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J Minim Invasive Surg 2017; 20(1): 3-4

Published online March 15, 2017

https://doi.org/10.7602/jmis.2017.20.1.3

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Single-incision Robotic Cholecystectomy: Initial Experience and Results

Ji Hun Kim

Division of Pancreatobiliary Surgery, Department of Surgery, School of Medicine, Ajou University, Suwon, Korea

Correspondence to : Ji Hun Kim Division of Pancreatobiliary Surgery, Department of Surgery, School of Medicine, Ajou University, San-5, Wonchon-dong, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5207, Fax: +82-31-219-5755, E-mail: kjhmd93@ajou.ac.kr

Received: March 2, 2017; Accepted: March 6, 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

The first single-incision laparoscopic surgery (SILS) was performed in 1997. Although there are many studies for safety or feasibility of SILS, most surgeons agree some disadvantages such as difficult making triangulation, instruments crowding, and collisions. To overcome these limitations of laparoscopy, the robotic platform developed with advantages including three-dimensional view, magnification, and articulated instrument. The first single-incision robotic cholecystectomy (SIRC) was successfully performed in human in 2010. Safety and feasibility of SIRC have been publishing in many reports. Single-incision robotic cholecystectomy is a safe procedure for gallbladder diseases. To adopt the SIRC to all patients with gallbladder diseases, however, there are some problems to be solved, such as cost, indications, and incisional hernia. Therefore, further studies to clarify benefits of SIRC is needed in the future, with long-term outcome or large comparative analysis compare to laparoscopic and multiport robotic procedures.

Keywords Cholecystectomy, Robotic procedure, Single-incision cholecystectomy

Although there have been many studies of the safety or feasibility of single-incision laparoscopic surgery (SILS) since it was first performed in 1997,1 most surgeons agree that it has disadvantages such as difficulty conducting triangulation, instrument crowding, and collisions.2-4 To overcome these limitations of laparoscopy, the robotic platform was developed, providing advantages including three-dimensional view, magnification, and an articulated instrument.5 However, robotic surgery requires a longer set-up time and operation time than laparoscopy.6 For single-incision robotic cholecystectomy (SIRC), there are debates regarding operation time, with some authors reporting a longer operation time for SIRC than SILS (98 vs 68 min, p<0.001).7 Conversely, a significant difference in operation time was reported for RSSC (62 min) and SILS (83 min).8 A recent multicenter study showed a short operative time of RSSC of 52 min with a decreasing trend after 55~85 cases.9 However, that study was limited in that it did not include a comparative analysis for SIRC. In the present study, the operation time was 97.2 min, the console time was 49 min, and the docking time was 10 min, which is similar to other reports.7,10 The authors also described a decreasing trend of console time with accumulation of experience, indicating the potential to overcome the long operation time of SIRC.

The first single-incision robotic cholecystectomy (SIRC) was successfully performed in humans in 2010,11 and the safety and feasibility of SIRC have since been published in many reports. Moreover, there have been no severe complications, such as injury to the bile duct or conversion to laparoscopy or open surgery,11,12 although one case of postoperative hemorrhage associated with SIRC has been reported.13 Additionally, some authors have investigated cosmetic outcome and postoperative pain in comparative studies,14,15 with less pain and better cosmetic outcomes occurring in SILC.16,17 The results of the present study also showed good outcomes without any conversions or complications, even when no additional port was used during the procedure. In another recent study, the authors reported their experience of SIRC in a broadly inclusive patient population with six conversions to laparoscopy, one to open surgery, and one aborted case.18 Here, we focus on indications of SIRC. The surgical outcome in earlier studies was excellent because the initial inclusion criteria in most studies were limited in symptomatic gallstones or gallbladder polyps, and did not include high BMI or acute cholecystitis.6,8 To clarify the effectiveness of SIRC, operative indications should be extended in all cases of gallbladder diseases. However, gallbladder retraction is not easy in cases of edematous or dense fibrotic tissue. Some authors have described several methods of gallbladder retraction using sutures, clips, and magnets.19,20 In fact, few instruments of robotic single-site platform are articulated, unlike multiport robotic systems. This is a strong point to explain the reason why the widening of indication is difficult. According to a previous report, there are limitations to this procedure, such as short-term follow up and selection bias.9 Specifically, they found that the follow up period was too short to show the incisional hernia rate. Accordingly, additional studies investigating long-term outcomes are needed to establish the incisional hernia rate.

