Initial Experience and Surgical Setup of Robot-Assisted Nephroureterectomy Using the Hugo Robot-Assisted Surgery System.

Introduction and Hypothesis: Robot-assisted radical nephroureterectomy (RANU) has emerged as a valid alternative to open or laparoscopic nephroureterectomy in recent years. However, different types of robotic platforms can limit surgical maneuvers in various ways. This study aimed to describe the surgical procedure and demonstrate RANU's technical feasibility and safety using the Hugo robot-assisted surgery (RAS) system. Materials and Methods: Using the Hugo RAS system, we reported data from the first five consecutive patients who underwent RANU at Tottori University Hospital. We adjusted the docking angles of the four independent arm carts in each case and performed a complete RANU via a transperitoneal approach. We collected patients' sociodemographic and perioperative data, including complications, and compared them retrospectively with data obtained using the da Vinci surgical system. Results: Arms positions were modified after the first patient to be placed all at the back of the patient. Median overall operative time was 283 minutes (203-377) and the median time using the robotic system was 187 minutes (121-277). The median estimated blood loss was 20 mL (5-155). None of the patients required a blood transfusion and none suffered postoperative complications of Clavien-Dindo grade ≥3. These outcomes were similar to those obtained with the da Vinci Xi system. Conclusion: This series represents the first report of RANU executed using the novel Hugo RAS system. Our proposed arm-setup will assist other surgeons and help ensure safe implementation of RANU on the Hugo platform.

Incidence of port site complications in relation to timing of bevacizumab infusion.

INTRODUCTION: Bevacizumab is a monoclonal antibody that targets vascular endothelial growth factor, with a serious complication of wound healing complications. The package insert currently does not have recommendations on the management of bevacizumab administration around minor procedures, including port placements. Currently, there are only two trials that have examined the optimal timing of bevacizumab after port placement. METHODS: This is a single-center retrospective trial aiming to evaluate the rate of wound dehiscence and other port site complications depending on the time between port placement and bevacizumab infusion. Eligible patients who have had at least one port place and have received bevacizumab for an oncologic indication were identified in a study period of 1/1/2016-3/31/2021. The primary outcome of this study was the incidence of wound dehiscence in relation to the timing of bevacizumab infusion. RESULTS: A total of 243 patients met the inclusion criteria, and 116 port placements had a port site complication. For wound dehiscence, 6% was observed 0 days from port placement, 10% was observed 1 day from port placement, 0% was observed 2 days from port placement, 0% was observed 3-7 days from port placement, 3% was observed 8-14 days from port placement, and 3% was observed 15-30 days from port placement. CONCLUSIONS: The results of this study show an inverse relationship between the risk of wound dehiscence and port site complication and the timing of bevacizumab infusion to port placement, with an increase in absolute risk of wound dehiscence when bevacizumab is given within 2 days of port placement.

The risk of pocket infection or bloodstream infection following central venous port placement for the patients with Cetuximab therapy.

OBJECTIVE: Cetuximab is a molecular targeted drug that targets epithelial growth factor receptors. The skin toxicity of cetuximab arising from epithelial growth factor inhibition is well known. Some patients with cetuximab therapy decided to make central venous port during the long-term intravenous treatments. Therefore, the author hypothesized that cetuximab administration might increase the risk of central venous port-related infection due to damage to skin barrier function. The main aim of the present study was to investigate the relationship between cetuximab administration and central venous port-related infection. METHODS: A total of 83 patients had a central venous port placed from 2016 through 2021. We analyzed, retrospectively, the relationship between cetuximab therapy and the incidence of central venous port-related infection involving central line-associated bloodstream infection and pocket infection. Additionally, the risk factors of central venous port-related infection were examined in the population undergoing cetuximab therapy. RESULTS: In total populations (83 cases), central line-associated bloodstream infection happened in five patients (6%) and pocket infection happened in six patients (7%) after central venous port placement. In the cetuximab therapy group (45 cases), there were four patients with central line-associated bloodstream infection (9%) and six with pocket infection (13%). The pocket infection happened more frequently in the cetuximab group than the other group with significant differences. Additionally, in the cetuximab group, the patients who had an interval of less than seven days between central venous port placement and cetuximab dosing, or central venous port placement preceded by cetuximab dosing had more pocket infection with significant differences. CONCLUSION: Skin complications after the central venous port placement were related to cetuximab administration and the timing of cetuximab therapy.

