Single-Port Surgery and the Cost of Being Early
- Lee Zhao
- Jan 29
- 4 min read
Intuitive wins 3 new indications for da Vinci SP system
I.
There is a famous graph of the cost of solar power. It looks like a slide at a water park: an inexorable drop from "prohibitively expensive, best for space tech" in 1975 to "cheaper than coal" in 2023.
If you had written a blog post about solar panels in 1990, you would have been factually correct to say they were an inefficient, overpriced toy for rich eco-hobbyists. You would have pointed out that burning the crushed husks of 300 million year old trees was undeniably more cost-effective. You would have been right on the economics, right on the efficiency metrics, and completely wrong about the future.
I think about this curve when people complain about the cost of Single-Port (SP) robotic surgery. The critics—and I have been one—point out that doing a gallbladder removal (cholecystectomy) through a single 2.5cm incision costs significantly more than doing it through four tiny 8mm incisions. They argue that the clinical benefit is marginal. "Is a hidden scar worth $2,000?" they ask.
This is the "Static Analysis" view. It looks at the technology as it exists today—a frozen snapshot of cost vs. benefit. But if you switch to "Dynamic Analysis"—viewing SP not as a product, but as a trajectory—the picture changes completely. We aren't just paying for a hidden scar. We are paying the tuition for the next century of surgical capability.
II.
The fundamental error in the "it’s just a fancy stick" argument is that it mistakes the robot for a tool. The robot is not a tool; it is a platform. A scalpel is a tool. You can sharpen it, maybe make the handle ergonomic, but a scalpel in 2026 is fundamentally the same as a scalpel in 1926. It doesn't get firmware updates.
A robotic system is a platform. When you buy a da Vinci SP, you aren't just buying the metal arms. You are buying a digitizable interface between the surgeon's mind and the patient's body.
Right now, that interface is doing something very hard: it is solving the Triangulation Problem. In traditional laparoscopy, triangulation requires physical separation. You need to stand with your arms wide apart to get leverage. The SP robot solves this with software and "wristed" elbows. It allows the instruments to enter parallel and then deploy into a working triangle inside the body.
This is a "Zero to One" innovation. Standard laparoscopy hit its ceiling ten years ago. We can't make surgery using sticks much better. Multiport robotics makes standard laparoscopy much easier on the surgeon. SP robotics is still at the bottom of its S-curve. The software that drives those elbows can get better. The instruments can get smaller. The vessel sealer will come. We are currently using the iPhone 1 of single-port surgery. It doesn't have an App Store yet, and the battery life sucks. But betting against the iPhone 1 because "flip phones are cheaper and have buttons" was a bad bet.
III.
Let’s talk about "The Constraint."
In design, constraints are the engine of creativity. The constraint of Single-Port is: You have one cylinder of space. Make it work. This constraint is forcing us to rethink anatomy. When you can only approach an organ from one vector, you have to understand the fascial planes perfectly. You can't just bully the tissue out of the way with four different retractors. You have to flow with the anatomy. This has unlocked procedures that were previously nightmares. Consider my own specialty, reconstructive urology. Narrowing of the urethra after prostatectomy used to be a condition that was not treated surgically. Fixing the narrowing was fraught with risk--incontinence, rectal injury, recurrent stricture. Now, I can make an incision in the bladder, and go transvesically with the SP. Incise the stricture and augment with a graft. Single incision, same day discharge. What about in general surgery instead of urology? Transanal Minimally Invasive Surgery (TAMIS). If you have a rectal tumor, the old way to get it out involved massive abdominal incisions, potentially removing the sphincter, and a permanent colostomy bag. With SP, we can go through the natural orifice (the anus), deploy the elbows, and dissect the tumor out from the inside. No skin incision. No bag. The "luxury" technology suddenly becomes the only thing standing between a patient and a life-altering disability. By practicing on "simple" gallbladders, surgeons are building the muscle memory and the spatial reasoning required to pull off these "impossible" surgeries. The routine cases are the training ground for the miraculous ones.
IV.
There is also a weird Puritanism in surgery that suggests "Patient Experience" is a frivolous metric. The argument goes: "As long as the cancer is out and the patient doesn't die, who cares if they have one scar or four? Who cares if they take one Tylenol or four Oxycodone?" I think this is wrong. We should care about the aesthetic outcome. We should care that a patient can look down at their abdomen and not see a zipper or a constellation of holes. We should care that the reduced trauma means less pain, less opioids, faster return to regular life.
Innovation in surgery has always been about reducing the collateral damage of the cure.
Ether reduced the trauma of pain.
Antisepsis reduced the trauma of infection.
Laparoscopy reduced the trauma of access.
Single-Port is the logical extension of that trend. If we can do a major operation and leave no trace that we were ever there—like a thief in the night stealing a diseased organ, or for me, like a plumber who fixes the leaking pipe without shutting off the water main—that is a noble goal. It respects the integrity of the human body in a way that "big whack" open surgery never did.
V.
So, is Single-Port robotic surgery "good" or "bad"?
If you are a hospital CFO looking at this quarter's spreadsheet, it is "bad." It is an expense line item that makes your margins thinner.
But if you are a patient, a hospital CEO thinking of the next quarter century, or a surgeon who loves the craft, it is overwhelmingly "good."
We are currently in the awkward adolescence of the technology. It’s expensive, sometimes finicky, and easy to mock. But we are climbing the hill. And the view from the top—a world where major surgery is an outpatient procedure without visible scars and superhuman precision—is worth the climb.