (P1⁄4 0.841). Total operation time (132.6 vs 99.12 min; P1⁄4 0.009), actual dissection time (51.6 vs 30.28 min; P1⁄4 0.001), and console time (84.4 vs 50.46 min; P1⁄4 0.001) were all significantly shorter in the SSRC-R group. Mean intraoperative blood loss was minimal in both groups (20 vs 12.4 mL, P1⁄4 0.467), and bile spillage occurred in 2 patients of the SSRC-R group. There was one case of laparoscopic conversion in the SSRC-R group. The reverse port technique described in this study successfully widened Calot’s triangle and improved the safety of the current robotic surgical system for single-site robotic cholecystectomy. (Medicine 94(42):e1871) Abbreviations: ASA score = American Society of Anesthesiologists n Lee, Chang Moo Kang, and Woo Jung Lee robotic laparo-endoscopic single-site surgery, SILC = single incision laparoscopic cholecystectomy, SSRC = single-site robotic cholecystectomy, SSRC-O = single-site robotic cholecystectomy using the original single port group, SSRC-R = single-site robotic cholecystectomy using the reverse single port group. INTRODUCTION L aparoscopic cholecystectomy (LC) has been a gold standard treatment modality for benign pathologic conditions of the gallbladder from the early 1990s. With the accumulation of experience and advances in instrument design, LC has become a safer and more familiar procedure. Although conventional 4-port LC is the standard method, there has been a great effort to reduce the number and size of ports in order to achieve the goal of performing truly minimally invasive surgery. Recently singleincision laparoscopic cholecystectomy (SILC) has been performed by many surgeons. However, despite these novel advances in SILC, technical and ergonomic problems remained, such as instrument crowding, ergonomic discomfort experienced by the operator, difficulties in gallbladder retraction, and poor exposure of Calot’s triangle. Due to these limitations, SILC can be performed by only a small number of experienced surgeons and long learning curve time is required, which has prevented the frequent application of SILC in benign gallbladder disease. In 2011, the Da Vinci Surgical system (Intuitive surgical Inc, Sunnyvale, CA) developed a set of single-site instruments and accessories (R-LESS, robotic laparo-endoscopic single-site surgery). After the development of R-LESS, several surgeons reported their early experiences of single-site robotic cholecystectomy (SSRC). We also began performing SSRC using R-LESS from October 2013; however, we felt that dissection of Calot’s triangle was uncomfortable and not safe mainly due to the narrow triangle that resulted from the medial upward retraction of the gallbladder caused by the assistant port. One of the most important points for ‘‘safe’’ cholecystectomy is ensuring full exposure of Calot’s triangle by retracting the gallbladder in a cephalad and right lateral direction. This traction is intended to facilitate the opening Calot’s triangle, leading to a widening angle between the cystic duct and common bile duct. This widened angle allows the surgeon to perform selective dissection of the cystic duct and cystic artery away from the common bile duct, thereby avoiding unnecessary bile duct injury. However, we found that the right lateral retraction of the gallbladder was very difficult during SSRC using the commercialized da Vinci single site surgical port, as the assistant port access was located at the left side of the camera port access (Fig. 1A–C). In this dynamic manuscript, we described a reverse port technique for SSRC. For the effective gallbladder retraction, we turned the port platform upside down to relocate the assistant e of camera port. We found reverse port seful and more feasible for performing iginal technique. www.md-journal.com | 1 (2) FIGURE 1. Original Da-Vinci single port platform: (A) red and blue circles indicate assistant port access and CO2 insufflation access, respectively. (B) CO2 insufflation line insertion status. (C) Red arrow indicates the assistant port. Assistant port is located at the left side of e ci ind Jung et al Medicine Volume 94, Number 42, October 2015 MATERIALS AND METHODS