Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC): comparison of learning curves. First European experience

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

The Revo-i Robotic Surgical System in Advanced Pancreatic Surgery: A Second Non-Randomized Clinical Trial and Comparative Analysis to the da Vinci™ System

PURPOSE

Numerous robot-assisted pancreatic surgery are being performed worldwide. This study aimed to evaluate the feasibility and safety of the Revo-i robot system (Meerecompany, Seoul, Republic of Korea) for advanced pancreatic surgery, and also compare this new system with the existing da Vinci™ robot system (Intuitive Surgical, Sunnyvale, CA, USA) in the context of robot-assisted pancreaticoduodenectomy (RPD).

MATERIALS AND METHODS

This study was a one-armed prospective clinical trial that assessed the Revo-i robot system for advanced pancreatic surgery. Ten patients aged 30 to 73 years were enrolled between December 2019 and August 2020. Postoperative outcomes were retrospectively compared with those of the da Vinci™ surgical system. From March 2017 to August 2020, a total of 47 patients who underwent RPD were analyzed retrospectively.

RESULTS

In the prospective clinical trial, pancreaticoduodenectomy was performed in nine patients and one patient underwent central pancreatectomy. Among the 10 study participants, the incidence of major complications was 0% in hospital stay. There were eight postoperative pancreatic fistula (POPF) biochemical leaks (80%). In the retrospective analysis that compared the Revo-i and da Vinci™ robotic systems, 10 patients underwent Revo-i RPD and 37 patients underwent da Vinci™ RPD, with no significant differences in complication or POPF incidence rates between the two groups (p=0.695, p=0.317).

CONCLUSION

In this single-arm prospective study with short-term follow-up at a single institution, the Revo-i robotic surgical system was safe and effective for advanced pancreatic surgery. Revo-i RPD is comparable to the da Vinci™ RPD and is expected to have wide clinical application.

Clinical status and future prospects of single-incision robotic-assisted surgery: a review

Since the advent of conventional multiport laparoscopic surgery, the prosperity of minimally invasive surgery has been thriving on the advancement of endoscopic techniques. Cosmetic superiority, recovery benefits, and noninferior surgical outcomes weigh single-incision laparoscopic surgery as a promising modality. Although there are surgical challenges posed by steep learning curve and technological difficulties, such as instruments collision, triangulation loss and limited retraction, the establishment of robotic surgical platform as a solution to all is inspiring. Furthermore, with enhanced instrument maneuverability and stability, robotic ergonomic innovations adopt the advantages of single-incision laparoscopic surgery and surmount its recognized barriers by introducing a novel combination, single-incision robotic-assisted surgery. As was gradually diffused in general surgery and other specialties, single-incision robotic-assisted surgery manifests privileges in noninferior clinical outcomes an satisfactory cosmetic effect among strictly selected patients, and has the potential of a preferable surgical option for minimally invasive surgery.

Beyond the Scalpel: A Tapestry of Surgical Safety, Precision, and Patient Prosperity

In modern surgical practice, the focus extends beyond simply making and closing incisions. We aim to investigate the various complex aspects that redefine the criteria for achieving effective surgical outcomes. This narrative combines current knowledge, integrating practical experiences and academic viewpoints to comprehend the changing field of surgical care thoroughly. The tapestry explores the detailed aspects of surgical safety, examining the most recent progress in protocols, technology, and team dynamics that strive to reduce procedural risks. Examining precision in surgery, this narrative goes beyond conventional limits to explore the incorporation of advanced technologies, such as robotics and navigational systems. The complex interplay between the surgeon's proficiency and these technology aids is crucial in attaining unparalleled accuracy and favorable patient results. The focal point of this investigation is the patient's well-being, encompassing postoperative care, rehabilitation, and long-term health. Actual accounts from surgical procedures highlight the significant influence of comprehensive patient-centered methods, emphasizing the crucial need for empathy, communication, and individualized care plans in promoting healing and adaptability. As we explore this complex situation, the combination of real-life stories and academic discussions creates a clear and detailed image of a surgical environment that goes far beyond the boundaries of the operating room. "Beyond the Scalpel" seeks to engage practitioners, scholars, and stakeholders in a conversation that redefines the criteria for surgical success. It aims to establish a new benchmark that combines safety, precision, and patient well-being, ultimately shaping the future of surgical practice.

Innovative Approaches to Safe Surgery: A Narrative Synthesis of Best Practices

By encompassing a wide range of best practices within the ever-changing realm of modern surgical care, this exhaustive narrative compendium attempts to unravel the complex tapestry of novel approaches to safe surgery. Within the context of a dynamic surgical environment, this research endeavors to illuminate and integrate state-of-the-art methods that collectively methodically improve patient safety. The narrative elucidates a diverse array of practices that seek to revolutionize the paradigm of safe surgery, emphasizing technological progress, patient-centric approaches, and global viewpoints. The combined effectiveness of these methods in fostering an all-encompassing culture of safety, improving surgical precision, and decreasing complications is revealed by the results obtained from their implementation. The recognition of the dynamic interplay among multiple components, including the active participation of patients, the integration of cutting-edge technologies, and the establishment of comprehensive quality improvement programs, is fundamental to this narrative. By their collective composition, these components support the notion that secure surgical practices are intricate and interrelated. The present synthesis functions as a fundamental resource for healthcare professionals, policymakers, and researchers, providing an enlightening examination of the current condition of secure surgical practices. By emphasizing the promotion of innovation, continuous development, and the utmost quality of patient care, it offers a strategic guide for navigating the complex terrain of safe surgery. In the ever-evolving landscape of surgical care, this narrative synthesis serves as a guiding principle for stakeholders striving to understand better and implement safe surgical procedures in various healthcare environments.

Single-site robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A systematic review and meta-analysis

Background

The possibilities of minimally invasive cholecystectomy have emerged since the beginning of single-incision laparoscopic cholecystectomy (SILC) and single-site robotic cholecystectomy (SSRC). This study aimed to compare the feasibility, safety, and pain scores between SSRC and SILC.

Methods

The authors searched randomized or non-randomized controlled trials and observational studies in PubMed, EuroPMC, and ClinicalTrials.gov from April 2012 until April 2022. The authors analyzed the operation time, hospital stay, blood loss volume, conversion rate, intraoperative complication rates, postoperative complications, visual analog scale (VAS) immediately after surgery, and VAS at hospital discharge. This study aligned with PRISMA and AMSTAR guidelines.

