Reduced-port robotic partial hepatectomy using a simultaneous colostomy-closure site via a glove-port: a case report

Abstract

Introduction:

In patients with prior colorectal cancer, subsequent liver resection adds surgical trauma. We present a reduced-port robotic liver resection that reused the simultaneous colostomy closure site as a glove-port to minimize new incisions.

Case presentation:

An 81-year-old woman had a 12-mm indeterminate lesion in liver segment 5 on surveillance computed tomography, 10 months after semi-emergency laparoscopic sigmoidectomy with a diverting colostomy for obstructing sigmoid colon cancer. The lesion was atypical for metastasis on positron emission tomography and gadoxetic acid-enhanced MRI, but could not be excluded as a metachronous metastasis, so simultaneous colostomy closure and robotic partial hepatectomy were performed. After bowel closure, a glove-port – a Small Alexis (R) wound retractor with a surgical glove – was placed at the stoma site and accommodated an 8-mm robotic trocar and a 12-mm assistant trocar through a single incision; three additional 8-mm robotic trocars and a Pringle tourniquet were inserted. The tumor was resected using a double bipolar technique and retrieved through the stoma site with the retractor left in place, without a retrieval bag. Histology revealed a benign focal nodular hyperplasia–like lesion; recovery was uneventful without surgical site infection.

Discussion:

Reusing a stoma site as a glove-port reduces skin incisions and avoids a separate extraction incision; the dual-ring wound retractor and a purse-string closure mitigate the infection risk associated with simultaneous stoma closure.

Conclusion:

The glove-port technique using a stoma closure site is a feasible, minimally invasive option for selected patients with existing stomas, achieving an uneventful recovery without surgical site infection in this case.

Introduction

Robotic-assisted surgery has increasingly been adopted for liver resection, offering enhanced three-dimensional visualization and articulated instrument control that facilitates precise parenchymal transection^[1,2^]. For patients with a history of colorectal cancer, subsequent liver resections for suspected metachronous metastases often compound the cumulative surgical trauma and incisional burden. These patients frequently have temporary stomas or pre-existing abdominal scars. Minimizing additional abdominal wall trauma is, therefore, a key priority to enhance postoperative recovery, improve cosmesis, and reduce the risk of incisional hernia.

HIGHLIGHTS

• Reusing a colostomy site as a glove-port in robotic hepatectomy.

• A stoma closure and liver resection minimized the number of incisions.

• The glove-port accommodated both a robotic arm and an assistant trocar.

• This technique is a cost-effective way to reduce surgical trauma.

Reduced-port surgery aims to decrease the number of surgical incisions. Although dedicated multichannel commercial single-port devices are available, they are often rigid and costly; a glove-port assembly, fashioned from a wound retractor and a sterile surgical glove, provides a flexible, low-cost alternative^[3^]. In conventional laparoscopic surgery, the reuse of a previous stoma site for port access has been reported as a useful way to minimize additional trauma^[4,5^]. Recently, dedicated single-port robotic platforms have also been applied to minor and major hepatectomies with encouraging early outcomes^[6,7^]. However, the reuse of an existing stoma wound as a reduced-port access site in robotic liver resection has not, to our knowledge, been reported.

Here, we present a case of robotic partial hepatectomy using a modified reduced-port technique. By placing a glove-port at the site of a simultaneous colostomy closure, we repurposed the existing wound for both robotic and assistant access, as well as for specimen extraction. This case report has been prepared in accordance with the SCARE 2025 criteria^[8^].

Case presentation

An 81-year-old woman had undergone semi-emergency laparoscopic sigmoidectomy with a diverting transverse colostomy for obstructing sigmoid colon cancer ten months earlier. Routine follow-up computed tomography revealed a 12-mm indistinct lesion in segment 5 of the liver (Fig. 1), and, suspecting a metachronous liver metastasis, the referring physician sent her to our department. Positron emission tomography showed no significant uptake, and on gadoxetic acid-enhanced (hepatobiliary-phase) MRI, the lesion was not typical of a metastatic tumor; nevertheless, because a hepatic lesion had newly appeared only ten months after resection of the colorectal primary, a metachronous metastasis could not be excluded. As the diverting colostomy was also due for reversal, we planned a simultaneous colostomy closure and robot-assisted partial hepatectomy as diagnostic treatment to obtain a definitive histological diagnosis and potential cure while restoring bowel continuity. The clinical timeline is summarized in Table 1.

