Robotic Laparoendoscopic Single-site Surgery Research Articles

Effectiveness and safety of SR-ENS-600endoscopic surgical system in benign and malignant gynecological diseases: a prospective, multicenter, clinical trial with 63 cases

Single-port laparoscopy has gained more attention, but inherent technical challenges hinder its wider use. To overcome the disadvantage of traditional single-port surgery, robotic laparoendoscopic single-site surgery system was designed and clinically utilized. This multi-center single-arm trial was aimed to present the clinical outcomes of the SHURUI robotic endoscopic single-site surgery system. 63 women with ovary cysts, myoma, cervical epithelial neoplasm, or endometrial carcinoma were recruited at 6 academic medical centers in different districts of China. The trial was registered on September 5, 2023, with the register number: ChiCTR2300075431, retrospectively registered. Patients underwent robotic LESS surgery with the SHURUI endoscopic surgical system from January 17 to May 26, 2023. Demographic information, perioperative parameters, complications, scar healing, and operator satisfaction scores were recorded. Patients were followed up for 30 ± 4 days. Average operative time and estimated blood loss were 157.03 ± 75.24 min and 63.86 ± 98.33 ml, respectively, for all surgeries. Average anal exhaust time and hospitalization stay were 30.99 ± 14.25 h and 3.63 ± 1.59 days, respectively. Patients’ postoperative rehabilitation assessment showed satisfactory results on the day of discharge and 30 ± 4 days after surgery. The surgery achieved good cosmetic benefits and was surgeon friendly. There were no conversions to alternative surgical modalities, complications, or readmissions. The SHURUI endoscopic surgical system showed both the technical feasibility and safety of this surgical modality for gynecologic patients. Further randomized studies comparing this modality with traditional LESS surgery are suggested.

“Less is More, is R-LESS More?”—The Use of Robotic Laparoendoscopic Single-Site Surgery in Gynaecology: A Scoping Review

Background: Since the Da Vinci system was introduced in the gynaecological profession, for benign and most malignant procedures, it appeared that using 5 incisions for trocar insertion could jeopardize the system’s mini-invasiveness. To protect this important characteristic, robotic laparoendoscopic single-site surgery was developed and authorized for gynaecological use in 2013. Using a single small incision for the entire treatment appears to be a promising attempt to improve cosmetic results while lowering wound infections, postoperative pain, and recovery time. After nearly ten years of use, several limitations of this technique became apparent, such as a limited set of non-articulating instruments and electrical possibilities compared to multiport surgery, smoke evacuation and visual impairment. By examining the most relevant research, the goal of this review was to emphasize the indications, risks, and benefits of R-LESS in gynaecological surgery. Methods: A scoping review was conducted on Pubmed, Scopus, Web of Science, and Embase. Publications in English or Italian in the previous 10 years on the use of single-site robotic surgery in gynaecology for benign disorders were included. Results: This review includes 37 of the 297 papers that were retrieved. Myomectomy, hysterectomy, pelvic floor surgery, and endometriosis were the most common indications for single-site surgery. Several studies have reported R-LESS usage in cancer patients. According to the data analysis, the R-LESS approach is comparable to robotic multi-port surgery as regards feasibility and safety, with faster operative and postoperative durations, reduced pain, and a superior cosmetic outcome. Conclusions: The single-port robotic technique is gaining popularity. Our findings provide preliminary evidence of the global experience of surgical teams. Standardizing operative durations and conducting comparative research on the R-LESS learning curve represent one of the most significant future difficulties, as do surgical outcomes, costs, and patient satisfaction in the long run.

Feasibility of two robotic single-site surgery techniques for adolescent endometriosis: Focal versus butterfly.

