Single port access adrenalectomy

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

[Minimally invasive techniques in adrenal gland surgery]

Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.

Single-incision robotic adrenalectomy (SIRA): the future of adrenal surgery?

In compliance with the trend toward less invasive techniques, single incision robotic surgeries have become more common and they have been increasingly used for several surgeries including adrenalectomy. Single incision robotic adrenalectomy (SIRA) aims to combine the merits of robotic surgery with previously defined single incision laparoscopic techniques. It has been shown to be safe and feasible, however, there are only few studies on this new technique. Due to scant data on SIRA in the current literature, it remains to be a current challenge in adrenal surgery. In this review, our goal is to present current literature on SIRA and discuss the data regarding perioperative outcomes, patient selection, learning curve, and its limitations.

Transanal Surgery: A History of taTME Ancestry

Transanal total mesorectal excision (taTME) is the culmination of major developments in rectal cancer management and minimally invasive surgery. This surgical breakthrough holds great promise and excitement for the care of the rectal cancer patient. We would be remiss in discussing taTME to not acknowledge the role of transanal abdominal transanal proctosigmoidectomy, transanal endoluminal microsurgery, laparoscopy, and natural orifice transluminal endoscopic surgery that got us to this modern day explosion of the taTME approach. In this article, we detail and explain the convergence of these disparate experiences, how they culminated in the development of the taTME, and explore future directions in this field.

Effect of preoperative computed tomography parameters and obesity on surgical outcomes of laparoendoscopic single-site adrenalectomy

BACKGROUND

The aims of the present study were to (1) analyse preoperative computed tomography (CT) parameters, (2) investigate whether obesity and CT parameters affect surgical outcomes in patients undergoing LESS lateral retroperitoneal adrenalectomy, and (3) further establish the optimal cutoff point of CT parameters for tolerable operating time.

METHODS

Between January 2010 and August 2016, patients who underwent LESS adrenalectomy through the retroperitoneal approach in our hospitals were included. Patients' demographic data, preoperatively measured CT parameters (the depth and horizontal width to the adrenal gland in the axial view of abdominal CT, the vertical height in the coronal view of CT, and the angle of the depth and horizontal width), and intraoperative (operative time and blood loss) and postoperative (hospital stay and complications) parameters were retrospectively reviewed. Linear regression was performed to determine factors that potentially affect surgical outcomes.

RESULTS

In 116 patients, depth was the only CT parameter associated with surgical outcomes. Large depth (P = 0.005; 95% CI 1.739-9.256) and high BMI (P = 0.012; 95% CI 0.357-2.851) were factors significantly associated with longer operative time. The area under the ROC curve for the depth was 0.69 (P = 0.002), and the cutoff point 10.48 cm may be the tolerable operating time.

CONCLUSIONS

Our results suggest a depth limit of 10.48 cm for the optimal prediction of operating time less than 90 min; although obese patients and deeper adrenal glands had longer operative time, LESS adrenalectomy could be performed in the obese patients without increased blood loss, prolonged hospital stay, or increased pain.

Comparison of Technical Details and Short-term Outcomes of Single-incision Versus Multiport Laparoscopic Adrenalectomy

To date, the single-incision laparoscopic surgery (SILS) technique has been applied to a wide range of general surgical procedures; however, there are still scant data and debates on adrenal procedures. The aim of this study was to compare surgical outcomes of single-incision versus laparoscopic multiport adrenalectomy. The patients were divided into 2 study groups on the basis of the surgical approach: SILS (group 1) and multiport laparoscopic surgery (group 2). Patient demographics and their perioperative and postoperative results were evaluated retrospectively from the medical records. A total of 80 patients were included in the study. There were 44 patients in group 1 and 36 patients in group 2. The average operative time, estimated blood loss, and tumor size were similar between the study groups. There were no mortalities in both groups and the mean duration of hospital stay was 3 days for both groups. Without using any single-incision access trocars and articulated instrumentation, we achieved the same surgical outcomes in our SILS adrenalectomy series compared with conventional multiport laparoscopy series in terms of postoperative short-term outcomes and cost-effectivity.

Early results of single-incision laparoscopic cholecystectomy in comparison with the conventional: Does it have any impact on quality of life?

Background

Laparoscopic cholecystectomy is the standard treatment for gallbladder diseases. In recent times, single-incision laparoscopic cholecystectomy(SILC) has developed as a less invasive alternative technique to conventional laparoscopy. In the literature, many studies have compared SILC and conventional laparoscopic cholecystectomy (CLC) procedures but a limited number of studies have compared the two techniques with regard to quality of life (QOL). The choice of surgical procedure was effected by QOL of the patients. The effects of SILC on QOL remain unclear. In this study, we aimed to compare the effects of conventional laparoscopic cholecystectomy (CLC) and single-incision laparoscopic cholecystectomy (SILC) procedures on the clinical outcomes and quality of life of patients by short-term follow-up evaluation.

Material and methods

In this study, 142 patients who underwent cholecystectomy operations with either technique underwent SILC and CLC were evaluated. The quality of life index in the patients was measured with short form 36 (SF 36) test.

Results

The results of mean operative time, length of stay and complication rate for SILC and CLC were similar. The postoperative health-related quality of life (HRQOL) scores were not significantly different between the SILC and CLC patients but only physical functioning score were higher in SILC patients.

Conclusions

SILC is a safe and effective alternative to CLC. To detect the effects of SILC on HRQOL, we need long-term prospective comparative studies.

Feasibility of single-port retroperitoneoscopic adrenalectomy in dogs

OBJECTIVE

To evaluate the feasibility of single-port retroperitoneoscopic adrenalectomy (SPRA) in dogs.

STUDY DESIGN

A pilot experimental study.

ANIMALS

Eight healthy beagle dogs.

