Robotics May Overcome Technical Limitations of Single-Trocar Surgery An Experimental Prospective Study of Nissen Fundoplication

Objective: To compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeon's hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments. Design: Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. Setting: A research institute. Participants: Three surgeons with different experience. Main Outcome Measures: Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. Results: All of the procedures were successfully completed. Mean operative time (45.6 +/- 11.2 vs 65.4 +/- 10.7 minutes; P=.03) and number of conflicts (1.0 +/- 0.9 vs 3.8 +/- 1.2; P<.001) were significantly reduced in the robotic series. Conclusions: Use of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.