This study examined the feasibility of robotic laparoendoscopic single-site surgery (LESS) for the treatment of adolescent endometriosis (n=36). Additionally, we assessed a novel technique known as butterfly resection for severe cases. This was a retrospective study of women from 12 to 21 years old who received therapeutic robotic LESS for symptomatic endometriosis by a single experienced surgeon. There were 32 cases of peritoneal and four cases of deep infiltrating endometriosis (DIE). Focal resection was performed in 9/32 peritoneal and all DIE cases; butterfly resection was performed in the remaining 23/32 peritoneal. At 3 months, 16/23 had complete resolution of pelvic pain in the butterfly group versus 10/13 in the focal group (P=0.64). Robotic LESS produces safe outcomes with low complication rates. Butterfly resection may be considered for extensive lesions, with similar levels of pain relief compared to traditional focal resection techniques. Single-site robotic surgery produces safe outcomes with low complication rates in adolescents with endometriosis, with techniques customized based on disease severity.

Robotic LESS and Reduced-Port Hysterectomy Using the da Vinci SP Surgical System: A Single-Institution Case Series

Study ObjectiveTo present a series of robotic laparoendoscopic single-site surgery (LESS) and reduced-port hysterectomy cases and discuss the surgical technique required for successful use on this new platform.DesignRetrospective case series.SettingAcademic medical center.PatientsAll patients undergoing robotic LESS or reduced-port hysterectomy with the SP1098 da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA) from December 2019 to March 2020.InterventionsRobotic LESS or reduced-port hysterectomy.Measurements and Main ResultsA total of 8 cases of hysterectomy were performed successfully. Four cases included concomitant resection of endometriosis. Five cases required placement of an additional port. The average uterine weight was 136.1 g ± 61.5 g (range 87–246). The average estimated blood loss was 37.5 mL ± 27 mL (range 20–100). The average operative time was 86.5 minutes ± 27.1 minutes (range 60–132). The time required for vaginal cuff closure was available for patients 5 to 8, and ranged from 10 minutes to 13 minutes. All patients had same-day discharge. There were no conversions to alternative surgical modality, complications, or readmissions.ConclusionOur preliminary experience with the SP1098 da Vinci SP Surgical System demonstrated the technical feasibility and safety of this surgical modality for gynecologic surgery. Additional studies examining postoperative outcomes and prospective studies comparing this modality with traditional robotic surgery are indicated.

Robotic laparoendoscopic single-site surgery for concurrent hysterectomy and cholecystectomy

With the quality ergonomics and rapid learning curve of the robotic surgery system taken into consideration, robotic laparoendoscopic single-site surgery (R-LESS) appears to be the best integration for maximizing the benefits of single-site surgery. However, there are drawbacks of robot-assisted procedures which include longer operative time and higher cost, because of this, we hypothesized that the burden of robotic surgery would be reduced if two surgeries could be completed within one session in R-LESS. Three cases of R-LESS were performed for combined hysterectomy and cholecystectomy in patients with concomitant benign uterine disease and cholecystopathy. The combined surgeries were successfully conducted without additional port insertion or conversion and included the benefits of decreased hospital stay, anesthesia risk, and cost compared with the sum of two separate surgeries. Therefore, in cases in which concomitant pathologies are detected in the abdominopelvic cavity, R-LESS can be an option for selected patients with the benefit of minimally invasive surgery.

Robotic natural orifice transluminal endoscopic surgery (NOTES) hysterectomy as a scarless and gasless surgery.

