Single Port robotic surgery sucks — Am I right?
- Steve Bell
- Mar 4
- 15 min read
There’s nothing like a good clickbait title and image to get you to the post. And today I’m going full on with no holds barred to give my hyper opinionated view about single port surgery - so strap in.
Back in the late 90’s some people came up with an idea to make multiport laparoscopic surgery “Better.” They decided that sticking a massive port at the umbilicus was way better than sticking lots of little ports around the abdomen.
Then they thought that crossing over instruments and working like inverted chopsticks through that port would actually be a good idea. They even came up with a funky name - SILS (Single Incision Laparoscopic Surgery) - was that SILS or SILLY ? I struggle to remember because it was a fad. Oh of course there are some die hard surgeons today that persist with it… but… but…
I get the idea - less scars is better, and it was a stepping stone to “No Scars” as we had a flourish of NOTES and NOS coming onto the scene.
But step forwards over 20 years and all I ask is “Where is it now?” Why didn’t SILS take off and dominate the world of laparoscopy?
Well in my opinion it was a solution looking for a problem. And that never bodes well. The idea was “The gallbladder or specimen is coming out of the umbilical port - so just make it bigger and put all, the instruments through that one port. No more small scars around the abdomen. You don’t even see the umbilical scar if done right…”
But talk about taking something difficult and making it ten times more difficult for virtually no gain. Manual lap for most people is hard to master - but now crowd your instruments in one point - cross them - invert them and add some flexion. And you just made that stupid hard.
Now as the crossing over - and the management of instruments is hard - some bright spark at a robotics company decided that much of that complication of movements can be removed if you just make SILS robotic. Give people three flexible instruments and a 3D flexible camera and it all becomes easy… right?
Single Port robotics is not new
Many of the old schoolers of the Si will remember that there were 5mm instruments and that you could set up the robot to do a sort of SILS through a single umbilical approach by crossing them over. And again many hard core users tried this. It wasn’t a true Single Port device - but it was using a multiport as if it were a single port device.
But somehow - for many - it just neverfelt right. It never worked as the teams at Intuitive wanted; and it still required a lot of set up - and arm management. You see the multi arms all needed to work together. And there was a huge amount of movement outside the patient resulting in arm clash. Even the addition of flexible tips didn’t make all that movement go away - it simply removed some of the clash.
Now. What did come out of that work was the advent of TORS. Trans Oral Robotic Surgery. And this made sense because you had no choice. If you wanted to use the robot in the mouth then you needed a single point of access. Likewise for low rectal tumours - you could use this sort of single port configuration for trans anal work.
I asked a surgeon once “What’s your biggest desire for transoral robotic surgery?”
He said, “To get the robot before it’s used for transanal surgery.”
Surgeon humour at its finest.
But it was clear that with this natural orifice approach, the clustering of instruments was not a nice to have - but an absolute necessity. And several engineers in several companies were starting to think that using multi arm robots for this had severe drawbacks. And some were wondering… should they make a dedicated single port approach robot.
One of those companies was the ill fated Titan Medical. A company from Canada that was looking to develop SPORT (sport single port orifice robotic technology). The concept was to use a single boom outside the patient - and then use flexible instruments for arms and camera to pass through a single trocar and simplify all those complex movements outside and give surgeon ease by controlling the entire thing from a console.
But the company was plagued by technical issues, funding issues (never go public until you have a shit load of quarterly sales that repeat) and they could just never get the system out to a commercially viable product. Now they did have a ton of IP, and that today sits in a holding company and they have converted all of that into the “value of the company.” I commend Titan for what they achieved - but robotics is hard to survice. Single port alone is nigh on impossible.
So what happened?
Intuitive and the rise of the SP
I still cannot get to the facts here. But the urban myth goes something like this…
Intuitive had been toying with the single port approach with the Si and their 5mm flexible instruments. The Si gave way to the Xi and the 5mm flexible instruments were seeimngly abandoned (shelved) to leave the much more widely used 8mm end-wrist instruments. And few people have any issue with those 8mm dilated port sites. (Just saying.)
But that clearly wasn’t ideal for transoral and transanal - as too big and not elbow flexing - which meant way too parallel an approach through those orifices.
