Robotic single-port surgery

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. In the gynecological field, minimally invasive surgery is becoming increasingly popular due to its short hospitalization period, rapid recovery, and cosmetic benefits [1,2]. With the U.S. Food and Drug Administration approval of the da Vinci® Surgical System (Intuitive Surgical Inc., Synnyvale, CA, USA), robotic surgery (RS) has become widespread to overcome the shortcomings of laparoscopic surgery, such as collisions and clashing of instruments and limited range of motion [3]. Introduction of RS has numerous benefits, including less postoperative pain, the reduced blood loss during surgery, and shorter hospital stay. In 2013, a single-site platform of da Vinci Si Surgical System was introduced for performance of gynecologic procedures through a single umbilical incision similar to laparoendoscopic single-site surgery. Robotic single-site surgery (RSSS) maintains the advantages of the RS that were already mentioned above, but in addition, the patient's cosmetic satisfaction for a single site scar on the umbilicus remains high and the complications related to accessory port sites can be avoided [4]. Although the feasibility and safety of RSS surgery using the da Vinci Si or Xi Surgical System have been investigated in hysterectomy or myomectomy, there are still limitations due to semi-rigid and non-articulating instruments with lack of triangulation in those systems [5-7]. In order to perform more robotic single-site surgeries successfully, we must develop good surgical skills and better suturing techniques with the current set of limited instruments [7-9]. Therefore, the da Vinci SP Surgical System was recently introduced in 2018 to overcome the limitations of RSSS using the da Vinci Si or Xi Surgical System. The new da Vinci SP System enabled sufficient articulation with fully wristed, double-jointed instruments, and included a flexible three-dimensional camera. The surgeons were able to perform meticulous sutures comfortably with all three instruments of the da Vinci SP Surgical System even through a single umbilical incision [10]. Preliminary data were reported that robotic singleport surgery (RSPS) using the da Vinci SP Surgical System might be an alternative surgical technique for various benign gynecologic diseases. Especially, robotic single-port myomectomy (RSPM) using the da Vinci SP Surgical System is a feasible surgical modality for women with symptomatic myoma and is expected to increase indications of single port myomectomy with following advantages (in submission). Single-port instruments have sufficient mechanical power to hold and suture thicker tissues than previous Single-site instruments. The utilization of three instruments separately from the camera is possible. Therefore, Robotic single-port surgery