Figure 1.

Dynamic computed tomography demonstrated a hypoattenuating tumor, 12 mm in size, in segment 5 of the liver (arrow).

Table 1.

Clinical timeline.

Time point	Event
10 months before admission	Semi-emergency laparoscopic sigmoidectomy with a diverting transverse colostomy for obstructing sigmoid colon cancer
Routine follow-up (10 months later)	Surveillance computed tomography revealed a 12-mm indistinct lesion in liver segment 5 (Fig. 1); referred to our department under suspicion of metachronous metastasis
Preoperative workup	Positron emission tomography showed no significant uptake; the lesion was atypical for metastasis on gadoxetic acid-enhanced MRI, but a metachronous metastasis could not be excluded
Admission/Operation	Simultaneous transverse colostomy closure + reduced-port robotic partial hepatectomy via a glove-port (hepatectomy operative time 150 min; estimated blood loss 30 mL)
Pathology	Benign focal nodular hyperplasia (FNH)-like lesion; no malignancy
Postoperative day 1	Mobilization
Postoperative day 2	Resumed oral intake
Postoperative day 10	Discharged home
1-year follow-up	No surgical site infection, bile leak, or incisional hernia at the stoma/glove-port site

The operation commenced with the closure of the transverse colostomy in the right upper quadrant. Following secure closure of the bowel and its return to the abdominal cavity, the stoma site was repurposed as the primary access site for the robotic hepatectomy (da Vinci Xi system).

A glove-port was constructed at the stoma site by inserting a Small Alexis (R) wound retractor and securing a sterile surgical glove to its rim to form an airtight seal. Two openings were made in the glove to accommodate a 12-mm reusable assistant trocar and an 8-mm robotic trocar side-by-side through this single stoma incision (Fig. 2a). In addition to the glove-port, three standard 8-mm robotic trocars were placed horizontally across the upper abdomen, and a tourniquet for the Pringle maneuver was inserted in the left subcostal region (Fig. 2b). In total, six trocars were used through only five skin incisions, as the stoma site accommodated two trocars via the glove-port.

Figure 2.

Reduced-port robotic setup. (A) Intraoperative view of the glove-port assembly: a Small Alexis(R) wound retractor with a surgical glove secured to its rim allowed the introduction of both an 8-mm robotic trocar and a 12-mm assistant trocar through a single stoma incision; the two trocars are labeled. (B) Port placement for the reduced-port robotic partial hepatectomy. Three standard 8-mm robotic trocars (R1, R3, and R4) were placed; the glove-port at the site of simultaneous colostomy closure accommodated both an 8-mm robotic trocar (R2) and a 12-mm assistant trocar within a single incision; a tourniquet (P) was inserted in the left subcostal region for the Pringle maneuver. The reused stoma site and the camera and assistant trocars are annotated.

A summary of the procedure is shown in Supplemental Digital Content Video 1, available at: https://links.lww.com/IJSCR/A121. After establishing pneumoperitoneum, the robotic cart was docked, and all robotic arms were successfully attached. Through the 12-mm assistant trocar placed in the glove-port, the assistant surgeon effectively performed suction, liver retraction, clip application, and intraoperative ultrasonography. Guided by ultrasonography, the ventral branch of the Glissonean pedicle feeding the lesion in segment 5 was isolated and doubly clipped. Parenchymal transection was carried out using a double bipolar technique for precise, bloodless division (Fig. 3), with the Pringle maneuver applied as necessary. Despite the flexible nature of the glove-port, no significant instrument clashing or loss of triangulation occurred between the robotic arm and the assistant instrument sharing the same incision.

Figure 3.