METHODS

SPRA was performed on the left and right sides (4 dogs each). Resection of the adrenal gland was performed through a SILS port using a retroperitoneal approach. Operative time was defined from skin incision to the completion of skin suture. Postoperative pain was evaluated by using 3 pain scores. Integrity of the adrenal gland capsule was evaluated by histologic assessment.

RESULTS

Mean time taken to complete the SPRA was 44.1 minutes (range, 37-51) and was significantly longer on the right side than on the left side (P < .05). There were no complications intraoperatively or during 14 days of postoperative monitoring. The adrenal gland capsule was found to be injured in 3 of the 8 dogs by histologic assessment.

CONCLUSION

This is the first report of SPRA in the veterinary literature. With this technique it is possible to perform adrenalectomy with some risk of capsule penetration and with excellent visibility.

CLINICAL SIGNIFICANCE

This study suggests that SPRA is feasible and can be used to resect small adrenal tumors with minimal complications.

Robot-assisted laparoendoscopic single site adrenalectomy: A comparison of 3 different port platforms with 3 case reports

RATIONALE

Laparoscopic adrenalectomy is currently the standard of care for adrenal lesion. Minimal invasive laparoscopic surgery such as laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to improve cosmetic outcomes and reduce postoperative pain. However, there are still some problems related to instruments and port limitation during LESS surgery. Robot-assisted laparoscopic surgery may help to overcome these problems, and port platforms selection is an important issue.

PATIENT CONCERNS

Three cases received robot-assisted LESS adrenalectomy due to adrenal tumor were enrolled. Blood loss, hospital stay, and analgesia injection were compared.

DIAGNOSES

Preoperative evaluations were done in a usual manner. Benign tumors were suspect for two patients, while metastatic tumor could not be excluded for the other patient with prior malignancy history. The pathology reports were all benign adrenal cortical adenoma after operation.

INTERVENTIONS

Three different port platforms, Da Vinci Single-Site Surgical Platform, GelPOINT, and homemade glove port were used. Trans-peritoneal approach was used for two patients, while the other one received trans-retroperitoneal approach. The advantage and disadvantage of different port platforms were discussed.

OUTCOMES

All patients underwent the operation smoothly without major complications or conversion to open surgery. Blood loss amount was small, hospital stay was short, and only one patient received one single dose of opioid analgesia injection after the surgery.

LESSONS

The main problems of LESS are the loss of a working triangle and the limitations of the instruments. Robot-assisted LESS may help surgeons overcome part of these problems. Many different port platforms are available, and based on our initial experience, we believe that the GelPoint may be a more suitable platform, for it maintains the endo-wrist function of the Da Vinci instruments, and allows the surgeon to design the position of ports freely to minimize external and internal collision.

Preoperative selective vs non-selective α-blockade in PPGL patients undergoing adrenalectomy

PURPOSE

Preoperative preparation for adrenalectomy for pheochromocytomas and paragangliomas (PPGL) is universally recognized as necessary, while the optimal strategy remains controversial. Our aims were to increase intraoperative hemodynamic stability, expedite postoperative recovery, decrease side effects and reduce costs for patients with PPGL undergoing adrenalectomy.

METHODS

We identified 526 patients undergoing open adrenalectomy for PPGL in the West China Hospital of Sichuan University between May, 2007 and December, 2016. 149 patients received preoperative selective α-blockade with phenoxybenzamine, and 377 patients received non-selective α-blockade with prazosin, doxazosin or terazosin. There were no statistical differences between groups regarding preoperative patient and tumor characteristics. Operations were planned once hypertensive patients were well-controlled with blood pressure ≤130/85 mmHg. Intraoperatively, all patients received arterial blood pressure monitoring, and indwelling urinary catheters to record urine output. We recorded intraoperative hemodynamics, status in the postanesthesia or intensive care unit, postoperative recovery and complications.

RESULTS

Patients in the non-selective group showed a more significant decline in postoperative systolic blood pressure than the selective group (P = 0.041). Also, patients in the non-selective group appeared to receive a long-term anti-hypertensive effect, especially for diastolic blood pressure (P = 0.037), which was a novel finding, based on the current literature.

CONCLUSIONS

Our results confirmed that non-selective α-blockade produced a more significant anti-hypertensive effect than selective α-blockade. However, we found no significant difference in intraoperative hemodynamic instability, postoperative recovery and postoperative complications between groups.

Patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical laparoendoscopic single-site adrenalectomy

INTRODUCTION

Laparoendoscopic single-site surgery is a recently innovated urologic surgical procedure. Transumbilical laparoendoscopic single-site adrenalectomy (LESS-A) is technically safe and feasible in patients with benign adrenal tumors. To improve patient counseling and informed consent, we evaluated patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical LESS-A.

METHODS

We reviewed 24 patients who underwent transumbilical LESS-A and assessed their operative and esthetic outcomes and incisional pain. Incisional pain was evaluated using a 10-point visual analog scale, and the body image and cosmetic satisfaction were measured using a questionnaire that included a body image scale (range, 5-20 points) and a cosmetic scale (range, 3-24 points).

RESULTS

Pure LESS-A was performed on 10 patients using a multichannel port; an additional 5-mm trocar was used in two obese patients. Supplementary to the single-incision approach, one or two 3-mm ports were used in 12 patients. The mean operative time was 203 min; the mean blood loss was 41 mL. The mean pain visual analog scale scores on postoperative days 1, 3, and 7 were 3.5, 2.2 (P = 0.012), and 1.5 points (P = 0.018), respectively. The mean body image scale and cosmetic scale scores indicating wound satisfaction 1 month after the surgery were 20 and 22 points, respectively. Although one patient had liver injury during surgery, the postoperative course during the 3-month follow-up was uneventful.

