The current state of miniature in vivo laparoscopic robotics

Minimally invasive surgery (MIS) reduces patient trauma and shortens recovery time, but also limits the dexterity of the surgeon because degrees of freedom are lost due to the fulcrum effect of the entry incisions. Visual feedback is also limited by the laparoscope, which typically provides two-dimensional feedback and is constrained by the entry incision. Developments within surgical robotics aim to mitigate these constraints. However, these developments have primarily included large external machines that augment vision and improve dexterity, but are still fundamentally constrained by the use of long tools through small incisions. An alternative concept is the use of miniature in vivo surgical robots that can be placed entirely into the peritoneal cavity through either an abdominal incision, or, after insertion into the stomach through the esophagus, can enter through a gastrotomy. This paper reviews the development of fixed-base camera robots for providing auxiliary views of the surgical field and of mobile robots with a movable platform for vision and task assistance in laparoscopic procedures. Moreover, the progress towards the application of similar robots for natural orifice transluminal endoscopic surgery (NOTES) and forward environments is discussed.     

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.     

Dexterous miniature robot for advanced minimally invasive surgery

This study demonstrates the feasibility of using a miniature robot to perform complex, single-incision, minimal access surgery. Instrument positioning and lack of triangulation complicate single-incision laparoscopic surgery, and open surgical procedures are highly invasive. Using minimally invasive techniques with miniature robotic platforms potentially offers significant clinical benefits. A miniature robot platform has been designed to perform advanced laparoscopic surgery with speed, dexterity, and tissue-handling capabilities comparable to standard laparoscopic instruments working through trocars. The robotic platform includes a dexterous in vivo robot and a remote surgeon interface console. For this study, a standard laparoscope was mounted to the robot to provide vision and lighting capabilities. In addition, multiple robots could be inserted through a single incision rather than the traditional use of four or five different ports. These additional robots could provide capabilities such as tissue retraction and supplementary visualization or lighting. The efficacy of this robot has been demonstrated in a nonsurvival cholecystectomy in a porcine model. The procedure was performed through a single large transabdominal incision, with supplementary retraction being provided by standard laparoscopic tools. This study demonstrates the feasibility of using a dexterous robot platform for performing single-incision, advanced laparoscopic surgery.     

Miniature in vivo robot for laparoendoscopic single-site surgery

Background  

The aim of this study was to develop a multidexterous robot capable of generating the required forces and speeds to perform surgical tasks intra-abdominally. Current laparoscopic surgical robots are expensive, bulky, and fundamentally constrained by a small entry incision. A new approach to minimally invasive surgery places the robot completely within the patient. Miniature in vivo robots may allow surgeons to overcome current laparoscopic constraints such as dexterity, orientation, and visualization.     

Natural orifice surgery with an endoluminal mobile robot

Natural orifice transgastric endoscopic surgery promises to eliminate skin incisions and reduce postoperative pain and discomfort. Such an approach provides a distinct benefit as compared with conventional laparoscopy, in which multiple entry incisions are required for tools and camera. Endoscopy currently is the only method for performing procedures through the gastrointestinal tract. However, this approach is limited by instrumentation and the need to pass the entire scope into the patient. In contrast, an untethered miniature robot inserted through the mouth would be able to enter the abdominal cavity through a gastrotomy for exploration of the entire peritoneal cavity. In this study, the authors developed an endoluminal robot capable of transgastric abdominal exploration under esophagogastroduodenoscopic (EGD) control. Under EGD control, a gastrotomy was created, and the miniature robot was deployed into the abdominal cavity under remote control. Ultimately, future procedures will include a family of robots working together inside the gastric and abdominal cavities after their insertion through the esophagus. Such technology will help to reduce patient trauma while providing surgical flexibility.     

