Development of scar-less laparoscopic hernia repair (TAPP-252) facilitated by new 2mm instruments

Introduction: To minimize the invasiveness of laparoscopic transabdominal preperitoneal hernia repair (TAPP) for the treatment of adult inguinal hernia, we developed a new operative technique with the use of only one 5?mm port and two 2?mm punctures (TAPP-252).

Material and methods: To facilitate TAPP-252, we developed seven kinds of new 2?mm instruments, including grasping forceps, hook shaped electrode, mesh pusher, needle driver, scissors, laparoscope and port.

Results: TAPP-252 was stably performed in 35 patients with minimal abdominal wall destruction and excellent cosmetic result without any recurrence or morbidity.

Conclusions: The newly developed 2?mm devices showed sufficient performance and durability in TAPP-252. Further investigation is necessary to assess durability and long-term outcomes.     

Successful cholecystectomy during robotic gastrectomy

Abstract

Background: Surgeons have successfully combined various laparoscopic procedures with increasing technical ease. However, few reports exist regarding the feasibility of combined robotic operations. We present our institution's successful concomitant robotic surgery for early gastric cancer and coexisting gallbladder disease. Material and methods: From our prospectively collected database, seven patients who received robotic cholecystectomies during their robotic gastric cancer operations were retrospectively compared to 247 patients who underwent robotic gastrectomies alone. Preoperative patient characteristics, operative factors, postoperative length of stay, and complications were evaluated. Results: The preoperative patient characteristics and operative factors did not differ between the two groups. All robotic cholecystectomies were performed with the same ports and instruments used during robotic gastrectomies without open conversion, robot redocking or patient repositioning. Mean time to perform robotic cholecystectomies was 15.1 + 3.2 minutes. The combined group had no mortality, one wound infection, and one intraabdominal fluid collection at the gastric resection bed, which were comparable to the gastrectomy alone group. The mean postoperative length of hospital stay was unaltered by the addition of the cholecystectomy. Conclusions: Robotic cholecystectomies can safely and efficiently be combined with robotic gastric cancer surgery, yielding several benefits. Improving robotic technology and experience may allow surgeons to efficiently combine more complicated procedures.     

A study of an assisting robot for mandible plastic surgery based on augmented reality

Background: Mandible plastic surgery plays an important role in conventional plastic surgery. However, its success depends on the experience of the surgeons. In order to improve the effectiveness of the surgery and release the burden of surgeons, a mandible plastic surgery assisting robot, based on an augmented reality technique, was developed.

Material and methods: Augmented reality assists surgeons to realize positioning. Fuzzy control theory was used for the control of the motor. During the process of bone drilling, both the drill bit position and the force were measured by a force sensor which was used to estimate the position of the drilling procedure.

Results: An animal experiment was performed to verify the effectiveness of the robotic system. The position error was 1.07?±?0.27?mm and the angle error was 5.59?±?3.15°. The results show that the system provides a sufficient accuracy with which a precise drilling procedure can be performed. In addition, under the supervision’s feedback of the sensor, an adequate safety level can be achieved for the robotic system.

Conclusion: The system realizes accurate positioning and automatic drilling to solve the problems encountered in the drilling procedure, providing a method for future plastic surgery.     

A novel locally operated master-slave robot system for single-incision laparoscopic surgery

Abstract

Purpose: Single-incision laparoscopic surgery (SILS) provides more cosmetic benefits than conventional laparoscopic surgery but presents operational difficulties. To overcome this technical problem, we have developed a locally operated master-slave robot system that provides operability and a visual field similar to conventional laparoscopic surgery. Material and methods: A surgeon grasps the master device with the left hand, which is placed above the abdominal wall, and holds a normal instrument with the right hand. A laparoscope, a slave robot, and the right-sided instrument are inserted through one incision. The slave robot is bent in the body cavity and its length, pose, and tip angle are changed by manipulating the master device; thus the surgeon has almost the same operability as with normal laparoscopic surgery. To evaluate our proposed system, we conducted a basic task and an ex vivo experiment. Results: In basic task experiments, the average object-passing task time was 9.50 sec (SILS cross), 22.25 sec (SILS parallel), and 7.23 sec (proposed SILS). The average number of instrument collisions was 3.67 (SILS cross), 14 (SILS parallel), and 0.33 (proposed SILS). In the ex vivo experiment, we confirmed the applicability of our system for single-port laparoscopic cholecystectomy. Conclusion: We demonstrated that our proposed robot system is useful for single-incision laparoscopic surgery.     

