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OPEN A single‑center experience

of over 300 cases of single‑incision
robotic cholecystectomy
comparing the da Vinci SP
with the Si/Xi systems
Yoo Jin Choi 1,3, Nguyen Thanh Sang 1,2,3, Hye‑Sung Jo 1, Dong‑Sik Kim 1 & Young‑Dong Yu 1*

Minimally invasive surgery is usually more beneficial than open surgeries in various fields of surgery.
With the newly developed Single-Port (SP) robotic surgical system, even single-site surgery has
become easier to access. We compared single-incision robotic cholecystectomy between the Si/
Xi and SP systems. This retrospective single-center study enrolled patients who underwent single-
incision robotic cholecystectomy between July 2014 and July 2021. The clinical outcomes of the da
Vinci Si/Xi and SP systems were compared. In total, 334 patients underwent single-incision robotic
cholecystectomy (118 Si/Xi vs. 216 SP). The SP group had more chronic or acute cholecystitis than
the Si/Xi group did. There was more bile spillage in the Si/Xi group during the surgery. The total
operative and docking times were significantly shorter in the SP group. There was no difference in
the postoperative outcomes. The SP system is safe and feasible regarding comparable postoperative
complication rates and is more convenient regarding docking and techniques.

The robotic surgical system, which will be a leading surgical technique in the future, was first developed and
commercialized in 1997. This robotic system has been gradually developed by improving the limitations of the
previous system, from the first da Vinci model to the latest da Vinci SP. Single-incision surgery in the robotic
surgical field became possible with the introduction of the da Vinci Si model in 2009. Additionally, it was in the
spotlight at that time because there were several restrictions on single-incision laparoscopic surgery.
The da Vinci Si and Xi in single incision surgeries reduced internal collision of the instruments and external
collision of surgeons’ hands by using the triangulation of i­ nstruments1 and eliminated potential collision between
the operator and the camera assistant by allowing control of the camera by the operator himself. However, there
was still an element of discomfort using the Si and Xi systems. Contrary to the da Vinci Si and Xi multiport
instruments, one of the biggest limitations was the lack of endo-wrist movement in the instruments. Similar to
the disadvantages seen in single-incision laparoscopic surgery, they are not fully ergonomic. In addition, these
systems require assistance for the lateral traction of the gallbladder.
In 2018, the fourth-generation da Vinci surgical system, the da Vinci SP system, was launched. It was devel-
oped for advanced single-incision and narrow-space surgeries. The system includes three robotic arms, each with
multiple joints, wrist, and elbow, and the first fully wristed three-dimensional high-definition camera. Apply-
ing this system to cholecystectomy for the first time, Cruz et al. demonstrated that robotic SP cholecystectomy
was feasible, safe, and effective, and showed better perioperative outcomes than robotic Si cholecystectomy.
Moreover, da Vinci SP has been used in more complex hepatobiliary and pancreatic surgeries, such as distal
­pancreatectomy2.
To date, only a few studies have compared the perioperative and postoperative outcomes of different robotic
systems during robotic cholecystectomy. Recently, two reports have compared robotic cholecystectomy. One
study compared the SP to the Si system in 30 consecutive p ­ atients3, and another multicenter study compared
SP to the Xi s­ ystem4. However, the study cohort that underwent cholecystectomy in these studies was relatively

1
Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine,
73 Goryeodae‑ro Seongbuk‑gu, Seoul 02841, Korea. 2Department of Surgery, Trung Vuong Hospital, Ho Chi Minh
City, Vietnam. 3These authors contributed equally: Yoo Jin Choi and Nguyen Thanh Sang. *email: hust1351@
naver.com

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small. To date, this study is the largest series comparing Si/Xi versus SP with three times as many SP cases as in
previous studies.
This study aimed to investigate the clinical advantages of the SP system in a large patient cohort by comparing
the clinical outcomes between the new SP system and previous Si/Xi systems.