Plus the vast majority of the people were using 8mm multiport with absolutely no issues in the abdomen. Small scars on the abdomen were not a real issue - (in the west !!!!). But just to add some context - many Asian countries - South Korea being one - have some historic issue over scars (especially the head and neck.) And especially the women where flawless skin used to be very desirable.. It had a social stigma but that is changing…
However there was a big push in Korea for various minimally invasive - and reduced scar surgery. (That is perhaps by South Korea has such a big uptake of the SP vs most other countries?)
So back to the urban legends. A group of engineers inside Intuitive were (supposedly) convinced there was a market for SILS with a robot: and there was a key medical need for the transanal and transoral market where the move to the Xi has left a performance gap. Legend goes that some of the senior management did not see a huge potential for a single port as, the multiport was growing and growing without a lot of push for a single port. So the SP remained a little bit of an orphan project within Intuitive... as the company focused on the main task in hand - that of growing the standard multiport business.
Now if that is true or not - I don’t know - but the resource push I saw, and the relegation of SP to what felt like a curious product launch makes me think it may have some truth. And I don’t know if the SP project was driven hardest by the trans orifice approaches or people genuinely thought there was a market for a single port set of abdominal procedures and a return to SILS?
Or was it just a back up project, as they could see other companies looking in this area?
It doesn’t really matter - because in my opinion the SP is what finished off Titan Medical. And let me explain my thoughts…
Firstly, if you have a two arm system and the competition comes out with three arms - you are literally out of the arms race. (Take note Vicarious Surgical… more later.)
Plus the minute that Intuitive said they would be bringing their might to that approach - it makes it way more difficult for anyone to gain traction. And that can also be with investors - especially if you are on the public markets. The threat of Intuitive just railroading you to one side is all too scary.
The SP was commercially launched 2018 / 2019 - and wel,l by then it was all but over for Titan. Especially as (again just my opinion) the SP launch and results were “light” at best. With a very low number - (even today in the hundreds) it appears the market has voted with its cheque book. This is a tiny fraction of the number of Xi systems that flew off the shelf at a completely different rate of growth.
I believe that all of this has combined to see Titan sell (license) off its assets to companies like Medtronic - who seem to be having the ENOS system (either architecture or system) still bubbling along in a skunk works project.
I will come back in a minute to the main theme of today’s article - why I think single port systems “Suck” - well okay… why I think they have little fan base and can only be part of a bigger portfolio.
The rise of other systems
What is evidently clear to me is that a single port system cannot, and will never be a able to be a stand alone and viable “business” as such.
Clearly Intuitive (even though they again are the leaders) are not the only game in town. The defunct Titan Medical has morphed into Conavi Medical Corp. And has licensed some of its critical IP to other companies such as Medtronic. And I think even Intuitive. (You know Titan had some forward thinking engineers.)
I am convinced that single ports will become like assholes. Eventually every company will have one. (Hang on I think I mixed up a few sayings there.)
If you have a multi arm - then to be able to fully compete in tenders and Group Purchasing contracts - the SP will need to be part of the offering. It's early but it will head that way.
But let me list out what single ports are either out there or in development first.
Vicarious Surgical - Single Port
Microport Medbot - Toumai Single Arm
Titan Medical - Enos 2 (now most likely will morph into something at Medtronic)
Bejing Surgical Robotics Company - Shurui SP
Edge Medical - SP 1000
Momentis Surgical - ANOVO
Harbin Sagebot - Flexible Oral Robot
If you want a full breakdown of all these systems then go buy access to THE LIST here -
where there are lost of details on all of these single ports as part of the 60 plus robots available.
Note: There are other platforms like Virtual Incision and Virtuoso Surgical - But even though they are “single site approach” architecture, they really are not single port systems in this sense, and have a totally different approach that does not run head to head with a da Vinci SP. And does not try and have a “single port paradigm.” So for now take these off the SP list... arguable you may say.
So all of the other systems above are working to displace the Da Vinci SP in one area or another.
Let me talk about them a little.
Vicarious Surgical has some very novel ideas. They are using really cool arms that have a slightly different decoupled actuator mechanism. What that means is they control each joint via a separate cable. So that stops tension stacking up as you try to control various joints using the same actuators. Way more complex - way more difficult - but technically it makes control better and flexibility greater.
They also went for a very novel camera system that uses a small “pill cam” like camera to get 3D. It has a lot of innovations including blinking. (Self cleaning.)
But I think it has limitations. First is that innovation for innovations sake can bring benefits and drawbacks. Standard camera are defuse - because they work and work well.