Initial perioperative outcomes of robot-assisted thoracoscopic lobectomy using a confronting setting.

PURPOSE: Most robot-assisted thoracoscopic surgery (RATS) is performed from the vertical view. This study evaluates the initial outcomes of our novel confronting RATS technique, in which the patient was viewed horizontally, as in open thoracotomy. METHODS: We reviewed data on patients who underwent thoracoscopic lobectomy between January, 2019 and April, 2022. Perioperative outcomes were compared between RATS and video-assisted thoracoscopic surgery (VATS), using propensity-score matching. RESULTS: RATS and VATS were performed for 83 and 571 patients, respectively. After propensity-score matching, data on 81 patients from each of the two groups were retrieved. The operative time was significantly longer for RATS than for VATS (199 ± 44 min vs. 173 ± 37 min, p < 0.001). There was no mortality or conversion to thoracotomy in either of the groups. The rates of overall complications and prolonged air leak did not differ significantly between the groups. The serum creatine phosphokinase level on postoperative day 4 was higher after RATS than after VATS. The number of resected lymph nodes and the rates of nodal upstaging did not differ significantly between the groups. CONCLUSION: The initial perioperative outcomes of RATS using the confronting settings were comparable to those of VATS.

Port Placement Variations for Robotic Lung Resection: Focusing on Their History, Conventional Look-Up-View and Horizontal Open-Thoracotomy-View Techniques, and More.

This is a narrative review that summarizes the variations in approaches and port placements used for performing robotic lung resections on the da Vinci Surgical Platforms. Currently, the four-arm, look-up-view method, in which the intrathoracic cranial side is viewed from the caudal side, is considered the mainstream approach worldwide. Several variations were devised from this conventional technique, including the so-called horizontal open-thoracotomy-view techniques in which the intrathoracic craniocaudal axis is aligned with the horizontal direction of the console monitor, and fewer port and incision techniques. In September 2022, 166 reports were surveyed using a PubMed English literature search, and this review finally included 30 reports describing the approaches. We categorized the variations into four-phase groups considering advent histories: (I) early era, three-arm technique with utility incisions; (II) four-arm, total port technique without robotic staplers; (III) four-arm technique using robotic staplers; (IV) maximizing the functional features of the Xi, significant alterations in viewing directions, and reducing ports, including the ultimate uniport technique. To comprehensibly visualize these variations for practical use, we created elaborate illustrations based on the literature. The familiarity of thoracic surgeons with the variations and characteristics allows them to choose the optimal procedure that best suits each patient and their preferences.

Medial versus lateral camera port placement for robotic nephron-sparing surgery: evaluating surgical complications and outcomes.

As the growing popularity of robotic-assisted laparoscopic procedures for the treatment of renal cancer increases, there exists a variation in surgical technique among institutions and surgeons alike. One variation that exists in robotics is the anatomical placement of the camera port (medial versus lateral camera port placement). The purpose of this study is to evaluate surgical complications and outcomes in comparison to site of camera port placement during nephron-sparing surgery in an academic setting. Over a three-year period, outcomes for all robotic surgeries for renal cancer were examined. A total of 229 cases were discovered. Patient demographics and comorbidities were analyzed along with perioperative surgical data including location of camera port, surgery length, warm ischemia time, blood loss, pathological tumor margins, tumor size, length of stay and laboratory data. 134 patients had surgery performed with lateral camera port placement versus 95 patients with medial camera port placement. Operative time was significantly lower with an average operative time of 165.8 min for the lateral group versus 209.1 min in the medial group (p < 0. 0001). Warm ischemia time was also less in the lateral group with an average of 11 min versus 15.5 min for the medial group (p < 0. 0001). Blood loss was less in the lateral camera port group with an average of 158.2 mL (± 196.5 mL) versus 248.6 mL in the medial group (± 252.6) (p = 0.0040). Drain use, positive surgical margin rate, transfusion rate, conversion to radical nephrectomy, change in pre-operative versus postoperative creatinine and glomerular filtration rate and length of hospital stay did not statistically differ. Lateral camera port placement is associated with decreased operative time and warm ischemia time in this series. There may be certain laparoscopic advantages through a better visualization of surgical anatomy, thus allowing for faster extirpation of renal lesions and decrease in surgical time. These advantages may result in better long-term renal function and decreased clinical sequela from chronic kidney disease.

