Clinical status and future prospects of single-incision robotic-assisted surgery: a review.

After the introduction of MIS in various surgical specialties, surgeons’ pursing for invasiveness minimization of surgical interventions has never been impeded. Combining robotic technology with single-incision endoscopic surgery, the novel SIRAS approach provides a new solution to the awkward dilemma of balancing invasiveness and surgical benefits. Associated with better cosmesis, minimal postoperative pain, faster recovery and declined port-related complications, SIRAS is being explored and validated for feasibility, safety, and surgical oncology by randomized controlled trials in several operations of urology and gallbladder surgery. Provided by robotic surgical platform, magnified vision, ergonomics enhancement, instrument dexterity and stability, surgical precision, as well as convenient relocation, counteract the technical obstacles of SILS, such as instrument collision, triangulation loss, poor exposure, and retraction, multisite dissection of technological demanding operations. However, there are still several difficulties we might encounter when performing SIRAS in practice. First, in the narrow pelvis during SIRAS anterior resection, the conventional trans or peri-umbilical single-incision does not provide an ideal angulation for intracorporeal stapler dissection that usually required an extra trocar in inferior abdomen. Although there was a small-scale study reported their initial attempts in pure SIRAS natural orifice transluminal endoscopic surgery transanal TME, extensive and long-term explorations are still demanded. The issue is also a public concern in the fields of SIRAS total colectomy, SIRAS pancreatic surgery and the further application of SIRAS in stomach surgery. Second, the learning curve of SIRAS in technical demanding surgery has not been determined. This novel approach was reported to be easily handled in skilled surgeons and there was no significant difference found in the uptake of SIRAS between the inexperienced and experienced in relatively simpler operations, such as cholecystectomy and inguinal hernia repair. However, evidence is too scarce to form a robust conclusion under the circumstance that most of the current studies remain to be small-scale case reports for feasibility and safety examination. In addition, for complex surgeries, systematic and generalized training programs, standardized guidelines, refined protocols, and customized instruments for each specialty are expected to be improved. Third, the cost effect of SIRAS cannot be omitted. The investment of purchasing the latest robotic surgical platform compatible with SIRAS, such as Da Vinci Single-Site or SP, was no easy decision for medical institutions of any level, as it could cost millions of dollars along with all the axcessory and annual maintenance fee, just for starters 33 . This considerably hindered the availability and widespread adoption of SIRAS. Other than that, even in ‘robot-existing’ model, the cost benefit of SIRAS varied in different types of surgery 170 . The discordance is probably related to the balance of operative time and hospital stay, among a large number of other possible variables. Therefore, further investigations about this aspect is needed to allow an exact estimate on this issue. Finally, surgeons are never satisfied with current surgical plans and are always striving perfection in the ongoing loop of technological innovation and application. Further modification and adaption of the Da Vinci robotic system should be investigated to both alleviate workload and bend the steep learning curve for inexperienced surgeons in commonly adopted surgeries and facilitate better performance for technically challenging procedures. In terms of long-term follow-up of patients who underwent SIRAS, current literature exhibits a scarcity of outcomes from large-volume prospective study and well-designed randomized controlled trial and cannot finalize the controversies and concerns accompanied with the debut of novel surgical approach. To protect the rights of participants, oncologic safety and postoperative quality of life should not be sacrificed at any situation, which are the priority in carrying out clinical research of SIRAS. Other aspects that affect the choice of SIRAS for surgeons and patients should be given more attention, such as the general cost for SIRAS and its economic effect possibly causing bias in patient enrollment, and discussion for appropriate indications and contraindications of SIRAS to reduce the misuse of this novel approach.

The data that support the study findings are available upon reasonable request from the corresponding authors (Ren Zhao, Xiaopin Ji, Xi Cheng, and Kun Liu).