Mobile in vivo camera robots provide sole visual feedback for abdominal exploration and cholecystectomy

The use of small incisions in laparoscopy reduces patient trauma, but also limits the surgeon’s ability to view and touch the surgical environment directly. These limitations generally restrict the application of laparoscopy to procedures less complex than those performed during open surgery. Although current robot-assisted laparoscopy improves the surgeon’s ability to manipulate and visualize the target organs, the instruments and cameras remain fundamentally constrained by the entry incisions. This limits tool tip orientation and optimal camera placement. The current work focuses on developing a new miniature mobile in vivo adjustable-focus camera robot to provide sole visual feedback to surgeons during laparoscopic surgery. A miniature mobile camera robot was inserted through a trocar into the insufflated abdominal cavity of an anesthetized pig. The mobile robot allowed the surgeon to explore the abdominal cavity remotely and view trocar and tool insertion and placement without entry incision constraints. The surgeon then performed a cholecystectomy using the robot camera alone for visual feedback. This successful trial has demonstrated that miniature in vivo mobile robots can provide surgeons with sufficient visual feedback to perform common procedures while reducing patient trauma.     

A primer on natural orifice transluminal endoscopic surgery: building a new paradigm

Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. During NOTES, commercially available flexible video endoscopes are used to create a controlled transvisceral incision via natural orifice access to enter the peritoneal cavity. Common incision-related complications such as wound infections, incisional hernias, postoperative pain, aesthetic disdain, and adhesions could be minimized or eliminated by NOTES. NOTES has evolved from more than 2 centuries of technological innovations and continued growth in the field of surgical endoscopy. Innovative surgical endoscopists have slowly developed means to surpass the constraints of the gastrointestinal lumen by using a flexible endoscope. The future of surgical endoscopy may be the shared entity of NOTES, which further integrates endoscopy, gastroenterology, and minimally invasive and general surgery. Although the promise of NOTES is electrifying to surgeons and endoscopists, several key issues need to be characterized prior to the incorporation of NOTES into routine practice. This article reviews the status, contemporary body of literature, limitations, and potential future implications accompanying the development of NOTES.     

Natural Orifice Translumenal Endoscopic Surgery with a miniature in vivo surgical robot

Background  The application of flexible endoscopy tools for Natural Orifice Translumenal Endoscopic Surgery (NOTES) is constrained due to limitations in dexterity, instrument insertion, navigation, visualization, and retraction. Miniature endolumenal robots can mitigate these constraints by providing a stable platform for visualization and dexterous manipulation. This video demonstrates the feasibility of using an endolumenal miniature robot to improve vision and to apply off-axis forces for task assistance in NOTES procedures. Methods  A two-armed miniature in vivo robot has been developed for NOTES. The robot is remotely controlled, has on-board cameras for guidance, and grasper and cautery end effectors for manipulation. Two basic configurations of the robot allow for flexibility during insertion and rigidity for visualization and tissue manipulation. Embedded magnets in the body of the robot and in an exterior surgical console are used for attaching the robot to the interior abdominal wall. This enables the surgeon to arbitrarily position the robot throughout a procedure. Results  The visualization and task assistance capabilities of the miniature robot were demonstrated in a nonsurvivable NOTES procedure in a porcine model. An endoscope was used to create a transgastric incision and advance an overtube into the peritoneal cavity. The robot was then inserted through the overtube and into the peritoneal cavity using an endoscope. The surgeon successfully used the robot to explore the peritoneum and perform small-bowel dissection. Conclusion  This study has demonstrated the feasibility of inserting an endolumenal robot per os. Once deployed, the robot provided visualization and dexterous capabilities from multiple orientations. Further miniaturization and increased dexterity will enhance future capabilities. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Presented at the 2008 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting, Philadelphia, Pennsylvania, April 9–12, 2008.     

