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.     

LESSons in minimally invasive urology

Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. LaparoEndoscopic Single Site (LESS) surgery potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. Technological developments in instrumentation, access and optics devices are overcoming some of the challenges that are raised when operating through a single site. Further advances in the technique have included the incorporation of robotics (R-LESS), which exploit the ergonomic benefits of ex vivo robotic platforms in an attempt to further improve the implementation of LESS procedures. In the future, urologists may be able to benefit from in vivo micro-robots that will allow the manipulation of tissue from internal repositionable platforms. The use of magnetic anchoring and guidance systems (MAGS) might allow the external manoeuvring of intra-corporeal instruments to reduce clashing and facilitate triangulation. However, the final promise in minimally invasive surgery is natural orifice transluminal endoscopic surgery (NOTES), with its scarless technique. It remains to be seen whether NOTES, LESS, or any of these future developments will prove their clinical utility over standard laparoscopic methods.     

Comparative results between vertical ringed gastroplasty and duodenal switch in morbid obesity

Natural orifice transluminal endoscopic surgery (NOTES) is a novel concept which combines aspects of flexible endoscopy with laparoscopic surgery with the aim of creating a new field of patient friendly "incisionless" surgery. This will require novel advanced technologies to be developed specifically for NOTES. We discuss the technical requirements and the process of creating NOTES instrumentation and illustrate the process with some current enabling devices. The development process is outlined, including the requirements for NOTES, the current technology that can be used, and some prototype devices for access, retraction, and tissue approximation. Endoscopes for NOTES must have high resolution, large instrument channels, some degree of triangulation, and the ability to lock into position inside the abdominal cavity. Instrumentation should echo the capabilities of current laparoscopic tools. They should be large and sturdy, torque-able, and offer the full spectrum of end-effectors. Finally, NOTES technology must permit secure, tailorable tissue approximation. The "R" scope from Olympus and the Transport scope from USGI Medical are possible solutions to the design requirements for access and visualization. Eagle Claw (Olympus), The Swain system (Ethicon), and the G-prox (USGI) are current tissue approximation systems under development and investigation in clinical trials. NOTES is a potential advance in surgical care. This new approach requires the development of new platform devices, tailored to allow the safe and effective practice of this advanced endoscopic approach.     

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.     

Review and update: robotic transanal surgery (RTAS)

As the field of surgery advances, new approaches have allowed surgeons additional flexibility to perform further interventions with minimal or no external incisions. For many years, single site access (SSA) has been used for transanal procedures, and platforms allowing modified endoscopic approaches have been available. These platforms have limitations related to access, visualization, dexterity, camera control, and instrumentation. Recently, surgical robotics companies have developed and introduced new technologies and platforms, which may help address some of these limitations. Comprehensive internet, open access, and medical and industry conference reviews of robotic surgery platforms and technology available for use in SSA surgery were conducted and 30 articles were found using keywords “robotic surgery, transanal, single site, robotic transanal surgery”. A PubMed, Medline, Journals @OVID and open access search for data related to these platforms and technologies was also performed yielding 11 articles. Abstracts were reviewed for those written in the English language, leaving 40 articles which were then filtered for those pertaining to robotic surgery, transanal. 58 abstracts were found, duplicates were eliminated, and the remaining 35 articles were read in their entirety by two reviewers. Several new and existing platforms are identified for use in SSA surgery for transanal surgery as well as abdominal and transoral surgery. These are reviewed, including brand, features, approved and suggested uses, and potential limitations. New robotic technologies serve to enhance the ability of surgeons to perform SSA surgery. This next generation of robotic surgery technology overcomes some of the limitations of preceding endoscopic SSA surgery technology and will enhance the advancement of robotic transanal surgery, but outcomes and performance data are still limited.     

Laparoscopic Transumbilical Cholecystectomy Without Visible Abdominal Scars

Introduction  We present a novel surgical technique for cholecystectomy utilizing three laparoscopic ports placed through the umbilicus. This new method is natural orifice transumbilical surgery (NOTUS) and describes a laparoscopic operation that can be performed with all incisions placed within the umbilicus obviating visible abdominal scars. Objectives  To develop a novel laparoscopic surgical technique for cholecystectomy utilizing only transumbilical incisions. Summary Background Data  Natural orifice translumenal endoscopic surgery (NOTES) has become an exciting area of surgical development. Significant limitations to this surgical concept, however, are lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is NOTUS. Methods  We describe a patient in whom a laparoscopic surgical technique for cholecystectomy utilized incisions all placed entirely within the umbilicus. This new technique is called NOTUS and describes a laparoscopic operation that can be performed without visible abdominal scar. Results  The operative time was 70 min. There were no intraoperative complications. The patient did well postoperatively and was discharged on the same operative day. There were no postoperative complications at 2 months follow-up. Conclusion  Cholecystectomy performed through laparoscopic incisions placed within the umbilicus was technically feasible and safe in our patient. Development of advanced flexible instrumentation and visualization platforms may facilitate this new operative approach. Further advantages of NOTUS cholecystectomy compared to conventional laparoscopic cholecystectomy will ultimately require a randomized clinical trial.     