CONCLUSION

Transumbilical LESS-A confers less postoperative pain and better cosmetic satisfaction than conventional laparoscopic adrenalectomy. Therefore, this procedure could potentially become a standard treatment option for benign adrenal tumors.

Laparoendoscopic single site, laparoscopic or open surgery for adrenal tumors: Selecting the optimal approach

Numerous surgical modalities are available to treat adrenal lesions. Minimally-invasive approaches for adrenalectomy are indicated in most circumstances, and new evidence continues to be accumulated. In this context, current indications for open surgical adrenalectomy (OS-A), minimally-invasive adrenalectomy (MI-A), and laparoendoscopic single-site adrenalectomy (LESS-A) remain unclear. A comprehensive English-language literature review was performed using MEDLINE/PubMED to identify articles and guidelines pertinent to the surgical management of adrenal tumors. A comprehensive chart review was performed for three illustrative cases. Clinical recommendations were generated based on relevant literature and the expertise of the investigator group. MI-A offers advantages over OS-A in properly selected patients, who experience fewer complications, lower blood loss, and shorter hospital stays. Robot-assisted laparoscopic and retroperitoneoscopic adrenalectomy may offer advantages over transperitoneal surgery, and LESS-A may be an even less-invasive option that will require further evaluation. MI-A remains the surgical treatment of choice for most adrenal lesions. Tumor size and stage are the primary indications for selecting alternative treatment modalities. OS-A remains the gold standard for large tumors (> 10 cm) and suspected or known advanced stage malignancy. LESS-A appears to be an appropriate initial approach for small tumors (< 4-5 cm), including pheochromocytoma and isolated adrenal metastases.

Laparo-endoscopic single-site left adrenalectomy using conventional ports and instruments

Laparo-endoscopic single-site adrenalectomy (LESS-A) is commonly performed using specialized access devices and/or instruments. We report a LESS-A in a 47-year-old woman with a left aldosteranoma via a subcostal approach utilizing conventional laparoscopic ports and instruments. The feasibility and cost-effectiveness of this approach are highlighted and the literature on the subject is reviewed.

The Optimal Approach for Laparoscopic Adrenalectomy through Mono Port regarding Left or Right Sides: A Comparative Study

Introduction. Several studies have shown the feasibility and safety of both transperitoneal and posterior retroperitoneal approaches for single incision laparoscopic adrenalectomy, but none have compared the outcomes according to the left- or right-sided location of the adrenal glands. Materials and Methods. From 2009 to 2013, 89 patients who received LAMP (laparoscopic adrenalectomy through mono port) were analyzed. The surgical outcomes attained using the transperitoneal approach (TPA) and posterior retroperitoneal approach (PRA) were analyzed and compared. Results and Discussion. On the right side, no significant differences were found between the LAMP-TPA and LAMP-PRA groups in terms of patient characteristics and clinicopathological data. However, outcomes differed in which LAMP-PRA group had a statistically significant shorter mean operative time (84.13 ± 41.47 min versus 116.84 ± 33.17 min; P = 0.038), time of first oral intake (1.00 ± 0.00 days versus 1.21 ± 0.42 days; P = 0.042), and length of hospitalization (2.17 ± 0.389 days versus 3.68 ± 1.38 days; P ≤ 0.001), whereas in left-sided adrenalectomies LAMP-TPA had a statistically significant shorter mean operative time (83.85 ± 27.72 min versus 110.95 ± 29.31 min; P = 0.002). Conclusions. We report that LAMP-PRA is more appropriate for right-sided laparoscopic adrenalectomies due to anatomical characteristics and better surgical outcomes. For left-sided laparoscopic adrenalectomies, however, we propose LAMP-TPA as a more suitable method.

Visceral fat is correlated with prolonged operative time in laparoendoscopic single-site adrenalectomy and laparoscopic adrenalectomy

OBJECTIVE

To investigate the effect of visceral fat on operative time and discuss whether the measurement of adipose accumulation could be used as a sensitive predictor of technical difficulty in performing laparoendoscopic single-site adrenalectomy (LESS-A) and laparoscopic adrenalectomy (LA).

METHODS

We reviewed the medical records of 106 patients undergoing LA or LESS-A at our institution. Total fat area (TFA) and visceral fat area (VFA) were measured at the level of the L4 vertebra by computed tomography. To categorize the type of obesity, the VFA/TFA ratio was calculated. Multiple logistic regression analyses were performed to identify independent predictors of prolonged operative time.

RESULTS

The VFA/TFA ratio does not always coincide with body mass index (BMI, r = 0.415), and a higher correlation coefficient was observed between operative time and the VFA/TFA ratio (r = 0.359) than with that of BMI (r = 0.189). Multivariate analysis revealed that pheochromocytoma, tumor size ≥ 5 cm, and the VFA/TFA ratio ≥ 0.35, defined as the visceral type of adipose accumulation, were independent predictive factors for prolonged operative time in LA and LESS-A. We were able to stratify patients into short, intermediate, and long operative times using these preoperative variables.

CONCLUSION

This study revealed that the visceral type of adipose accumulation increases operative complexity in LA and LESS-A as measured by operative time. The VFA/TFA ratio might be a more sensitive indicator of technical difficulty than that of BMI.

Changing surgical approaches for laparoscopic adrenalectomy: single-surgeon data of a 6-year experience

AIM

To evaluate outcomes of laparoscopic adrenalectomy (LA) and laparoendoscopic single-site surgery (LESS) for adrenal masses in the light of changing laparoscopic surgical techniques.