Results

Thirteen studies were selected with 817 and 757 patients who underwent SSRC and SILC. Thus, this study demonstrated a lower incidence of intraoperative complication rates [relative risk (RR) 0.57 (95% CI 0.34-0.96), p = 0.03] and lesser VAS score at hospital discharge [Std. Mean Difference (SMD) -0.23 (95% CI -0.46, -0.01), p = 0.04] in the SSRC group. Regarding operation time and cost, SSRC revealed a longer time [SMD 1.02 (95% CI 0.45, 1.59), p = 0.0004] and higher cost [SMD 4.18 (95% CI 1.77, 6.58), p < 0.00001], respectively. Meanwhile, SSRC did not differ from SILC during a hospital stay, blood loss volume, conversion rate, postoperative complication rates, and VAS immediately after surgery.

Conclusions

Concerning intraoperative complication rates and VAS score at hospital discharge, SSRC was superior to SILC. Thus, SSRC is considered a feasible and safe procedure.

A systematic review of robot-assisted cholecystectomy to examine the quality of reporting in relation to the IDEAL recommendations: systematic review

INTRODUCTION

Robotic cholecystectomy (RC) is a recent innovation in minimally invasive gallbladder surgery. The IDEAL (idea, development, exploration, assessment, long-term study) framework aims to provide a safe method for evaluating innovative procedures. This study aimed to understand how RC was introduced, in accordance with IDEAL guidelines.

METHODS

Systematic searches were used to identify studies reporting RC. Eligible studies were classified according to IDEAL stage and data were collected on general study characteristics, patient selection, governance procedures, surgeon/centre expertise, and outcome reporting.

RESULTS

Of 1425 abstracts screened, 90 studies were included (5 case reports, 38 case series, 44 non-randomized comparative studies, and 3 randomized clinical trials). Sixty-four were single-centre and 15 were prospective. No authors described their work in the context of IDEAL. One study was classified as IDEAL stage 1, 43 as IDEAL 2a, 43 as IDEAL 2b, and three as IDEAL 3. Sixty-four and 51 provided inclusion and exclusion criteria respectively. Ethical approval was reported in 51 and conflicts of interest in 34. Only 21 reported provision of training for surgeons in RC. A total of 864 outcomes were reported; 198 were used in only one study. Only 30 reported a follow-up interval which, in 13, was 1 month or less.

CONCLUSION

The IDEAL framework was not followed during the adoption of RC. Few studies were conducted within a research setting, many were retrospective, and outcomes were heterogeneous. There is a need to implement appropriate tools to facilitate the incremental evaluation and reporting of surgical innovation.

Case report of pure single-port robotic left lateral sectionectomy using the da Vinci SP system

INTRODUCTION

Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform.

PATIENT CONCERNS AND DIAGNOSIS

A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater.

INTERVENTIONS

The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed.

OUTCOMES

The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications.

CONCLUSION

We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy (LC) is one of the most frequently performed gastrointestinal surgeries worldwide. Bile duct injury (BDI) represents the most serious complication of LC, with an incidence of 0.3%-0.7%, resulting in significant perioperative morbidity and mortality, impaired quality of life, and high rates of subsequent medico-legal litigation. In most cases, the primary cause of BDI is the misinterpretation of biliary anatomy, leading to unexpected biliary lesions. Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings. The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Outcome after single-site robotic cholecystectomy: An initial single center's experience

BACKGROUND

Although laparoscopic cholecystectomy (LC) is the gold standard for symptomatic gallbladder disease, a single-incision approach may be a new challenge in order to achieve minimization of surgical trauma. Single-site robotic cholecystectomy (SSRC) is able to offset the ergonomic limitation of laparoscopic single-site cholecystectomy and improves cosmesis.

METHODS

We present a single-institution initial experience of SSRC for cholecystolithiasis. Intra-operative and post-operative data of patients were reviewed to assess the technical feasibility and cosmetic outcome.

RESULTS

We evaluated a series of 27 consecutive patients retrospectively analyzed and prospectively collected who underwent SSRC. One patient was excluded from the final analysis because they converted to open procedure. The female/male ratio was 17/9, with mean age of 48 ± 12 years. The body mass index mean value was 26.0 ± 4.2. The mean operative time was 99.6 ± 21.5 minutes. No intra- or post-operative complications and readmissions were recorded. At 12 months follow up, every patient received the Body Image Questionnaire (BIQ) and a Photo Series Questionnaire. We recorded three patients (11.5%) with post-operative incisional hernia. Scores of the BIQ subscale for body image perception were 6 ± 1.2, while the scores of scar cosmesis were 21.1 ± 3.0. A statistically significant improvement in scar self-rating from T0 to T1 (P < .01) was found.

CONCLUSION

In our initial experience SSRC may be preferred to treat patients with higher needs in terms of cosmesis and body image perception. Lower costs for rent, maintenance and consumables may allow the spread of robotic surgery also for singe site cholecystectomy.

Intraoperative and postoperative outcomes of robot-assisted cholecystectomy: a systematic review

BACKGROUND

Rapid adoption of robotic-assisted general surgery procedures, particularly for cholecystectomy, continues while questions remain about its benefits and utility. The objective of this study was to compare the clinical effectiveness of robot-assisted cholecystectomy for benign gallbladder disease as compared with the laparoscopic approach.

METHODS

A literature search was performed from January 2010 to March 2020, and a narrative analysis was performed as studies were heterogeneous.

RESULTS

Of 887 articles screened, 44 met the inclusion criteria (range 20-735,537 patients). Four were randomized controlled trials, and four used propensity-matching. There were variable comparisons between operative techniques with only 19 out of 44 studies comparing techniques using the same number of ports. Operating room time was longer for the robot-assisted technique in the majority of studies (range 11-55 min for 22 studies, p < 0.05; 15 studies showed no difference; two studies showed shorter laparoscopic times), while conversion rates and intraoperative complications were not different. No differences were detected for the length of stay, surgical site infection, or readmissions. Across studies comparing single-port robot-assisted to multi-port laparoscopic cholecystectomy, there was a higher rate of incisional hernia; however, no differences were noted when comparing single-port robot-assisted to single-port laparoscopic cholecystectomy.

CONCLUSIONS

Clinical outcomes were similar for benign, elective gallbladder disease for robot-assisted compared with laparoscopic cholecystectomy. Overall, the rates of complications were low. More high-quality studies are needed as the robot-assisted technique expands to more complex gallbladder disease, where its utility may prove increasingly beneficial.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020156945.

Propensity score-matching analysis for single-site robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A retrospective cohort study

BACKGROUND

Although the single-site robotic cholecystectomy(SSRC) has been performed with expectation of overcoming the limitation of single-incision laparoscopic cholecystectomy(SILC), there exists a lack of comparison studies involving SILC and SSRC. This study aimed to analyze surgical outcomes of single-site robotic cholecystectomy and single-incision laparoscopic cholecystectomy by propensity score-matching analysis.