Three-Arm Robotic Lung Resection via the Open-Thoracotomy-View Approach Using Vertical Port Placement and Confronting Monitor Setting: Focusing on Segmentectomy.

To perform robotic lung resections with views similar to those in thoracotomy, we devised a vertical port placement and confronting upside-down monitor setting: the three-arm, robotic "open-thoracotomy-view approach (OTVA)". We described the robotic OTVA experiences focusing on segmentectomy and its technical aspects. We retrospectively reviewed 114 consecutive patients who underwent robotic lung resections (76 lobectomies and 38 segmentectomies) with OTVA using the da Vinci Xi Surgical System between February 2019 and June 2022. To identify segmental boundaries, we administered indocyanine green intravenously and used the robotic fluorescence imaging system (Firefly). In all procedures, cranial-side intrathoracic structures, which are often hidden in the conventional look-up-view method, were well visualized. The mean durations of surgery and console operation were 195 and 140 min, respectively, and 225 and 173 min, for segmentectomy and lobectomy, respectively. In segmentectomy, console operation was significantly shorter (approximately 30 min, p < 0.001) and two more staplers (8.2 ± 2.3) were used compared with lobectomy (6.6 ± 2.6, p = 0.003). In both groups, median postoperative durations of chest tube placement and hospitalization were 0 and 3 days, respectively. This three-arm robotic OTVA setting offers natural thoracotomy views and can be an alternative for segmentectomy and lobectomy.

Robotic Mediastinal Tumor Resections: Position and Port Placement.

This study aimed to determine the optimal position and port placement during robotic resection for various mediastinal tumors. For anterior mediastinal tumors, total or extended thymectomy is commonly performed in the supine position using the lateral or subxiphoid approach. Although it is unclear which approach is better during robotic thymectomy, technical advantages of subxiphoid approach are beneficial for patients with myasthenia who require extended thymectomy. Partial thymectomy is performed in the supine position using a lateral approach. Superior, middle, and posterior mediastinal tumors are resected in the decubitus position using the lateral approach, whereas dumbbell tumor resection, which requires a posterior approach, can be performed in the prone position. The position and port placement should be chosen depending on the size, location, and aggressiveness of the tumor. In this study, we describe how to choose which of these different robotic approaches can be used based on our experience and previous reports.

Anatomy and assessment of a modified technique during totally robotic distal gastrectomy: A retrospective cohort study.

Background: Robotic surgery has potential benefits in the management of gastric cancer patients. This study compares the outcomes between totally robotic distal gastrectomy (TRDG) with modified port placement and arm positioning technique and conventional totally laparoscopic distal gastrectomy (CTLDG). Materials and methods: Fifty-two patients were enrolled into the study following a retrospective review of an in-patient database between January 2019 and June 2021. Patients who underwent gastric resection with the modified robotic technique were recruited into the study. Patients who did not receive treatment using the modified technique were excluded from the study. Data on demographic, clinical data and surgical outcomes were collected, analyzed, and presented. All statistical analyses were done using IBM SPSS statistical software. Results: Nineteen patients were in the TRDG group, and their mean age was 60.42 ± 11.53 years. There were no differences in demographic characteristics (all p > 0.05); nonetheless, laparoscopic patients had a significantly higher preoperative albumin level (p = 0.000). The operative time was longer in the TRDG group (223min), but the difference was insignificant. The reconstruction time was significantly shorter for the laparoscopic group (p = 0.000). Except for a significantly higher value of postoperative albumin level (p-value = 0.005) in the robotic group, there were no significant differences in all other surgical outcomes between the two groups. One (5.3%) patient had a severe complication in the robotic group compared to four (12.1%) in the laparoscopic group. Nevertheless, the differences in complications were statistically insignificant. Conclusion: The modified approach is a safe and feasible in totally robotic distal gastrectomy for the treatment of gastric cancer patients.