Single-incision robotic cholecystectomy is a safe procedure for gallbladder diseases. However, several problems need to be solved to adapt the SIRC to all patients with gallbladder diseases, such as cost, indications, and incisional hernia. Therefore, further studies to clarify the benefits of SIRC are needed to investigate long-term outcome and provide a large comparative analysis of laparoscopic and multiport robotic procedures.

  1. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, and Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.
    Pubmed CrossRef
  2. Rivas H, Varela E, and Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc 2010;24:1403-1412.
    Pubmed KoreaMed CrossRef
  3. Podolsky ER, and Curcillo PG. Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy. Surg Endosc 2010;24:3038-3043.
    Pubmed CrossRef
  4. Edwards C, Bradshaw A, and Ahearne P et al. Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases. Surg Endosc 2010;24:2241-2247.
    Pubmed CrossRef
  5. Breitenstein S, Nocito A, Puhan M, Held U, Weber M, and Clavien PA. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a case-matched control study. Ann Surg 2008;247:987-993.
    Pubmed CrossRef
  6. Pietrabissa A, Sbrana F, and Morelli L et al. Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology. Arch Surg 2012;147:709-714.
    Pubmed CrossRef
  7. Gustafson M, Lescouflair T, Kimball R, and Daoud I. A comparison of robotic single-incision and traditional single-incision laparoscopic cholecystectomy. Surg Endosc 2016;30:2276-2280.
    Pubmed CrossRef
  8. Spinoglio G, Lenti LM, and Maglione V et al. Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC):comparison of learning curves. First European experience. Surg Endosc 2012;26:1648-1655.
    Pubmed CrossRef
  9. Gonzalez A, Murcia CH, and Romero R et al. A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases. Surg Endosc 2016;30:2951-2960.
    Pubmed CrossRef
  10. Morel P, Buchs NC, and Iranmanesh P et al. Robotic single-site cholecystectomy. J Hepatobiliary Pancreat Sci 2014;21:18-25.
    Pubmed CrossRef
  11. Kroh M, El-Hayek K, and Rosenblatt S et al. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc 2011;25:3566-3573.
    Pubmed CrossRef
  12. Gagner M, Begin E, Hurteau R, and Pomp A. Robotic interactive laparoscopic cholecystectomy. Lancet 1994;343:596-597.
    CrossRef
  13. Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, and Georgiou M. Cholecystectomy using a novel Single-Site((R)) robotic platform: early experience from 45 consecutive cases. Surg Endosc 2012;26:2687-2694.
    Pubmed CrossRef
  14. Gangl O, Hofer W, Tomaselli F, Sautner T, and Fugger R. Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC)-a matched pair analysis. Langenbecks Arch Surg 2011;396:819-824.
    Pubmed CrossRef
  15. Lirici MM, Califano AD, Angelini P, and Corcione F. Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial. Am J Surg 2011;202:45-52.
    Pubmed CrossRef
  16. Marks JM, Phillips MS, and Tacchino R et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 2013;216:1037-1047.
    Pubmed CrossRef
  17. Tsimoyiannis EC, Tsimogiannis KE, and Pappas-Gogos G et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2010;24:1842-1848.
    Pubmed CrossRef
  18. Vidovszky TJ, Carr AD, Farinholt GN, Ho HS, Smith WH, and Ali MR. Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study. Ann Surg 2014;260:134-141.
    Pubmed CrossRef
  19. Colon MJ, Telem D, Mermelstein J, Weber KJ, Divino CM, and Chin E. Completely intracorporeal retraction of the gallbladder for laparoendoscopic single site (LESS) surgery. Surg Laparosc Endosc Percutan Tech 2011;21:e1-3.
    Pubmed CrossRef
  20. Reibetanz J, Wierlemann A, Germer CT, and Krajinovic K. A novel technique for fundal retraction of the gallbladder in single-port cholecystectomy. J Laparoendosc Adv Surg Tech A 2011;21:427-429.
    Pubmed CrossRef

Article

Editorial

J Minim Invasive Surg 2017; 20(1): 3-4

Published online March 15, 2017 https://doi.org/10.7602/jmis.2017.20.1.3

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Single-incision Robotic Cholecystectomy: Initial Experience and Results

Ji Hun Kim

Division of Pancreatobiliary Surgery, Department of Surgery, School of Medicine, Ajou University, Suwon, Korea