To report a new surgical technique for hysterectomy using robotic natural orifice transluminal endoscopic surgery (NOTES) as a scarless and gasless procedure. Thirteen consecutive patients with benign uterine disease underwent robotic NOTES hysterectomy at Eulji University Hospital between February 2017 and May 2018. Due to the presence of pelvic adhesions, one of these patients underwent hybrid robotic NOTES hysterectomy with the assistance of isobaric single port laparoscopy; however, there was no conversion to another hysterectomy type such as conventional laparoscopy, laparotomy, or traditional multiport robotic surgery. Median uterine weight was 290g (range 115-892g). Median docking and console times were 15min (range 5-25min) and 135min (range 92-215min), respectively. Mean change in hemoglobin on the first postoperative day was 0.67 ± 0.7g/dL. Median EBL was 50mL (20-450mL). Median postoperative hospital stay was 3days (3-4days). No patients experienced postoperative complications such as damage to adjacent organs, re-operation, or vaginal cuff hematoma. Our findings show that robotic NOTES hysterectomy is a feasible and safe scarless and gasless surgical technique. It is an effective, minimally invasive vaginal access alternate to NOTES-assisted vaginal hysterectomy or conventional robotic laparoendoscopic single-site surgery hysterectomy in the surgical management of benign uterine disease. Nevertheless, further prospective controlled studies are needed to determine its full clinical application.

Single-Incision Hysterectomy Outcomes With and Without Robotic Assistance

Objective:To evaluate the differences in operative time and postoperative complications for total laparoscopic hysterectomy (TLH) performed using conventional laparoendoscopic single-site surgery (LESS) versus a robotic-assisted LESS approach.Methods:A retrospective study was conducted of all cases of conventional LESS TLH (n = 47) and robotic LESS TLH (n = 129) for benign gynecologic conditions performed from November 2014 to October 2017. Patient characteristics, operative time for hysterectomy, estimated blood loss, duration of hospitalization, and short-term postoperative complications were compared using appropriate parametric and nonparametric statistical tests.Results:Conventional LESS TLH cases had a 16.36-minute longer mean operative time for hysterectomy (P < .01). No difference was found in uterine weight, estimated blood loss, hospitalization, or incidence of postoperative complications when LESS TLH was performed with or without robotic assistance. When comparing uterine weight < 100 g, conventional LESS TLH cases had significantly greater operative time than the robotic LESS TLH cases (78.10 ± 23.97 minutes vs. 59.97 ± 35.17 minutes, P < .01). When comparing uterine weight > 100 g, conventional LESS TLH cases again had significantly greater operative time than the robotic LESS TLH cases (98.73 ± 50.16 minutes vs. 80.00 ± 42.97 minutes, P < .01). There was no difference in postoperative complications.Conclusion:Robotic single-incision laparoscopy can result in decreased operative time compared to a conventional LESS approach. Robotic-assisted and conventional LESS are similar in rate of postoperative complications, if performed by surgeons with abundant LESS experience.

Recent advances in minimally invasive surgery for gynecologic indications.

Recently, an increasing interest in less invasive surgery has led to the advent of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES). LESS and NOTES could be technically challenging, but available literature has demonstrated the feasibility and safety of LESS for benign gynecologic diseases. However, the evidence is not strong enough to recommend the use of LESS over that of conventional multiport laparoscopic surgery (MLS). As per the results of the most recently published meta-analysis, the majority of surgical outcomes are equivalent between LESS and MLS, except for the longer operative time in LESS for both adnexal surgery and hysterectomy. Although an increasing number of studies have reported on robotic LESS, NOTES, and LESS for gynecologic malignancy, definite conclusions have not been drawn owing to the lack of sufficient information.

Feasibility of sentinel lymph node fluorescence detection during robotic laparoendoscopic single-site surgery in early endometrial cancer: a prospective case series

BackgroundIn the last few decades, the introduction of technologies such as single-site surgery, robotics, and sentinel lymph node detection has reduced invasiveness in the treatment and staging of endometrial cancer patients. The goal of the present prospective cohort study is to evaluate the feasibility of lymph node fluorescence detection with robotic single-site approach in low-risk endometrial cancer.ResultsFifteen non consecutive low-risk endometrial atypical hyperplasia (EAH) patients underwent sentinel lymph node (SLN) biopsy and total hysterectomy utilizing the Da Vinci Si Single-Site Surgical. System and Firefly 3D imaging. Indications for surgery included eight (53.3%) IA FIGO stage G1 EC, three (20%) IA FIGO stage G2 EC, and four (26.6%) EAH. Mean operative time was 155 min (range 112–175). One vaginal laceration was the only perioperative complication encountered, and all patients were discharged within 48 h of surgery.SLN was detected in 86.6% of cases; 1/29 (3.4%) SLN results were positive for isolated tumor cells (ITCs) at immunohistochemical analysis.ConclusionsThe present study demonstrates the feasibility and applicability of robotic single-site approach with SLN fluorescence detection for the staging of low-risk endometrial cancer.