And Vicarious has just two flexible instruments. And the market leader has three. Intuitive are not stupid and know you really need three to have a true single port approach where you can get retraction and exposure as well as working instrument retraction.
But honestly - Vicarious's biggest problem, in may humble opinion, is that they went for the public markets via a SPAC (Special Purpose Acquisition Company) a trend a few years ago to do a simplified way to access public markets.
Soap box time. Unless you have got a clockwork like revenue stream in surgical robotics - you are better staying away from the public markets. They are pain with no gain. You have to drop your shorts every quarter and expose the good the bad and the dangly. Not great if you are not way ahead of plan.
I do love the way Vicarious are thinking out of the box - and even pushing things like glassesless 3D consoles. But my fear is they might not get to bring that all to market. Much like Titan. But we should all root for them!
I think Titan suffered from this markets issue, and I think Vicarious is suffering from it - happy to be corrected but that is my opinion on that. Stay private as long as possible.
Now Toumai SP - this is the single arm variant of the Toumai Multiarm - using a similar tower and console to the Toumai. But they have opted for a very clever dual C- frame technology that seems to allow them to repurpose some of the drive train.
In one way it is a clone of the SP... but delivered in quite a cute way. IP work around? Maybe? But it looks nice and will have all of the benefits of a Medbot product - including 5G tele- surgery.
Finally back to the big followers - Medtronic and JNJ. I think Medtronic will be doing something similar to ENOS 2 - I mean all that great works has been done, so why not stand on those shoulders? And JNJ with the Auris 6 arm Ottava promised a single port function, flexible instruments and more.
They’ve rowed back with the 4 arm Verb- Auris hybrid Variant - but for sure will be thinking single port as part of their future portfolio... well if the want to compete with da Vinci.
Why does Single Port suck?
Oh yes where was I?
So if single port sucks… why are so many companies literally going down this rabbit hole?
Let me reiterate again that I think it is a technology looking for a solution - in Abdominal single port. Let me be clear from this point on - transoral and transanal it is super good and super exciting for many reasons I will come to. And I will add at that point why Harbin Sagebot has been smart in going after a transoral version of a single port only.
So let’s tackle the abdomen first. You will end up with a circa 25mm hole in the sub umbilical fascia - or worse for some approaches above the umbilicus or below the umbilicus - to get reach. Sticking big holes in the midline fascia is less painful but has drawbacks.
Often you will need a type of “floating port” such as an Applied Medical Gelport - or the Intuitive SP access kit.
And well now we are moving from the sublime to the ridiculous in my opinion. We are getting a bigger and bigger midline access port and racking up the millimetres of incision. For what?
The beautiful image most of us have in mind is that small single port of the robot being the ONLY port in the abdomen. Nahhhhhh.
There are several principals needed for abdominal surgery. And fairly large organs that need retracting and counter retracting. One big issue for me is the limitations of a small working area and the limited ability to retract big structures out of the way - like reflecting a liver lobe etc. Yes you can “drive under them” in some instances - but in my mind - the SP approach alone for major exposure becomes limited. It's not impossible - but it is technically challenging for most. And a product must be "for most."
To that end people start to add another trocar to put another instrument through. So now we are no longer at a “Single Port.”
Now you can delude yourself all you want that “as we are using a single access port - Gel port - we are technically single port - even if you add other ports through that Gelport.” -
Ahem - cough cough - BS - cough cough.
If you use more than one port - be that for whatever reason - it is NOT a Single Port case. So at that point when you publish Single Port vs MultiPort comparative data - you are fudging it.
You are really doing "Big diameter multiport" vs a few 8mm Multiports. Period. Be honest.
The next issue is - that as of today there is no advanced energy and no stapler on the single port variants of any system. Fact. Yes they are in development - but today ... no.
So we hear from one side of Intuitive's mouth - “You need the full optionality of Sureform staplers from the console… advanced energy from the console… the full range of instruments… ICG etc etc”.
And then out of the other side of the mouth… “Unless you want an SP system and then all of that was just fluff.”
(voice in my head - "But it's different you don't pick cases where you need advanced energy or stapling. And you avoid them until you have them...") Ya can't have it both ways.
You see for me - abdominal single port surgery is just a stack up of compromises that make something simple - that works well - complex. Way more complex than it needs to be. And you leave a massive hole in the Linea Alba at best.
And as someone that has spend a career watching umbilical hernias get fixed… I question it.