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis

Background: The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer.

Material and methods: A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review.

Results: A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups.

Conclusions: Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.     

Needlescopic intragastric surgery facilitated by newly developed 2mm instruments

Background: Intragastric surgery is a percutaneous endoluminal surgery in the stomach aimed at resection of tumors located at the esophagogastric junction (EGJ). We developed needlescopic intragastric surgery performed via 2?mm, 2?mm, and 5?mm ports (PEIGS-225).

Material and methods: In cooperation with Niti-On Co., Ltd. we developed a series of 2?mm instruments including grasping forceps, a cannula, a laparoscope, an electrocautery, scissors, and a needle holder. Operative technique: Two 2?mm trocars and a 5?mm one are inserted into the gastric lumen percutaneously. Intragastric procedures are performed by the instruments brought through those three ports. The specimen is extracted via the esophageal-oral route. The defect in the gastroesophageal wall is closed by hand-suture. After the intragastric procedure, the 5?mm stab wound on the gastric wall is closed by hand-suture, while the 2?mm wounds are left untreated. Patients: Between March and August 2015 PEIGS-225 was performed in five patients.

Results: There was no operative conversion. The mean operation time was 96?minutes. There were no perioperative complications. Pathological findings indicated that the margin was negative in all cases.

Conclusion: Needlescopic intragasric surgery performed via the smallest access (2?mm, 2?mm, 5?mm) is enabled by the 2?mm instruments developed by us.     

Comparison of single-incision and conventional laparoscopic surgery for benign adnexal masses

Background: Our aim was to compare single incision and conventional laparoscopic surgeries performed for benign adnexal masses with regard to their intraoperative characteristics and postoperative pain levels.

Material and methods: The main outcome measures were laparoscopic entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay.

Results: A total of 71 women, 39 in the conventional laparoscopy group and 32 in the SILS group, participated in the study. Demographic findings did not differ between the two groups. Similarly, rates of intraoperative complications, rates of conversion to laparotomy, pre- and postoperative hematocrit levels were not significantly different between the groups. Laparoscopic entry time was shorter in the SILS group (10.4?±?5.9?min. vs. 5.28?±?1.7?min.). However, total operation time was similar in the two groups. The groups did not show significant differences regarding additional analgesic requirements, or postoperative pain scores after 24?h. However, pain scores in the recovery room and after six and 12?h were lower in the SILS group.

Conclusion: SILS seems to be effective and safe for the treatment of benign adnexal masses. SILS appears to be advantageous regarding postoperative pain especially in the early period.     

Changes in abdominal wall thickness during laparoscopy: implications for the use of magnetic assisted surgery

Abstract

Introduction: Recently, magnetic solutions have been proposed to minimize surgical invasiveness. These are comprised of deployable instruments containing magnets which are inserted into the abdominal cavity through a single access point. The manipulation of the internal elements occurs via magnets held on the external surface of the abdominal wall. This technology relies on the magnetic force between the magnets, which is inversely related to the abdominal wall thickness (AWT). The aim of this study was to establish the expected change in AWT from before and after initiation of pneumoperitoneum.

Material and methods: Patients scheduled for laparoscopic procedures were assessed by ultrasound for AWT immediately before and during laparoscopy. Change of AWT during laparoscopy was calculated. Statistical analysis was performed using Student’s t-test.

Results: Thirty-two patients undergoing various laparoscopic procedures were included. Twenty patients were male (62.5%) and ten were morbidly obese (31%). Mean age was 51?years (range 18–76) and average BMI was 28.1?kg/m² (range 19.0–41.0). AWT decreased on average by 15.6% once pneumoperitoneum was initiated in both obese and non-obese patients (p?=?.01).

Conclusion: Our data suggest that following preoperative assessment of AWT with abdominal wall ultrasound, more patients than expected might be candidates for the use of trans-abdominal magnetic devices.     