Robotic Laparoendoscopic Single Site: Pyeloplasty and Nephrectomy Chapter.

Robotic laparoendoscopic single site (RLESS) for upper tract procedures is safe and feasible in the correctly selected patient. An ideal candidate is young, has a low body mass index, and is undergoing surgery for benign indications. For RLESS procedures, we utilize a GelPOINT® access platform for "single-port" placement and ports are configured in a diamond shape. Five millimeter EndoWrist® robotic instruments are placed under direct vision. Range of motion is increased by utilizing the chopstick technique. The surgeon must always be aware of the orientation of each instrument to prevent counter-springing associated with their crossing at the level of the abdominal wall. The robotic camera lens and instruments must be moved synchronously, given their coaxial orientation relative to each other. In this chapter, we describe our technique for two of the most common RLESS upper tract procedures: pyeloplasty and nephrectomy.

Gynecologic Laparo-endoscopic Single-Site Surgery: Where do we Stand and what is on the Horizon?

Objective: The objective of this article is to review the current literature on laparo-endoscopic single-site (LESS) surgery in gynecology, discuss recent developments, and what is on the horizon for LESS surgery. Design: Appraisal of articles published on the use of laparo-endoscopic single-site surgery in gynecology from 2008 to the present. PubMed, Medline, and the Cochrane Central Register of Controlled Trials were systematically searched using the terms “laparo-endoscopic single-site”, “single-site laparoscopy”, “single port laparoscopy”, “SPA”, “SILS”, “LESS”, “robotic single-site surgery”, and “R-LESS” between January 1, 2016 and February 15, 2016. Publication date restrictions were all publications 2008 and later. Non-English language was excluded. Results: LESS and R-LESS is safe, feasible, and equivalent to traditional multiport laparoscopy and robotic surgery. Cosmesis is potentially the most obvious advantage associated with LESS surgery. Instrument crowding with associated external instrument space conflicts is a major problem since all the instruments are inserted through a single point on the abdomen. For the experienced laparoscopist, the learning curve for LESS is shorter and associated with less morbidity when compared to the learning curve of multiport laparoscopy. Conclusion: LESS surgery is another option of approach to minimally invasive gynecologic surgery. There is a clear body of literature demonstrating that LESS is feasible, safe, and equivalent to traditional multiport and robotic surgery. There is growing literature regarding improved cosmesis, improved pain control, quicker recovery, and shorter hospitalizations but these studies, even when combined, are underpowered. Both traditional and robotic laparoendoscopic single site surgeries are still in the early development and diffusion. Keywords: Laparo-endoscopic single-site, single-site laparoscopy, single port laparoscopy, LESS, robotic surgery, R-LESS.

Robotic Single-Site Sacrocolpopexy with Retroperitoneal Tunneling.