Another big reason is - the cost. Now you need another robot. A whole other robot. A robot that can’t do multiport. So you are going to need two robots at least. When one multiport would do everything you need (well not quite.) But you get my drift - right?
And the flexible instruments are way more expensive than the regular 8mm wristed instruments. (as of writing.)
So for me - for abdominal surgery - the negatives far outweigh the positives. And if you do a meta-anlysis of the literature it is sparse evidence that maybe… maybe there is a cosmetic preference, some potential reduction in pain and opiate use (not used in Europe much for lap procedures) and potentially some shorter hospital stay. But…
I had imagined it was technically easier to use the SP especially for multi quadrant surgery - but the avoidance of arm clash (rare) and set up (similar times) do not seem, to outweigh the harder technical requirements of the operation inside the patient. So again - why?
I know the South Korean surgeons will be arguing fervently against this - but come on. That’s a bubble.
Me. I see this like SILS - but who am I? Oh hang on the almost 9700 multiport vs 270+ single port - the market seems to be saying it as well. And I trust surgeons and hospitals more than I trust my own misguided insights. (That’s less than 3% vs Multiports - and that ain’t just a timing thing. It’s a mirror of SILS vs multi lap.)
It tells me that if anyone is chasing a big market of abdominal single ports as a stand alone company without a multiport… forget it. But as said - if you have a multiport, you will most likely need a Single port. Why? Because Intuitive has one.
So where doesn’t Single Port suck?
I eluded to it before - natural orifice.
If you want to operate at the base of the tongue, or on sleep apnea, or in the low rectum trans anal. Multiports suck. The angles are wrong - the arms can clash and you don’t have instrument elbows in there. You can force it to work but it's a force fit.
I think that for TORS and Transanal, an SP like system or endolumenal system is an absolute must. Just go Youtube the procedures and there is absolutely no comparison. The ability to bring in three arms and a camera and separate them inside the cavity opening makes it perfect.
Plus the surgery is well adapted to the technology. You don’t have massive surgical volume areas to work across. You don’t have large organs to retract. You don’t need advanced energy and staplers. The set up doesn’t require an SP plus one. It is all just way better suited for the technology in its purest form.
I am a huge fan of both transanal and trans oral access using a single port system. This is where it wins for me.
And this is where Harbin Sagebot have been smart - they too have understood the market is TORS. And their system is aimed right at that market. They are not starting abdominal. Goooood.
Others that have banked on abdominal first… And don’t have a multiport… will go the way of Titan I fear.
Companies will absolutely need a Single Port as part of a portfolio. But not for the abdominal side of things - but instead the ENT (ORL) head and neck surgeons have a massive say in Tenders and contracting, and they will ensure that any provider must provide and option for them. I've seen it in my daily life.
So anyone providing robots must be able to provide a multi-arm lap robot - and a single port TORS or Transanal robot IMHO.
Now, if that then gets used for curious low lob procedures by curious abdominal surgeons that want to be one of the first to say do “a single port prostate” etc. Then have at it at that point. If it’s there along side the Xi and you want to “have a dabble” then by all means go for it. It will be a great abstract.
If the single port is a side kick to the Multiport for say Intuitive - Microport or Medtronic - then have at it. Fill your boots.
But as a stand alone replacement of the Xi — I’m giggling. And anyone out there with a strategy to have their single port “replace all the Xis” is in my category of delusional (for now.)
Ohhh intrigue……. Not for this post - but there is a point when a single port hybrid starts to make some kind of sense… I’ve eluded to it before - but a future is endolumenal - and rendezvous….
But that is a full on discussion in another post… https://www.howtostartupinmedtech.com/post/endolumenal-robotic-endoscopes-where-is-it-going
But Am I right?
I did preface this post with me being opinionated. I have been... and well… I hope that is what you expect from the purple menace.
I’m wanting to get this out to agitate a bit. To get us thinking. Just because you can do something - doesn’t meant mean you should. Doesn’t mean it’s the best tool. A friend’s father had a hammer. Just a hammer. He would nock nails in with it. And knock screws in with it. He would cut wood with it by smashing it to bits. You see what I’m saying.
The single port systems are a marvel of modern engineering. But use a hammer for nails - a screwdriver for screws and saw for cutting wood. And some days you will use all those things in the right amounts when you build a piece of furniture. Especially if the flexible hammer is more expensive than the other tools.
These are merely opinons of the author for educational purposes. All products and trademarks remain property of their respective companies. It's just opinion.
Comments