Correspondence to:Ji Hun Kim Division of Pancreatobiliary Surgery, Department of Surgery, School of Medicine, Ajou University, San-5, Wonchon-dong, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5207, Fax: +82-31-219-5755, E-mail: kjhmd93@ajou.ac.kr

Received: March 2, 2017; Accepted: March 6, 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The first single-incision laparoscopic surgery (SILS) was performed in 1997. Although there are many studies for safety or feasibility of SILS, most surgeons agree some disadvantages such as difficult making triangulation, instruments crowding, and collisions. To overcome these limitations of laparoscopy, the robotic platform developed with advantages including three-dimensional view, magnification, and articulated instrument. The first single-incision robotic cholecystectomy (SIRC) was successfully performed in human in 2010. Safety and feasibility of SIRC have been publishing in many reports. Single-incision robotic cholecystectomy is a safe procedure for gallbladder diseases. To adopt the SIRC to all patients with gallbladder diseases, however, there are some problems to be solved, such as cost, indications, and incisional hernia. Therefore, further studies to clarify benefits of SIRC is needed in the future, with long-term outcome or large comparative analysis compare to laparoscopic and multiport robotic procedures.

Keywords: Cholecystectomy, Robotic procedure, Single-incision cholecystectomy

Body

Although there have been many studies of the safety or feasibility of single-incision laparoscopic surgery (SILS) since it was first performed in 1997,1 most surgeons agree that it has disadvantages such as difficulty conducting triangulation, instrument crowding, and collisions.2-4 To overcome these limitations of laparoscopy, the robotic platform was developed, providing advantages including three-dimensional view, magnification, and an articulated instrument.5 However, robotic surgery requires a longer set-up time and operation time than laparoscopy.6 For single-incision robotic cholecystectomy (SIRC), there are debates regarding operation time, with some authors reporting a longer operation time for SIRC than SILS (98 vs 68 min, p<0.001).7 Conversely, a significant difference in operation time was reported for RSSC (62 min) and SILS (83 min).8 A recent multicenter study showed a short operative time of RSSC of 52 min with a decreasing trend after 55~85 cases.9 However, that study was limited in that it did not include a comparative analysis for SIRC. In the present study, the operation time was 97.2 min, the console time was 49 min, and the docking time was 10 min, which is similar to other reports.7,10 The authors also described a decreasing trend of console time with accumulation of experience, indicating the potential to overcome the long operation time of SIRC.

The first single-incision robotic cholecystectomy (SIRC) was successfully performed in humans in 2010,11 and the safety and feasibility of SIRC have since been published in many reports. Moreover, there have been no severe complications, such as injury to the bile duct or conversion to laparoscopy or open surgery,11,12 although one case of postoperative hemorrhage associated with SIRC has been reported.13 Additionally, some authors have investigated cosmetic outcome and postoperative pain in comparative studies,14,15 with less pain and better cosmetic outcomes occurring in SILC.16,17 The results of the present study also showed good outcomes without any conversions or complications, even when no additional port was used during the procedure. In another recent study, the authors reported their experience of SIRC in a broadly inclusive patient population with six conversions to laparoscopy, one to open surgery, and one aborted case.18 Here, we focus on indications of SIRC. The surgical outcome in earlier studies was excellent because the initial inclusion criteria in most studies were limited in symptomatic gallstones or gallbladder polyps, and did not include high BMI or acute cholecystitis.6,8 To clarify the effectiveness of SIRC, operative indications should be extended in all cases of gallbladder diseases. However, gallbladder retraction is not easy in cases of edematous or dense fibrotic tissue. Some authors have described several methods of gallbladder retraction using sutures, clips, and magnets.19,20 In fact, few instruments of robotic single-site platform are articulated, unlike multiport robotic systems. This is a strong point to explain the reason why the widening of indication is difficult. According to a previous report, there are limitations to this procedure, such as short-term follow up and selection bias.9 Specifically, they found that the follow up period was too short to show the incisional hernia rate. Accordingly, additional studies investigating long-term outcomes are needed to establish the incisional hernia rate.

Single-incision robotic cholecystectomy is a safe procedure for gallbladder diseases. However, several problems need to be solved to adapt the SIRC to all patients with gallbladder diseases, such as cost, indications, and incisional hernia. Therefore, further studies to clarify the benefits of SIRC are needed to investigate long-term outcome and provide a large comparative analysis of laparoscopic and multiport robotic procedures.