Methods
Patients. A total of 334 patients underwent single-incision robotic cholecystectomy between July 2014 and
July 2021 at a single tertiary referral center. The data were prospectively collected and retrospectively analyzed.
The follow-up periods were 5.37 ± 2.57 months with range from 0 to 35 months.
As robotic surgery is more expensive than open or laparoscopic surgery, not all patients with gallbladder
disease undergo robotic cholecystectomy. In general, robotic cholecystectomy is recommended for patients with
no or minimal inflammation of the gallbladder. All patients who underwent robotic cholecystectomy using either
the Si/Xi or SP system were included in this study. Patients who previously underwent upper abdominal surgery
were not recommended for single-incision robotic surgery because of the possible conversion to multiport
laparoscopic or open cholecystectomy owing to postoperative adhesions.
Before the SP system was introduced at our center in April 2020, all robotic cholecystectomies were performed
using either the Xi or Si system. Subsequently, all subjects underwent single-incision robotic cholecystectomy
only with the SP system because the surgeons felt more comfortable with the SP system. This retrospective study
was approved by the institutional review board of Korea University Anam Hospital (#2022AN0151). The waived
informed consent was approved by IRB of Korea University Anam Hospital. All methods were performed in
accordance with the relevant guidelines and regulations.

Time measurement. The docking, console, and total operative time were measured during the operation.
The docking time represented the time interval from the incision to the end of docking of the robotic arm to the
cannula. The console time was defined as the time spent by the surgeon at the console during the robotic proce-
dure. The total operative time was defined as the time interval from incision to wound closure.

Procedure. Procedures with both the Si/Xi and SP systems shared similar surgical procedures, except for the
docking techniques. Under general anesthesia, the patient was placed in the supine position. A trans-umbilical
incision of approximately 3 cm was made and different ports were placed in the wound.
In the Si/Xi system, a Single-site Port ® (Intuitive Surgical, Sunnyvale, California, USA) was placed in the
umbilical incision. After a pneumoperitoneum was achieved with 12–15 mmHg, the patients were positioned
in reverse Trendelenburg with the right side up, one straight robotic cannula for the camera was inserted in the
middle, and two curved-designed robotic cannulas were inserted on the left and right sides. It was ensured that
these two curved cannulas crossed each other with the right cannula placed on the left cannula. Subsequently,
the assistant inserted the gallbladder grasper through the port and grabbed the GB for retraction. The robot
was docked to the cannulas, and the robotic camera was inserted, followed by the insertion of instruments with
bending flexibility. The hook was inserted into the left cannula and a grasper was inserted to the right (Fig. 1).
The robotic software reconfigures the right and left sides, such that surgeons can move normally using hooks
with the right hand and graspers with the left hand. These two curved cannulas allow for internal triangulation,
which maximizes the range of motion.
In the SP system, the gel port® was placed in the umbilical incision, and pneumoperitoneum and patient
positioning were performed in the same manner as with Si/Xi. A 25-mm SP cannula was inserted through the
gel port, followed by the insertion of the SP multi-channel guide port into the cannula (Fig. 2). Subsequently, the
robot, placed on the left side of the patient, was docked to the cannula, and the robotic camera and three robotic

Figure 1.  Robotic ports insertion diagram in the single incision surgery with Si or Xi system. The middle port
is for the camera. It can be observed that the two side ports have crossed each other. Thus, the right port is for
the grasper and the left port is for the hook or hemo-lock clips.

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Figure 2.  Robotic arms position in the SP robotic system.

arms were inserted into the cannula (Fig. 3). In the multi-channel guide port, the camera was placed at the lower
side, a hook at the right arm, fenestrated bipolar forceps at the left arm, and Cadiere forceps at the upper side.
Since the SP system itself had the third arm, cardiac forceps, for GB retraction, there was no need for an assistant.
Afterward, the cholecystectomy and wound closure procedures for both systems were similar, including
dissection around Calot’s triangle, ligation of the cystic duct and artery with robotic hemolocks, and dissection
of the GB from the liver bed.

Intraoperative findings. There were four types of intraoperative findings on GB. Adhesion in Calot’s trian-
gle referred to omental adhesions around GB. Acute inflammation was noted if GB was distended or edematous
with or without gangrenous change of the wall. This finding was different from the preoperative radiological
diagnosis of acute cholecystitis in Table 1. Wall thickening was observed when GB was cut open after the opera-
tion. Bile spillage referred to the tearing of GB during the dissection of GB from the liver.