MATERIALS AND METHODS

From March 2009 to August 2015, 290 consecutive patients underwent SSRC or SILC at Severance Hospital, Seoul, Korea. Potential confounding factors for operative outcomes were adjusted by propensity score-matching analysis. One hundred four patients from each group were evaluated for perioperative outcomes and compared for a retrospective cohort study.

RESULTS

There was no difference in potential cofounders such as gender, age, body mass index (BMI), and perioperative cholecystitis-related symptoms between two groups after propensity score-matching. However, mean operation time was shorter (56.69 ± 13.65 vs. 101.57 ± 27.05 min; p < 0.001) and median bleeding amount during surgery was less (0 (0-50) vs. 0 (0-100) mL; p < 0.001) in the SILC group. There was no significant difference between the two groups regarding conversion to conventional multiport cholecystectomy. Bile leakage due to perforation of the gallbladder during surgery was more common in the SILC group (6.7% vs. 17.3%; p = 0.019). Moreover, bile spillage rate was significantly increased in conjunction with a higher BMI in the SILC group, whereas BMI did not affect the bile leakage rate in the SSRC group.

CONCLUSIONS

SSRC is not superior to SILC except regarding bile spillage incidence. However, the technical stability and clinically undetected advantages of SSRC are expected to prompt surgeons to perform this more reliable procedure.

Robotic Biliary Surgery

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Initial Experience With a New Robotic Surgical System for Cholecystectomy

Background. Laparoscopic cholecystectomy has been the gold standard treatment for symptomatic cholelithiasis for more than 3 decades. Robotic techniques are gaining traction in surgery, and recently, the Senhance^™ robotic system was introduced. The system offers advantages over other robotic systems such as improved ergonomics, haptic feedback, eye tracking, and usability of standard laparoscopic trocars and reusable instruments. The Senhance was evaluated to understand the feasibility, benefits, and drawbacks of its use in cholecystectomy. Study Design. A prospectively maintained database of the first 20 patients undergoing cholecystectomy with the Senhance was reviewed at a single hospital. Data including operative time, console time, set up time, and adverse events were collected, with clinical outcome and operative time as primary outcome measures. A cohort of 20 patients having laparoscopic cholecystectomy performed by the same surgeon was used as a comparator group. Results. The 2 groups had comparable demographic data (age, sex, and body mass index). In the Senhance group, 19 of the 20 procedures (95%) were completed robotically. The median (interquartile range) total operating, docking, and console times were 86.5 (60.5-106.5), 11.5 (9-13), and 30.8 (23.5-35) minutes, respectively. In the laparoscopic group, the median (interquartile range) operating time was 31.5 (26-41) minutes. Postoperatively, only one patient had a surgical complication, namely a wound infection treated with antibiotics. Conclusion. Our results suggest that Senhance-assisted cholecystectomy is safe, feasible, and effective, but currently has longer operative times. Further prospective and randomized trials are required to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Robotic Single-Port Platform in General, Urologic, and Gynecologic Surgeries: A Systematic Review of the Literature and Meta-analysis

BACKGROUND

Robotic platforms have recently acquired progressive importance in different surgical fields, such as urology, gynecology, and general surgery. Through the years, new surgical robots have become available as single-port robotic platform. The study is aimed to value the single-port robotic platform characteristics in different surgical specialties.

METHODS

The terms "LESS" OR "single port" OR "single site" AND "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. A total of 57 studies were considered eligible for the present review. The articles included were divided according to the surgical field in which the study was conducted: General surgery (29 articles), Gynecology (18 articles), Urology (10 articles).

RESULTS

Most part of the articles showed the feasibility of robotic single-port surgical procedures and described advantages in terms of cosmetic, hospital stay, and in some series even cost reduction. A meta-analysis was conducted, showing a significant increment of complications using RSP if compared with SLPS and a trend (P = 0.008) when RSP was compared with LESS. The comparison of different techniques in terms of conversion to laparotomy did not show any significant difference.

CONCLUSION

Robotic single port potentially furnishes an important surgical and post-operatory improvement; however, some limits still prolong the surgical time and complication rate.

Minimally Invasive Single-Site Cholecystectomy in Obese Patients: Laparoscopic vs. Robotic

Purpose

Laparoscopic cholecystectomy is treatment method for management of benign gallbladder diseases. Further attempts are made to operate single-port laparoscopic cholecystectomy. However, single-port laparoscopic cholecystectomy, the procedure remains technically difficult, especially in obese patient. Recently, a robotic surgical system for minimal invasive surgery was introduced to overcome the limitations of conventional laparoscopic surgery.

Methods

From April 2009 to August 2017, we retrospectively reviewed the medical records of patients with single-site, minimally invasive (laparoscopic and robotic) cholecystectomy with high BMI (>25 kg/m²). We analyzed general characteristics and perioperative outcomes between the single-fulcrum laparoscopic cholecystectomy group and the robotic single-site cholecystectomy (RSSC) group.

Results

Operation time (57.56±11.10 vs 98.5±12.28 p<0.001) was significantly longer and postoperative pain score (3.61 vs 5.15 p=0.000) was significantly higher in the robotic single-site cholecystectomy (RSSC) group, but the actual dissection time (25.85±11.09 vs 25.79±13.35 p=0.978) was not significantly different between the two approaches. Iatrogenic gallbladder perforation, (13 vs 6 p=0.005), patients undergoing RSSC showed a significantly smaller amount than did those undergoing single-fulcrum laparoscopic cholecystectomy (SFLC).

Conclusion

It is difficult to say for certain that RSSC is clearly better than SFLC in obese patients. However, because of the technical convenience and efficiency of surgery with RSSC, RSSC can be practically worthwhile. Further study is mandatory.

Feasibility and safety of single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy in an ambulatory setting

BACKGROUND

Single-incision laparoscopic surgery has emerged as an alternative to conventional laparoscopic cholecystectomy (LC) in the clinical setting. Limited information is available on the possibility of performing single-incision laparoscopic surgery as an ambulatory procedure. This study aimed to determine the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC) versus conventional LC in an ambulatory setting.

METHODS

Ninety-one patients were randomized to SILC (n = 49) or LC (n = 42). The success rate, operative duration, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, total cost, complications, pain score, vomiting, and cosmetic satisfaction of the two groups were then compared.

RESULTS

There were significant differences in the operative time (46.89 ± 10.03 min in SILC vs. 37.24 ± 10.23 min in LC; P < 0.001). As compared with LC, SILC was associated with lower total costs (8012.28 ± 752.67 RMB vs. 10258.91 ± 1087.63 RMB; P < 0.001) and better cosmetic satisfaction (4.94 ± 0.24 vs. 4.74 ± 0.54; P = 0.031). There were no significant differences between-group in terms of general data, success rate, blood loss, hospital stay, gallbladder perforation, drainage, delayed discharge, readmission, complications, pain score, and vomiting (P > 0.05).

