rSILS: initial clinical experience with single-port robotic (SPr) right colectomy

Initial Experience With Single-Port Robotic Right Colectomies: Results of an Investigator-Initiated Investigational Device Exemption Study Using a Novel Single-Port Robotic Platform

BACKGROUND

Minimally invasive surgical techniques have been widely adopted in colorectal surgery. New technological breakthroughs have led to even less invasive alternatives like single-port surgery, but this has been hindered by technical challenges such as the collision of robotic arms within a limited space. The Intuitive da Vinci Single-Port robotic platform is a novel system that overcomes some of these challenges.

IMPACT OF INNOVATION

This study aimed to assess the safety and feasibility of the Intuitive da Vinci Single-Port robotic platform in right segmental colectomies among adult patients. These findings may set the stage for more widespread use of single-port robotic surgery.

TECHNOLOGY, MATERIALS, AND METHODS

The Intuitive da Vinci Single-Port robot is a system designed specifically for single-port robotic surgery. This platform enables flexible port location and efficient internal and external range of motion using a single C-shaped arm. In the present study, right colectomies were performed in adult patients using this platform between May 2022 and November 2022, and they were compared to right colectomies in adult patients performed using the standard multiport platform between January 2019 and December 2022. The main outcome measure was safety and quality event rates.

PRELIMINARY RESULTS

Of 30 patients, 16.7% of patients (n = 5) underwent single-port robotic right colectomy and 83.3% (n = 25) underwent multiport right colectomy. In the single-port group, 40% of patients (n = 2) developed a safety/quality event (postoperative portal vein thrombosis and excessive postoperative pain). In the multiport group, 32% of patients (n = 8) developed 1 safety/quality event and 8% (n = 2) had more than 1 event.

CONCLUSIONS AND FUTURE DIRECTIONS

This preliminary study, one of the first Food and Drug Administration-approved, investigator-initiated uses of this platform in colorectal surgeries, shows that this platform is a safe and feasible option for right colectomies. On preliminary evaluation, it appears comparable in terms of relevant safety/quality events to the multiport platform.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT05321134.

Da Vinci single-port robotic system current application and future perspective in general surgery: A scoping review

BACKGROUND

The da Vinci Single-Port Robot System (DVSP) allows three robotic instruments and an articulated scope to be inserted through a single small incision. It received FDA approval in 2014 and was first introduced in 2018. The aim of this new system was to overcome the limitations of single-incision laparoscopic and robotic surgery. Since then, it has been approved for use only for urologic and transoral surgeries in some countries. It has been used as part of experimental protocols in general surgery.

OBJECTIVE

By obtaining the CE mark at the end of January 2024, DVSP will soon enter the European market. This review aims to comprehensively describe the applications of DVSP in general surgery.

DESIGN

A search of PubMed, Embase, and Ebsco databases up to March 2024 was conducted, with registration in PROSPERO (CRD42024536430), following the preferred reporting items for Systematic reviews and Meta-analyses for scoping review (PRISMA-Scr) guidelines. All the studies about the use of DVSP in general surgery were included.

RESULTS

Fifty-six studies were included. The following surgical areas of use were identified: transabdominal and transanal colorectal, cholecystectomy, abdominal wall repair, upper gastroesophageal tract, liver, pancreas, breast, and thyroid surgery. The reported surgical and short-term outcomes are promising; a wide range of procedures have been performed safely. Some groups have found advantages, such as faster discharge, shorter operative time, and less postoperative pain compared to multiport robotic surgery.

CONCLUSION

Five years after its initial clinical applications, the use of the DVSP in general surgery procedures has demonstrated feasibility and safety. Hernia repair, cholecystectomy, and colorectal surgery emerge as the most frequently conducted interventions with this robotic system. Nevertheless, there is anticipation for further studies with larger sample sizes and extended follow-up periods to provide more comprehensive insights and data on the long-term outcomes, including the incidence of incisional hernia.

A first report of right-hemicolectomy for ascending colon cancer in Japan with the da Vinci SP surgical robot system

BACKGROUND

The da Vinci SP robotic surgical system received regulatory approval for use in colorectal cancer surgery in Japan in April 2023. Given the advantages of the precision of a robot and the postoperative cosmesis of single-site surgery, the system is expected to be further utilized for minimally invasive surgeries, in addition to the curative and safety-assured laparoscopic technique.