Introduction:This series of cases was an investigation of the safety and feasibility of robotic laparoendoscopic single-site surgery (R-LESS) as a method of performing sacrocolpopexy.Case Presentation:This is a retrospective series of 15 cases of R-LESS sacrocolpopexy with the V-Loc (Medtronic, Minneapolis, Minnesota, USA) suture and a retroperitoneal tunneling technique performed by a single surgeon, combined with a literature review. Patient demographic information and perioperative data were analyzed. The standard robotic sacrocolpopexy steps were followed, but the surgeon used a combined technique of V-Loc suture and retroperitoneal tunneling to simplify the procedure. No additional ports were necessary in any of the patients.Management and Outcome:Using the pelvic organ prolapse quantification (POP–Q) scoring method, the mean preoperative C-point of the 15 patients was +1.16 compared to the mean immediate postoperative C-point, which was −5.5. The mean total sacrocolpopexy time was 74.7 (range, 50–99) minutes and mean mesh anchoring time was 22.60 ± 3.85 minutes. The mean sacral promontory fixation and tunneling and mesh position times were 11.87 ± 3.02 and 5.80 ± 2.14 minutes, respectively. All 15 cases were performed without perioperative or long-term complications.Discussion:R-LESS in combination with the V-Loc suture and the retroperitoneal tunneling technique can be safely and feasibly performed, especially in sacrocolpopexy and, potentially, in other POP surgeries. With adequate and systematic training, surgeons can acquire the necessary skills to perform this complex surgical procedure.

Robotic laparoendoscopic single-site benign gynecologic surgery: a single-center experience.

The da Vinci Xi surgical system was released with several upgrades and modifications compared to the previous robotic generations to facilitate minimal invasive surgery. Herein, we present our preliminary experience of robotic laparoendoscopic single-site gynecologic surgery performed for benign indications with the da Vinci Xi robotic system in a single center. Thirty-five female patients underwent robotic single-site surgery between June 2016 and January 2017. The median console time for hysterectomy with or without salpingo-oophorectomy was 41min. The median intracorporeal vaginal cuff closure time was 18min. Two cases (5.7%) were converted to robotic-assisted multiport surgery. There was one major intraoperative complication (2.9%). None of the patient required blood transfusion. When comparing our first 12 cases to subsequent 12 cases of R-LESS hysterectomy, there was a statistically significant decrease in surgical times and estimated blood loss. On logistic regression analysis, no association was detected between BMI and port entry time (OR 0.93, 95% CI 0.83-1.04, p=0.23), console time (OR 0.98, 95% CI 0.94-1.02, p=0.37), cuff closure time (OR 0.9, 95% CI 0.76-1.09, p=0.33), operative time (OR 1, 95% CI 0.98-1.01, p=0.97), and estimated blood loss (OR 0.98, 95% CI 0.96-1.01, p=0.33). Our preliminary experience with robotic laparoendoscopic single-site surgery using the da Vinci Xi system has demonstrated feasibility and safety in select patients. Further studies with greater number of patients in multiple settings will help us to fully elucidate the role of da Vinci Xi surgical system in single-site gynecologic surgery.

Development of a novel robotic platform with controllable stiffness manipulation arms for laparoendoscopic single-site surgery (LESS).

For current LESS robotic systems, the trade-off between dexterity and payload capability is always present. This paper presents a novel LESS robotic platform equipped with controllable stiffness manipulation arms. Each manipulation arm with an articulated section and a controllable stiffness continuum section (CSCS) can be switched between a 7-DoF compliant status and 5-DoF rigid status according to the operation requirement. Screw theory and product exponential formula are used to quantify the kinematic performance. The stiffness of the manipulation arm promotes 3.03 to 4.12 times from compliant to rigid CSCS with maximum payload of 10N in rigid status. The shortest rigid/compliant switching time is 5s. The precision of a tracking test and an ex vivo procedure verified the accuracy and effectiveness of the controllable stiffness manipulation arms. This robot could potentially improve the surgical performance and further expand robotic LESS procedures.