CONCLUSIONS

Ambulatory SILC is safe and feasible for selected patients. The advantages of SILC as compared with LC are improved cosmetic satisfaction and lower total costs.

[Robot-assisted surgery - Progress or expensive toy? : Matched-pair comparative analysis of robot-assisted cholecystectomy vs. laparoscopic cholecystectomy]

AIM AND METHODS

By means of a matched-pair analysis comparing data obtained from laparoscopic cholecystectomy (LC) and robot-assisted laparoscopic cholecystectomy (RAC), the value of both methods as well as the advantages and disadvantages of both approaches were elucidated. The consideration was carried out by evaluation of postoperative surgical results, a cost analysis and a subjective survey of the patients using a questionnaire. Thus, from the 35 consecutive RAC, 35 (parallel) retrospectively matched pairs were established.

RESULTS

Postoperative surgical results did not show any significant differences between LC and RAC. In the individual assessment by each patient, there were also no significant differences; however, there was a tendency towards the assessment of the RAC to be slightly worse. A striking difference was found with respect to the cost analysis at the time of surgery.

CONCLUSION

The RAC operation alone is significantly more expensive compared to LC with respect to maintenance and acquisition costs. In addition, RAC can at present not be completely reimbursed under the current German diagnosis-related system. The postulated advantages of RAC comprise mainly the precise preparation within narrow confinements and the favorable ergonomic handling for the surgeon. The basic prerequisites are control of the costs and a reasonable reflection in the current reimbursement system.

Robotic single-site surgery for mature cyst teratoma cystectomy: an initial case series study in a single medical center in China

Objective

To report the first case series of robotic single-site (RSS) surgery via the da Vinci Si Surgical System for mature cyst teratoma cystectomy in China.

Materials and methods

The study was devised as a retrospective study in a single medical center. Five patients with mature cyst teratomas requested a minimally invasive surgical treatment. These patients were treated with RSS surgery for mature cyst teratoma between January 2014 and January 2015. RSS mature cyst teratoma cystectomies were performed with the da Vinci single-site platform in the Hainan branch of PLA General Hospital. Data regarding patient characteristics, surgical approach, and perioperative clinical outcomes were collected and analyzed in a retrospective study.

Results

All RSS procedures were completed successfully in the five patients. No instrument failure was noted during the procedures. The median operating time was 65 minutes (range 45–100 minutes). The median docking time was 20 minutes (range 18–28 minutes). No instrument failure was noted during any surgical procedures. The median blood loss was 30 mL (range 10–70 mL). No patient had massive intraoperative bleeding nor required a transfusion. No extra trocar was placed during the surgery. None of the patients had bladder or rectal injury. The median length of stay in hospital was 2.8 days. All patients were followed up until 6 months postoperatively, and no surgical complication occurred.

Conclusion

RSS mature cyst teratoma cystectomy using the wristed semirigid instrumentation is feasible. Randomized controlled trials with a larger number of patients and longer postoperative follow-up should be conducted to further evaluate the effect of this therapeutic strategy.

Single-incision robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is the result of the ongoing trend to minimally invasive of laparoscopy, but some surgeons thought that the SILC can increase the risk of bile duct injure or bile spillage, and the single-incision robotic cholecystectomy (SIRC) can overcome the drawbacks of SILC. Some articles described that the SIRC had longer operative time and more cost than SILC. The advantages and disadvantages of SIRC have still not been extensively studied. We aimed to investigate the outcomes of SIRC compared to SILC and evaluate the safety and feasibility of SIRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were searched to seek information in English literature from 2011 to 2017. Studies comparing SIRC to SILC, for any indication, were included in the analysis. This systematic review and meta-analysis were performed with RevMan Version 5.3.

RESULTS

Six comparative studies (n = 633 patients) were included in our analysis. The data showed that the SIRC and SILC had equivalent outcomes for operative time [mean difference (MD) = 17.32, 95% confidence interval (CI): -8.93-43.57, P = .20], intraoperative complications [odd ratio (OR) = 0.48, 95% CI: 0.17-1.39, P = .18], postoperative complications (OR = 0.62, 95% CI: 0.21-1.86, P = .39), hospital stay (MD = -0.01, 95% CI: -0.21-0.19, P = .90), readmissions rate (OR = 0.70, 95% CI: 0.09-5.63, P = .74), and conversion rate (OR = 0.52, 95% CI: 0.14-1.96, P = .33), but total cost was statistically significant (MD = 3.7, 95% CI: 3.61-3.79, P < .00001).

CONCLUSION

SIRC is a safe and feasible procedure for cholecystectomy, and the operative time is same as SILC, but the total cost of SIRC is significantly higher than SILC.

Robotic-assisted versus laparoscopic cholecystectomy for benign gallbladder diseases: a systematic review and meta-analysis

BACKGROUND

Robotic surgery, an emerging technology, has some potential advantages in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted cholecystectomy (RAC) is still a controversial issue on its comparative merit compared with conventional laparoscopic cholecystectomy (LC). The aim of this study was to evaluate the safety and efficacy of RAC compared with LC for benign gallbladder disease.

METHODS

A systematic literature search was conducted using the PubMed, EMBASE, and Cochrane Library databases (from their inception to December 2017) to obtain comparative studies assessing the safety and efficacy between RAC and LC. The quality of the literature was assessed, and the data analyzed using R software, random effects models were applied.

RESULTS

Twenty-six studies, including 5 RCTs and 21 NRCSs (3 prospective plus 18 retrospective), were included. A total of 4004 patients were included, of which 1833 patients (46%) underwent RAC and 2171 patients (54%) underwent LC. No significant differences were found in intraoperative complications, postoperative complications, readmission rate, hospital stay, estimated blood loss, and conversion rate between RAC and LC groups. However, RAC was related to longer operative time compared with LC (MD = 12.04 min, 95% CI 7.26-16.82) in RCT group, which was consistent with NRCS group; RAC also had a higher rate of incisional hernia in NRCS group (RR = 3.06, 95% CI 1.42-6.57), and one RCT reported that RAC was similar to LC (RR = 7.00, 95% CI 0.38-129.84).

CONCLUSIONS

The RAC was not found to be more effective or safer than LC for benign gallbladder diseases, which indicated that RAC is a developing procedure instead of replacing LC at once. Given the higher costs, the current evidence is in favor of LC in cholecystectomy.

Safety of single-incision robotic cholecystectomy for benign gallbladder disease: a systematic review

BACKGROUND

Multiport laparoscopic cholecystectomy (MLC) is the gold standard technique for cholecystectomy. In order to reduce postoperative pain and improve cosmetic results, the application of the single-incision laparoscopic cholecystectomy (SILC) technique was introduced, leading surgeons to face important challenges. Robotic technology has been proposed to overcome some of these limitations. The purpose of this review is to assess the safety of single-incision robotic cholecystectomy (SIRC) for benign disease.