Economizing on a 12 mm port incision site: modification of robotic bowel stapling technique in Da Vinci X/Xi left colonic resections-the modified Norfolk and Norwich robotic stapling technique.

The modified Norfolk and Norwich technique allows to replace a 12 mm port incision site by an 8 mm one, therefore reducing potential postoperative complications linked to 12 mm incisions by robotically stapling through the routinely placed suprapubic Alexis port.

Emergency rollout and conversion procedures during the three-arm robotic open-thoracotomy-view approach.

OBJECTIVES: To conduct robotic lung resections (RLRs) with views similar to those in open-thoracotomy surgery (OTS), we adopted a vertical port placement and confronting upside-down monitor setting: the robotic open-thoracotomy-view approach (OTVA). We herein discuss the procedures for emergency rollout and conversion from the robotic OTVA to OTS or video-assisted thoracoscopic surgery (VATS). METHODS: We retrospectively reviewed the cases of 88 patients who underwent RLR with three-arm OTVA using the da Vinci Xi Surgical System between February 2019 and July 2021. Robotic ports were vertically placed along the axillary line, and 2 confronting monitors and 2 assistants were positioned on each side of the patient. Three possible conversions were prepared: (i) emergency thoracotomy using an incision along the ribs in a critical situation, (ii) cool conversion using vertical incision thoracotomy in a calmer condition and (iii) conversion to confronting VATS. All staff involved in the surgery repeatedly rehearsed the emergency rollout in practice. RESULTS: No emergent or cool conversion to OTS occurred. Two patients (2.3%) experienced confronting VATS conversions. One patient underwent an urgent conversion for a moderate haemorrhage from a pulmonary artery branch during left upper lobectomy in the introduction phase. Another patient underwent a calmer conversion during an extended RS6 + S10a segmentectomy, where staples could not be inserted appropriately due to lung lacerations. In all patients, postoperative courses were uneventful. CONCLUSIONS: The OTVA setting is a possible option for RLRs. This report describes the emergent rollout and subsequent conversion procedures for this method.

Effective Port Placement for Left Sided Gallbladder Cholecystectomy.

Introduction: Left sided gallbladder (sinistroposition) is a well described congenital abnormality that can pose an unexpected challenge for the surgeon, especially regarding port placement for safe and effective dissection. Case Description: In this case, a 36 -year-old woman with biliary colic was taken to the operating room for elective cholecystectomy and found, after port placement, to have sinistroposition of the gallbladder. The operation was completed with relative ease using our typical port placement of a 5 mm port at Palmer's point, a 12 mm port at the umbilicus; and two additional 5 mm ports, one in the right midclavicular line, and one in the right anterior axillary line. Discussion: Multiple port placements for safe and effective dissection of a left sided gallbladder have been discussed. Identification of sinistropic gallbladder often occurs after ports are already placed in position for right sided cholecystectomy. In this case, our typical port placement where the operating surgeon's right-hand port is located at Palmer's point provided excellent positioning for dissection. No alterations to the surgeon's left-hand port or the assistant port were necessary. The dissection was able to be completed from familiar angles, so dissection and identification of anatomy was performed with relative ease. This is important as sinistroposition can at times lead to abnormalities of the biliary tree, though none were noted in this case.

Robotic cholecystectomy with a new port placement: Is it really beneficial?

