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When Less is More: Single-Site Robotic Surgery Offers Improvements for Surgeon and Patient

By Helen K. Kelley

From ATLANTA Medicine, Vol. 85, No. 4

robotic surgeryAs minimally invasive surgery becomes a more common and popular option for patients undergoing certain medical procedures, the technology used to perform these procedures is constantly evolving. New techniques allow doctors to perform both minor and complex surgeries as outpatient procedures, with only a few small incisions – a great improvement over open surgeries that formerly required much larger incisions, along with lengthier hospital stays and recovery times for patients.

Robotic laparoscopic surgery, performed with the assistance of technology such as the da Vinci® Surgical System, is now considered the gold standard of treatment for many medical conditions. Robotic surgery has reduced the number of open surgeries for common operations by enhancing the surgeon’s capabilities in performing minimally invasive procedures.

Improving patient and surgeon experience

Introduced in the late 1990s, the da Vinci® Surgical System continues to undergo enhancements that are changing and improving the surgical experience for both surgeon and patient.

Recent improvements have created a more efficient surgical environment for the OR staff. During the procedure, the surgeon sits at a console that offers a 3-D high-definition image of the patient – while viewing that image, the surgeon then uses controls to manipulate robotic arms with tools to perform the surgery.

In earlier years, the robot was permanently docked at the beginning of a surgery. If the patient required repositioning, surgical staff then had to stop and also reposition the robot. Today’s da Vinci’s® systems allow the surgeon and OR staff to move around to different regions of the patient’s anatomy without undocking the robot. Also, the system’s camera is no longer stationary as in previous generations of the technology – it can now be moved and placed on any one of the robotic arms at any time.

Additionally, new tools are giving surgeons even better precision for certain procedures, with improved results for the patient.

For example, laparoscopic cholecystectomy (laparoscopic gallbladder removal) – a big advancement over what was previously an open surgery that meant several days in the hospital for the patient – is an outpatient procedure that involves four approximately inch-long incisions in the abdomen. Now, a recent technological improvement has made an even less invasive procedure possible. Single-Site™ Instrumentation is a new operating platform attached to the da Vinci® Si™ Surgical System that allows surgeons to remove the gallbladder through a single incision.

Patrick Kenney, D.O., a board-certified general surgeon at North Fulton Hospital in Roswell, first observed the da Vinci® Surgical System more than 10 years ago. Though impressed with its ability to increase precision in laparoscopic surgeries, he knew the system was somewhat limited in its applications at the time. Later, when the manufacturer added some helpful tools, Kenney decided to undergo training to begin using the system.

“In the first few years, the system only worked well for certain operations, such as gynecological procedures,” he says. “But when da Vinci developed improved technologies and added devices to seal blood vessels and staple, it opened up new applicability.”

Dr. Kenney, who began performing laparoscopic procedures using the da Vinci® Si™ Surgical System a little over two years ago, says the newest development is making some procedures, such as gallbladder removal, less invasive than ever before.

“The single-site platform features improved instrumentation that allows surgeons to perform certain procedures with only one incision,” he explains. “So now, a gallbladder removal can be done by making one small incision through the belly button – and the patient has less pain and scarring.”

The single-incision technique also offers surgeons much-improved control over the instrumentation, according to Dr. Kenney.

“I have better visualization and precision when I perform these procedures,” he states. “I feel that it leads to safer surgeries and improved outcomes for the patients, like less blood loss, less pain, fewer complications and faster recovery time.”

robotic surgery 2Where’s the scar?

Clara Parry, a patient of Dr. Kenney’s, says she was pleased to have the option of single-site surgery. Parry, who ended up in the emergency room during a recent gall bladder attack, was examined by Dr. Kenney and offered the choice of a four-incision removal or a single incision.

“The single incision just sounded like the right way to go. One incision versus four seems more logical,” she says. “And the recovery was really not bad at all.”

Parry underwent the procedure on a Thursday. By the following Monday, she was already getting out of the house to do errands.

“I’d never had surgery before. But this was not at all what I was expecting. I woke up in the recovery room and asked if it was over!” she recalls. “I was a little uncomfortable, but I didn’t have any nausea and needed very little pain medication. I was able to shower right away and it felt good to get up and walk.”

Parry and Kenney agree that the single incision has an additional benefit.

“Belly buttons hide scars wonderfully!” Dr. Kenney says.

“There’s just a small scar,” adds Parry. “You’d have to really be looking for it to see it.”

About Single-Port Laparoscopy

Single-port laparoscopy (SPL), or single-incision laparoscopic surgery, is a minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s navel. Unlike a traditional multi-port laparoscopic approach, SPL leaves only a single scar.

SPL has been used to perform many types of surgery, including:

• adjustable gastric banding

• appendectomy

• cholecystectomy

• colectomy

• hernia repair

• hysterectomy

• sleeve gastrectomy

• nephrectomy

• sacrocolpopexy

Benefits include less postoperative pain, less blood loss, faster recovery time and better cosmetic results.

However, there may also be complications from SPL, such as significant postoperative pain, injury to organs, bleeding, infection, incisional hernia, intestinal adhesions and scarring.

The Whole Team

The da Vinci Si System is an integration of advanced technologies, including:

Firefly™ Fluorescence Imaging. The Firefly Fluorescence Imaging Vision System enables surgeons to use a special video camera and glowing dye to view blood flowing in vessels, and tissue or bile moving through ducts during minimally invasive surgical procedures. It is intended to provide real-time endoscopic visible and near-infrared fluorescence imaging. Firefly enables minimally invasive surgery using standard endoscopic visible light as well as visual assessment of vessels, blood flow and related tissue perfusion, and at least one of the major extrahepatic bile ducts (cystic duct, common bile duct and common hepatic duct), using near infrared imaging.

Single-Site®. Single-Site’s transumbilical entry enables a virtually scarless surgery. Instruments and camera cross within the Single-Site port and use remote center technology to avoid cannula collisions, arm interferences and port-site movement. Single-Site is commercially available for laparoscopic cholecystectomy, hysterectomy and salpingo-oophorectomy for benign conditions only.

Skills Simulator™. Skills Simulator’s built-in metrics enable users to assess skills, receive real-time feedback and track progress. Administrative tools let users structure their own curriculum to fit with other learning activities in their institution. The open architecture of the system software allows for the future development and incorporation of additional practice modules.

Advanced Instrumentation. The Si System enables mechanical function of advanced instruments including EndoWrist One Vessel Sealer and EndoWrist Stapler 45.



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