CASE PRESENTATION

A 73-year-old man presented at our hospital with positive fecal occult blood. He was diagnosed with cT2N0M0 (Stage I) ascending colon cancer and underwent a right hemicolectomy, which was performed with the da Vinci SP system. The operation was performed safely, and the patient was discharged without complications. Pathology findings showed that complete mesocolic excision was achieved.

CONCLUSIONS

Herein, we report the first colorectal cancer surgery performed using the da Vinci SP system in Japan. The use of this robotic surgical system with access forms for right hemicolectomy is safe and oncologically appropriate.

Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC).

METHODS

A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures.

RESULTS

Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045).

CONCLUSIONS

Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

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.

A prospective phase II clinical trial/IDEAL Stage 2a series of single-port robotic colorectal surgery for abdominal and transanal cases

AIM

Slow laparoscopy adoption accelerated the uptake of robotic surgery. However, the current robotic platforms have limitations in transanal applications and multiple port sites. The da Vinci single-port (SP) robot is currently used on trial for colorectal surgery, and broad assessment of outcomes is needed. We aimed to report findings of a phase II clinical trial of SP robotic colorectal surgery.

METHODS

A sequentially reported prospective case series was performed on patients using SP robotics at a tertiary referral centre from 1 October 2018 to 31 August 2021. Cases were stratified into abdominal and transanal cohorts. Demographics, intra-operative variables and 30-day postoperative outcomes were evaluated. Univariate analysis was performed, with statistical process control for the docking process. Main outcomes were conversion rates, morbidity, mortality and point of standardization of docking.

RESULTS

In all, 133 patients were included: 93 (69.92%) abdominal and 40 (30.08%) transanal. The main diagnosis was rectal cancer (n = 59) and the procedure performed a robotic transanal abdominal transanal radical proctosigmoidectomy (n = 30). There were no conversions to open surgery. Two abdominal (2.15%) and three transanal cases (7.50%) were converted to laparoscopy. All colorectal adenocarcinomas had negative margins, proper lymph node harvest and complete mesorectal excision, as appropriate. Docking became a standardized process at cases 34 (abdominal) and 23 (anorectal). After surgery, bowel function returned on mean day 2 (abdominal) and 1 (transanal). The morbidity rate was 15.05% (abdominal) and 27.50% (transanal). There were two major morbidities in each cohort. Overall, there were three (2.65%) readmissions, one reoperation and no mortality.

CONCLUSIONS

Single-port robotics is feasible for all types of colorectal procedures, with good clinical and oncological outcomes. With this development in colorectal surgery, further studies can develop best practices with this novel technology.

Robotic abdominoperineal resection for T4b rectal cancer using the da Vinci SP platform

PURPOSE

The aim of the present report wasto describe a novel technique of robotic abdominoperineal resection (APR) for the treatment of T4b low rectal cancer using the da Vinci® Single-Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA).

METHODS

A 3-cm transverse incision was made in the left lower quadrant of the abdomen, in the area designated for permanent colostomy. A Uniport® (Dalim Medical, Seoul, Korea) was introduced and a 25 mm multichannel SP trocar was inserted into the Uniport. A 5-mm laparoscopic assistant port was introduced on the upper midline. A video showing each step of the technique is attached.

RESULTS

Two consecutive female patients (70 and 74 years old) underwent SP robotic APR with partial resection of the vagina 8 weeks after preoperative chemoradiotherapy. In both cases, rectal cancer was located 1 cm above the anal verge and invaded the vagina (initial stage and ymrT stage T4b). Operative time was 150 and 180 min, respectively. Estimated blood loss was 10 and 25 ml, respectively. No postoperative complications occurred. The length of postoperative hospital stay was 5 days in both cases. The final pathological stage was ypT4bN0 and ypT3N0 respectively.

CONCLUSIONS

In this first experience, SP robotic APR appears to be a safe and feasible procedure for locally advanced low rectal cancer. In addition, the invasiveness of the procedure is reduced by means of the SP system, which only requires a single incision in the area designated for colostomy. Prospective studies on a larger number of patients are necessary to confirm the outcomes of this technique compared to other minimally invasive approaches.