OBJECTIVE: This study compared the effect of robotic cholecystectomy (RC) with a new port placement versus that of laparoscopic cholecystectomy (LC) on surgical pain and postoperative complications. METHODS: We prospectively collected medical data from 100 patients who underwent cholecystectomy (RC = 50, LC = 50) from March 2017 to January 2019. In the RC group, ports were positioned in the left-lower, mid-lower, and umbilical areas. In the LC group, ports were placed in the xiphoid, right-upper, and umbilical areas. RESULTS: Patient characteristics were similar between the two groups. Pain levels at 2, 4, and 8 h were significantly lower in the RC group than in the LC group (p = 0.04, 0.02, and 0.02, respectively). The LC group received more analgesics after surgery (RC = 0.3 ± 0.5 vs. LC = 0.7 ± 0.9, p = 0.03). However, the total medical cost was significantly higher in the RC group (RC = 7355.2 ± 1270.9 USD vs. LC = 4814.8 ± 1572.5 USD, p < 0.01). Mean operative time, length of hospital stay, and postoperative complications were not significantly different between the two groups. CONCLUSION: Regardless of the surgical procedure, postoperative complications were similar. RC with the new port placement can be recommended for patients who are more concerned about postoperative pain, incision, and hospital stay than surgical cost.

Ergonomic port placement in robotic colorectal surgery.

AIM: The aim of the study was to determine how spacing between ports and alignment of ports (oblique or vertical) influences manipulation angles in robotic colorectal surgery. METHOD: Abdominal CT scans of 10 consecutive robotic right hemicolectomy and 10 consecutive robotic high anterior resection patients were analysed. The manipulation angles were calculated using fixed points on the preoperative abdominal coronal CT scan. Port placements were marked on the CT scan. The fixed points used to measure the manipulation angles were from the most lateral part of the caecum, hepatic flexure, splenic flexure, the descending colon/sigmoid colon junction and the sigmoid colon/rectum junction. RESULTS: For right hemicolectomy and high anterior resection surgery, a port spacing of 8 cm compared with 6 cm resulted in greater manipulation angles. With 6-cm port spacing, wider manipulation angles were not achieved with vertical port alignment compared with oblique alignment except for dissection at the splenic flexure. CONCLUSIONS: The greatest manipulation angles were achieved with the oblique 8-cm port spacing, which should be used in most cases.

Robotic open-thoracotomy-view approach using vertical port placement and confronting monitor setting.

OBJECTIVES: Robotic lung resections (RLRs) are conventionally performed using look-up views of the thorax from the caudal side. To conduct RLR with views similar to those in open thoracotomy, we adopted a vertical port placement and confronting upside-down monitor setting, which we called robotic 'open-thoracotomy-view approach'. We herein present our experience of this procedure. METHODS: We retrospectively reviewed 58 patients who underwent RLR (43 with lobectomy; 15 with segmentectomy) with 3-arm open-thoracotomy-view approach using the da Vinci Surgical System between February 2019 and October 2020. The patient cart was rolled in from the left cranial side of the patient regardless of the side to be operated on. Robotic ports were vertically placed along the axillary line, and 2 confronting monitors and 2 assistants were positioned on each side of the patient. The right-side monitor, which was set up for the left-side assistant to view, projected the upside-down image of the console surgeon's view. RESULTS: All procedures were safely performed. The median duration of surgery and console operation was 215 and 164 min, respectively. Emergency conversion into thoracotomy and severe morbidities did not occur, and the median postoperative hospitalization duration was 3 days. In all procedures, the console surgeon and 2 assistants had direct 'bird-eye' views of the cranially located intrathoracic structures and instrument tips, which are sometimes undetectable with the conventional look-up view. CONCLUSIONS: The open-thoracotomy-view approach setting is a possible option for RLR. It offers natural thoracotomy views and can circumvent some of the known limitations of the conventional procedure.

A Systematic Review of Laparoscopic Cholecystectomy in Situs Inversus.