MATERIALS AND METHODS

Seventy-three patients were analyzed retrospectively. There were 2 groups; group 1 included patients who had conventional transperitoneal LA and transperitoneal LESS, and group 2 included patients who had lateral retroperitoneal LA, retroperitoneal LA in prone position, and retroperitoneal LESS. Demographic data, urine 3-methoxy-4-hydroxymandelic acid, normetanephrine, epinephrine, serum cortisol, aldosterone, adrenocorticotropic hormone, American Society of Anesthesiologists score, side and size of mass, conversion to open surgery, complications, estimated blood loss, operation time, pathological results were recorded and analyzed.

RESULTS

There was no difference in demographic data and serum parameters between both groups. Tumor size, estimated blood loss, operation time, transfusion rate and hospital stay were less for group 2 (p < 0.05, p = 0.0001). However, the complication rate was similar in both groups; in retroperitoneal prone position, the complication rate was less than for other surgical approaches, but statistically significant results could not be assessed.

CONCLUSIONS

Even if the diameter of adrenal mass is larger than 6 cm, LA may be considered as the gold standard. The retroperitoneal approach especially in prone position may be a promising treatment method in the near future for adrenalectomy in selected patients.

Combined surgical procedures using laparoendoscopic single-site surgery approach

INTRODUCTION

As our experience with laparoendoscopic single-site (LESS) surgeries increased, we considered how it might be employed if two or more surgeries were to be combined. LESS surgeries' cosmetic advantages, decreased parietal trauma and better patient satisfaction relative to standard multiport laparoscopy have been previously reported, but its special role in combined surgeries has never been stressed. In this series, we present the advantages of LESS procedure over multiport laparoscopy in combined surgical procedures. To the best of our knowledge, this has never been reported before.

METHODS

A retrospective analysis of 27 patients was performed. The patients underwent combined LESS procedures between February 2010 and January 2012 at GEM Hospital, Coimbatore, India. All patients were of ASA grade 1 or 2. Patients with previous surgery in the umbilical region were not offered single-incision surgery.

RESULTS

We successfully performed 27 combined LESS procedures over a span of 2 years. Twenty patients were women and seven were men. Mean age was 35.94 years (range, 10-66 years). Mean BMI was 27.2. There were no major intraoperative complications. Mean blood loss was 45.7 mL (range, 0.0-120.0 mL). Mean postoperative hospital stay was 3.08 days (range, 1-5 days).

CONCLUSION

When a suitable case of multiple pathologies is encountered and LESS surgery is feasible for all of them, performing LESS surgery not only has cosmetic advantages over standard laparoscopy, but it also avoids the need for additional ports to achieve adequate visualization and access. All quadrants of the abdomen remain under reach through umbilicus.

Transumbilical single-incision laparoscopic multiple organ procedures: initial experience of 20 cases

BACKGROUND

Cure of disease with the least possible injury is an ideal of surgery. Herein we share our experience with transumbilical single-incision laparoscopic multiple organ procedures using conventional instruments.

SUBJECTS AND METHODS

We reviewed data from 20 patients who underwent transumbilical single-incision laparoscopic surgery of multiple organs between May 2009 and March 2012 at Shengjing Hospital. All 20 patients had laparoscopic cholecystectomy, which was combined with appendectomy in 16 patients, resection of hepatic hemangiomas in 2 patients, and partial gastrectomy for gastric mesenchymal tumor in 2 patients. All procedures were successful with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus.

RESULTS

All the operations were successfully completed without conversion to conventional laparoscopic or open surgery. No intraoperative complications occurred. Patients were satisfied with the therapeutic and cosmetic outcomes.

CONCLUSIONS

Transumbilical single-incision laparoscopic combined procedures appear to be a technically feasible alternative to standard laparoscopic procedures in simultaneous management of two different coexisting pathologies. Larger studies are required to confirm these findings.

EAU guidelines on robotic and single-site surgery in urology

CONTEXT

This is a short version of the European Association of Urology (EAU) guidelines on robotic and single-site surgery in urology, as created in 2013 by the EAU Guidelines Office Panel on Urological Technologies.

OBJECTIVE

To evaluate current evidence regarding robotic and single-site surgery in urology and to provide clinical recommendations.

EVIDENCE ACQUISITION

A comprehensive online systematic search of the literature according to Cochrane recommendations was performed in July 2012, identifying data from 1990 to 2012 regarding robotic and single-site surgery in urology.

EVIDENCE SYNTHESIS

There is a lack of high-quality data on both robotic and single-site surgery for most upper and lower urinary tract operations. Mature evidence including midterm follow-up data exists only for robot-assisted radical prostatectomy. In the absence of high-quality data, the guidelines panel's recommendations were based mostly on the review of low-level evidence and expert opinions.

CONCLUSIONS

Robot-assisted urologic surgery is an emerging and safe technology for most urologic operations. Further documentation including long-term oncologic and functional outcomes is deemed necessary before definite conclusions can be drawn regarding the superiority or not of robotic assistance compared with the conventional laparoscopic and open approaches. Laparoendoscopic single-site surgery is a novel laparoscopic technique providing a potentially superior cosmetic outcome over conventional laparoscopy. Nevertheless, further advantages offered by this technology are still under discussion and not yet proven. Due to the technically demanding character of the single-site approach, only experienced laparoscopic surgeons should attempt this technique in clinical settings.

PATIENT SUMMARY

This work represents the shortened version of the 2013 European Association of Urology guidelines on robotic and single-site surgery. The authors systematically evaluated published evidence in these fields and concluded that robotic assisted surgery is possible and safe for most urologic operations. Whilst laparoendoscopic single-site surgery is performed using the fewest incisions, the balance between risk and benefit is currently unclear. The evidence to support the conclusions in this guideline was generally poor, but best for robotic assisted radical prostatectomy. As such, these recommendations were based upon expert opinion, and further high-quality research is needed in this field.