Operative findings during parenchymal transection. The ventral branch of the Glissonean pedicle to segment 5 [G5(1)] was clipped and divided, while the dorsal branch [G5(2)] was preserved.

Upon completion of the resection, the specimen was retrieved directly through the colostomy (glove-port) site, with the Alexis retractor left in place and without using a retrieval pouch; because the wound edges were already protected by the wound retractor, a retrieval bag was unnecessary. This eliminated the need to enlarge any other port site or create a new incision for specimen extraction. The skin at the stoma site was then closed using a purse-string suture. The operative time for the hepatectomy was 150 minutes, and the estimated blood loss was 30 mL.

Histopathological analysis revealed a benign focal nodular hyperplasia (FNH)-like lesion with no evidence of malignancy. The patient recovered uneventfully; she was mobilized on postoperative day 1, resumed oral intake on day 2, and was discharged home on day 10. No surgical site infection (SSI), bile leak, or incisional hernia were observed at the stoma/glove-port site during the 1-year follow-up (Table 1).

Discussion

This case demonstrates the feasibility of a glove-port-assisted, reduced-incision approach to robotic liver surgery, in which a simultaneous colostomy closure site was repurposed for robotic and assistant access, as well as for specimen extraction. We regard this report as a proof-of-concept rather than an established standard. The strategy is most applicable to selected patients who already require stoma closure and who harbor a hepatic lesion amenable to a limited resection. The tumor need not be small; rather, the principal determinants of feasibility are the location of the lesion and the extent of resection, since deep-seated or posterosuperior lesions, or those requiring an anatomically complex or major resection, may be less suited to a shared glove-port, as discussed below.

Standard minimally invasive hepatectomy typically employs five to six trocars plus an additional extraction incision (e.g., a Pfannenstiel incision or enlargement of a port site) for specimen retrieval. Recent large series and consensus statements report robotic liver resection to be safe, with operative times broadly comparable to – or somewhat longer than – laparoscopy and with low blood loss^[2,9^]. In a propensity-matched meta-analysis, robotic resection was associated with less intraoperative bleeding and fewer conversions than laparoscopy, albeit at a higher cost^[10^]. Against this background, our approach used six trocars but only five skin incisions, because the stoma wound accommodated two trocars through the glove-port and also served as the extraction site, thereby avoiding a dedicated extraction incision. The hepatectomy operative time (150 minutes) and blood loss (30 mL) were within the range reported for minor robotic resections^[6^]. Ergonomically, although the glove-port is flexible, the rigidly docked robotic arm maintained a stable platform, and we observed no significant instrument collisions or loss of triangulation between the robotic and assistant instruments sharing the incision (Supplemental Digital Content Video 1, available at: https://links.lww.com/IJSCR/A121). This contrasts with pure laparoscopic single-incision surgery, in which loss of triangulation and instrument clashing (the ‘sword-fighting’ or ‘chopsticks’ effect) are well-recognized limitations^[11^].

Interest in reducing the access footprint of robotic hepatectomy is growing. Dedicated single-port robotic platforms (e.g., the da Vinci SP) have recently been applied to minor and even major hepatectomies with encouraging early outcomes^[6,7,12,13^]. However, such platforms are costly and not universally available. The reuse of a stoma site as a port has precedent in conventional laparoscopy – for example, single-port access through a colostomy site for Hartmann’s reversal^[4^], and reuse of a cutaneous ureterostomy stoma as a multichannel port for laparoscopic nephroureterectomy^[5^] – but to our knowledge, it has not been described for robotic liver resection. Our glove-port technique thus offers a low-cost, widely reproducible means of reducing incisions on the standard multi-arm Xi system, and it uniquely exploits an existing stoma wound rather than creating a new single-port site.