Background: In case of situs inversus (SI), laparoscopic cholecystectomy (LC) is challenging. This systematic review aimed to assess the appropriate technique for LC in SI.Methods: An electronic search was carried out using the following keywords: "Situs inversus" and "Laparoscopic cholecystectomy". The main endpoints were surgical procedures, intra-operative cholangiography (IOC) use, common bile detection, operative time, bile duct injury, conversion, mortality, and morbidity.Results: We retained 93 cases. Essentially two types of laparoscopy port placement reported were reported: the "American mirror technique" and the "French mirror technique". One report of a left-handed surgeon was retained. Fourteen cases operated by a right-handed surgeon: "American mirror technique" used in 33 cases and "French mirror technique" used in 7 cases. The operative time was mentioned in 52 cases with a mean of 74 min without any statistical difference between the two techniques. No cases of postoperative death, major complications or bile duct injury were reported. IOC was performed in 16 cases (17.2%). An associated common bile duct stone was found in eight cases (8.6%). ERCP with endoscopic sphincterotomy was used to treat the associated CBD stones in 7 cases and a choledecoscopy was conducted in one case to extract stones. The conversion rate in this systematic review was 1.07%.Conclusions: LC in SI is easier for left-handed surgeons. The fastest technique for right-handed surgeons seems to be the "American mirror technique" and some modifications of the port placement can facilitate it.

A prospective randomised control trial to compare the perioperative outcomes and ergonomic challenges between triangular versus midline port placement in total extra-peritoneal repair of uncomplicated unilateral inguinal hernia.

BACKGROUND: Routine TEP technique requires three skin incisions for placement of three trocars in the midline. Otherwise, this can be done by three-port triangular technique or two-hand technique. This study reports a randomised trial of perioperative outcomes and ergonomics characteristics of this procedure using two different techniques of port insertion. METHODS: N = 28 patients were randomised into two groups for triangular three-port (TTEP) versus midline three-port TEP (MTEP) hernioplasty after informed written consent in Department of Surgery, King George's Medical University UP between September 2016 and September 2017 after institutional ethical approval. Patient-related outcomes in terms of quality of life (QOL) and ergonomic evaluation of the technique were compared in double-blinded fashion. RESULTS: Postoperative pain score at 24 h post surgery (5.1 ± 0.6; 95% CI 4.9-5.3 vs. 4.8 ± 0.4; 95% CI 4.6-4.9) differed, while hospital stay, time to return to routine work, tolerance to oral feeds and intraoperative complications occurrence (OR 2.1; 95% CI 0.2-24.3) were comparable in both groups. Time to return to office work (5.5 ± 0.5; 95% CI 5.4-5.7 vs. 4.0 ± 0.8; 95% CI 3.7-4.3) and immediate postoperative sensation of mesh and pain score were significantly higher in MTEP compared to TTEP. Ergonomic parameters including visualization of landmark score, spreading of mesh score and total surgeon satisfaction score (TTEP 8.4 ± 0.7; 95% CI 8.1-8.6 vs. MTEP 7.0 ± 0.8; 95% CI 6.7-7.3), mental effort quotient (SMEQ score: TTEP 50.6 ± 12.7; 95% CI 45.9-55.3 vs. MTEP 70.8 ± 12.6: 95% CI 66.1-75.4) and physical effort quotient (LEDQ scores in wrist, hand, arm and shoulders) were also superior in triangular technique of port placement. CONCLUSION: Triangular three-port TEP hernioplasty is ergonomically feasible and enables a surgeon to perform surgery safely using basic principles of laparoscopy.

Totally robotic right hemicolectomy: a multicentre case-matched technical and peri-operative comparison of port placements and da Vinci models.