Short-term outcomes of single-incision robotic colectomy versus conventional multiport laparoscopic colectomy for colon cancer

Since the da Vinci SP (dVSP) surgical system was introduced, single-incision robotic surgery (SIRS) for colorectal diseases has gained increasing acceptance. Comparison of the short-term outcomes between SIRS using dVSP and those of conventional multiport laparoscopic surgery (CMLS) was performed to verify its efficacy and safety in colon cancer. The medical records of 237 patients who underwent curative resection for colon cancer by a single surgeon were retrospectively reviewed. Patients were divided into two groups according to surgical modality: SIRS (RS group) and CMLS (LS group). Intra- and postoperative outcomes were analyzed. Of the 237 patients, 140 were included in the analysis. Patients in the RS group (n = 43) were predominantly female, younger, and had better general performance than those in the LS group (n = 97). The total operation time was longer in the RS group than in the LS group (232.8 ± 46.0 vs. 204.1 ± 41.7 min, P < 0.001). The RS group showed faster first flatus passing (2.5 ± 0.9 vs. 3.1 ± 1.2 days, P = 0.003) and less opioid analgesic requirement (analgesic withdrawal within 3 postoperative days: 37.2% vs. 18.6%, P = 0.018) than the LS group. The RS group showed a higher immediate postoperative albumin level (3.9 ± 0.3 vs. 3.6 ± 0.4 g/dL, P < 0.001) and lower C-reactive protein level (6.6 ± 5.2 vs. 9.3 ± 5.5 mg/dL, P = 0.007) than the LS group during the postoperative period. On multivariate analysis after adjusting for deviated patient characteristics, no significant difference was observed in short-term outcomes, except for operation time. SIRS with dVSP showed short-term outcomes comparable with those of CMLS for colon cancer.

Single-port versus multiport robotic total mesorectal excision for rectal cancer: initial experiences by case-matched analysis of short-term outcomes

Purpose

The da Vinci single-port (SP) system has been used in various surgical fields, including colorectal surgery. However, limited experience has been reported on its safety and feasibility. This study aims to evaluate the short-term outcomes of SP robotic surgery for the treatment of rectal cancer compared with multiport (MP) robotic surgery.

Methods

Rectal cancer patients who underwent curative resection in 2020 were reviewed. A total of 43 patients underwent robotic total mesorectal excision (TME), of which 26 (13 in each group, SPTME vs. MPTME) were included in the case-matched cohort for analysis. Intraoperative and postoperative outcomes and pathological results were compared between the 2 groups.

Results

Median tumor height was similar between the 2 groups (SPTME vs. MPTME: 5.9 cm [range, 2.2-9.6 cm] vs. 6.7 cm [range, 3.4-10.0 cm], P = 0.578). Preoperative chemoradiotherapy was equally performed (38.5%). The median estimated blood loss was less (20.0 mL [range, 5.0-20.0 mL] vs. 30.0 mL [range, 20.0-30.0 mL], P = 0.020) and the median hospital stay was shorter (7 days [range, 6-8 days] vs. 8 days [range, 7-9 days], P = 0.055) in the SPTME group. Postoperative complications did not differ (SPTME vs. MPTME: 7.7% vs. 23.1%, P = 0.587). One patient in the SPTME group and 3 in the MPTME group experienced anastomotic leakage.

Conclusion

SP robotic TME showed perioperative outcomes similar to MP robotic TME. The SP robotic system can be considered a surgical option for the treatment of rectal cancer. Further prospective randomized trials with larger cohorts are required.

New Robotic Platforms in General Surgery: What's the Current Clinical Scenario?