In vivo robotic laparoscopy

Laparoscopy reduces patient trauma but limits the surgeon's ability to view or touch the surgical environment directly. The surgeon's ability to visualize and manipulate target organs can be improved using currently available external robotic systems. However, tool tip orientation and optimal camera placement remain limited because the robot instruments and cameras are still constrained by the entry incisions. Placing a robot completely within the abdominal cavity would provide an unconstrained platform that could provide an enhanced field of view from arbitrary angles and dexterous manipulators not constrained by the abdominal wall fulcrum effect. Several in vivo robots have been developed and successfully tested in a porcine model. These in vivo robots have been used to observe trocar and tool insertions and placement, and to provide additional camera angles that improved surgical visualization. Equipped with a grasper, such robots will provide task assistance. These in vivo robots will be much less expensive than the current generation of large external robotic surgical systems and will ultimately allow a surgeon to be a remote first responder irrespective of the location of the patient.     

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women’s views on a new technique

Background  

Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES.     

Laparoscopic sleeve gastrectomy with NOTES visualization—a step toward NOTES procedures

BackgroundTo demonstrate that bariatric procedures can be done with natural orifice visualization (NOTES) at 2 institutions (Nucleo Universitario de Estudos de Notes Centro de Cirurgia Experimental Vila do Conde–Junqueira, Vila do Conde, Portugal and Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, RS, Brasil). NOTES is a new surgical approach that is being developed. It consists of the use of a minimally invasive technique in which the surgical procedure is performed through natural orifices, thereby circumventing incisions through the skin.MethodsWe performed vertical gastrectomy or laparoscopic sleeve gastrectomy in a porcine model using vaginal route visualization.ResultsA laparoscopic vertical sleeve gastrectomy with NOTES visualization in a porcine model was performed with safety.Conclusion: Bariatric procedures can be done with NOTES with results as good as those using laparoscopic techniques.     

Natural orifice cholecystectomy using a miniature robot

Background  Natural orifice translumenal endoscopic surgery (NOTES) is surgically challenging. Current endoscopic tools provide an insufficient platform for visualization and manipulation of the surgical target. This study demonstrates the feasibility of using a miniature in vivo robot to enhance visualization and provide off-axis dexterous manipulation capabilities for NOTES. Methods  The authors developed a dexterous, miniature robot with six degrees of freedom capable of applying significant force throughout its workspace. The robot, introduced through the esophagus, completely enters the peritoneal cavity through a transgastric insertion. The robot design consists of a central “body” and two “arms” fitted respectively with cautery and forceps end-effectors. The arms of the robot unfold, allowing the robot to flex freely for entry through the esophagus. Once in the peritoneal cavity, the arms refold, and the robot is attached to the abdominal wall using the interaction of magnets housed in the robot body with magnets in an external magnetic handle. Video feedback from the on-board cameras is provided to the surgeon throughout a procedure. Results  The efficacy of this robot was demonstrated in three nonsurvivable procedures in a porcine model, namely, abdominal exploration, bowel manipulation, and cholecystectomy. After insertion, the robot was attached to the interior abdominal wall. The robot was repositioned throughout the procedure to provide optimal orientations for visualization and tissue manipulation. The surgeon remotely controlled the actuation of the robot using an external console to assist in the procedures. Conclusion  This study has shown that a dexterous miniature in vivo robot can apply significant forces in arbitrary directions and improve visualization to overcome many of the limitations of current endoscopic tools for performing NOTES procedures. Presented at the 2008 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting, Philadelphia, Pennsylvania, April 9–12, 2008.     

NOTES über den transösophagealen/transgastrischen Zugang

The new surgical concept of ?natural orifice transluminal endoscopic surgery“ (NOTES) breaks with the old dogma that gastrointestinal flexible endoscopy should be performed exclusively within the gastrointestinal lumen. It guides flexible endoscopy into the peritoneal cavity and to date any access to this was and is a feared complication. NOTES offers a new potential alternative to open surgery as well as laparoscopic surgery. Technical challenges of this new technique include the need for the development of new tools and devices. This is most important for the access to and closure of incisions to the peritoneal and thoracic cavities. The successful incision and closure is a prerequisite for the development of acceptable indications for this new method. In this overview the access and closure techniques currently used as well as some of those which are being considered will be described. Furthermore, possible indications for NOTES will be evaluated and discussed.     