METHODS

An Embase and Pubmed literature search was performed in February 2017. Randomized controlled trial and prospective observational studies were selected and assessed using PRISMA recommendations. Primary outcome was overall postoperative complication rate. Secondary outcomes were postoperative bile leak rate, total conversion rate, operative time, wound complication rate, postoperative hospital stay, and port site hernia rate. The outcomes were analyzed in Forest plots based on fixed and random effects model. Heterogeneity was assessed using the I² statistic.

RESULTS

A total of 13 studies provided data about 1010 patients who underwent to SIRC for benign disease of gallbladder. Overall postoperative complications rate was 11.6% but only 4/1010 (0.4%) patients required further surgery. A postoperative bile leak was reported in 3/950 patients (0.3%). Conversion occurred in 4.2% of patients. Mean operative time was 86.7 min including an average of 42 min should be added as for robotic console time. Wound complications occurred in 3.7% of patients. Median postoperative hospital stay was 1 day. Port site hernia at the latest follow-up available was reported in 5.2% of patients.

CONCLUSIONS

The use of the Da Vinci robot in single-port cholecystectomy seems to have similar results in terms of incidence and grade of complications compared to standard laparoscopy. In addition, it seems affected by the same limitations of single-port surgery, consisting of an increased operative time and incidence of port site hernia.

Single-site robotic cholecystectomy versus multi-port laparoscopic cholecystectomy: A systematic review and meta-analysis

OBJECTIVE

To investigate the outcomes of single-site robotic cholecystectomy (SSRC) compared to multi-port laparoscopic cholecystectomy (MLC), evaluate the safety and feasibility of SSRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were used to seek information in English literature from 2011 to 2017. Studies comparing SSRC to MLC, for any indication, were included in the analysis. This systematic review and meta-analysis was performed with RevMan Version 5.3.

RESULTS

Seven studies (two randomized control trails (RCTs) and five comparative studies, n = 1657 patients) were included in our analysis. The data showed that the SSRC and MLC had equivalent outcomes for operative time (MD = -3.06, 95% CI: -7.61-1.49, p = 0.19), bleeding (OR = 1.63, 95%CI: 0.40-6.56, p = 0.49), postoperative complications (OR = 1.11, 95%CI: 0.35-3.51, p = 0.86), bile leakage (OR = 0.38, 95%CI: 0.07-2.00, p = 0.26), wound infection (OR = 1.92, 95%CI: 0.86-4.32, p = 0.11), conversion rate (OR = 1.30, 95% CI: 0.71-2.37, p = 0.40), and hospital stay (MD = -0.02, 95% CI: -0.60-0.57, p = 0.96). However, in the SSRC group the risk of incisional hernia is higher than the MLC group (OR = 4.23, 95% CI: 1.87-9.58, p = 0.0005), incidence of incisional hernia rate in SSRC group is higher than MLC group (5.8% vs. 0.9%), and the total costs in the SSRC group is higher than MLC group (MD = 3.51, 95% CI: 0.31-6.71, p = 0.03).

CONCLUSIONS

The medical cost is significantly higher in SSRC compared with MLC, and SSRC can increasing the risk of incisional hernia. Therefore, surgeons must be carefully balanced its advantage, disadvantage and risk.

Single-site robotic-assisted laparoscopic cholecystectomy in children and adolescents: a report of 20 cases

BACKGROUND

Single-site laparoscopy is increasingly popular for straightforward operations like appendectomy. Due to limited triangulation and maneuverability, single-site cholecystectomy is riskier and more difficult. Robotics offer to make it easier and safer.

METHODS

Twenty children and adolescents underwent robotic-assisted single-site cholecystectomy at a large academic children's hospital. Patients were not randomized; patients were offered the option of robotic-assisted single-site (SSR) or standard four-incision laparoscopic (LAP) cholecystectomy. Demographics and perioperative details were compared with those of a comparable cohort who underwent LAP during the same period.

RESULTS

The two groups were similar in physical characteristics and indications for operation. The robotic operations took longer but both groups received similar PRN doses of parenteral opiates. Patients in the SSR group were all discharged on the first postoperative day. There were no major complications in either group but a slightly higher incidence of minor wound complications in the SSR group.

CONCLUSION

Robotic-assisted single-site cholecystectomy appears to be a safe alternative to standard laparoscopy with a similar postoperative pain profile, short postoperative lengths of stay, and, for some, a superior cosmetic result. Nevertheless, it comes with longer set-up and operative times, a higher incidence of minor wound complications, an unknown but possibly higher risk of incisional hernia, and higher costs.

Robotic single-site versus multiport laparoscopic cholecystectomy: a case-matched analysis of short- and long-term costs

BACKGROUND

Multiport laparoscopy is the gold-standard approach for cholecystectomy, and single-port laparoscopy has been developed to further reduce its invasiveness. A specific robotic single-port platform (da Vinci single-site, Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2011, which could technically facilitate single-site cholecystectomy. Current data show its feasibility; however, detailed short- and long-term analyses of costs and comparisons relative to multiport laparoscopy are not available to date.

METHODS

Patients who underwent robotic single-site cholecystectomy for benign, clinically noninflammatory disease between 2011 and 2015 were matched for disease, age, gender, BMI, ASA classification, diagnosis, and elapsed year of surgery to a cohort of multiport cholecystectomies. Demographic, perioperative, and long-term data were collected retrospectively and analyzed. Perioperative and long-term costs including re-operations due to the primary procedure until February 2017 were compared across both cohorts.

RESULTS

99 patients who underwent robotic single-site cholecystectomy were matched to 99 patients with multiport cholecystectomy. A higher rate of outpatient procedures in the robotic cohort (31.3 vs. 17.2%, p = 0.0305) was found, and demographic parameters and perioperative clinical outcomes were similar. Perioperative costs were significantly higher for the robotic single-site patients (6158.0 vs. 4288.0 USD, p < 0.0001). With similar follow-up times of 59.0 and 58.9 months, respectively (p = 0.9552), significantly more patients of the robotic Single-Site cohort underwent follow-up surgery (7.1 vs. 0.0%, p = 0.0140), and follow-up costs were significantly higher for the robotic cohort (694.7 vs. 0.0 USD, p = 0.0145).

CONCLUSION

With similar early postoperative clinical results and a higher rate of re-operations, perioperative and long-term costs are significantly higher with robotic Single-Site cholecystectomy compared with multiport cholecystectomy. Considering the unclear clinical value of robotic single-site cholecystectomy and the significant short- and long-term costs, a call for further research and a debate as to who should bear the costs beyond the ones of the gold-standard treatment appear reasonable.