Thoracoscopic wedge resection through a single incision using a thin puncture device

Video-assisted thoracic surgery (VATS) has been enthusiastically used as a less-invasive diagnostic or therapeutic surgical procedure in recent years. VATS results in considerably less postoperative pain than traditional thoracotomy incisions. The current trend is to reduce the number of ports and minimize the length of incisions to further reduce postoperative pain, chest wall paresthesia, and length of hospitalization. Although several accounts of reduced port surgery, such as single-incision laparoscopic surgery (SILS), have been reported, there are few descriptions of single-incision thoracoscopic surgery (SITS) using a thin puncture device for a variety of diseases. Herein, we describe a minimally invasive SITS technique using a thin puncture device.

Teaching single-incision laparoscopic appendectomy in pediatric patients

There is a significant learning curve in acquiring singleincision laparoscopic appendectomy skills in pediatric patients.

Introduction:

Laparoscopic appendectomy is accepted as the gold standard technique for the treatment of acute appendicitis. Recently single-incision laparoscopic surgery (SILS) was tried in the pediatric population and was shown to be both feasible and safe. We describe our early experience in teaching the SILS procedure for appendicitis in a large community hospital center surgical residency program.

Methods:

SILS appendectomy was performed in 40 consecutive patients with acute appendicitis who were admitted by a single surgeon from May 2011 to August 2011. All patients over the age of 4 y presenting with noncomplicated and complicated appendicitis (perforated) were offered SILS appendectomy. Execution of the technical aspects of 20 SILS operations done by 3 PGY III residents was evaluated.

Results:

The average age of the patient was 11.1 y (range, 7 to 15). SILS was performed successfully in 19 out of 20 patients. Nineteen patients underwent emergent or urgent appendectomy, while 1 patient underwent an interval procedure. Nine patients were found to have perforated appendicitis, while the other 11 had noncomplicated acute appendicitis. One patient was converted to conventional 3-port laparoscopy due to difficulties during the procedure. The mean operative time was 73 min (range, 47 to 112). A significant learning curve to successfully execute the critical steps of the SILS procedure was noted in all residents evaluated.

Conclusion:

SILS technology appears promising for the treatment of acute appendicitis. However, its successful incorporation into surgical training programs will depend on the development of innovative simulation strategies.

Laparoendoscopic single site adrenalectomy: initial results of cosmetic satisfaction and the potential for postoperative pain reduction

Background

Recent reports have suggested that laparoendoscopic single site (LESS) surgery is technically feasible. The aim of this study was to describe our initial experience with LESS adrenalectomy for benign adrenal tumors, focusing the attention about cosmetic satisfaction and reduction of postoperative pain.

Methods

Medical records of consecutive patients undergoing LESS adrenalectomy were analyzed. All procedures were performed through a single multichannel port. Demographic and operative data were assessed. A visual analog scale (VAS) was used with a 10-point scale for an objective assessment of incisional pain and incisional cosmesis.

Results

Between January 2010 and July 2012, 14 consecutive patients with benign adrenal tumors underwent LESS adrenalectomies. Of the planned LESS adrenalectomies, 12 (86%) were completed with a single-port, whereas two required an additional port placement. Mean operating time was 128.1 ± 31.5 min and mean blood loss 10.5 ± 12.1 ml. Mean pain scores using the VAS on postoperative days 1, 3, and 14 were 2.3, 1.0, and 0.3 points, respectively. The rate of analgesic use was also lower within 12 hours after surgery (14%). The patient was highly satisfied with the single small wound procedure, and mean cosmesis scores of postoperative days 3 and 14 were 9.4 and 9.8 points, respectively. The postoperative course was uneventful with no morbidity within one month of follow-up.

Conclusions

LESS adrenalectomy is a safe and technically feasible procedure for patients with benign adrenal tumors, and offers cosmetic benefit and the potential for postoperative pain reduction. However, surgeons with lack of experience as LESS surgery should be comprehended that the assistance of the needlescopic instrument does not compromise the cosmetic outcomes for difficult cases and the obese patients may not always be suitable candidates for pure LESS technique.

Randomized prospective study to compare laparoscopic appendectomy versus umbilical single-incision appendectomy

INTRODUCTION

The use of single-incision laparoscopic surgery may represent an improvement over conventional laparoscopic surgery. In recent years, more and more articles have been published demonstrating the feasibility of this approach. Hence, for this reason, we present this randomized prospective study to compare the 2 techniques.

METHODS

Between September 2009 and December 2010, a total of 184 patients with a diagnosis of acute appendicitis and indicated for surgery were included in the study, of whom, 91 received an appendectomy via a single umbilical incision and 93 via conventional laparoscopy. The study protocol was approved by the ethical committee of the Virgen de la Arrixaca University Hospital (Murcia). The study was registered on ClinicalTrials.gov with inscription number NCT0151529. All the operations were performed by the same team of surgeons.

RESULTS

As far as the demographical results of the study population are concerned, there were no significant differences between the 2 groups for age, weight, sex, body mass index, and removed appendix type. Operating time was longer with the single-port approach: 38.13 ± 13.49 versus 32.12 ± 12.44 minutes (P = 0.02). Significant differences were observed for postoperative pain, which was measured on the visual analog scale, with less pain reported in the single-incision group: 2.76 ± 1.64 versus 3.78 ± 1.76 (P < 0.001). There were no significant differences between the 2 groups for early and late complications and lengths of hospital stay measured in postoperative hours.

CONCLUSIONS

The transumbilical single-port approach is seen as a feasible technique for performing appendectomy. It does not increase the rate of complications and represents a possible alternative to conventional laparoscopic appendectomy.

[Current state of single-port transumbilical surgery in urology: challenges and applications]

CONTEXT

Laparoscopic surgery in urology is considered to be an important advance, although it is not exempt from some morbidity associated to the use of multiple trocars and specifically to the extraction of the specimen. In order to decrease this morbidity and improve esthetics, other techniques are being developed, such as natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). It is aimed to review the current status of laparoendoscopic single site surgery in urology.