Surgery with cooperative robots.

Advances in endoscopic techniques for abdominal procedures continue to reduce the invasiveness of surgery. Gaining access to the peritoneal cavity through small incisions prompted the first significant shift in general surgery. The complete elimination of external incisions through natural orifice access is potentially the next step in reducing patient trauma. While minimally invasive techniques offer significant patient advantages, the procedures are surgically challenging. Robotic surgical systems are being developed that address the visualization and manipulation limitations, but many of these systems remain constrained by the entry incisions. Alternatively, miniature in vivo robots are being developed that are completely inserted into the peritoneal cavity for laparoscopic and natural orifice procedures. These robots can provide vision and task assistance without the constraints of the entry incision, and can reduce the number of incisions required for laparoscopic procedures. In this study, a series of minimally invasive animal-model surgeries were performed using multiple miniature in vivo robots in cooperation with existing laparoscopy and endoscopy tools as well as the da Vinci Surgical System. These procedures demonstrate that miniature in vivo robots can address the visualization constraints of minimally invasive surgery by providing video feedback and task assistance from arbitrary orientations within the peritoneal cavity.     

Robotic cardiac surgery: overview

Most endoscopic procedures are excisional, not reconstructive or microsurgical, mostly because conventional endoscopic instrumentation lacks dexterity due to long, nonarticulated instruments, a fixed pivot point and counterintuitive movement of the instrument tip, and lack of depth perception. Endoscopic approaches to cardiac surgery have not been successful; however, the development of robotic surgical systems has overcome many limitations of endoscopy. Computer-assisted surgery has created a computerized digital interface between the surgeon's hands and surgical instrument tips and enhances surgical ability, thereby enabling endoscopic microsurgery. Recently, robotic systems have allowed cardiac surgeons to perform minimally invasive endoscopic coronary artery bypass grafting (CABG) and valve procedures. This article summarizes the use of robotics in cardiac surgery and discusses its potential in our specialty.     

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.     

Natural orifice translumenal surgery: Flexible platform review

Natural orifice translumenal surgery (NOTES) has garnished significant attention from surgeons and gastroenterologists, due to the fusion of flexible endoscopy and operative technique. Preliminary efforts suggest that NOTES holds potential for a less invasive approach with certain surgical conditions. Many of the hurdles encountered during the shift from open to laparoscopic surgery are now being revisited in the development of NOTES. Physician directed efforts, coupled with industry support, have brought about several NOTES specific devices and platforms to help address limitations with current instrumentation. This review addresses current flexible platforms and their attributes, advantages, disadvantages and limitations.     

Single-incision laparoscopic surgery: initial urological experience and comparison with natural-orifice transluminal endoscopic surgery

Laparoscopic approaches have increasingly assumed a central role in the management of benign and malignant surgical diseases. While laparoscopy is less morbid than open surgery, it still requires several incisions, each > or =1-2 cm long. Each incision risks morbidity from bleeding, hernia and/or internal organ damage, and incrementally decreases cosmesis. An alternative to conventional laparoscopy is single-incision laparoscopic surgery (SILS), in which articulating or bent instrumentation with specialized multi-lumen ports is used. These technical innovations obviate the need to externally space trocars for triangulation, thus allowing the creation of a small, solitary portal of entry into the abdomen. Laboratory and early clinical series showed the feasibility as well as safe and successful completion of SILS. Natural-orifice transluminal endoscopic surgery (NOTES) is another exciting development in minimally invasive urology, but existing flexible endoscopes and instruments are limited in providing a platform for this form of advanced surgery, resulting in the slow adoption of NOTES. Future work is needed to improve existing instrumentation, increase clinical experience, assess the benefits of both surgical approaches, and explore other potential applications for these novel techniques.     

Single Laparoscopic Incision Transabdominal (SLIT) Surgery—Adjustable Gastric Banding: A Novel Minimally Invasive Surgical Approach

Natural orifice transluminal endoscopic surgery (NOTES) has become an exciting area of surgical development. However, there are significant limitations to this surgical concept due to the lack of surgical expertise and appropriate flexible instrumentation. An alternative and competing technology to NOTES is single-access surgery. We present a novel surgical technique for placement of an adjustable gastric band utilizing a single laparoscopic incision which was ultimately used for implanting the subcutaneous access port. This new technique is called single laparoscopic incision transabdominal (SLIT) surgery which describes an advanced laparoscopic bariatric operation that can be performed through a tiny slit. The operative time was 55 min. There were no intraoperative complications. The patient did well postoperatively and was discharged on postoperative day 1. There were no postoperative complications at 1-month follow-up. Adjustable gastric banding performed through a single laparoscopic incision is technically feasible. The procedure was performed with mostly existing ports, laparoscopic instrumentations, and visualization platform. Advantages of SLIT surgery compared to conventional laparoscopic surgery will ultimately require further randomized clinical trials.     