Statistical analysis. Continuous variables are presented as mean ± standard deviation. Categorical vari-
ables are expressed as proportions and analyzed using the chi-squared or Fisher’s exact test. All statistical analy-
ses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).

Results
The Si/Xi and SP groups included 118 and 216 patients, respectively (Table 1). There were significantly more
women in the SP group; however, there were no significant differences in age, body mass index (BMI), Ameri-
can Society of Anesthesiology (ASA) score, previous lower abdominal surgery, or preoperative ERCP perfor-
mance between the Si/Xi and SP groups. The total mean age was 46.21 ± 11.40 years and the mean BMI was
25.95 ± 22.36 kg/m2. All the patients were ASA I or II. None of the patients underwent previous upper abdominal
surgery, except for one patient who had open abdominal surgery for duodenal perforation, and only 3% had

Figure 3.  The patient was positioned in reverse Trendelenburg and right-up position. The robot was docked to
the cannula with the insertion of the robotic camera and three robotic arms.

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Si/Xi SP Total
Variables (n = 118) (n = 216) (N = 334) P-value
Age (year) 44.14 ± 11.41 47.34 ± 11.26 46.21 ± 11.40 0.014
Sex, male (%) 32 (27.1%) 94 (43.5%) 126 (37.7%) 0.003
BMI (kg/m2) 23.85 ± 3.95 27.09 ± 27.61 25.95 ± 22.36 0.205
ASA (%) 0.286
0 1 (0.8%) 0 1 (0.3%)
1 98 (83.1%) 188 (87.0%) 286 (85.6%)
2 19 (16.1%) 28 (13.0%) 47 (14.1%)
Previous lower abdominal surgery 6 (5.1%) 4 (1.9%) 10 (3.0%) 0.195
Preoperative diagnosis 0.014
Polyp 56 (47.5%) 63 (29.2%) 119 (35.6%)
Gallstone 59 (50.0%) 139 (64.4%) 198 (59.3%)
Polyp and stone 2 (1.7%) 7 (3.2%) 9 (2.7%)
Chronic cholecystitis 0 2 (2.3%) 2 (0.6%)
Acute cholecystitis 1 (0.8%) 5 (2.3%) 6 (1.8%)
Preoperative ERCP 2 (1.7%) 7 (3.2%) 9 (2.7%) 0.404

Table 1.  Demographics. BMI, body mass index; ASA, American Society of Anesthesiology; ERCP, endoscopic
retrograde cholangiopancreatography.

previous lower abdominal surgery. A preoperative diagnosis showed significant differences between the two
groups, with the Si/Xi group having more patients with simple polyps and the SP group having more patients
with multiple gallstones, and chronic or acute cholecystitis cases. Moreover, additional patients in the SP group
underwent preoperative ERCP for CBD stones.

Operative outcomes. All defined operative times demonstrated significant statistical differences. SP
robotic cholecystectomy took less docking and console (including the dissection time) times (Table 2). The
docking time of the Si/Xi system was 20 min in the first case and was decreased with more consecutive cases,
whereas that of the SP system maintained constant inclination (Fig. 4).
Three patients underwent conversion surgery from robotic to laparoscopic and open surgery: one in the Si/
Xi group and two in the SP group. Two cases were converted to multiport laparoscopic surgeries because one
had acute cholecystitis and the other had severe adhesions from previous upper abdominal surgery. The other
case was converted to open surgery because intraoperative findings could not rule out GB cancer. There were
no significant differences in the adhesion in Calot’s triangle and wall thickening, which commonly indicate the
presence of inflammation. The actual intraoperative findings of acute inflammation did not differ significantly.
However, the Si/Xi group had more bile spillages than the SP group (12.7% Si/Xi vs. 4.2% SP., P = 0.004). The
estimated blood loss for all patients was < 50 ml, except for cases that were converted to laparoscopic or open
surgery. There were no intraoperative complications, such as massive bleeding or bile duct injuries.