ACQUISITION OF EVIDENCE

A nonsystematic review has been carried out by means of the bibliographic search using the terms LESS and Urology from 2007 to 2012. The current LESS experience in urology is described, and its principal indications and the different single site devices and instruments available on the market are described.

SYNTHESIS OF EVIDENCE

LESS surgery arose as one more step in the constant evolution of minimally invasive surgery in an attempt to improve esthetics, reduce surgical trauma and decrease pain and the post-operative complications associated to the conventional laparoscopy with multiple trocars. Since it was first described in 2007, the experience has been increasing exponentially and the LESS technique, whether assisted or not by robot, is becoming consolidated for a large spectrum of urological indications (both in oncological and reconstructive surgery) on a much greater scale than the NOTES technique. Even though most of the existing data are not randomized and very rarely comparative, with the selection bias that this represents, it seems clear that the esthetic benefit and analgesic control associated to the LESS surgery is real and reproducible. The complications associated to it are greater in cases of major oncology surgery and are due more to the technique itself then to the approach.

CONCLUSIONS

Although the real benefit of the LESS surgery in urology cannot be appropriately quantified, the cosmetic improvement, less pain and greater patient satisfaction with their wound are clear. Appropriate training in this type of procedures in centers having large volumes and the continuous technical improvements in the instrumental development by the biomedical industry has resulted in the fact that the transumbilical LESS technique in urology has been born to stay.

Single-incision laparoscopic adrenalectomy at Viet Duc University Hospital

INTRODUCTION

Laparoscopic adrenalectomy is the technique of choice in the treatment of adrenal tumors. SILS has recently been introduced in this field and applied in Viet Duc University Hospital. Herein, we report our experience with single-incision transperitoneal adrenalectomy.

METHODS

Between August 2010 and January 2012, 61 patients (23 men, 38 women) underwent SILS adrenalectomy at our institution. The diagnoses consisted of 20 patients with pheochromocytoma, 17 with nonfunctioning adenoma, 16 with Conn syndrome, 4 with Cushing syndrome and 4 with adrenal cysts. The mean age was 47.8 years (range, 21-68 years). There were 29 right-sided and 32 left-sided tumors; their mean diameter was 30.7 mm (range, 8-59 mm). Patients were in the flank position with the operated side up. A 2.5-cm pararectal incision at the level of the umbilicus was made to insert the SILS Port.

RESULTS

The mean operating time was 78 min (range, 50-120 min), and mean blood loss was approximately 70 mL. Left-sided tumors were excised entirely with the SILS technique. Right-sided lesions sometimes required an additional trocar (hybrid technique). No drainage was needed at the operating site. There were no intraoperative or postoperative complications, but one case was converted to the conventional three-port technique. The mean length of hospital stay was 3.4 days (range, 2-6 days).

CONCLUSION

Our preliminary results show that SILS adrenalectomy is safe and technically feasible. It should be considered among the surgical managements for selected patients with adrenal tumors.

Feasibility of a novel extraperitoneal two-port laparoendoscopic approach for radical prostatectomy: an initial study

The aim of this study was to describe the surgical technique and to report the early outcomes of an original extraperitoneal two-port laparoendoscopic approach for radical prostatectomy. A total of 22 consecutive patients diagnosed with early-stage prostate cancer (cT1c, cT2N0) were operated on and included in this analysis. A multichannel port with three 5-mm trocars, providing easier instrument handling, was inserted extraperitoneally through a 2.5-cm lower umbilical "U" incision. An additional 12-mm port was inserted into the left fossa to allow an adequate working angle to facilitate the most critical steps of the surgical procedures. The operation was successfully completed in all patients; one patient required an additional 5-mm port to control bleeding. The median operation time was 259 min (range 207-453 min), and the fluid loss, including urine and blood, was 946 mL (range 257-1821 mL). The median Foley catheter indwelling period was 6 days (range 3-11 days) after surgery. No intraoperative complications occurred. Judging from this initial trial, this procedure can be safely carried out if the surgeon is familiar with conventional five-port laparoscopic radical prostatectomy.

Single-port laparoscopic distal gastrectomy with D1+β lymph node dissection for gastric cancers: report of 2 cases

The use of single-port laparoscopic surgery for treating various diseases has increased rapidly. This approach can offer better cosmetic results and less incisional pain. We report the cases of single-port laparoscopic distal gastrectomy with D1+β lymph node dissection for 2 patients with gastric cancers.

Single-incision transperitoneal laparoscopic left adrenalectomy

BACKGROUND

Laparoscopic adrenalectomy via three or four trocars is a well-established procedure. This report describes the initial experience with single-incision laparoscopic surgery (SILS) using the transperitoneal approach for left adrenalectomy.

METHODS

Between April 2010 and August 2011, all consecutive patients with adrenal masses, including Conn's syndrome, Cushing's adenoma, and nonfunctional adrenal tumors, who agreed to undergo SILS adrenalectomy were included in a prospective study. The left 2.5-cm subcostal incision was the sole point of entry. Data of patients who underwent SILS adrenalectomy were compared with those from an uncontrolled group of patients who underwent conventional laparoscopic adrenalectomy during the same study period.

RESULTS

There were 20 patients in each study group (20 men, 20 women; mean age [SD] = 50 [6.5] years). SILS was successfully performed and none of the patients required conversion to an open procedure. In one case of SILS procedure, an additional lateral 5-mm port was needed for retraction of the kidney. The mean (SD) duration of the operation was 95 (20) min in the SILS group and 80 (8) min in the conventional laparoscopic adrenalectomy group (p = 0.052). There were no intraoperative or postoperative complications. There were no differences between the two study groups with respect to postoperative pain, number of patients who resumed oral intake within the first 24 h, final pathologic diagnosis, and length of hospital stay.