Five millimetre-instruments in paediatric robotic surgery: Advantages and shortcomings

Purpose: The study was designed to assess the utility and controversies surrounding the usage of 5-mm instruments in paediatric robotic surgery. Adequate, delicate instruments for surgery in very narrow spaces are still lacking. Material and methods: Thirty children underwent elective abdominal robotic surgery. Working sites, assembly and operative time, hospital stay, advantages, complications and shortcomings are reported. Results: Interventions were performed in the following anatomical sites: 11 upper abdominal, nine pelvic, ten renal procedures. The majority of procedures required two operative trocars. A 2–3 mm accessory port was necessary for operations in the renal area and upper abdomen. The ports had to be placed at least 3 cm from the costal margins and superior iliac spines and at an angle of at least 130° with respect to the camera trocar. This configuration allowed intra-corporal knotting, vessel ligation and dissection with instruments in the inverted position. Operative times and hospital stays were similar to those reported for 8 mm-instruments. Conclusion: The use of 5-mm instruments was advantageous in renal and pelvic sites. The benefits in upper abdominal surgery need further evaluation, particularly in patients weighing <10 kg. Smaller sized instruments with high endowrist dexterity would resolve the problems encountered in paediatric robotic-assisted surgery using 5-mm instruments.     

Rate of skill acquisition in the use of a robotic laparoscope holder (FreeHand®)

Background: Robotic equipment can greatly add to the ergonomics of a surgical procedure and pre-operative simulation can provide risk-free training of the surgeon leading to precision surgery and less trauma to the patient. Freehand^® is a second-generation robotic camera-holding device, which has recently become available to laparoscopic surgeons. It is controlled by the operator selecting a direction using head movement followed by activation with a foot pedal. The purpose of this study was to assess the rate of skill acquisition in the use of the FreeHand^® robotic laparoscope holder by a group of laparoscopic surgeons by enrolling them into a programme of training modules at The ICENI Centre, Colchester Hospital University, UK.

Material and methods: Twenty surgical registrars performed a series of exercises, escalating in difficulty, to test their skill in controlling the FreeHand^® robot. Subjective and objective assessments were evaluated by an observer and by tracking analysis software created for this trial.

Results: The observed number of head movements showed a Percentage Performance Score (PPS) of 98% by the end of the third repetition of all exercises, the mean Total Head Movements Score (HMS) reached a plateau of performance at 72%. Fifty per cent of the participants selected ‘Effective control of movements without difficulty’ in the subjective evaluation by the end of the third repetition of exercises, while 35% selected ‘competent intuitive movements’.

Conclusion: The FreeHand^® robotic laparoscope holder is a useful device, which is easy to operate and requires a very short course of training to achieve competence in its use.     

Single incision endoscopic surgery for lumbar hernia

Abstract

Single Incision Endoscopic Surgery (SIES) has emerged as a less invasive surgery among laparoscopic surgeries, and this approach for incisional hernia was reported recently. This is the first report of SIES for an incisional lumbar hernia. A 66-year-old Japanese woman was referred to our institution because of a left flank hernia that developed after left iliac crest bone harvesting. A 20-mm incision was created on the left side of the umbilicus and all three trocars (12, 5, and 5 mm) were inserted into the incision. The hernial defect was 14 × 9 cm and was repaired with intraperitoneal onlay mesh and a prosthetic graft. The postoperative course was uneventful. SIES for lumbar hernia offers a safe and effective outcome equivalent compared to laparoscopic surgery. In addition, SIES is less invasive and has a cosmetic benefit.     

Laparoscopically assisted suprapubic surgery for adnexal tumors under epidural anesthesia

Objective: To evaluate the feasibility and safety of laparoscopically assisted surgery for benign ovarian tumors via a single suprapubic incision under epidural anesthesia.

Methods: Forty-three patients underwent laparoscopically assisted surgery via a single suprapubic incision under epidural anesthesia. Types of surgery were classified as follows: type I – suprapubic incision surgery without laparoscopic support, type II – suprapubic incision surgery with laparoscopic support but without CO₂ inflation; and type III – suprapubic incision surgery with laparoscopic support and CO₂ inflation.