Roboterunterstützte Laparoskopie in der Urologie Radikale Prostatektomie und rekonstruktive retroperitoneale Eingriffe

Complex reconstructive laparoscopic procedures in the field of urology such as radical prostatectomy and pyeloplasty have attracted increased attention in the past 2 years. However, extensive laparoscopic experience is required to master these procedures. Therefore, it remains questionable whether these techniques, which have been shown to be of profit to the patient in the hands of a specialist, will achieve widespread distribution. We have employed computer technology to bridge the gap between open surgery and laparoscopic access and used the daVinci Surgical System to establish laparoscopic radical prostatectomy as well as pyeloplasty and other retroperitoneal procedures at our institution. With experience of more than 70 procedures, we find that with the assistance of the daVinci Surgical System both radical prostatectomy and retroperiteoneal procedures can be easily translated from open to minimally invasive procedures with a considerably shorter learning curve and without compromising patient safety. We expect that large incisions will be soon a thing of the past in urologic surgery. Computer technology, together with mechanical engineering, will play a major role in enabling us to achieve better results despite minimal invasiveness.     

Robot-assisted general surgery

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.     

Current experience and future directions of completely NOTES colorectal resection

Clinical implementation and widespread application of natural orifice translumenal surgery (NOTES) has been limited by the lack of specialized endoscopic equipment, which has prevented the ability to perform complex procedures including colorectal resections. Relative to other types of translumenal access, transanal NOTES using transanal endoscopic microsurgery (TEM) provides a stable platform for endolumenal and direct translumenal access to the peritoneal cavity, and specifically to the colon and rectum. Completely NOTES transanal rectosigmoid resection using TEM, with or without transgastric endoscopic assistance, was demonstrated to be feasible and safe in a swine survival model. The same technique was successfully replicated in human cadavers using commercially available TEM, with endoscopic and laparoscopic instrumentation. This approach also permitted complete rectal mobilization with total mesorectal excision to be performed completely transanally. As in the swine model, transgastric and/or transanal endoscopic assistance extended the length of proximal colon mobilized and overcame some of the difficulties with TEM dissection including limited endoscopic visualization and maladapted instrumentation. This extensive laboratory experience with NOTES transanal rectosigmoid resection served as the basis for the first human NOTES transanal rectal cancer excision using TEM and laparoscopic assistance. Based on this early clinical experience, NOTES transanal approach using TEM holds significant promise as a safe and substantially less morbid alternative to conventional colorectal resection in the management of benign and malignant colorectal diseases. Careful patient selection and substantial improvement in NOTES instrumentation are critical to optimize this approach prior to widespread clinical application, and may ultimately permit completely NOTES transanal colorectal resection.     

Improvements in robotic natural orifice surgery with a novel material handling system

Background

Natural orifice translumenal endoscopic surgery (NOTES) has many potential advantages over other minimally invasive surgical techniques, but it presents a number of challenges introduced by the restrictive natural access points. Fully insertable dexterous in vivo robots have been developed that eliminate the spatial restrictions of the entry point, but they also are isolated within the abdomen. A material handling system (MHS) developed to bridge the gap between the in vivo robots and the surgical team promises a number of improvements over other current technologies.

Methods

The MHS was implemented with two different nonsurvival swine models to validate the utility and benefits of the system. The first procedure was attempted transgastrically but proved too difficult because the geometry of the esophagus was prohibitively small. The system was instead inserted via a 50-mm GelPort and tested for robustness. The second procedure used a transvaginal insertion via a custom 25-mm trocar. Throughout both procedures, the practitioners were asked for qualitative feedback regarding the effectiveness of the device and its long-term efficiencies.

Results

The MHS was able to deliver a standard surgical staple securely to the peritoneal cavity. The practitioner was able to use the laparoscopic grasper both to insert and to remove the staple from the MHS. The system also proved capable of maintaining insufflation pressure throughout a procedure. It was cycled a total of five times in both the insertion and the retraction directions. Visualization from the MHS camera was poor at times because the lighting on the system was somewhat inadequate. No excessive bleeding or collateral damage to surrounding tissues was observed during the procedure.