Postoperative outcomes. Postoperative outcomes, including postoperative complications and length of

hospital stay, did not show significant differences (Table 3). The rate of postoperative complications in all cases
was 11.1%, with 11.9% in the Si/Xi group and 10.6% in the SP group. The most common complications were
wound problems, including seroma and infection (8.5% Si/Xi vs. 8.3% SP). The incisional hernia rate was only

Si/Xi SP Total
Variables (n = 118) (n = 216) (N = 334) P-value
Adhesion in Calot’s triangle 9 (7.6%) 12 (5.6%) 21 (6.3%) 0.456
Acute inflammation 3 (2.5%) 7 (3.2%) 10 (3.0%) 0.720
Wall thickening 15 (12.7%) 34 (15.7%) 49 (14.7%) 0.455
Bile spillage 15 (12.7%) 9 (4.2%) 24 (7.2%) 0.004
*Conversion rate 1 (0.8%) 2 (0.9%) 3 (0.9%) 0.714
Docking time (min) 7.50 ± 3.87 3.07 ± 1.46 4.63 ± 3.34 < 0.000
Console time (min) 29.58 ± 14.92 21.18 ± 12.91 24.15 ± 14.21 < 0.000
Actual dissection time (min) 37.08 ± 17.49 24.25 ± 13.46 28.78 ± 16.20 < 0.000
Total operative time (min) 61.06 ± 21.89 21.89 ± 16.10 51.41 ± 19.66 < 0.000

Table 2.  Intraoperative findings and operative times. * Conversion to laparoscopic or open. * EBL: all were
less than 50 ml.

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Figure 4.  Docking times in chronological order.

Si/Xi SP Total
Variables (n = 118) (n = 216) (N = 334) P-value
Postoperative complication 14 (11.9%) 23 (10.6%) 37 (11.1%) 0.910
Wound seroma 4 (3.4%) 7 (3.2%) 11 (3.3%)
Wound infection 6 (5.1%) 11 (5.1%) 17 (5.1%)
Incisional hernia 2 (1.7%) 3 (1.4%) 5 (1.5%)
Operative site fluid collection 0 1 (0.5%) 1 (0.3%)
Postoperative stay (day) 2.43 ± 0.947 2.39 ± 0.71 2.41 ± 0.80 0.674

Table 3.  Postoperative outcomes.

1.5%, with 1.7% in the Si/Xi and 1.4% in the SP. One case of fluid collection in the abdominal cavity required
percutaneous drainage in the SP group.

Discussion
Minimally invasive surgery is entering the era of robotic surgery, beyond the era of laparoscopic surgery. Robotic
surgery has overcome the non-ergonomic limitations of laparoscopic surgery and makes MIS possible in several
complicated surgeries. Robotic systems have also been developed gradually, and even SP robot systems that can
operate with a single hole with minimal invasiveness have been developed. Since the da Vinci SP was launched
in 2018, it has only been applied in a few surgical fields. Single-incision surgeries themselves have not received
attention because of the risk of surgeries and challenging techniques and have not been popularized to develop
more. However, there are several advantages of the SP system in overcoming the potential limitations of single-
incision surgeries. We anticipate that our experience with SP robotic cholecystectomy and some previous studies
will enable us to pursue MIS with easier techniques and patient safety.
At our center, we have had experience with three types of robotic systems. First, we performed cholecystec-
tomy with the Si and Xi systems and observed that docking was difficult. Hand movements were still uncom-
fortable and caused collisions of the robotic arms. Subsequently, when we attempted the newly introduced SP
cholecystectomy, we found that the SP system was more convenient and ergonomic than the Si or Xi systems and
continued to use this system for single-incision robotic cholecystectomy. To confirm the safety, feasibility, and
convenience of the new SP system, we analyzed the experiences of all three systems at our center.
In the beginning of experiences at our center, the patient population receiving robotic surgeries primarily
consisted of young female patients with a lower BMI, or a lower ASA score, who often have greater concerns in
cosmesis. Since robotic cholecystectomy is a relatively new technology that requires further safety evaluation, we
tended to exclude complicated cases. Due to the lack of sufficient evidence regarding the safety and effectiveness
of robotic surgery, there was a possibility of increased danger to such patients. Patients who may have a higher
risk of operative or postoperative complications for any surgery were typically excluded from consideration for
robotic surgery. Given that the Si/Xi system was introduced before the SP system at our center, we were more
careful in selecting cases during the early stages of our experience with Si/Xi. After the SP system was introduced,
we believed that it was superior to the Si/Xi system in terms of improved and refined function, such as instrument
articulation, and performed robotic cholecystectomy using the SP system in most cases. Thus, regarding safety,
this might explain the demographic outcome that there were significantly younger patients and more females
in the Si/Xi group. However, at present, there is no limitation on age or gender unless the patient disagreed with
robotic surgery.
The case selection was also applied to clinically complicated cases which included patients who had undergone
previous upper abdominal surgeries or preoperative ERCP or were diagnosed with severe cholecystitis. These
complicated cases might increase the risk of conversion to laparoscopic or open surgery because of inflamma-
tion and adhesion. Nevertheless, there were a few cases in which robotic cholecystectomy was performed in

