J Hepatobiliary Pancreat Sci (2014) 21:18–25 DOI: 10.1002/jhbp.36
TOPICS
Robotic single-site cholecystectomy Philippe Morel · Nicolas C. Buchs · Pouya Iranmanesh · François Pugin · Leo Buehler · Dan E. Azagury · Minoa Jung · Francesco Volonte · Monika E. Hagen
Published online: 21 October 2013 © 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Background Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy. Methods From February 2011 to February 2013, all consecutive robotic single site cholecystectomies (RSSC) were prospectively collected in a dedicated database. Demographic, intra- and postoperative data of all patients that underwent RSSC at our institution were analyzed. Data were evaluated for the overall patient cohort as well as after stratification according to patient BMI (body mass index) and surgeon’s experience. Results During the study period, 82 patients underwent robotic single site cholecystectomy at our institution. The dominating preoperative diagnosis was cholelithiasis. Mean overall operative time was 91 min. Intraoperative complications occurred in 2.4% of cases. One conversion to open surgery due to the intraoperative finding of a gallbladder carcinoma was observed and two patients needed an additional laparoscopic trocar. The rate of postoperative complications was 4.9% with a mean length of stay of 2.4 days. No significant differences were observed when comparing results between robotic novices and robotic experts. Patients with higher BMI trended towards longer surgical console and overall operative time, but resulted in similar rates of conversions and complications when compared to normal weight patients.
P. Morel · N. C. Buchs · P. Iranmanesh · F. Pugin · L. Buehler · D. E. Azagury · M. Jung · F. Volonte · M. E. Hagen (*) Division of Digestive Surgery, University Hospitals Geneva, 4 Rue Gabrielle-Perret-Gentil, Geneva 1211, Switzerland e-mail: [email protected]
Conclusions Robotic Single-Site cholecystectomy can be performed safely and effectively with low rates of complications and conversions in patients with differing BMI and by surgeons with varying levels of experience. Keywords Cholecystectomy · Da Vinci · Docking · Robotic · Single incision · Single site Introduction Minimally invasive surgery is an ever-evolving effort striving for the best possible clinical outcome for the patient. While cholecystectomy established itself as one of the surgical procedures routinely performed laparoscopically [1], the continuous effort to further reduce invasiveness of this procedure resulted in the development of single-incision cholecystectomy [2–4]. Even though many reports demonstrate the general feasibility of single-site surgery, particularly for simpler procedures such as cholecystectomy, widespread use has not been observed so far [5, 6], particularly in challenging patients or by relatively inexperienced surgeons. This might be due to the technical challenges of manual single incision laparoscopy including loss of triangulation and the limited number of instruments that can be used at a time, resulting in compromised assistance and retraction and instrument crowding and collisions. These challenges increase the complexity of a procedure that would be considered simple using a multi-incision approach. In 2011, the da Vinci Single-Site Instrumentation and Accessories (Intuitive Surgical, Sunnyvale, CA, USA) were launched to address these limitations [7–9]. This set of instruments is designed to be used with the da Vinci Si Surgical System (Intuitive Surgical) to perform single incision laparoscopic surgery [10, 11]. These semi-rigid instruments are delivered into the abdominal cavity through curved cannulae that are inserted into a specific port in a
J Hepatobiliary Pancreat Sci (2014) 21:18–25
single fascial incision. Unlike the conventional robotic instruments, the Single-Site technology is non-wristed and only provides rotation. However, ergonomics are greatly improved, and this system allows for an additional port for assistance [12]. Details about the system, the technical specifications and the surgical setup have been described previously [7, 8, 12, 13]. Very early data reporting the feasibility to perform simple procedures such as cholecystectomy was confirmed by larger post-market case series [10, 11], one comparative paper to conventional single site laparoscopy [13] and a multicenter publication from Italy [14]. However, the body of scientific knowledge is relatively light at this current point in regard to the widespread application of this technology with challenging patients and robotically inexperienced surgeons. To our knowledge, this publication is to date the largest single-institution experience reporting the clinical outcomes of robotic single-site cholecystectomy using the da Vinci Surgical System with sub-analyses in regard to patient BMI and surgeon’s experience.