Advantages of the glove port docking technique in robotic single-site cholecystectomy: comparison with the conventional silicone port

Although the da Vinci Single-Site^® silicone port allows exact alignment and effective triangulation of instruments, it also has drawbacks. We introduce an alternative docking technique using the Glove port^®. From April 2014 to December 2016, respective 50 patients of the conventional silicone port and the glove port group were compared. The mean docking time was 16.6 ± 6.6 min in the silicone port group and 10.6 ± 3.6 min in the glove port group. Re-docking during the operation was needed in three patients in the silicone port group and readjustment of cannulae without re-docking could be simply performed in five patients in the glove port group. Skin injury was observed in 17 patients in the silicone port group and 0 patients in the glove port group without significant complications. Some limitations of the conventional silicone port were improved by the glove port.

Randomized controlled trial of EndoWrist-enabled robotic versus human laparoendoscopic single-site access surgery (LESS) in the porcine model

INTRODUCTION

A robotic laparoendoscopic single-site access surgery (R-LESS) platform that incorporates the EndoWrist function of robotic instruments may provide better triangulation and retraction during LESS. The aim of the study is to assess if R-LESS is feasible with standard robotic instruments via a single incision and whether the approach could reduce the difficulty of the procedure and confer additional benefits over conventional LESS.

METHODS

This was a prospective randomized controlled study investigating the workload performance, efficacy, and risks of performing R-LESS when compared with human LESS (H-LESS) in a survival porcine model for cholecystectomy and gastrojejunostomy. The primary outcome is the NASA task load index. Secondary outcomes included the difficulty of the procedures, procedural time, morbidities, and mortalities.

RESULTS

Twenty-four cholecystectomies and gastrojejunostomies using the R-LESS or H-LESS approach (12:12) were performed. None of the swine suffered from procedural adverse events and none of the procedures required conversion. In both the cholecystectomy and gastrojejunostomy groups, R-LESS was associated with significantly lower NASA task load index (P < 0.001) and reduced difficulties in various steps of the procedures. No differences in the overall procedure times of the two procedures were observed (P = 0.315).

CONCLUSION

The R-LESS approach significantly reduced the workload and difficulties of LESS cholecystectomies and gastrojejunostomies. A dedicated single-site platform that could reduce instrument clashing while retaining the EndoWrist function is eagerly awaited.

Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: A meta-analysis

BACKGROUND

Robotic cholecystectomy is a novel approach that offers the surgeon improved high-definition, 3-dimensional views and enhanced instrument ergonomics, which represent a technical development from previous operative platforms that include conventional and single-incision laparoscopy. This review compares its short-term outcomes with conventional laparoscopic cholecystectomy by a meta-analysis.

METHODS

A literature search was conducted using the MEDLINE, EMBASE, and PubMed databases (January 1990-October 2015). Studies identified were appraised with standard selection criteria. Data were extracted and a meta-analysis performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Thirteen studies, 12 retrospective trials and one randomized controlled trial comprising 1,589 patients (laparoscopic cholecystectomy, n = 921; robotic cholecystectomy, n = 668) were examined. There was a trend of a greater median total operative time (115.3 min vs 128.0 min; pooled MD = 31.22, 95% confidence interval = -2.48 to 59.96; Z = 2.13; P = .03) and preoperative time (32.4 min vs 53.4 min; pooled MD = 20.98, 95% confidence interval = 15.74 to 26.23; Z = 7.84; P < .001) in the robotic cholecystectomy group. Intraoperative complications (P = .52), conversion rate (P = .06), estimated blood loss (P = .55), postoperative complications (P = .28), duration of hospital stay (P = .36), and readmission rate (P = .85) were similar between both groups.

CONCLUSION

Robotic cholecystectomy is associated with greater operative times related primarily to the preparatory phase of the operation but with similar safety and perioperative outcome as conventional laparoscopic cholecystectomy. For it to gain acceptance, future studies are required to define specific measures to quantify equipment benefits to the surgeon and to evaluate the potential advantage of its use in the acute setting.

Da Vinci single site© surgical platform in clinical practice: a systematic review

BACKGROUND

The Da Vinci single-site© surgical platform (DVSSP) is a set of single-site instruments and accessories specifically dedicated to robot-assisted single-site surgery.

METHODS

The PubMed database from inception to June 2015 was searched for English literature on the clinical use of DVSSP in general surgery, urology and gynecology.

RESULTS

Twenty-nine articles involving the clinical application of DVSSP were identified; 15 articles on general surgery (561 procedures), four articles on urology (48 procedures) and 10 articles on gynecology (212 procedures). All studies have proven the safety and feasibility of the use of DVSSP. The principal reported advantage is the restoration of intra-abdominal triangulation, while the main reported limitation is the lack of the endowrist.

CONCLUSIONS

Da Vinci systems have proven to be valuable assets in single-site surgery, owing to the combination of robot use with the dedicated single-incision platform. However, case-control or prospective trials are warranted to draw more definitive conc lusions. Copyright © 2015 John Wiley & Sons, Ltd.

Cosmesis, patient satisfaction, and quality of life after da Vinci Single-Site cholecystectomy and multiport laparoscopic cholecystectomy: short-term results from a prospective, multicenter, randomized, controlled trial

BACKGROUND

Single-incision laparoscopic cholecystectomy evolved from the traditional multiport laparoscopic technique. Prior trials have demonstrated improved cosmesis with the single-incision technique. Robotic single-site surgery minimizes the technical difficulties associated with laparoscopic single-incision approach. This is the first prospective, randomized, controlled study comparing robotic single-site cholecystectomy (RSSC) and multiport laparoscopic cholecystectomy (MPLC) in terms of cosmesis and patient satisfaction.

METHODS

Patients with symptomatic benign gallbladder disease were randomized to RSSC or MPLC. Data included perioperative variables such as operative time, conversion and complications and cosmesis satisfaction, body image perception, quality of life using validated questionnaires, at postoperative visits of 2, 6 weeks and 3 months.

RESULTS

One hundred thirty-six patients were randomized to RSSC (N = 83) and MPLC (N = 53) at 8 institutions. Both cohorts were dominated by higher enrollment of females (RSSC = 78%, MPLC = 92%). The RSSC and MPLC cohorts were otherwise statistically matched. Operative time was longer for RSSC (61 min vs. 44 min, P < 0.0001). There were no differences in complication rates. RSSC demonstrated a significant superiority in cosmesis satisfaction and body image perception (P value < 0.05 at every follow-up). There was no statistically significant difference in patient-reported quality of life. Multivariate analysis of female patients demonstrated significantly higher preference for RSSC over MPLC in cosmesis satisfaction and body image perception with no difference seen in overall quality of life.