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patients with acute cholecystitis and in patients undergoing preoperative ERCP using the SP system. Almost all
the procedures were successfully performed, except in one case with acute cholecystitis, which was converted to
open surgery. In the study by Kang et al., significantly more cholecystectomies were also attempted in patients
with acute cholecystitis using the SP than the Xi system (31.9% vs. 1.6%; P < 0.001)4, which might indicate that
acute inflammation or disease severity affected the surgeons’ preference for a specific type of robotic system
when performing robotic cholecystectomy. However, when deciding to perform robotic surgery, in addition to
the safety of the operation, the medical costs of robotic surgery should not be ignored.
Financial and administrative issues were also factors in case selection. Robotic surgeries often cost two or
three times as much as open or laparoscopic surgeries in Korea. Complicated cases have more chances of con-
version surgery, which can result in additional expenses for patients without the anticipated benefits of robotic
surgery. Thus, patients without personal insurance often face difficulties in accessing robotic surgeries due to
financial issues. Moreover, some of them require urgent surgery, for which robotic cholecystectomy is difficult to
perform due to scheduling and administrative issues. The case selection in our study aligned with those in two
previous studies conducted in ­Korea3,4. It is always a concern before robotic surgery in Korea. In the future, we
are planning to include more complicated cases and analyze the postoperative outcomes.
Regarding intraoperative outcomes, iatrogenic bile spillage was observed to occur more frequently in the
Si/Xi group. Most of the bile spillage occurred from the gallbladder wall during the dissection of the gallblad-
der from the liver (cystic plate dissection). The Si/Xi system, which did not have wrist movement in its robotic
arms, was limited in its ability to achieve the appropriate angle required for dissection, whereas the SP system
with its multidirectional wrist movement allowed for more refined dissection, resulting in reduced bile spillage.
In addition, the conversion rate in MIS is generally an important indicator of safety and feasibility. The total
conversion rate was as low as 0.9%, with no significant difference between the two groups. Previous studies
including patients undergoing single-incision cholecystectomy with the Si or Xi system have also reported low
conversion rates of 0–3.3%1,3,5.
One of the most distinguishing features between Si/Xi and SP systems was the operation time. There were
significant differences in all aspects of the operation time, including the docking, console, and actual dissection
times. Shorter console and actual dissection times might indicate easier control of the robotic arms during chol-
ecystectomy. Cruz et al., also reported that all three operative times were shorter with the SP system.
Because the Si and Xi systems require a skilled technique for inserting the robotic curved cannula and dock-
ing the robot arm, it could take time, and possible dislocation can result in an intracorporeal collision. In Fig. 3,
the graph of the docking time in the Si/Xi system gradually decreases in consecutive cases, whereas the graph in
the SP system shows a minimal change. This finding demonstrated that the learning curve of the docking in the
Si/Xi system is longer compared to that in the SP system. This may be due to the structural advantage of the SP
system which only requires a single arm for docking whereas the Si/Xi system requires the docking of 3 arms. In
addition, the articulating function of instruments in the SP system is more ergonomic and enables easier learn-
ing and more comfortable dissection leading to a shorter dissection time and operation time. We believe that
since the two systems are structurally different, previous experiences with the Si/Xi system may have had only
minimal impact on the learning curve and operative times.
The postoperative outcomes, postoperative complications, and postoperative stay were comparable between
the two groups. The cosmesis of the umbilical wounds in both groups was similar (data not shown). The SP sys-
tem requires at least a 2.7 cm transumbilical incision to insert the robotic cannula, whereas the Si/Xi system may
require an incision as small as 2.5 cm. These do not affect cosmetic results because the incision is hidden inside
the umbilicus. However, the size of the incision may be associated with the rate of incisional hernia formation.
In the present study, the total rate of incisional hernias was 1.5%, with no significant difference between the SP
and Si/Xi groups. Previously, the rate of umbilical port site hernia after Si/Xi cholecystectomy was reported to
be 5.2–8%5–7.
Technically, the SP system was simpler and more convenient (Table 4). First, among the numerous advanta-
geous features of the SP system, the third arm controlled by the surgeon for traction of the gallbladder (Fig. 5) and
the multidirectional EndoWrist function (Fig. 6) are by far the most important factors for easier dissection and
easier control of the GB, respectively. Second, in the case of Si/Xi, the previous study by Jung et al.8 introduced
the reverse-port technique to perform dissection around the cystic duct and cystic artery. However, in SP, the
arms can be extended using the EndoWrist. Third, in acute cholecystitis, the cystic duct can sometimes become
dilated and is thus difficult to ligate using a typical single-size medium-large (green) robotic hemolock. In the
SP system, the assistant can insert a larger hemolock (purple) through the gel port or other access port (ex. glove
port) beside the insertion site of the SP cannula to clip the cystic duct (Fig. 7). Furthermore, if the cystic duct is
too thick or accompanies Mirizzi syndrome, it cannot be ligated even with a large hemolock. However, in the SP
system, because it is easier to suture with EndoWrist, primary repair can be performed on the cystic duct stump.
However, this study has some limitations. Its retrospective nature and relatively small sample size may have
limited the results. However, all robotic cholecystectomies were performed at a single center, which might help
maintain the consistency of the procedure. There were case selections in both groups. Thus, either robotic sys-
tems may not be applied to certain patients who have high BMI or underlying diseases that would significantly
affect the surgical outcomes.
Robotic SP cholecystectomy is safe and feasible in terms of comparable perioperative complications and low
conversion rates and is convenient for many newly applied systems. We believe that robotic SP cholecystectomy
is more advantageous in terms of the docking process and three robotic arms with multi-joint EndoWrist move-
ment, which gives us reasons not to return to the Xi system.

