Tech Update: Single Port Robot-Assisted Laparoscopic Gynecologic Surgery

The daVinci® Surgical System received FDA approval for use in gynecologic surgery in 2005. Since then, significant enhancements have been made as surgeons challenged themselves to perform a wider range of procedures through fewer and smaller incisions. As traditional laparoscopy made moves to single incision surgery, so too did robotically-assisted procedures. Surgeons looked to the robot in an attempt to address the various technical and ergonomic frustrations they encountered in laparoscopic single site surgery including poor triangulation and instrument crowding.^[i]lacked range of motion and their semi-rigidity made suturing through thicker tissues and knot tying more difficult.^[ii]

The Da Vinci Single Port (SP^TM) System was FDA approved for urology procedures in 2018 and for otolaryngology in 2019 and addresses many of the problems encountered with DVSSP. The SP system introduces three instruments through a port operated by one robotic arm using a single cannula. The instruments are multi-jointed and wristed, and the camera also articulates for improved triangulation. Since its introduction, reports of an increasingly wide range of safely performed procedures have been published. The largest case series describes the first 100 pelvic and retroperitoneal urologic procedures performed at a single institution, including prostatectomy, nephrectomy, cystectomy and lymph node dissection.^[iii]

Though the SP platform has not yet received FDA approval for gynecologic surgery, experience in this area is increasing. A recent preliminary review of 31 procedures performed at a single institution in Seoul, South Korea shows feasibility and safety for various benign gynecologic procedures.^[iv] The series includes hysterectomy, myomectomy, sacrocolpopexy and adnexal surgeries. The surgeons used a 27-mm transumbilical skin incision and a GelPass One-Port system (Meden, Seoul, Korea). An assistant trocar was placed 1.5cm from the robotic port, within the GelPass. There were no major complications or conversions to multiport procedure or laparotomy. The authors note that the ability to articulate the camera greatly improved visualization, crowding and triangulation. The rigid, articulating instruments were much preferred to semi-rigid and non-articulating instruments as they allowed greater force to be used without bending or rebounding of instruments and easier execution of finer dissections when compared to DVSSP.

Additional studies are needed to ensure safety, efficacy and feasibility across procedures and pathologies. Randomized trials and long-term follow-up data are required to evaluate outcomes.

^[i] Escobar et al. Robotic-Assisted Laparoendoscopic Single-Site Surgery in Gynecology: Initial Report and Technique. Journal of Minimally Invasive Gynecology 16(5) 2009; 589-591

[ii] Scheib S and Fader A. Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. AJOG. 2015 Feb:212(2):179e1-179e8

[iii] Kaouk J, et al. Single-port robotic urological surgery using Purpose-built Single-port Surgical System: Single-institutional experience with the first 100 cases. Urology. 2020 Mar 3

[iv] Shin et al, Robotic single-port surgery using the da Vinci SP surgical system for benign gynecologic disease: A preliminary report. Taiwan J Obstet Gynecol. 2020 Mar;59(2):243-247