CONCLUSION

SILS left adrenalectomy is a technically feasible and safe procedure in carefully selected patients. The definitive clinical, aesthetic and functional advantages of this technique require further analysis.

Single-port laparoscopic adrenalectomy for a right-sided aldosterone-producing adenoma: a case report

Introduction

Single-port laparoscopic adrenalectomy is one of the most interesting surgical advances. Here, we evaluate the safety and feasibility of single-port laparoscopic adrenalectomy as treatment for a right-sided aldosterone-producing adenoma.

Case presentation

A 39-year-old Japanese woman presented with hypertension and hypokalemia. Abdominal computed tomography and an endocrinological workup revealed a 19mm right adrenal tumor with primary aldosteronism. Our patient was informed of the details of the surgical procedure and our efforts to reduce the number of incisions needed - ideally, to a single incision - when removing her adrenal gland. A single-port laparoscopic adrenalectomy was attempted. A multichannel port was inserted through a 2.5cm umbilical incision. A 5mm flexible laparoscope, articulating laparoscopic dissector and tissue sealing device were the primary tools used in the operation. The right liver lobe was evaluated using a percutaneous instrument, providing good visualization of the operative field surrounding her right adrenal gland. The single-port laparoscopic adrenalectomy was successfully completed without any intraoperative complications. The operating time was 76 minutes, and her blood loss was 5mL. Oral intake was resumed on the first postoperative day, and the length of her hospital stay was three days. Her postoperative course was uneventful with no morbidity within one month of follow-up, and our patient had excellent cosmetic results.

Conclusions

Single-port laparoscopic adrenalectomy is a safe and feasible procedure for patients with a right-sided adrenal tumor when performed by a surgeon experienced in laparoscopic and adrenal surgery. However, more surgical experience using this technique is required to confirm our initial impressions.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution

INTRODUCTION

Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion.

METHODS

We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus.

RESULTS

Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m with a mean of 30 kg/m. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon's first ten cases.

CONCLUSIONS

The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

Comparison of single-surgeon series of transperitoneal laparoendoscopic single-site surgery and standard laparoscopic adrenalectomy

OBJECTIVE

To assess the feasibility, safety, and efficacy of transperitoneal laparoendoscopic single-site (LESS) adrenalectomy and determine whether it shows any objective advantage compared with standard laparoscopy.

METHODS

From August 2009 to May 2011, 13 transperitoneal LESS adrenalectomies were performed through a 2-3-cm skin incision using the TriPort access system. This cohort was compared with a contemporary 1:2 matched-pair group of 26 patients undergoing standard laparoscopic adrenalectomy by the same urologist. The perioperative outcomes, including cosmetic satisfaction scores, were statistically analyzed.

RESULTS

The 2 groups were comparable with respect to patient demographics, estimated blood loss, and postoperative hospitalization (P > .05). The LESS procedures had a longer mean operative time (148.5 vs 112.9 minutes, P = .032) but a significantly lower postoperative visual analog pain scale score (2.3 vs 3.7, P = .001), fewer patients requiring analgesics (30.8% vs 73.1%, P = .011), and an earlier resumption of oral intake (21.6 vs 26.0 hours, P = .002). The mean length of the scar in the LESS group was much smaller (2.3 vs 5.9 cm, P < .0001) with a statistically significant greater mean cosmetic satisfaction score (9.5 vs 9.1, P = .042).

CONCLUSION

The perioperative outcomes of transperitoneal LESS adrenalectomy for small adrenal tumors were comparable to those with the standard laparoscopic approach. It also provides better postoperative pain control, faster recovery of bowel function, and better cosmetic satisfaction than standard laparoscopy, albeit with a longer operative time.

Single-port laparascopic cholecystectomy: scarless cholecystectomy

Objective. Single-incision laparoscopic surgery is a new advanced technology to further minimize the invasiveness of laparoscopy through a single small incision hidden in the umbilicus. The objective is to describe short and long-term outcomes of SILS cholecystectomy. Methodology. Patients with gallbladder pathologies were unselectively enrolled and were prospectively studied between April 2009 and April 2010 and completed a post-operative follow-up for 12 months. Results. There were 22 women and 8 men. Mean age was 46 years. Twenty-one patients had biliary colic, seven had acute cholecystitis, one had gallbladder polyp, and another had resolving acute pancreatitis. Mean operative time was 104.3 ± 44 minutes. Mean BMI was 30.42 and the average pain score was 3.2 ± 1.1. One more port was inserted to help in finishing the procedure in one patient. There was no conversion to a standard laparoscopic or open technique. There was one post-operative bile collection from a missed cyctic duct of Luschka. Mean hospital stay was 1.2 days. Conclusion. Single-port laparoscopic cholecystectomy is feasible. Early conversion to a standard laparoscopic technique is advised to avoid serious complications. The procedure has an obvious cosmetic benefit. Additional prospective trials are necessary to define the benefits of single-port laparoscopic cholecystectomy.

Transumbilical single port laparoscopic adrenalectomy: a technical report on right and left adrenalectomy using the glove port

Recently, single port laparoscopic surgery has been the focus of attention due to the advanced laparoscopic skills accumulated from experience and developments in laparoscopic instruments. Herein, we present two cases of initial single port laparoscopic adrenalectomies. Case 1 was a 38-year-old female patient diagnosed with primary hyperaldosteronism because of a the right adrenal 2.5-cm sized adenoma, and case 2 was a 31-year-old female patient diagnosed with primary adrenal Cushing's syndrome because of a left adrenal 2.9-cm sized adenoma. Both patients successfully underwent single port laparoscopic adrenalectomies via a transumbilical transperitoneal approach. There was no estimated blood loss and the total operating times were 60 and 70 minutes, respectively. Both patients recovered uneventfully. We believe that this technique presented could provide potential benefits (lesser wound pain, better cosmetic satisfaction, and shorter convalescence) if the indications are carefully selected.

