Master Class

da Vinci Single-Site, the virtually scarless intra-abdominal hysterectomy


Cannulas for the Single-Site Port come in two lengths: There is a set of short, 250-mm cannulas and a set of long, 300-mm cannulas. When to use these cannulas depends on the working area and the patient’s size. Generally, the shorter cannulas are used for everything but the cuff closure. Then arm 2 is replaced with the longer cannula for the extra rigidity needed to suture. My use of the different cannula lengths has varied depending on the patient’s body size, and with growing experience I have sometimes gone without exchanging them.

Dissection through cuff closure

Courtesy Dr. Dwight Im

Single-Site cannula setup with system docked to patient.

I start all my cases on the right side, holding the infundibulopelvic (IP) or utero-ovarian ligament on tension and skeletonizing it. I then coagulate the IP ligament with the fenestrated bipolar grasper (setting: 35 watts).

At this point and throughout the surgery, consistent use of the "cut" mode on the da Vinci console makes both dissection and sealing cleaner and more precise, with significantly less charring.

I use AirSeal for insufflation and automatic smoke evacuation.

Courtesy Dr. Dwight Im

Side docking approach showing assistant access for uterine manipulation.

As I do with all minimally invasive hysterectomies, regardless of modality, I work to find and develop the pararectal space. This space is bordered by the ureter medially, the hypogastric or internal iliac artery laterally, and the base of the cardinal ligament anteriorly, with the levator ani muscle as the floor. Defining and developing the space enable me to visualize the ureter so that I can dissect it off the peritoneum and drop it out of harm’s way. It puts me in a much better position, moreover, to handle dissection in more complex cases involving large fibroids or endometriosis.

Once the pararectal space is developed and the ureter dissected, I proceed with transection of the round ligament. Dissecting the round ligament any earlier would be particularly troublesome in a Single-Site robotic hysterectomy because it would be challenging to achieve the necessary degree of uterine manipulation.

Courtesy Dr. Dwight Im

Ureter identification during right side retroperitoneal dissection.

In developing the bladder flap, one must be conscious of the highly magnified view, as the bladder appears closer with the 30-degree 8.5-mm endoscope than it would with a 0-degree scope. A combination of traction and countertraction, small bites, and selective coagulation – one vessel at a time – is critical as dissection proceeds and the bladder flap is created.

Because the pararectal space has been developed early on, the ureter can be seen throughout the dissection and there is no need to coagulate the vessels from the level of the internal os and downward, as many surgeons are traditionally taught. Vessels are coagulated right near the location of the VCare cup. It is important that all bleeding vessels are coagulated prior to colpotomy. Again, using the "cut" mode on the console during the colpotomy minimizes charring.

Courtesy Dr. Dwight Im

Horizontal cuff closure technique using Fenestrated Bipolar Grasper and Curved Needle Driver.

Vaginal cuff closure is the most technically challenging aspect of Single-Site hysterectomy. I tried numerous instruments and approaches and found a technique that works for me. The fenestrated bipolar grasper has been just as effective as the crocodile grasper, which is cost-effective because I use this instrument for dissection as well. Use of the fenestrated bipolar at this point also allows me to cauterize any small vessels that were not coagulated earlier.

I advise use of 2-0, barbed, 9-12\" absorbable suture on a 24- to 35-mm reverse-cutting needle. I recommend the 2-0 V-LOC reverse-cutting P-14 needle; this is the one that has worked for me with minimal difficulty. Because the suture is barbed, there is no need to tie.

Courtesy Dr. Dwight Im

Average time breakdown of first 55 consecutive Single-Site hysterectomy cases.

I closed the cuff vertically in my initial cases – as I do in multiport cases – but at my 13th case I began horizontal cuff closures. Effectively grasping the needle, finding the correct combination of traction and countertraction, and achieving the correct angles take time and practice. I move in a transverse direction, right to left, in every case. The anterior cuff requires angled insertion of the needle, whereas the posterior cuff requires vertical insertion of the needle. The assistant may hold the bladder peritoneum as necessary throughout the closure to expose the cuff, but should not grasp and suspend the cuff itself.

I deliver the needle transvaginally, but alternatively it may be delivered through the camera port or the 10-mm assistant port. The tip of the needle should not be grasped in any circumstance, or it will be dulled.

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