Results: Type I, II, and III procedures were performed on 16, 21, and six patients, respectively. Most patients (n?=?35) were discharged on postoperative day 1 or 2. No surgical complication was encountered. Types of surgery exhibited different surgical characteristics. Type I was adopted for larger diameter tumors than types II or III (p?=?.016), whereas type III had a longer operative time (p?=?.024) than types I and II. Other characteristics, such as age, body mass index, and length of hospital stay, did not differ significantly among surgical types.

Conclusion: Laparoscopically assisted surgery for adnexal tumors via a single suprapubic incision under epidural anesthesia is feasible and safe, and should be viewed as an alternative approach to conventional minimally invasive surgery.     

Underwater robotic suturing

Background Laparoscopic and robotic surgeries have become popular, and this popularity is increasing. However, the environment in which such surgeries are performed is rarely discussed. Similar to arthrosurgery performed in water, artificial ascites could be a new environment for laparoscopic surgery. This study was performed to determine whether robotic surgery is applicable to complicated suturing underwater. Material and methods A da Vinci Surgical System S was used. A weighted fabric sheet was placed at the bottom of a tank. Identical sets were made for each environment: One tank was dry, and the other was filled with water. The suturing task involved placement of a running silk suture around the perimeter of a small circle. The task was performed eight times in each environment. The task time and integrity score were determined. The integrity score was calculated by evaluating accuracy, tightness, thread damage, and uniformity; each factor was evaluated using a five-point scale. Results Although statistically significant differences were not shown in either task time or integrity score between the underwater and air environments, robotic suturing underwater is not inferior to performance in air. Conclusions The feasibility of robotic suturing underwater was confirmed under the herein-described experimental conditions.     

A new oval multichannel port to facilitate reduced port distal gastrectomy

Background: This report describes the techniques and outcomes of reduced port distal gastrectomy (RPDG) using a new oval multichannel port. Material and methods: We performed reduced port distal gastrectomy through the E·Z Access? oval type device with three trocars in the umbilical incision, plus the use of additional 5 mm and 2 mm ports. All routine procedures performed in conventional laparoscopic distal gastrectomy (CLDG) were achieved in RPDG. Results: We employed this technique without the use of additional trocars or conversion to laparotomy in all 25 patients. The median length of the operation was 340 (range, 220–487) minutes, and the median estimated blood loss was 30 (range, 5–440) ml. Neither major postoperative complications, such as anastomotic leakage and stricture, nor postoperative mortality were observed. The mean length of the hospital stay was 11 days. The umbilical wound was indistinct. The patients were also highly satisfied with the cosmetic outcome. Conclusion: Reduced port surgery using the E·Z Access? oval type device was successfully applied for gastric cancer. This method is technically feasible, produces superior cosmetic results and thus could be an attractive surgical option for gastric cancer patients.     

Short-term clinical and oncological outcomes after single-incision plus one-port laparoscopic surgery for rectosigmoid cancer: a retrospective clinical analysis of 30 cases

ObjectiveTo evaluate the safety and feasibility of single-incision laparoscopic surgery+1 (SILS+1) radical resection of sigmoid and upper rectal cancer.MethodsThe clinical data of 30 consecutive patients with sigmoid and upper rectal cancer who underwent SILS+1 radical resection between October 2018 and January 2020 in our hospital were retrospectively analyzed. An initial 5-cm periumbilical transverse incision was made. Then, a multiport device was placed in the umbilical incision. Two 10-mm ports were used for laparoscope insertion, and the other two ports were used for laparoscope device insertion. A 12-mm trocar was placed in the right lower abdominal quadrant under laparoscopic view and served as the surgeon’s dominant operating channel.ResultsAll operations were performed successfully without conversion to conventional laparoscopic surgery or open operation. Three patients developed postoperative complications: one patient developed ileus, one developed postoperative bleeding, and one developed wound infection. There were no perioperative deaths.ConclusionsThe safety and feasibility of SILS+1 radical resection of sigmoid and upper rectal cancer was established by experienced surgeons in our study. However, further studies are needed to demonstrate the advantages of this procedure compared with the benefits of conventional laparoscopic surgery.     

Is the bipolar vessel sealer device an effective tool in robotic surgery? A retrospective analysis of our experience and a meta-analysis of the literature about different robotic procedures by investigating operative data and post-operative course

Background: The latest robotic bipolar vessel sealing tools have been described to be effective allowing to perform procedures with reduced blood loss and shorter operative times. The aim of this study was to assess the efficacy and reliability of these devices applied in different robotic procedures.