Conventional laparoscopic adrenalectomy versus laparoscopic adrenalectomy through mono port

A standard procedure for single-port laparoscopic adrenal surgery has not been established. We retrospectively investigated intraoperative and postoperative outcomes after laparoscopic adrenalectomy through mono port (LAMP) and conventional laparoscopic adrenalectomy to assess the feasibility of LAMP. Between March 2008 and December 2009, 22 patients underwent adrenalectomy at the Department of Surgery, Kangbuk Samsung Hospital. Twelve patients underwent conventional laparoscopic adrenalectomy and 10 patients underwent LAMP. The same surgeon performed all the surgeries. The 2 procedures were compared in terms of tumor size, operating time, time to resumption of a soft diet, length of hospital day, and postoperative complications. The 2 groups were similar in terms of tumor size (30.08 vs. 32.50 mm, P=0.796), mean operating time (112.9 vs. 127 min, P=0.316), time to resumption of a soft diet (1.25 vs. 1.30 d, P=0.805), and length of hospital day (4.08 vs. 4.50 d, P=0.447). Despite 1 patient in the LAMP group experiencing ipsilateral pleural effusion as a postoperative complication, this parameter was similar for the 2 groups (P=0.195). Perioperative mortality, blood transfusion, and conversion to open surgery did not occur. Perioperative outcomes for LAMP were similar to those for conventional laparoscopic adrenalectomy. LAMP appears to be a feasible option for adrenalectomy.

Transumbilical laparoscopic surgery using GelPort through an umbilical zigzag skin incision

INTRODUCTION

We report herein a new method of transumbilical laparoscopic surgery using a GelPort through an umbilical zigzag skin incision. The method involves collaborating with plastic surgeons to ensure the procedure was minimally invasive.

MATERIALS AND SURGICAL TECHNIQUE

After marking a zigzag skin incision in the umbilical region, the skin was incised along this line. Then, a GelPort double-ring wound retractor was inserted through the incision, which enlarged the diameter of the fascial opening to 6 cm. The Gelport was latched on the wound retractor ring, following the inflation of the pneumoperitoneum by CO (2). One or more additional ports were inserted as necessary. All operations were performed in the standard fashion. The specimen was easily extracted from the abdomen through the umbilical incision, and anastomosis was performed. Using the above method, we performed the following procedures: one total gastrectomy, one distal gastrectomy, three gastric local resections, five right hemicolectomies, two high anterior resections, three cholecystectomies, and seven transabdominal preperitoneal hernioplasties. All cases were accomplished without any complications using this method. The wounds of the umbilical region were almost "scarless" in all cases.

DISCUSSION

We developed an umbilical zigzag skin incision technique to perform abdominal laparoscopic operations using a GelPort, with a minimal number of skin incisions. We consider that our method reduces the technical difficulties associated with laparoscopic surgery and maintains cosmesis.

Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocellular carcinoma

BACKGROUND

Single-port laparoscopic surgery is slowly but steadily gaining popularity among surgeons performing minimally invasive abdominal surgeries. The aim of the present study is to assess our initial experience with single-port laparoscopic liver resection for hepatocellular carcinoma.

METHODS

Between March 2009 and April 2011, 24 patients underwent single-port laparoscopic liver resection for hepatocellular carcinoma. Of these, 13 were laparoscopic segmentectomies, 4 were laparoscopic left lateral sectionectomies, 1 was a right hepatectomy, 1 was a left hepatectomy, and 4 were nonanatomical resections.

RESULTS

Median operating time and blood loss were 205 min (95-545 min) and 500 ml (100-2,500 ml), respectively. Two procedures were converted to multiport laparoscopic hepatectomy due to instrument length limitations, and four were converted to open surgery. There were no serious intraoperative or postoperative complications in this series. Median postoperative stay was 8.5 days (5-16 days).

CONCLUSIONS

Although the procedure requires a lot of technical expertise added to the skill of liver surgery, single-port laparoscopic liver resection for hepatocellular carcinoma seems a feasible approach in a variety of well-selected cases. In spite of the demanding nature of the procedure and the requirement of better instrumentation for single-port laparoscopic surgery, the results seem to compare favorably with conventional laparoscopic surgery and open surgery.

Robotic single-port cholecystectomy using a new platform: initial clinical experience

BACKGROUND

The technique of single-port laparoscopy was developed over the past years in an attempt to reduce the invasiveness of surgery. A reduction of incisions and their overall size might result in enhanced postoperative cosmesis and potentially reduce pain when compared to conventional techniques. While manual single-port laparoscopy is technically challenging, a newly approved robotic platform used with the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA, USA) might overcome some of the difficulties of this technique.

METHODS

Patients with cholelithiasis were scheduled for robotic single-port cholecystectomy in an initial clinical trial. Demographic data, intra- and short-term postoperative results were assessed prospectively.

RESULTS

Twenty-eight patients (22 females/6 males; median age, 48 years) underwent robotic single-port cholecystectomy in our first week of clinical cases. Median OR time was 80 min with a median docking time of 8 min and median robotic console time of 53 min. Two patients underwent intraoperative cholangiography. Eight cases presented with adhesions, tissue alterations, or anatomical abnormalities. No conversions, intra- or postoperative complications occurred.

CONCLUSION

Robotic single-port cholecystectomy appears feasible and safe in our early experience. The robotic approach to single-port surgery seems to overcome some of the technical difficulties of manual single-port surgery. This robotic platform may facilitate completion of more complex cases.