Conclusions

This study demonstrated that the MHS is fully capable of achieving payload transport during a NOTES operation. The system is intuitive and easy to use. It dramatically decreases collateral trauma in the natural access point and can advantageously reduce the overall duration of a procedure.     

重症急性胰腺炎腹腔镜手术治疗的临床研究

目的 探索重症急性胰腺炎（SAP）微创外科治疗的可行性、时机与方式。方法 运用微创外科技术对13例SAP患者实施腹腔镜手术治疗,其中SAP早期用膜腔及网膜囊大量积液3例、胰腺实质及胰周组织不同程度局限性坏死伴感染4例、胰周囊肿（或）脓肿形成6例,手术方式因SAP不同阶段而异。结果 （１）SAP的急性反应期腹腔粘连轻、腹腔积液未局限,腹腔镜扩创引流术快捷、创伤小、术后恢复快。（2）SAP的亚急性期,尚未形成良好的包裹,组织水肿,腹腔内粘连,此期腹腔镜手术显露困难、出血多、时间长。（3）SAP后期,B超定位导向下的腹腔镜扩创引流术安全、快捷、可靠,13例患者无1例死亡。结论 SAP的腹腔镜外科手术治疗应遵循个体化原则,在熟练掌握腹腔镜操作技能的前提下开展SAP的腹腔镜手术治疗,是安全有效的。     

Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor

Background and objective  Laparoscopic wedge resection using a linear stapler is widely accepted as a treatment for gastric submucosal tumor (SMT). Although this surgery is simple, it can lead to excessive normal tissue removal. To avoid the latter, we have introduced endoscopic full-thickness resection with laparoscopic assistance, known as laparoscopy-assisted endoscopic full-thickness resection (LAEFR). Herein, we present the preliminary results of LAEFR for gastric SMT patients. Methods  Four patients with gastric SMT underwent LAEFR. LAEFR consists of four major procedures: (1) a circumferential incision as deep as the submucosal layer around the lesion by the endoscopic submucosal dissection technique, (2) endoscopic full-thickness (from the muscle layer to the serosal layer) incision around the three-fourths or two-thirds circumference on the above-mentioned submucosal incision under laparoscopic supervision, (3) completion of the full-thickness incision laparoscopically from inside the peritoneal cavity, and (4) handsewn closure of the gastric-wall defect. Results  LAEFR was successfully carried out without any intraoperative or postoperative adverse events. Mean operating time and estimated blood loss were 201 min and 27 mL, respectively. Contrast roentgenography on postoperative day 3 showed neither gastric deformity nor disturbance of gastric emptying in all the patients. Conclusions  LAEFR may be considered one of the so-called hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques because a peroral endoscope advances into the peritoneal cavity. LAEFR enabled whole-layer excision as small as possible with an adequate margin. LAEFR is a safe and minimally invasive treatment for patients with gastric SMT, and could be a more reasonable and economical alternative to other laparoscopic procedures.     

Primera nefrectomía transvaginal híbrida por cáncer renal

NOTES (Natural Orifice Transluminal Endoscopic Surgery) is a surgical modality that uses empty organs as an access to the peritoneal cavity, avoiding skin incisions. If we combine this surgery with the classical laparoscopic approach, a new hybrid technique is obtained. This approach will permit us to work on wide operating fields with large organs, as the kidney, minimizing skin incisions. We present the first hybrid transvaginal radical nephrectomy due to renal cancer. In order to perform this procedure, we used a vaginal access for introduction of a deflectable camera and the assistance of two additional abdominal trocars. The vaginal incision for the trocar was enlarged for organ removal. Hybrid transvaginally NOTES assisted radical nephrectomy is a reproducible and feasible technique that has to be kept in mind for women who are candidates to nephrectomy for renal cancer.