Material and methods: All robotic operations, between 2014 and 2016, were performed using the EndoWrist One VesselSealer (EWO, Intuitive Surgical, Sunnyvale, CA), a bipolar fully wristed device. Data, including age, gender, body mass index (BMI), were collected. Robot docking time, intraoperative blood loss, robot malfunctioning and overall operative time were analyzed. A meta-analysis of the literature was carried out to point the attention to three different parameters (mean blood loss, operating time and hospital stay) trying to identify how different coagulation devices may affect them.

Results: In 73 robotic procedures, the mean operative time was 118.2?minutes (75–125?minutes). Mean hospital stay was four days (2–10 days). There were two post-operative complications (2.74%).

Conclusions: The bipolar vessel sealer offers the efficacy of bipolar diathermy and the advantages of a fully wristed instrument. It does not require any change of instruments for coagulation or involvement of the bedside assistant surgeon. These characteristics lead to a reduction in operative time.     

Ovarian cystectomy for a dermoid cyst with the new single-port robotic system

We report a 27 year-old patient with a dermoid cyst who underwent robotic single port transumbilical ovarian cystectomy. She was operated through a 2 cm long single midline umbilical incision using a new platform from Intuitive Surgical. The operative time was 45 minutes and the docking time was 15 minutes. Ovarian cystectomy using the da Vinci single-port system is feasible and effective. This new semi-rigid robotic surgery platform may increase access to the potential advantages of single-site surgery. Robotic systems designed specifically for single port approach have the potential of alleviating several of the limitations associated with traditional laparoscopic single-site surgery.     

Development of a novel controllable,multidirectional, reusable metallic port with a wide working space

Abstract

Background: Endoscopic surgery is currently a standard procedure in many countries. Furthermore, conventional four-port laparoscopic cholecystectomy is developing into a single-port procedure. However, in many developing countries, disposable medical products are expensive and adequate medical waste disposable facilities are absent. Advanced medical treatments such as laparoscopic or single-port surgeries are not readily available in many areas of developing countries, and there are often no other sterilization methods besides autoclaving. Moreover, existing reusable metallic ports are impractical and are thus not widely used. Material and methods: We developed a novel controllable, multidirectional single-port device that can be autoclaved, and with a wide working space, which was employed in five patients. Results: In all patients, laparoscopic cholecystectomy was accomplished without complications. Conclusion: Our device facilitates single-port surgery in areas of the world with limited sterilization methods and offers a novel alternative to conventional tools for creating a smaller incision, decrease postoperative pain, and improve cosmesis. This novel device can also lower the cost of medical treatment and offers a promising tool for major surgeries requiring a wide working space.     

Single incision laparoscopic surgery (SILS) using cross hand technique

Abstract

Single incision laparoscopic surgery (SILS) was developed as a less invasive surgical procedure, but it remains difficult because of its specific skills and left-right reversal of the instruments. Such a difference makes manipulating endoscopic instruments more challenging and increases the risk. In this study, we introduce the cross hand technique allowing the surgeon to manipulate instruments with intuitive movement.     

Use of natural user interfaces for image navigation during laparoscopic surgery: initial experience

Background: Surgical environments require special aseptic conditions for direct interaction with the preoperative images. We aim to test the feasibility of using a set of gesture control sensors combined with voice control to interact in a sterile manner with preoperative information and an integrated operating room (OR) during laparoscopic surgery.

Material and methods: Two hepatectomies and two partial nephrectomies were performed by three experienced surgeons in a porcine model. The Kinect, Leap Motion, and MYO armband in combination with voice control were used as natural user interfaces (NUIs). After surgery, surgeons completed a questionnaire about their experience.

Results: Surgeons required <10?min training with each NUI. They stated that NUIs improved the access to preoperative patient information and kept them more focused on the surgical site. The Kinect system was reported as the most physically demanding NUI and the MYO armband in combination with voice commands as the most intuitive and accurate. The need to release one of the laparoscopic instruments in order to use the NUIs was identified as the main limitation.

Conclusions: The presented NUIs are feasible to directly interact in a more intuitive and sterile manner with the preoperative images and the integrated OR functionalities during laparoscopic surgery.