Background and Objectives: Robotic surgery has been widely adopted in general surgery worldwide but access to this technology is still limited to a few hospitals. With the recent introduction of new robotic platforms, several studies reported the feasibility of different surgical procedures. The aim of this systematic review is to highlight the current clinical practice with the new robotic platforms in general surgery. Materials and Methods: A grey literature search was performed on the Internet to identify the available robotic systems. A PRISMA compliant systematic review was conducted for all English articles up to 10 February 2023 searching the following databases: MEDLINE, EMBASE, and Cochrane Library. Clinical outcomes, training process, operating surgeon background, cost-analysis, and specific registries were evaluated. Results: A total of 103 studies were included for qualitative synthesis after the full-text screening. Of the fifteen robotic platforms identified, only seven were adopted in a clinical environment. Out of 4053 patients, 2819 were operated on with a new robotic device. Hepatopancreatobiliary surgery specialty performed the majority of procedures, and the most performed procedure was cholecystectomy. Globally, 109 emergency surgeries were reported. Concerning the training process, only 45 papers reported the background of the operating surgeon, and only 28 papers described the training process on the surgical platform. Only one cost-analysis compared a new robot to the existing reference. Two manufacturers promoted a specific registry to collect clinical outcomes. Conclusions: This systematic review highlights the feasibility of most surgical procedures in general surgery using the new robotic platforms. Adoption of these new devices in general surgery is constantly growing with the extension of regulatory approvals. Standardization of the training process and the assessment of skills' transferability is still lacking. Further studies are required to better understand the real clinical and economical benefit.

Single-incision robotic colorectal surgery with the da Vinci SP® surgical system: initial results of 50 cases

PURPOSE

The da Vinci SP® (dVSP) surgical system (Intuitive Surgical, Sunnyvale, CA, USA), a robotic platform designed for single-incision surgery, overcame the need for multiple ports in traditional robotic surgery and issues including triangulation and retraction in single-incision laparoscopic surgery. However, previous studies only included case reports or series with small sample sizes. The aim of this study was to assess the safety and performance of the dVSP surgical system and its instruments and accessories for colorectal procedures.

METHODS

The medical records of patients who had surgery with the dVSP from March 2019 to September 2021 at Ewha Womans University Seoul Hospital were investigated. The pathologic and follow-up data of patients who had malignant tumors were analyzed separately to evaluate oncological safety.

RESULTS

Fifty patients (26 male and 24 female) with a median age of 59 years (interquartile range 52.5-63.0 years) were enrolled. The procedures included low anterior resection with total mesorectal excision (n = 16), sigmoid colectomy with complete mesocolic excision and central vessel ligation (CME + CVL) (n = 14), right colectomy with CME + CVL (n = 9), left colectomy with CME + CVL (n = 4), right colectomy (n = 6), and sigmoid colectomy (n = 1). Operative time significantly decreased after 25 cases (early phase vs. late phase; operative time 295.0 min vs. 250.0 min, p = 0.015; docking time 16.0 min vs. 12.0 min, p = 0.001; console time 212.0 min vs. 190.0 min, p = 0.019). Planned procedures were successfully completed in all patients. Postoperative outcomes were acceptable with only six cases of mild adverse events through a 3-month follow-up. No local recurrence and only one case of systemic recurrence occurred within 1 year postoperatively.

CONCLUSIONS

This study demonstrated the surgical and oncological safety and feasibility of dVSP, which may be a novel surgical platform for colorectal surgery.

Single-Port Robotic Intersphincteric Resection for the Treatment of Rectal Cancer

BACKGROUND

The da Vinci Single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of intersphincteric resection (ISR) using the SP platform and evaluated the technical safety and feasibility of this procedure for the treatment of very low rectal cancer.

MATERIALS AND METHODS

Eleven rectal cancer patients who underwent SP robotic ISR between August 2020 and July 2021 were included. Patients' clinical characteristics, operative and pathologic findings of the patients were retrospectively analyzed.

RESULTS

The median tumor height was 3 cm (range, 2-4 cm). A single docking was performed, and the median docking time was 3 min 10 sec (range, 2 min 50 sec-3 min 30 sec). The median total operation time was 210 min (range, 150-280 min), and the median time of pelvic dissection was 57 min (range, 45-68 min). All patients presented with negative distal resection margins [median 1 cm (range, 0.5-2.0 cm)], and only one patient had less than 1mm of circumferential resection margin (0.9 mm).

CONCLUSIONS

Our initial experience suggests that SP robotic ISR is safe and feasible.

Oncologic long-term outcome of single-incision laparoscopic surgery (SILS) for colorectal cancer

PURPOSE

Single-incision laparoscopic surgery (SILS) has been introduced as a less invasive alternative to multi-port laparoscopic surgery (MLS). MLS is widely accepted for the treatment of colorectal cancer, but there remains minimal evidence for the use of SILS. Thus, we compared both short- and long-term outcomes of SILS and open surgery (OS) in matched cohorts of colorectal cancer patients.