The effect of robotic assistance on learning curves for basic laparoscopic skills

BACKGROUND: We hypothesized that laparoscopic tasks performed with ZEUS robotic assistance would be done with greater precision and with a different learning curve than when performed in a standard laparoscopic trainer. METHODS: Participants were divided into the surgically experienced (n = 11) and the surgically naive (n = 17). Two laparoscopic tasks (bead transfer and rope pass) were repeated for five repetitions. RESULTS: For all drills and participants, completion time and error rate decreased across the five repetitions for each platform. Precision averaged 97% for both platforms over all drills. For both groups, completion time for tasks was shorter on the laparoscopic platform. ZEUS allowed for greater consistency in performance. CONCLUSIONS: Compared with performance on a standard laparoscopic trainer, robotic assistance allows for increasing speed and consistency while maintaining precision over multiple repetitions. Understanding how robotics affects learning curves will allow for modifications in the training experience with this new technology.     

Laparoendoscopic Single-site and Natural Orifice Transluminal Endoscopic Surgery in Urology: A Critical Analysis of the Literature

Context

Natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed to benefit patients by enabling surgeons to perform scarless surgery.

Objective

To summarize and critically analyze the available evidence on the current status and future perspectives of LESS and NOTES in urology.

Evidence acquisition

A comprehensive electronic literature search was conducted in June 2010 using the Medline database to identify all publications relating to NOTES and LESS in urology.

Evidence synthesis

In urology, NOTES has been completed experimentally via transgastric, transvaginal, transcolonic, and transvesical routes. Initial clinical experience has shown that NOTES urologic surgery using currently available instruments is indeed possible. Nevertheless, because of the immaturity of the instrumentation, early cases have demanded high technical virtuosity. LESS can safely and effectively be performed in a variety of urologic settings. As clinical experience increases, expanding indications are expected to be documented and the efficacy of the procedure to improve. So far, the quality of evidence of all available studies remains low, mostly being small case series or case-control studies from selected centers. Thus, the only objective benefit of LESS remains the improved cosmetic outcome. Prospective, randomized studies are largely awaited to determine which LESS procedures will be established and which are unlikely to stand the test of time. Technology advances hold promise to minimize the challenging technical nature of scarless surgery. In this respect, robotics is likely to drive a major paradigm shift in the development of LESS and NOTES.

Conclusions

NOTES is still an investigational approach in urology. LESS has proven to be immediately applicable in the clinical field, being safe and feasible in the hands of experienced laparoscopic surgeons. Development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.     

Robotic renal surgery

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.     

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.     

Minimally invasive abdominal surgery: lux et veritas past, present, and future

BACKGROUND: Laparoscopic surgery has developed out of multiple technology innovations and the desire to see beyond the confines of the human body. As the instrumentation became more advanced, the application of this technique followed. By revisiting the historical developments that now define laparoscopic surgery, we can possibly foresee its future. DATA SOURCES: A Medline search was performed of all the English-language literature. Further references were obtained through cross-referencing the bibliography cited in each work and using books from the authors' collection. CONCLUSION: Minimally invasive surgery is becoming important in almost every facet of abdominal surgery. Optical improvements, miniaturization, and robotic technology continue to define the frontier of minimally invasive surgery. Endoluminal resection surgery, image-guided surgical navigation, and remotely controlled robotics are not far from becoming reality. These and advances yet to be described will change laparoscopic surgery just as the electric light bulb did over 100 years ago.     

NOTES: new dimension of minimally invasive surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery. NOTES eliminates abdominal incisions and incision‐related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Since the first NOTES was reported by Kalloo et al. in 2004, significant achievements in the laboratory have occurred. Clinical use in humans has been limited, but several cases and one small clinical trial were published recently. As a further technical revolution in minimally invasive surgery, NOTES has the promising potential to be safer, less invasive, provide better cosmesis and possibly be more cost‐effective. The purpose of the present article was to review the development and current status of NOTES and highlight important advances associated with this innovative approach.     

Past,Present, and Future of Minimally Invasive Abdominal Surgery

Laparoscopic surgery has generated a revolution in operative medicine during the past few decades. Although strongly criticized during its early years, minimization of surgical trauma and the benefits of minimization to the patient have been brought to our attention through the efforts and vision of a few pioneers in the recent history of medicine. The German gynecologist Kurt Semm (1927–2003) transformed the use of laparoscopy for diagnostic purposes into a modern therapeutic surgical concept, having performed the first laparoscopic appendectomy, inspiring Erich Mühe and many other surgeons around the world to perform a wide spectrum of procedures by minimally invasive means. Laparoscopic cholecystectomy soon became the gold standard, and various laparoscopic procedures are now preferred over open approaches, in the light of emerging evidence that demonstrates less operative stress, reduced pain, and shorter convalescence. Natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS) may be considered further steps toward minimization of surgical trauma, although these methods have not yet been standardized. Laparoscopic surgery with the use of a robotic platform constitutes a promising field of investigation. New technologies are to be considered under the prism of the history of surgery; they seem to be a step toward further minimization of surgical trauma, but not definite therapeutic modalities. Patient safety and medical ethics must be the cornerstone of future investigation and implementation of new techniques.