CONCLUSIONS

Results from this trial show that RSSC is associated with improved cosmesis satisfaction and body image perception without a difference in observed complication rate. The uncompromised safety and the improved cosmesis satisfaction and body image perception provided by RSSC for female patients support consideration of the robotic single-site approach. ClinicalTrials.gov identifier NCT01932216.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Competence acquisition for single-incision laparoscopic cholecystectomy

Background and Objectives:

Within the past few years, there has been a push for an even more minimally invasive approach to biliary disease with the adoption of single-incision laparoscopic cholecystectomy. We sought to compare 4 individual surgeon experiences to define whether there exists a learning curve for performing single-incision laparoscopic cholecystectomy.

Methods:

We performed a retrospective review 290 single-incision laparoscopic cholecystectomies performed by a group of general surgeons, with varying levels of experience and training, at 3 institutions between May 2008 and September 2010. The procedure times were recorded for each single-incision laparoscopic cholecystectomy, ordered chronologically for each surgeon, and subsequently plotted on a graph. The patients were also combined into cohorts of 5 and 10 cases to further evaluate for signs of improvement in operative efficiency.

Results:

Of the 4 surgeons involved in the study, only 1 (surgeon 4, laparoscopic fellowship trained with <5 years' experience) confirmed the presence of a learning curve, reaching proficiency within the first 15 cases performed. The other surgeons had more variable procedure times, which did not show a distinct trend. When we evaluated the cases by cohorts of 5 cases, surgeon 4 had a significant difference between the first and last cohort. Increased body mass index resulted in a slightly longer operative time (P < .0063). The conversion rate to multiport laparoscopic surgery was 3.1%.

Conclusions:

Our results indicate that among experienced general surgeons, there does not seem to be a significant learning curve when transitioning from conventional laparoscopic cholecystectomy to single-incision laparoscopic cholecystectomy. The least experienced surgeon in the group, surgeon 4, appeared to reach proficiency after 15 cases. Greater than 5 years of experience in laparoscopic surgery appears to provide surgeons with a sufficient skill set to obviate the need for a single-incision laparoscopic cholecystectomy learning curve.

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.

Single-incision laparoscopic surgery for biliary tract disease

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, has been employed in various fields to minimize traumatic effects over the last two decades. Single-incision laparoscopic cholecystectomy (SILC) has been the most frequently studied SILS to date. Hundreds of studies on SILC have failed to present conclusive results. Most randomized controlled trials (RCTs) have been small in scale and have been conducted under ideal operative conditions. The role of SILC in complicated scenarios remains uncertain. As common bile duct exploration (CBDE) methods have been used for more than one hundred years, laparoscopic CBDE (LCBDE) has emerged as an effective, demanding, and infrequent technique employed during the laparoscopic era. Likewise, laparoscopic biliary-enteric anastomosis is difficult to carry out, with only a few studies have been published on the approach. The application of SILS to CBDE and biliary-enteric anastomosis is extremely rare, and such innovative procedures are only carried out by a number of specialized groups across the globe. Herein we present a thorough and detailed analysis of SILC in terms of operative techniques, training and learning curves, safety and efficacy levels, recovery trends, and costs by reviewing RCTs conducted over the past three years and two recently updated meta-analyses. All existing literature on single-incision LCBDE and single-incision laparoscopic hepaticojejunostomy has been reviewed to describe these two demanding techniques.

Urgent and Elective Robotic Single-Site Cholecystectomy: Analysis and Learning Curve of 150 Consecutive Cases

BACKGROUND

The use of robotic single-site cholecystectomy has increased exponentially. There are few reports describing the safety, efficacy, and operative learning curve of robotic single-site cholecystectomy either in the community setting or with nonelective surgery.

MATERIALS AND METHODS

We performed a retrospective review of a prospective database of our initial experience with robotic single-site cholecystectomy. Demographics and perioperative outcomes were evaluated for both urgent and elective cholecystectomy. Cumulative sum analysis was performed to determine the surgeon's learning curve.

RESULTS

One hundred fifty patients underwent robotic single-site cholecystectomy. Seventy-four (49.3%) patients underwent urgent robotic single-site cholecystectomy, and 76 (50.7%) underwent elective robotic single-site cholecystectomy. Mean total operative time for robotic single-site cholecystectomy was 83.3 ± 2.7 minutes. Mean operative time for the urgent cohort was significantly longer than for the elective cohort (95.0 ± 4.4 versus 71.9 ± 2.6 minutes; P < .001). There was one conversion in the urgent cohort and none in the elective cohort. There was one bile duct injury (0.7%) in the urgent cohort. Perioperative complications occurred in 8.7% of patients, and most consisted of superficial surgical-site infections. There were no incisional hernias detected. The surgeon's learning curve, inclusive of urgent and elective cases, was 48 operations.

CONCLUSIONS

Robotic single-site cholecystectomy can be performed safely and effectively in both elective and urgent cholecystectomy with a reasonable learning curve and acceptable perioperative outcomes.

A comparison of robotic single-incision and traditional single-incision laparoscopic cholecystectomy

BACKGROUND

Surgeons continually strive to improve technology and patient care. One remarkable demonstration of this is the development of laparoscopic surgery. Once this proved to be a safe and reliable surgical approach, robotics seemed a logical progression of surgical technology. The aim of this project was to evaluate the utility of robotics in the context of single-incision laparoscopic cholecystectomy (SILC).

METHODS

A retrospective review of a prospectively maintained database of robotic single-incision laparoscopic cholecystectomy (RSILC) and traditional SILC performed by a single surgeon at our institution from July 2010 to August 2013 was queried. All consecutive patients undergoing RSILC and SILC during this time period were included. Primary outcomes include conversion rate and operative time. Secondary outcomes include length of stay, duration of narcotic use, time to independent performance of daily activities and cost. Categorical variables were evaluated using Chi-square analysis and continuous variables using t test or Wilcoxon's rank test.

RESULTS

Thirty-eight patients underwent RSILC and 44 underwent SILC. BMI was higher in the RSILC group, and the number of patients with prior abdominal surgeries was higher in the SILC group. Otherwise, demographics were similar between the two groups. There was no difference in conversion rate between RSILC and SILC (8 vs 11 %, p = 0.60). Mean operative time for RSILC was significantly greater compared with SILC (98 vs 68 min, p < 0.0001). RSILC was associated with a longer duration of narcotic use (2.3 vs 1.7 days, p = 0.0019) and time to independent performance of daily activities (4 vs 2.3 days, p < 0.0001). Total cost is greater in RSILC ($8961 vs $5379, p < 0.0001).

CONCLUSION

While RSILC can be safely performed, it is associated with longer operative times and greater cost.

Short-term outcomes of single-site robotic cholecystectomy versus four-port laparoscopic cholecystectomy: a prospective, randomized, double-blind trial

BACKGROUND

Randomized studies could not demonstrate significant outcome benefit after single-incision laparoscopic cholecystectomy compared to classic four-port laparoscopic cholecystectomy (CLC). The new robotic single-site platform might offer potential benefits on local inflammation and postoperative pain due to its technological advantages. This prospective randomized double-blind trial compared the short-term outcomes between single-incision robotic cholecystectomy (SIRC) and CLC.