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Si/Xi SP
3D visualization 3D visualization
Inversion of the instruments: wider movement, better ergonomics Easy docking process
Three working robotic arms Traction controlled by the
Curved 5 mm cannulas and semi-rigid instruments restore triangulation
surgeon
Remote center technology minimizes collisions, crowding, and trauma Multi-joint Endo-Wrist instruments articulation
Advantage Distal instrument triangulation (at the tip)
360-degree rotation
Access narrow space
24 cm reach
Flipped camera view
Broad versatile
No internal wrist No triangulation at tip No suction arms, no energy device
Two working robotic arms Need an assistant for GB retraction Narrow range of motion
Disadvantage
Difficult docking process
No suction arms, no energy device

Table 4.  Advantages and disadvantages of Si/Xi and SP.

Figure 5.  The SP system has three arms that can be controlled by the operator. The middle arm, in this case, the
Cardiere forceps arm, is used for GB traction (a) or liver traction (b).

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Figure 6.  The Endo-wrist in the SP system allowed approaching the surgical field with the appropriate angle.
(a) Hook; (b) hemo-lock applier.

Conclusions
Our results and successful patient outcomes suggest that SP cholecystectomy is a safe and feasible procedure
in terms of comparable postoperative complication rates and is more convenient in terms of docking and tech-
niques. The long-term outcomes of robotic SP cholecystectomy with a larger number of cases are needed in the
future.

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Figure 7.  (a, b) The large hemo-lock (red arrow; “purple” size) was inserted through the umbilical port by the
assistant to ligate the cystic duct.

Data availability
The datasets analyzed during the current study are available from the corresponding author on reasonable
request.

Received: 11 August 2022; Accepted: 28 May 2023

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Author contributions
Conception and design: Y.J.C., N.T.S. Administrative support: D.S.K., Y.D.Y., H.S.J. Provision of study and mate-
rials or patients: Y.D.Y., H.S.J. Collection and assembly of data: Y.J.C., Y.D.Y.Data analysis and interpretation:
Y.J.C., N.T.S. Manuscript writing and final approval of manuscript: All authors.

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Competing interests
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to Y.-D.Y.
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