When the Food and Drug Administration cleared the da Vinci Single-Site Technology for use in benign hysterectomy and salpingo-oophorectomy in February 2013, I wondered how these procedures could possibly be performed with instruments that lack articulating wrists. I came to realize that with a stepwise approach to initiating this virtually scarless surgery, an appreciation of its nuances, and repetition of best practices found in my learning curve, Single-Site hysterectomy is indeed achievable and reproducible.
Single-Site tools are flexible and semirigid, allowing them to fit through the port’s curved cannulas. The port accommodates insufflation tubing, an 8.5-mm endoscope, two 5-mm operating instruments, and an assistant instrument. A 30-degree endoscope, facing downward to view the operating instruments underneath, is essential for achieving necessary triangulation.
I perform dissection with the fenestrated bipolar grasper in arm 1 and the monopolar cautery hook in arm 2. For vaginal cuff closure, I keep the fenestrated bipolar in arm 1 and place a needle holder in arm 2.
The fenestrated bipolar grasper for Single-Site became available only recently. Until then I utilized the Maryland bipolar forceps for dissection and tried various instruments, including the crocodile grasper, for vaginal cuff closure. Use of the fenestrated bipolar has been a game-changer for vessel sealing and has worked beautifully for cuff closure as well.
Single-port robotic hysterectomy requires deliberate transition. One must be comfortable first with minimal or no bedside assistance during multiport robotic surgery. The surgeon should take a stepwise approach to minimizing assistance – moving, for instance, from the use of five ports, to four ports, to four ports with no bedside assistance, to three ports, and lastly a "single-plus one" approach in which an extra port is placed as a precaution. I used a "single-plus one" approach for my first 10 cases before moving to a pure Single-Site approach.
I also began with two cases of bilateral salpingo-oophorectomy before performing Single-Site hysterectomy, and advise others to start with such easier cases as well. Patients selected for initial Single-Site surgery also should be younger than 70, with few comorbidities and a good performance status (American Society of Anesthesiologists classification I-II). They should have BMI less than 30, a history of little or no previous intra-abdominal or pelvic surgery, and a reasonably sized uterus (less than 12 weeks), and be candidates for vaginal or laparoscopic hysterectomy.
The Single-Site approach requires meticulous dissection, one side at a time. The surgeon must skeletonize vessels before coagulation, and must coagulate each vessel individually. Selective coagulation/sealing of vessels is key, as the surgeon does not have the luxury of using a harmonic scalpel, vessel sealer, or other such tools. Too much bleeding can make a case difficult, if not impossible, to complete without conversion. Similarly, because assistance is limited, coagulation must be done in a cephalad direction in order to minimize back-bleeding.
Uterine manipulation is always an important task, but it is especially important for the Single-Site hysterectomy. It is the assistant’s main role. He or she must know not only how to turn the uterus for vessel coagulation and visualization of anatomy, but also the nuances of traction and countertraction for dissection and the colpotomy. Various uterine manipulators will work; I prefer the VCare uterine manipulator.
Setup and entry
While steep Trendelenburg positioning is used for multiport hysterectomy, it must be lessened for the single-port approach. Trendelenburg changes the distance of the cannulae to the uterus, so individual adjustments are necessary. I start the patient in steep Trendelenburg, then lessen it just enough to displace the small bowel while maintaining an appropriate distance for the instruments to reach the uterus.
Center docking provides greater range of motion and is therefore often preferred, especially during early cases. However, side docking on the dominant-hand side, with the camera arm toward the uterus, is my preferred method. It provides the assistant maximal access to the vaginal area and best affords the surgeon the ability to add another port if it is necessary later.
Entry and port placement are critical aspects of the Single-Site approach. The Single-Site Port requires a skin incision of 2.5 cm. I make this incision transversely, following the natural creases of the umbilicus. To get to the fascia, the umbilical stalk is transected, and a small hole – a hernia defect, in essence – is identified and lifted. A 3-cm vertical fascial incision is made to accommodate the Single-Site Port. It is important that this incision size is exact: If it is too short, the port will not expand to its natural state and there will be crowding of instruments, and if it is too large, leaking air will be a problem. I have found that placing stay sutures on the fascia at this point helps facilitate later closure.