The objective of the study was to review the technical and peri-operative outcomes using the da Vinci Xi (dVXi) and da Vinci Si (dVSi) models with suprapubic port placement (SPPP) or traditional port placements (TPP) during a robotic right hemicolectomy (RRHC). A retrospective review was undertaken of prospectively maintained databases of RRHC performed by two senior colorectal surgeons in the USA and Australia. Data were prospectively collected for patient demographics, intra-operative technical outcomes and peri-operative clinical outcomes. A cohort of 138 patients underwent RRHC between 2013 and 2017: 134 (97%) had intra-corporeal anastomoses (ICA), 50% for polyp disease and 38% for cancer. 16 (12%) patients had post-operative complications, 11 (8%) of whom had only one complication. There were five (4%) anaemias requiring transfusion; five (4%) anastomotic bleeds; one (1%) leucocytosis/sepsis; two (1%) paralytic ileus; and two (1%) delayed readmissions. There were no conversions to open operations, anastomotic leaks, 30-day readmissions, or 30-day mortalities. With dVSi compared to dVXi, median (IQR) total operation time (TOT) reduced by 16% [134 (118-169) min versus 113 (90-132), p < 0.001]. dVXi had shorter console times (CST) [75 (62-97) min vs 94 (77-108), p = 0.004]. SPPP seemed more advantageous than TPP with less CST [75 (60-98) min versus 85 (70-106), p = 0.02]; less TOT [110 (90-130) min versus 130 (108-167), p < 0.001]; and shorter LOS [2 (2-3) days versus 3(2-3), p = 0.03]. There are operative technical improvements and peri-operative patient clinical benefits during RRHC with ICA using either da Vinci models or port placement configurations. It appears more advantageous to use dVXi with SPPP configuration as our preferred setup for RHHC. Many gastrointestinal surgeons foresee potential benefits of robotic surgery (RS) over conventional laparoscopic surgery, hence evaluation of RS in both routine and more complex operations is needed (Kwak and Kim in J Robot Surg 5:65-72, 2011).

A prospective randomized controlled trial comparing conventional Intuitive® procedure card recommended port placement with the modified Indian (Manipal) technique.

INTRODUCTION: The da Vinci® X hybrid systems (Intuitive Surgical®, Sunnyvale CA) provides standard sites recommendations for port placement during robotic surgery; including that for colorectal procedures. The author's encountered challenges while adhering to the provided instructions, such as clash of instruments and arms and need for additional ports, and hence to overcome these challenges attempted a few innovative technical modifications. The surgical results as well as merits of the revised Indian (Manipal) port placement with single docking technique are presented here. METHODS: Twenty patients underwent robotic rectal resection at the Department of Surgical Oncology and Robotic Surgery, Manipal Comprehensive Cancer Centre, Bengaluru, India, between December 2017 and June 2018. A randomised controlled study was conducted to compare the two techniques. Ten patients were operated using hybrid da Vinci® 'X' system using the manufacturer's recommendations and 10 by the modified Indian (Manipal) port placement with a single docking technique. RESULT AND CONCLUSIONS: The Indian (Manipal) modifications of port placements are optimal for colorectal procedures such as low anterior resection as well as for ultralow anterior resections. The intraoperative parameters compared between the recommendations of the Intuitive® (da Vinci® systems) and attempted modifications demonstrated statistically significant advantages with the use of the revised techniques. The improvements offered by this modification include no additional requirements of ports or staplers, lesser clash amongst instruments as well as arms, better mobilisation of splenic flexure amongst others.

Cannula-Assisted Port Placement during Video Endoscopic Inguinal Lymphadenectomy (VEIL)-a Novel and Safe Technique.

To present our novel technique for subsequent port placement during video endoscopic inguinal lymphadenectomy (VEIL) surgery. VEIL has provided positive results in terms of reduction of pain, early recovery, and better cosmesis. Ten patients who underwent VEIL procedure during 2012-2015 were included in this study to assess feasibility, safety, and advantages of port placement by our new technique which include placement of subsequent ports with the help cannula of the first port. The size of incision, time taken for port placement, leakage of pneumo, any complication(s), and potential learning curve or special instrument requirements were noted in these patients. Median incision size was 10 mm and 5 mm for their respective sized ports with this new technique. Pneumo leakage was not seen in any patient. Median time taken for subsequent port placement was 2 min ± 15 s. No complication was noted to patients or the operating surgeon. The technique proved to be feasible and needed no special equipment or training. We report technical feasibility, safety, and advantages of a new technique for port placement during VEIL surgery emphasising its potential to become a standard technique in the near future.