Comparing Single-Site and Multiport Robotic Hysterectomy with Sentinel Lymph Node Mapping for Endometrial Cancer: Surgical Outcomes and Cost Analysis

Study ObjectiveTo compare operative times, surgical outcomes, and costs of robotic laparoendoscopic single-site (R-LESS) vs multiport robotic (MPR) total laparoscopic hysterectomy (TLH) with sentinel lymph node (SLN) mapping for low-risk endometrial cancer. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingAcademic university hospital. PatientsPatients with a biopsy-proven diagnosis of complex atypical hyperplasia (CAH) or low-grade (1 or 2) endometrial cancer with body mass index <30 kg/m2 and undergoing robotic TLH and SLN mapping between 2012 and 2016 were included. InterventionsSurgical outcomes and cost data were collected retrospectively and analyzed based on the surgical approach with R-LESS vs MPR assistance. Measurements and Main ResultsTwenty-seven patients who met the inclusion criteria were identified, including 14 patients who underwent R-LESS TLH with SLN mapping and 13 patients who underwent MPR TLH with SLN mapping. Median uterine weight was comparable in the 2 cohorts (111.3 g vs 83.8 g; p = .33). Operative and console times were equivalent with the R-LESS and MPR approaches (median, 175 minutes vs 184 minutes, p = .61 and 136 vs 140 minutes, p = .12, respectively). Median estimated blood loss was 50 mL in both cohorts. Successful bilateral SLN mapping occurred in 85.7% of the R-LESS procedures and 76.9% of MPR procedures. No intraoperative or 30-day complications were encountered, and all patients were discharged within 23 hours of surgery. MPR was associated with additional disposable instrument and drape costs of $460 to $660 compared with R-LESS, depending on the surgeon's instrument selection. Average total hospital charges were lower for R-LESS procedures ($13,410 vs $15,952; p < .05). ConclusionIn highly selected patients with CAH or low-grade endometrial cancer undergoing TLH and SLN mapping, R-LESS appears to result in equivalent perioperative outcomes as a MPR approach while offering a more cost-effective option. Further research is needed to determine the benefits of R-LESS procedures in the gynecologic oncology setting.

A comparison of robotic laparoendoscopic single site vs robotic multiport hysterectomy and sentinel lymph node mapping for low grade endometrial cancer: Surgical outcomes and cost analysis

A comparison of robotic laparoendoscopic single site vs robotic multiport hysterectomy and sentinel lymph node mapping for low grade endometrial cancer: Surgical outcomes and cost analysis

Incisional hernia after robotic single-site cholecystectomy: a pilot study

Robotic LaparoEndoscopic Single-Site Surgery Cholecystectomy has been performed for 5years using a dedicated platform (da Vinci® Single-Site®) with the da Vinci® Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). While short-term feasibility has been described, long-term assessment of this method is currently outstanding. The aim of this study was to assess long-term parietal complications of this technique. In this retrospective study, patients operated between 2011 and 2013 were evaluated. Parietal incision was assessed with ultrasonography and patients screened for residual pain from scar tissue. Demographic and perioperative data were also collected. We evaluated 48 patients [38 female, 79.2%; median age 49years (range: 24-81years)]; mean BMI 25.9kg/m2 [±SD 4.1kg/m2]. After a median follow-up of 39months (range: 25-46months), six incisional hernias (two patients had a positive echography but a negative clinical examination) were found (12.5%, 95% CI 7.5-30.2), and two patients had a surgical repair. The overall rate of incisional hernia was 16.7% (95% CI 7.5-30.2). Residual pain was observed in 5 of 48 patients. This preliminary study suggests that a clinically significant rate of incisional hernias can occur after R-LESS-C. Larger studies comparing R-LESS-C to alternative methods with long-term follow-up are necessary.

Current status of robotic single-port surgery.