Materials and methods From February 2011 to February 2013, all the consecutive robotic Single-Site cholecystectomies were prospectively collected in a dedicated database under an Institutional Review Board approved protocol. Demographic, peri- and postoperative data with a follow-up period of 30 days from all patients undergoing robotic single-incision cholecystectomies at our institution were thus collected prospectively from the very first patient in February 2011. Initial inclusion criteria were patients between 18 and 80 years with symptomatic cholelithiasis. Exclusion criteria were acute cholecystitits, suspicion of common bile duct stones, pregnancy, severe lack of cooperation due to psychological or severe systemic illness, and presence of medical conditions contraindicating general anesthesia or standard surgical approaches. However, a minor number of patients outside the in- and exclusion criteria underwent the procedure as a deviation from the protocol, and some patients were identified as having a different final diagnosis during the procedure. The da Vinci Si Surgical System with Single-Site Technology was used for all cases as previously described [13, 15, 16]. Surgeries were performed by seven surgeons with different levels of robotic, single-incision laparoscopic and overall surgical experience. Two surgeons were very experienced, with more than 100 complex robotic gastrointestinal procedures and some single-incision laparoscopic cases previously performed. Five surgeons had less than 20 complex procedures performed robotically, and among
19
them, three were within their first five robotic cases. All of these robotic novices had a limited experience with single incision laparoscopy. Overall patient characteristics and outcomes were summarized with descriptive statistics. Data were further stratified according to patient BMI and surgeon’s experience. Pairwise comparisons for each outcome of interest were made using a two-sample t-test. A P-value of
TOPICS
Robotic single-site cholecystectomy Philippe Morel · Nicolas C. Buchs · Pouya Iranmanesh · François Pugin · Leo Buehler · Dan E. Azagury · Minoa Jung · Francesco Volonte · Monika E. Hagen
Published online: 21 October 2013 © 2013 Japanese Society of Hepato-Biliary-Pancreatic Surgery
Abstract Background Minimally invasive approaches for cholecystectomy are evolving in a surge for the best possible clinical outcome for the patients. As one of the most recent developments, a robotic set of instrumentation to be used with the da Vinci Si Surgical System has been developed to overcome some of the technical challenges of manual single incision laparoscopy. Methods From February 2011 to February 2013, all consecutive robotic single site cholecystectomies (RSSC) were prospectively collected in a dedicated database. Demographic, intra- and postoperative data of all patients that underwent RSSC at our institution were analyzed. Data were evaluated for the overall patient cohort as well as after stratification according to patient BMI (body mass index) and surgeon’s experience. Results During the study period, 82 patients underwent robotic single site cholecystectomy at our institution. The dominating preoperative diagnosis was cholelithiasis. Mean overall operative time was 91 min. Intraoperative complications occurred in 2.4% of cases. One conversion to open surgery due to the intraoperative finding of a gallbladder carcinoma was observed and two patients needed an additional laparoscopic trocar. The rate of postoperative complications was 4.9% with a mean length of stay of 2.4 days. No significant differences were observed when comparing results between robotic novices and robotic experts. Patients with higher BMI trended towards longer surgical console and overall operative time, but resulted in similar rates of conversions and complications when compared to normal weight patients.