References

  1. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, and Donini I. One-wound laparoscopic cholecystectomy. Br J Surg 1997;84:695.
    Pubmed CrossRef
  2. Rivas H, Varela E, and Scott D. Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc 2010;24:1403-1412.
    Pubmed KoreaMed CrossRef
  3. Podolsky ER, and Curcillo PG. Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy. Surg Endosc 2010;24:3038-3043.
    Pubmed CrossRef
  4. Edwards C, Bradshaw A, and Ahearne P et al. Single-incision laparoscopic cholecystectomy is feasible: initial experience with 80 cases. Surg Endosc 2010;24:2241-2247.
    Pubmed CrossRef
  5. Breitenstein S, Nocito A, Puhan M, Held U, Weber M, and Clavien PA. Robotic-assisted versus laparoscopic cholecystectomy: outcome and cost analyses of a case-matched control study. Ann Surg 2008;247:987-993.
    Pubmed CrossRef
  6. Pietrabissa A, Sbrana F, and Morelli L et al. Overcoming the challenges of single-incision cholecystectomy with robotic single-site technology. Arch Surg 2012;147:709-714.
    Pubmed CrossRef
  7. Gustafson M, Lescouflair T, Kimball R, and Daoud I. A comparison of robotic single-incision and traditional single-incision laparoscopic cholecystectomy. Surg Endosc 2016;30:2276-2280.
    Pubmed CrossRef
  8. Spinoglio G, Lenti LM, and Maglione V et al. Single-site robotic cholecystectomy (SSRC) versus single-incision laparoscopic cholecystectomy (SILC):comparison of learning curves. First European experience. Surg Endosc 2012;26:1648-1655.
    Pubmed CrossRef
  9. Gonzalez A, Murcia CH, and Romero R et al. A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases. Surg Endosc 2016;30:2951-2960.
    Pubmed CrossRef
  10. Morel P, Buchs NC, and Iranmanesh P et al. Robotic single-site cholecystectomy. J Hepatobiliary Pancreat Sci 2014;21:18-25.
    Pubmed CrossRef
  11. Kroh M, El-Hayek K, and Rosenblatt S et al. First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform. Surg Endosc 2011;25:3566-3573.
    Pubmed CrossRef
  12. Gagner M, Begin E, Hurteau R, and Pomp A. Robotic interactive laparoscopic cholecystectomy. Lancet 1994;343:596-597.
    CrossRef
  13. Konstantinidis KM, Hirides P, Hirides S, Chrysocheris P, and Georgiou M. Cholecystectomy using a novel Single-Site((R)) robotic platform: early experience from 45 consecutive cases. Surg Endosc 2012;26:2687-2694.
    Pubmed CrossRef
  14. Gangl O, Hofer W, Tomaselli F, Sautner T, and Fugger R. Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC)-a matched pair analysis. Langenbecks Arch Surg 2011;396:819-824.
    Pubmed CrossRef
  15. Lirici MM, Califano AD, Angelini P, and Corcione F. Laparo-endoscopic single site cholecystectomy versus standard laparoscopic cholecystectomy: results of a pilot randomized trial. Am J Surg 2011;202:45-52.
    Pubmed CrossRef
  16. Marks JM, Phillips MS, and Tacchino R et al. Single-incision laparoscopic cholecystectomy is associated with improved cosmesis scoring at the cost of significantly higher hernia rates: 1-year results of a prospective randomized, multicenter, single-blinded trial of traditional multiport laparoscopic cholecystectomy vs single-incision laparoscopic cholecystectomy. J Am Coll Surg 2013;216:1037-1047.
    Pubmed CrossRef
  17. Tsimoyiannis EC, Tsimogiannis KE, and Pappas-Gogos G et al. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surg Endosc 2010;24:1842-1848.
    Pubmed CrossRef
  18. Vidovszky TJ, Carr AD, Farinholt GN, Ho HS, Smith WH, and Ali MR. Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study. Ann Surg 2014;260:134-141.
    Pubmed CrossRef
  19. Colon MJ, Telem D, Mermelstein J, Weber KJ, Divino CM, and Chin E. Completely intracorporeal retraction of the gallbladder for laparoendoscopic single site (LESS) surgery. Surg Laparosc Endosc Percutan Tech 2011;21:e1-3.
    Pubmed CrossRef
  20. Reibetanz J, Wierlemann A, Germer CT, and Krajinovic K. A novel technique for fundal retraction of the gallbladder in single-port cholecystectomy. J Laparoendosc Adv Surg Tech A 2011;21:427-429.
    Pubmed CrossRef

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