This new single-port platform for cholecystectomies — performed through an inch-long umbilical incision — tops the multi-port robotic approach for ease and intuitiveness, says Touliatos. “I didn’t believe it until I saw it.”
For multi-port robotic surgery, the surgeon must position the ports at certain distances and angles to keep the robotic arms outside the patient separated. “When you use multi-port, you have to make sure the spacing is right. If that’s off, then the robot arms can bump, thus limiting your range of motion,” Touliatos says.
“Single-port takes care of all that for you. You don’t have to think about the robot set-up. It’s the same for every case,” Touliatos says. “It doesn’t seem like it should be simpler, but it is.”
Da Vinci’s single-port uses a new curved trocar that guides the instruments into position in the abdomen. “They enter in a prescribed fashion, so it’s technically easier and universally adaptable. The only variable is the trocars. They come in two lengths determined by the distance from the umbilicus to the gall bladder,” Touliatos says.
The port offers four openings to hold a 3-D camera, two da Vinci laparoscopic instruments, and a traditional instrument.
To adapt to the trocar’s curve, the instruments for the single-port suite also became semi-rigid. They also come without the “wrist-action” to basically mimic the feel of straight laparoscopy. “But there’s no suturing typically needed for gall bladder removal,” Touliatos says. “For other single-port procedures, da Vinci will eventually release wristed instruments to allow for suturing and other complex maneuvers.
“This is the tip of the iceberg for the single-port robotic procedures,” Touliatos says. “It won’t be long before we’re doing adrenals, kidneys, possibly even colons. Anything we do with three- or four-port laparoscopy, we can do with the robot at a single site, once it’s approved.”
Cholecystectomies became the first single-port procedure to gain FDA approval for the robot. Da Vinci has broader usage outside the U.S., and as with other procedures and technology being used successfully in Europe, they’re apt to gain approval here in time.
For the cholecystectomy, Touliatos says the single-port robotic option proves easier than single-port traditional laparoscopy, because the robot provides the triangulation for better visualization. “To get the same exposure with traditional laparoscopy, I would have to cross my hands and retrain my left hand to do what my right hand normally does,” Touliatos says.
Da Vinci’s programming solves that problem. “On the robot, when I’m moving my right hand on the console, that’s the instrument moving in the viewer. But if you were looking at the patient with the naked eye, it’s the instrument on the left that’s moving,” Touliatos says. “So it looks and feels exactly like I’m doing straight laparoscopy. That’s why I’m ecstatic about this technology.”
But Touliatos notes that if the gall bladder is acutely inflamed, the robotic single-site can be more difficult than traditional multi-port laparoscopy. “Right now I’d hesitate to do this in a patient with acute cholecystitis. You might need more than three ports or quick instrument changes in the case of significant bleeding. But in the future, that may change as we gain more experience,” says Touliatos.
“Normally when they bring in new technology, even new laparoscopy procedures, there’s a learning curve,” Touliatos says. “But this one doesn’t feel any different from how I’ve been doing gall bladders for the last 12 years.”
One downside he cites for the da Vinci in gall bladder work is having to undock the robot to x-ray the bile ducts.
Touliatos sees no advantage in using the robot over traditional laparoscopy for multi-port procedures. “It’s overkill, because you have the same cosmesis, and you can do it cheaper and faster with traditional laparoscopy. But this all changes with single-site surgery. The robotic platform allows you to perform the same operation as with multi-port laparoscopy with better cosmesis and without sacrificing speed or safety.”
Touliatos has performed about 15 single-port cholecystectomies through traditional laparoscopy. “I likely won’t be doing single-site traditional laparoscopy anymore. I’ll use the robot,” he says. “Except maybe in some people with sick and inflamed gall bladders or if they’re morbidly obese, because these are more difficult.”
But Touliatos thinks this will change. With the broad range of motion offered by the robot, the spectrum of candidates for single-site surgery will ultimately broaden. “I see this single-port option being used for all types of surgeries in the near future.”