METHODS

Two groups of 30 eligible patients were randomized for SIRC or CLC. During the first postoperative week, patients and study monitors were blinded to the type of procedure performed by four dressing tapes applied on the abdomen. Pain was assessed at 6 h and on day 1, 7 and 30 after surgery, along with a 1-10 cosmetic score.

RESULTS

No significant difference in postoperative pain occurred in the two groups at any time point nor for any of the abdominal sites. Nineteen (63 %) SIRC patients reported early postoperative pain in extra-umbilical sites. Intraoperative complications which might influence postoperative pain, such as minor bleeding and bile spillage, were similar in both groups and no conversions occurred. The cosmetic score 1 month postoperatively was higher for SIRC (p < 0.001). Two SIRC patients had wound infection, one of which developed an incisional hernia.

CONCLUSIONS

SIRC does not offer any significant reduction of postoperative pain compared to CLC. SIRC patients unaware of their type of operation still report pain in extra-umbilical sites like after CLC. The cosmetic advantage of SIRC should be balanced against an increased risk of incisional hernias and higher costs.

TRIAL REGISTRATION NUMBER

ACTRN12614000119695 ( http://www.anzctr.org.au ).

Single-Site Robotic Cholecystectomy: The Timeline of Progress

AIM

To investigate the learning curve and perioperative outcomes of single-site robotic cholecystectomy during the first 102 cases by a single surgeon.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed on the first 102 cases of single-site robotic cholecystectomy. Patients were divided into five chronological groups based on the date of surgery, with 20 patients in each group except the 5th group which had 22 patients. The groups were compared by docking time, robotic dissection time, and overall surgery time. A P value of 0.05 was used as statistically significant.

RESULTS

The female to male ratio was 2:1. The mean age was 51 years (18-87) and the mean BMI was 28.26 (18-41). Overall, 69 % of the patients underwent elective cholecystectomy and 31 % required urgent surgery. In all, 17 % of patients had previous abdominal surgeries. In total, 45 % of procedures were regarded as same day surgery. The total mean length of stay was 1.97 days (0-8). The mean operative time was 110 min (36-265), mean robotic console time 70 min (26-179), and mean docking time 9 min (1-26). The overall conversion rate was 3.9 % and the complication rate was 4 %. The docking time, robotic time, and average operative time were significantly different in the first group as compared to the remaining the five groups (P = 0.001).

CONCLUSION

Single-site robotic cholecystectomy is safe in both elective and urgent conditions, and in patients with previous abdominal surgeries. It has a short learning curve.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Robotic single-site versus laparoscopic cholecystectomy: Which is cheaper? A cost report and analysis

OBJECTIVE

There is a need for a comparison of costs of robotic single-site cholecystectomy (RSSC) and laparoscopic cholecystectomy (LC) in the US healthcare model. Cholecystectomy is one of the most common procedures in general surgery. Single-incision laparoscopic surgery is beneficial but cumbersome. Robotic surgery is ergonomic but expensive. Costs of RSSC and LC have not been compared within the US healthcare model.

METHODS

Cost categories were compared between RSSC and LC in consecutive outpatient-elective cases during the same period. Cost efficiency of outpatient-elective cases before and after the first 50 institutional RSSC cases (including outpatients, inpatients, emergent, and elective) were compared to investigate for a learning curve that would subsequently affect cost.

RESULTS

A total of 458 cases included 177 RSSCs and 281 LCs. Non-emergent non-admitted cases included in cost analysis were 46 RSSCs and 175 LCs. Costs were less with RSSC: median total ($1319 vs. $1710, p < 0.001), driven mainly by cost category "Supplies" ($913 vs. $1244, p < 0.001), and to a lesser extent "Operating room" ($196 vs. $232, p < 0.001), and "Anesthesiology" ($127 vs. $168, p < 0.001). Supplies were responsible for 87% of median total cost reduction. Other cost categories were not significantly different. There were 11 and 9% drops (p < 0.006) in RSSC OR times and costs, respectively, after our 50th institutional case.

CONCLUSION

In a hospital that has already acquired infrastructure for robotic surgery, we observed procedural costs for RSSC that were lower than LC. This decreased cost was mainly driven by cutting down on supplies (87% of median total cost reduced), and to a lesser extent OR time. A steep learning curve exists after which RSSC OR times can be significantly shortened. A randomized study is needed.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.

Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique

OBJECTIVE

Multiple reports suggest that laparoendoscopic single-site surgery is technically feasible, safe, and effective in treating a variety of gynecological disease processes. The study purpose was to assess the feasibility and safety of a novel robotic single-site platform (R-LESS) for the surgical treatment of benign and malignant gynecological conditions.

STUDY DESIGN

A single-institution, prospective analysis of 40 women treated with R-LESS on the gynecology and gynecological oncology services from June 2013 through March 2014. Women undergoing hysterectomy or adnexal surgery for either a benign or malignant gynecological condition were offered robotic single-site surgery during the study period of June 1, 2013, through April 1, 2014. Patients underwent surgery through a single 2.5-3.0 cm umbilical incision with a multichannel port and utilizing the da Vinci robotic single-site platform. Two surgeons with extensive laparoendoscopic single-site experience participated.

RESULTS

Forty patients had R-LESS performed. Procedures included total laparoscopic hysterectomy, laparoscopic supracervical hysterectomy, salpingo-oophorectomy, ovarian cystectomy, excision of endometriosis, and a combined case of total laparoscopic hysterectomy and cholecystectomy. Median age and body mass index were 42 years and 28.2 kg/m(2), respectively. Median operating time, defined as the interval between incision start to closure, was 134 minutes (range, 84-311 minutes). Median vaginal cuff closure was 21 minutes (range, 9-77 minutes). Overall, there appeared to be a linear relationship between vaginal cuff closure time, console time, and operating time with number of cases performed. Procedures were successfully performed via R-LESS in 92.5% of cases; 2 cases required 1 additional port and there was 1 conversion to traditional multiport robotic surgery. There was 1 major postoperative complication (2.5%) and 1 readmission (2.5%). After a median follow-up period of 230 days (range, 61-256), there have been no postoperative hernias diagnosed.

CONCLUSION

We present one of the first series of robotic laparoendoscopic single-site surgery for the treatment of various gynecological conditions. When performed by experienced minimally invasive surgeons, R-LESS is feasible and safe in select patients. Further studies are needed to better define the ideal gynecological procedures to perform using robotic single-site surgery and to assess the benefits and costs of R-LESS compared with multiport robotic and conventional laparoscopic approaches.