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Feasibility and Learning Curve of Robotic Laparoendoscopic Single-Site Surgery in Gynecology

Single-site laparoscopy has proven to be a desirable option for patients undergoing gynecologic surgery, with some studies indicating improved cosmesis and less perioperative pain compared with standard approaches. This study describes the safety and feasibility of a novel robotic laparoendoscopic single-site surgery (R-LESS) platform as it is incorporated into a surgeon's practice with extensive multiport robotic surgical experience but limited LESS experience. We reviewed 83 women undergoing R-LESS by a single surgeon from September 2013 through August 2015. Operative times (total operative time, console time, docking time) were collected prospectively for the first 53 cases, and total operative time was collected retrospectively for the next 30 cases. Clinical parameters, including age, estimated blood loss, body mass index (BMI), prior abdominal surgeries, conversion to laparotomy, procedure type, uterine weight, length of hospital stay, and complications, were retrospectively collected from medical charts. Eighty-two of 83 surgeries were completed successfully with a single incision. One surgery was converted to multiport robotics for para-aortic lymph node dissection. Twelve surgeries were performed for cancer (ovary 1, uterus 8, and cervix 3). Eight patients underwent pelvic lymph node biopsy. The median total operative time for hysterectomies was 128 minutes (range, 60–275). After the first 13 hysterectomies the total operative time and the console time decreased significantly from 165.3 to 131.1 minutes (p = .032) and from 84.9 to 57.1 minutes (p = .028), respectively. Mean docking time halved from 7.8 minutes to 3.4 minutes comparing the first 10 cases to the last 10 cases. Surgical times were longer with larger BMIs, but the console time decreased with experience regardless of BMI. The mean uterine weight was 164 g (range, 30–460). Complications included 2 umbilical hernias (2.4%) and 1 conversion to multiport. In conclusion, R-LESS is a feasible and safe surgical platform for gynecologic procedures. A small number of cases are needed to significantly improve operative times when it is introduced on a surgeon's practice with limited experience in LESS but familiar with robotic surgery. Further study is needed to investigate the cost, benefits, and long-term outcomes of R-LESS.

Feasibility of Robotic-Assisted Laparoendoscopic Single-Site Surgery in the Gynecologic Oncology Setting

Study ObjectiveTo assess the feasibility of incorporating robotic laparoendoscopic single-site (R-LESS) surgery into gynecologic oncology care. DesignRetrospective study (Canadian Task Force classification II-3). SettingAcademic university hospital. PatientsPatients undergoing R-LESS hysterectomy for gynecologic malignancies, preinvasive disease, or risk reduction performed by a single gynecologic oncologist between 2014 and 2016. InterventionsWe incorporated R-LESS as part of standard surgical management for highly selected patients undergoing hysterectomy for common gynecologic oncology indications. Measurements and Main ResultsWe identified 30 patients undergoing R-LESS hysterectomy meeting study criteria over a 2-year period. Indications for surgery included uterine cancer (n = 13), preinvasive cervical or uterine disease (n = 9), cervical cancer (n = 3), and hereditary gynecologic cancer risk (n = 5). Median patient age was 52 years (range, 35–77), and body mass index was 26 kg/m2 (range, 19–34). Median uterine size was 8 cm (range, 5.5–11). Eighteen patients had prior abdominal surgery (60%). Twenty-seven patients underwent R-LESS extrafascial hysterectomy, 11 of whom underwent only robotic-assisted total laparoscopic hysterectomy ± bilateral salpingo-oophorectomy with a median operative time of 140 minutes (range, 115–179). Procedures performed concurrently for the remainder included pelvic sentinel lymph node mapping (n = 14) and pelvic lymphadenectomy (n = 2), with respective median operative times of 175 (range, 150–230) and 233 minutes. One patient with endometrial cancer was converted to multiport robotic surgery to complete a pelvic and para-aortic lymphadenectomy due to high-risk disease on frozen section. Three patients underwent R-LESS radical hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node mapping, and pelvic lymphadenectomy with a median operative time of 412 minutes (range, 336–451). No perioperative complications were encountered, and all patients were discharged within 24 hours of surgery. ConclusionIn highly selected patients, R-LESS extrafascial and radical hysterectomy is associated with acceptable operative times and perioperative outcomes. With additional experience, surgeons may offer this approach to patients undergoing increasingly complex procedures, even in the gynecologic oncology setting.