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+++++++++++++++++++++++++++++++++++++++ +++ +++ +++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: TECHNOLOGY+ + Single Site Robotic Cholecystectomy By Adrian Dan, MD S INCE THE FIRST cholecystec- tomy was performed in 1882, the technique remained nearly unchanged for over a century. In 1985, the advent of laparoscopic cholecystectomy ignited an avalanche of innovations that resulted in the minimally invasive revolution of the last 20 years. Advances in surgical technologies, instrumentation and training have led to refinements, improving upon the already excellent cosmetic outcomes of laparoscopic cholecystectomy. The past few years have brought about the introduction of single incision laparoscopic surgery (SILS), offering patients all the benefits of minimally invasive surgery with the added cosmetic advantage of no visible scars. This procedure, however, had several drawbacks. The cumbersome instrument proximity and crowding of the rigid instruments traveling at the same angle impeded surgical dexterity. In addition the ergonomic challenges posed to the surgeon and challenges to visualization were associated with surgeon fatigue and compromised dis- section. These problematic aspects have left surgeons seeking ways to overcome the shortcomings of the SILS approach. Robotic surgery, which has been com- monly used for gynecology and urology procedures over the past decade, has recently had a growing role in the realm of general surgery. This technology offers solutions to the challenges associ- ated with traditional single incision operations. The da Vinci Single site robotic surgery platform offers distinct advantages for patients undergoing cholecystectomy for biliary disease such as symptomatic cholelithiasis, cholecystitis and biliary dyskinesia. Patients enjoy all of the benefits of minimally invasive surgery such as less postoperative pain, a faster recovery, less need for pain medication and a faster return to work and livelihood. In addition, their operation is performed in a safe manner with no visible scars. The incision is placed within the umbilicus providing a virtually scar-free cosmetic result. This incision, typically just under 2 centimeters long, houses a soft port which holds the robotic camera and flexible working instruments. Patients resume a regular diet and are discharged home on the day of surgery. From the surgeon's standpoint, the utilization of the robot adds increased ergonomic comfort and decreases surgeon fatigue for single site operation when compared with the laparoscopic approach. The dexterity of dissection is improved as the curved instruments do not interfere with each other or with the robotic camera. The true three-dimensional optics of the system allows unparalleled visualization of the anatomic features and the surgical field. These advantages facilitate the comple- tion of the operation in a safe, effective manner and yield a cosmetic outcome which enhances patient satisfaction. While the single site platform is cur- rently approved for cholecystectomy, it will certainly play a growing role in other general surgical abdominal procedures already being performed robotically. These include robotic adrenalectomy, robotic Heller myotomy, vertical sleeve gastrectomy and robotic low anterior colon resection amongst others. Future platforms will be integrated within one much smaller-diameter component containing the camera port as well as the dissection instruments. The advantages conferred by the single site robotic tech- nology are likely to be further refined and render this advance as the first step in the development of techniques which represent the future of minimally invasive general abdominal surgery. Dr. Adrian Dan is the associate medi- cal director of Summa Health System's Bariatric Care Center and the associate director of Summa's advanced laparoscopy and bariatric surgery fellowship program. He also is an assistant professor of surgery at Northeastern Ohio Medical University (NEOMED). ■ SEPTEMBER-OCTOBER 2012 ■ MDNEWS.COM ■ MD NEWS Cleveland-Akron-Canton | 17