A principal concern when reusing a stoma closure site for an otherwise clean procedure is SSI, the incidence of which after stoma reversal is substantial^[14^]. We mitigated this risk by (1) completing the bowel closure and returning the bowel before commencing the clean hepatic phase, (2) using the dual-ring Alexis(R) wound retractor, whose circumferential barrier shields the subcutaneous and muscular layers during both stoma closure and specimen extraction, and (3) applying a purse-string skin closure, which is associated with lower SSI rates than primary linear closure after stoma reversal. No SSIs occurred. Nonetheless, we consider this technique appropriate only for carefully selected patients. Suggested selection criteria include the absence of gross intraoperative contamination, a clean or clean-contaminated field after bowel closure, a stoma site positioned to permit ergonomic robotic geometry for the target segment, and a hepatic lesion amenable to limited resection. Cases with significant contamination or active infection at the stoma site should be excluded.

From an economic standpoint, robotic surgery carries a high baseline cost, and we do not claim that the robotic approach itself is cost-saving. Rather, the incremental cost advantage lies in the access strategy: the glove-port is assembled from a wound retractor and a standard surgical glove with reusable trocars, which avoids the expense of commercial multichannel single-port devices, and reusing the stoma site obviates the materials and operative time associated with a separate extraction incision. These savings are modest relative to the overall cost of robotic surgery but are achieved without compromising the established advantages of the robotic platform.

The final histology revealed a benign FNH-like lesion. On imaging, the lesion was not typical of a colorectal metastasis – positron emission tomography showed no significant uptake and the hepatobiliary-phase MRI features were atypical – yet the appearance of a new hepatic nodule only 10 months after resection of the colorectal primary made it impossible to exclude a metachronous metastasis. We therefore proceeded with resection as diagnostic treatment, obtaining both a definitive histological diagnosis and potential cure in a single, minimally invasive procedure that was, moreover, already indicated for stoma reversal. This accords with the imaging behavior of FNH-like lesions, which are hypervascular and typically differ from the hypovascular appearance of colorectal liver metastases on the hepatobiliary phase, although they can resemble other hypervascular tumors (notably hepatocellular carcinoma) and may be difficult to characterize with confidence, particularly when small or atypical^[15^]; in comparable cases, dedicated hepatobiliary-phase MRI and, where appropriate, percutaneous biopsy may help to avoid unnecessary resection of benign disease.

This report has several limitations. First, it describes a single case, precluding any conclusion regarding reproducibility or comparative effectiveness. Second, the tumor was small (12 mm) and superficially located in segment 5; for larger tumors or lesions in posterosuperior segments (e.g., segments 7 and 8), the risk of collision between the robotic arm and the assistant instrument within a shared glove-port would likely increase, and the technique may not be feasible. Third, the stoma was situated in the right upper quadrant, a location favorable for right-liver access; a differently sited stoma might not afford suitable robotic geometry. Fourth, although the patient mobilized on postoperative day 1, resumed oral intake on day 2, and was discharged on day 10 without complications, we did not record validated pain scores or quality-of-life and functional-recovery measures; future application of this technique should incorporate such objective measures. The accumulation of further cases is required to define the safety, ergonomics, and patient-selection criteria of this approach.

Conclusion

A reduced-port robotic partial hepatectomy was successfully performed by reusing a simultaneous colostomy closure site as a glove-port for robotic access, assistant access, and specimen extraction. In appropriately selected patients with an existing stoma and a small, accessible hepatic lesion, this technique can reduce the number of skin incisions and avoid a separate extraction site while preserving the advantages of the robotic platform – here, – with an uneventful recovery and no surgical site infection. Further experience is needed to confirm its safety and define its indications.

Ethical approval

Ethical approval was waived by the Institutional Review Board of Dokkyo Medical University as this is a single case report. The study was conducted in accordance with the Declaration of Helsinki.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

The authors declare that they have no funding.

Author contributions

T.M. performed the operation. M.N. and T.M. drafted the manuscript. S.S., G.T., T.H., T.S., T.S., S.M., M.T., and K.I. participated in the care of the patient. TA supervised the manuscript. All authors read and approved the final manuscript.

Conflicts of interest disclosure

The authors declare that they have no conflicts of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Takatsugu Matsumoto, MD, PhD (corresponding author) is the guarantor of this work and accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

All data generated or analysed during this study are included in this published article. Further inquiries can be directed to the corresponding author.