Highlights The comprehensive literature review of single-incision robotic-assisted surgery (SIRAS) in the field of general surgery and abdominal surgery is lacking. And the combination of robotic technology and single-incision laparoscopic surgery is an upsurging trend in surgical exploration. This study reported the evolutionary process and developmental trends of robotic surgical platforms and customized instruments in a single-incision approach, and initially summarized the current clinical status of SIRAS in the field of general surgery and abdominal surgery. This study provided a readily comprehensible approach and an accessible presentation for elementary implantation in a novel and thriving area of surgical innovation. The SIRAS is a promising developing trend and will play an important role in the advancement of surgical technology in general surgery and abdominal surgery. Ever since the first advocation of conventional multiport laparoscopic surgery in 1980s, surgeons have always been pursuing preferable perioperative outcomes without concession on oncological safety and surgical purpose. With superior cosmesis, less postoperative pain and faster recovery, laparoscopic surgery rapidly spread out through various specialties. In addition to the advantages of declined analgesic requirements and shorter length of stay, conventional multiport laparoscopic surgery superseded traditional open surgery as the gold standard of treatment of surgical diseases soon after the validation of better perioperative outcomes and noninferior surgical outcomes supported by several multicenter randomized controlled trials 1 – 8 . However, the pursuit for less invasiveness continues to inspire surgeons to further explore the path of minimally invasive surgery (MIS), which leads to the inception of natural orifice transluminal endoscopic surgery 9 , 10 and single-incision laparoscopic surgery (SILS) 11 , 12 . By operating through only one major incision, SILS is considered a feasible alternative with even less pain, avoidance of multi-incision complications, cosmetic satisfaction, and comparable surgical outcomes 13 , 14 . However, concerns and controversies of SILS cause considerable attentions in terms of the steep learning curve and noticeable technological barriers, such as confined surgical fields, collision of laparoscopic instruments, loss of surgical triangulation, limited exposure and retraction, and stringent indications and exclusion criteria 15 – 17 . Another flying leap of the surgical breakthrough was made by technological innovation. The invention of cutting-edge devices, such as industrialized ports, bent instruments, customized staplers, grasper forceps, energy devices, and vessel sealing devices, plays a crucial role in the widespread application of laparoscopic surgery. In addition, after first introduced in the late 1990s, robotic surgical platforms gradually led another revolution in surgery and brought the superiority of laparoscopic surgery into full play, with unique advantages of three-dimensional (3D) vision, reduction of tremor transmission, and instrument maneuverability and stability 18 , especially in a narrow surgical field requiring delicate dissection. To overcome the recognized drawbacks of SILS, a novel integration of robotic technology and SILS, referred to as single-incision robotic-assisted surgery (SIRAS), has struck a considerable upsurge in public attention with its significant ergonomic improvement and simplified technological challenges (Fig. 1 ). The emerging trend in literature reviews of single-incision robotic-assisted surgery (SIRAS). In this review, we aim to discuss the early experience and evolution, research status, and prospects of SIRAS. We conducted a literature search using four English databases (PubMed, the Cochrane Library, Embase, and Web of Science) for relevant articles from 2005 to 2023. The search terms ‘single incision’, ‘single port’, ‘single site’, ‘single access’, and Medical Subject Heading (MeSH) terms ‘robotic surgical procedure’, were used in various combinations. After screening the abstract of the selected literature, and duplicates removed, a thorough full-text examination was carried out independently (Supplemental Fig. 1, Supplemental Digital Content 1, http://links.lww.com/JS9/B362 ).

X.C.: data curation, formal analysis, methodology, visualization, writing-original draft, writing-review and editing, funding acquisition. C.H.: data curation, formal analysis, methodology, visualization, writing-original draft. W.J. and Z.G.: data curation, formal analysis, methodology, visualization, writing-original draft, writing-review and editing. Y.S., Z.S., and H.H.: data curation, formal analysis, methodology. S.X. and H.L.: data curation, formal analysis, visualization. S.W. and Y.Z.: data curation, methodology, visualization. T.Z.: conceptualization, data curation, methodology, supervision, writing-review and editing, funding acquisition. K.L.: writing-review and editing, visualization, data curation, supervision, methodology, funding acquisition. X.J.: conceptualization, supervision, methodology. R.Z.: conceptualization, formal analysis, funding acquisition, methodology, supervision, writing-review and editing.

The study procedures were approved by the ethics committee of Shanghai Ruijin Hospital affiliated with Shanghai Jiao Tong University School of Medicine.

None.

This study was supported by the Shanghai Hospital Development Center, SHDC2020CR1026B (R.Z.); Shanghai Hospital Development Center, SHDC12022115 (R.Z); National Natural Science Foundation of China, 82271766 (R.Z.); National Natural Science Foundation of China, 82002475 (X.C.); Shanghai Sailing Program, 20YF1427700 (X.C.); Shanghai “Rising Stars of Medical Talents” Youth Development Program, Youth Medical Talents - Specialist Program (X.C.); National Natural Science Foundation of China, 82202839 (T.Z.); National Natural Science Foundation of China, 82003169 (H.R.F.).

Name of the registry: Not applicable. Unique Identifying number or registration ID: Not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable. Name of the registry: Not applicable. Unique Identifying number or registration ID: Not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): Not applicable.

Ren Zhao, Xiaopin Ji, Xi Cheng, and Kun Liu.

In conclusion, SIRAS proves to be safe and feasible with remarkable advantages in noninferior clinical outcomes and better cosmetic effect in the limited range of surgery among the strictly selected patients, providing surgeons with more instinctive surgical experiences. In the promising future, SIRAS has the potential to become the dominant surgical option for MIS after the verifications from a wide range of large randomized controlled trials and high level evidence.

The authors declare no conflict of interest.