METHODS

Some 910 patients had colorectal resections for cancer between 2006 and 2013, and 134 of them were operated on using SILS. Eighty of these SILS patients were compared to a cohort of patients who had open surgery that were matching in tumour stage and location, type of resection, sex, age and ASA Score. Disease-free survival at 5 years (5y-DFS) was the primary endpoint; morbidity and hospitalization were secondary parameters. The role of surgical training in SILS was also investigated.

RESULTS

Clavien Dindo ≥ IIIb complications occurred in 13.8% in both groups. 5y-DSF were 82% after SILS and 70% after OS (p = 0.11). Local recurrence after rectal cancer tended to be lower after SILS (0/43 (SILS) vs. 4/35 (OS), p = 0.117). Length of stay was significantly shorter after SILS (10 vs. 14 days, p = 0.0004). The rate of operations performed by surgical residents was equivalent in both groups (44/80 (SILS) vs. 46/80 (OS), p = 0.75).

CONCLUSION

The data demonstrates that SILS results in similar long-term oncological outcomes when compared to open surgery as well as morbidity rates. The hospital stay in the SILS group was shorter. SILS can also be incorporated in surgical training programmes.

An initial experience with a novel technique of single-port robotic resection for rectal cancer

BACKGROUND

The da Vinci single-port (SP) system is designed to facilitate single-incision robotic surgery in a narrow space. We developed a new procedure of rectal resection using this system. The aim of the present study was to evaluate the technical feasibility and safety of SP robotic rectal resection for rectal cancer patients based on our initial experience.

METHODS

A study was conducted on consecutive patients with mid or low rectal cancer who had SP robotic resection at our institution between July and September 2020. The demographic characteristics, perioperative data, and pathology results of the patients were retrospectively analyzed.

RESULTS

There were 5 patients (3 males, 2 females, median age 57 years (range 36-73 years). The median tumor height from the anal verge was 4 cm (range 3-5 cm). Two patients received preoperative chemoradiotherapy for advanced rectal cancer. A single docking was conducted, and the median docking time was 4 min 20 s (range 3 min 30 s to 5 min). The median total operation time was 195 min (range 155-240 min), and the median time of pelvic dissection was 45 min (range 36-62 min). All patients had circumferential and distal tumor-free resection margins. One patient experienced an anastomosis-related complication. The median duration of hospital stay was 7 days (range 7-8 days).

CONCLUSIONS

Our initial experience suggests that SP robotic rectal resection is safe and feasible. Further clinical trials comparing SP and multiport robotic rectal resection should be conducted to verify the superior aspects of this new system.

SP rTaTME: initial clinical experience with single-port robotic transanal total mesorectal excision (SP rTaTME)

BACKGROUND

The technical difficulty and steep learning curve of transanal total mesorectal excision (taTME) has limited widespread adoption. The single-port (SP) daVinci robot is designed to facilitate single-incision and natural-orifice transluminal endoscopic surgery (NOTES). This paper describes the first clinical experience of single-port robotic taTME (SP rTaTME).

METHODS

This was a prospective study on consecutive patients with rectal cancer who underwent SP rTaTME proctosigmoidectomy with handsewn coloanal anastomosis in December 2018 and January 2019. The primary outcome was technical feasibility of the procedure. The secondary outcomes include blood loss, intraoperative complications, length of hospital stay, quality of the TME specimen, short- and long-term morbidity and mortality, as well as short-term oncologic follow -up.

RESULTS

There were two patients, a 48-year-old male and a 38-year-old female. Both operations were completed successfully without complications or conversion. Estimated blood loss was 200 mL and 130 mL. In both cases the TME was completed transanally using the SP robot. In the first patient, the abdominal portion was completed through an abdominal single-incision; in the second patient the operation was entirely performed transanally as a pure NOTES procedure. In both cases, the final pathology report showed a complete TME with negative margins. Patients were discharged on postoperative day 3 and 4,respectively. There was no long-term morbidity or mortality.

CONCLUSIONS

SP rTaTME is feasible and can be safely performed. It provides excellent optics and dexterity to work in a limited space. Future studies are required to further define the safety profile and the ultimate utility of the SP robot for taTME.