P. Morel · N. C. Buchs · P. Iranmanesh · F. Pugin · L. Buehler · D. E. Azagury · M. Jung · F. Volonte · M. E. Hagen (*) Division of Digestive Surgery, University Hospitals Geneva, 4 Rue Gabrielle-Perret-Gentil, Geneva 1211, Switzerland e-mail: [email protected]
Conclusions Robotic Single-Site cholecystectomy can be performed safely and effectively with low rates of complications and conversions in patients with differing BMI and by surgeons with varying levels of experience. Keywords Cholecystectomy · Da Vinci · Docking · Robotic · Single incision · Single site Introduction Minimally invasive surgery is an ever-evolving effort striving for the best possible clinical outcome for the patient. While cholecystectomy established itself as one of the surgical procedures routinely performed laparoscopically [1], the continuous effort to further reduce invasiveness of this procedure resulted in the development of single-incision cholecystectomy [2–4]. Even though many reports demonstrate the general feasibility of single-site surgery, particularly for simpler procedures such as cholecystectomy, widespread use has not been observed so far [5, 6], particularly in challenging patients or by relatively inexperienced surgeons. This might be due to the technical challenges of manual single incision laparoscopy including loss of triangulation and the limited number of instruments that can be used at a time, resulting in compromised assistance and retraction and instrument crowding and collisions. These challenges increase the complexity of a procedure that would be considered simple using a multi-incision approach. In 2011, the da Vinci Single-Site Instrumentation and Accessories (Intuitive Surgical, Sunnyvale, CA, USA) were launched to address these limitations [7–9]. This set of instruments is designed to be used with the da Vinci Si Surgical System (Intuitive Surgical) to perform single incision laparoscopic surgery [10, 11]. These semi-rigid instruments are delivered into the abdominal cavity through curved cannulae that are inserted into a specific port in a
J Hepatobiliary Pancreat Sci (2014) 21:18–25
single fascial incision. Unlike the conventional robotic instruments, the Single-Site technology is non-wristed and only provides rotation. However, ergonomics are greatly improved, and this system allows for an additional port for assistance [12]. Details about the system, the technical specifications and the surgical setup have been described previously [7, 8, 12, 13]. Very early data reporting the feasibility to perform simple procedures such as cholecystectomy was confirmed by larger post-market case series [10, 11], one comparative paper to conventional single site laparoscopy [13] and a multicenter publication from Italy [14]. However, the body of scientific knowledge is relatively light at this current point in regard to the widespread application of this technology with challenging patients and robotically inexperienced surgeons. To our knowledge, this publication is to date the largest single-institution experience reporting the clinical outcomes of robotic single-site cholecystectomy using the da Vinci Surgical System with sub-analyses in regard to patient BMI and surgeon’s experience.
Materials and methods From February 2011 to February 2013, all the consecutive robotic Single-Site cholecystectomies were prospectively collected in a dedicated database under an Institutional Review Board approved protocol. Demographic, peri- and postoperative data with a follow-up period of 30 days from all patients undergoing robotic single-incision cholecystectomies at our institution were thus collected prospectively from the very first patient in February 2011. Initial inclusion criteria were patients between 18 and 80 years with symptomatic cholelithiasis. Exclusion criteria were acute cholecystitits, suspicion of common bile duct stones, pregnancy, severe lack of cooperation due to psychological or severe systemic illness, and presence of medical conditions contraindicating general anesthesia or standard surgical approaches. However, a minor number of patients outside the in- and exclusion criteria underwent the procedure as a deviation from the protocol, and some patients were identified as having a different final diagnosis during the procedure. The da Vinci Si Surgical System with Single-Site Technology was used for all cases as previously described [13, 15, 16]. Surgeries were performed by seven surgeons with different levels of robotic, single-incision laparoscopic and overall surgical experience. Two surgeons were very experienced, with more than 100 complex robotic gastrointestinal procedures and some single-incision laparoscopic cases previously performed. Five surgeons had less than 20 complex procedures performed robotically, and among
19
them, three were within their first five robotic cases. All of these robotic novices had a limited experience with single incision laparoscopy. Overall patient characteristics and outcomes were summarized with descriptive statistics. Data were further stratified according to patient BMI and surgeon’s experience. Pairwise comparisons for each outcome of interest were made using a two-sample t-test. A P-value of
