Single-Port Laparoscopic and Robotic Surgery

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The recently developed single-port, multichannel access approach to urologic surgery may allow many common laparoscopic and robotic procedures to be performed entirely through the patient's umbilicus, enabling essentially scarless abdominal surgery. To date, Cleveland Clinic has performed 115 single-port laparoscopic procedures for various indications.

This initial experience with urologic single-port laparoscopy is encouraging. A wide range of complex procedures were successfully performed. The umbilicus presents a versatile access platform to various abdominal and pelvic surgical quadrants. Robotic application is likely to further facilitate single-port laparoscopy. Our initial experience with a single-port robotic transumbilical surgery using the da Vinci robot provided better ergonomics and precision during radical prostatectomy, partial nephrectomy, ureteral reimplantation, radical nephrectomy, and pyeloplasty without complications.

Current laparoscopic techniques call for three to six small skin incisions, depending on the complexity of the procedure. The new FDA-registered single-port device with multichannel has a unique port through which specially designed curved laparoscopic instruments are deployed. This approach may allow for further reduced wound morbidity. Importantly, this method allows a surgeon to “convert” the one-port transumbilical procedure to a conventional laparoscopic procedure at any point during the operation, if necessary, by adding one or more conventional laparoscopic port(s), thus preserving existing standards of care.

To do this, the multichannel port is inserted through a 1.5-cm semicircular incision at the inner edge of the umbilicus for transperitoneal surgery. In addition, we have performed retroperitoneal single-port kidney procedures on eight patients. During the retroperitoneal approach, the multichannel port is inserted at the tip of the 12th rib. In some cases, through the pre-existing Veress needle access, 2-mm needlescopic instruments were used selectively. Data were collected prospectively into a database approved by the Investigational Review Board. Results were as follows:

Upper tract procedures (N=87): renal biopsy, cyst decortication (n=5), cryotherapy (n=13), pyeloplasty (n=16; including bilateral single-session n=4), ileal ureter (n=2), psoas hitch uretero-neocystostomy (n=4), nephrectomy (n=33; simple, n=8; radical, n=11; donor, n=14) and partial nephrectomy (n=14).

Pelvic procedures (N=28): varicocelectomy (n=3), sacrocolpopexy (n=14), radical prostatectomy (n=8) and radical cystectomy, extended lymphadenectomy (n=3).

Data (range): OR time (120-360 min), estimated blood loss (20-550 mL), and hospital stay (0-22 days). Nephron-sparing procedures: tumor size (1-6 cm), ischemia time (0-29 min). Donor nephrectomy: median warm ischemia time=4.7 min.

Complications (N=4): corneal abrasion (n=1), retained J-stent fragment (n=1), bleed requiring angioinfarction (n=1), and rectourethral fistula (n=1); conversion to standard laparoscopy for failure to progress (N=5) during: prostatectomy (n=2), adrenalectomy (n=1), pyeloplasty (n=1) and partial nephrectomy (n=1).

Mihir M. Desai, MD, Robert Stein, MD, Raymond R. Rackley, MD, Courtenay K. Moore, MD, Jeffrey Palmer, MD, and Inderbir S. Gill, MD, MCh, also contributed to this article.

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