Endoluminal minirobots for transgastric peritoneoscopy.

The performance of surgeries through small incisions or natural orifices minimizes the invasiveness to the patient as compared to open procedures. However, the constraints on visual feedback and dexterity limit the scope of these procedures. Recent robotic technologies attempt to mitigate these constraints for flexible endoscopy and laparoscopy. Much of the current work in flexible endoscopy is in the development of a fully autonomous endoscope capable of providing the surgeon with better control. Advancements in laparoscopic technologies have demonstrated abilities to improve visualization and dexterity through telerobotics and in vivo robotics. The application of new robotic technologies in flexible endoscopy and laparoscopy to natural orifice surgery promises to further benefit the patient by eliminating abdominal incisions, scarring, and the pain associated with these incisions. The safety and feasibility of such robotic technology has been successfully demonstrated for natural orifice transluminal endoscopic surgery (NOTES) in animal models.     

Surgical robots for SPL and NOTES: A review

Introduction: Single port laparoscopy (SPL) and natural orifice transluminal endoscopic surgery (NOTES) are next-generation minimally invasive surgery (MIS) procedures which could further reduce patient trauma. Robotic assistance shows great potential in providing augmented motion precision and manipulation dexterity. This article reviews the robotic systems recently developed for SPL and NOTES. Material and methods: A literature search was conducted based on Science Citation Index, Engineering Index, Medline, and PubMed databases. Results: Eleven robotic systems for SPL and six robotic systems for NOTES were identified. Structures and performances of these systems were reported. Special attention was directed to the systems using continuum mechanisms. Discussion and conclusion: Regarding the structure aspect, the reviewed systems for SPL and NOTES all deploy a vision unit and at least two manipulation arms for surgical interventions through an access channel. To date, the smallest diameter of such a channel is 12 mm. Regarding the functionality aspect, only a few systems demonstrated results promising enough for animal or clinical studies in the near future. Surgical robots using dual continuum mechanisms achieved both design compactness and functional versatility. The characteristics suggest that the use of continuum mechanisms is worth exploring through future developments of surgical robots.     

Best Practices for Minimally Invasive Procedures

Techniques and instrumentation for minimally invasive surgical procedures originated in gynecologic surgery, but the benefits of surgery with small incisions or no incisions at all have prompted the expansion of these techniques into numerous specialties. Technologies such as robotic assistance, single-incision laparoscopic surgery, natural orifice transluminal endoscopic surgery, and video-assisted thoracoscopic surgery have led to the continued expansion of minimally invasive surgery into new specialties. With this expansion, perioperative nurses and other members of the surgical team are required to continue to learn about new technology and instrumentation, as well as the techniques and challenges involved in using new technology, to help ensure the safety of their patients. This article explores the development of minimally invasive procedures and offers suggestions for increasing patient safety.     

Hybrid surgery: combined laparoscopy and natural orifice surgery

Hybrid procedures combine laparoscopy and natural orifice surgery techniques. Some groups are currently using hybrid procedures to investigate the concepts of pure natural orifice surgery. Thus far, hybrid procedures have validated the safety of transgastric peritoneoscopy, although improved instrumentation is imperative before widespread clinical applications. As technical improvements develop from hybrid surgery, gastrointestinal endoscopy and abdominal surgery could be revolutionized.     

Next-generation robotic surgery - from the aspect of surgical robots developed by industry

At present, much of the research conducted worldwide focuses on extending the ability of surgical robots. One approach is to extend robotic dexterity. For instance, accessibility and dexterity of the surgical instruments remains the largest issue for reduced port surgery such as single port surgery or natural orifice surgery. To solve this problem, a great deal of research is currently conducted in the field of robotics. Enhancing the surgeon’s perception is an approach that uses advanced sensor technology. The real-time data acquired through the robotic system combined with the data stored in the robot (such as the robot’s location) provide a major advantage. This paper aims at introducing state-of-the-art products and pre-market products in this technological advancement, namely the robotic challenge in extending dexterity and hopefully providing the path to robotic surgery in the near future.     

Transvesical peritoneoscopy: initial clinical evaluation of the bladder as a portal for natural orifice translumenal endoscopic surgery

Abdominal surgery has traditionally been performed through large incisions into the peritoneal cavity. In the past decade, traditional open surgery has been increasingly replaced by minimally invasive laparoscopic and robotic techniques. In comparison to open surgery, these approaches can decrease postoperative pain, shorten the convalescence period, and improve cosmesis. Nonetheless, these techniques require multiple small entry incisions and are therefore associated with risk of wound infection and incisional hernia. The latest surgical advance is performance of procedures via natural body openings such as the mouth, anus, vagina, and bladder. To date, clinical experience with natural orifice translumenal endoscopic surgery (NOTES) is extremely limited. Herein, we describe the initial clinical case in which we evaluated the bladder as a portal for NOTES. Our experience indicates clinical feasibility of transvesical peritoneoscopy with existing clinical equipment, but additional refinements of the technique and associated instrumentation appear warranted. In comparison to other portals, the urinary tract seems to have distinct clinical advantages for NOTES.     

Robotic natural orifice transluminal endoscopic surgery (R-NOTES): Literature review and prototype system

In minimally invasive surgery methods such as laparoscopic surgery, surgical instruments are introduced through small incisions to minimize patient trauma and recovery times. To reduce the number of incisions, new techniques such as natural orifice transluminal endoscopic surgery (NOTES) have been proposed. Compared to laparoscopic surgery, the NOTES approach, which requires new technology and improved instruments, presents some unique challenges. Robotic NOTES (R-NOTES) could be an enabling technology for these procedures. In this paper, we first review relevant work in R-NOTES. We then present our work and the system architecture for an R-NOTES prototype system incorporating wireless command and control. The system was tested twice in swine animal studies.     

Present and future advanced laparoscopic surgery

Modern laparoscopy, starting with Kurt Semm's insufflators and the first successful appendectomies, has only been around for approximately 30 years. Since those early successes, the technology has grown from the inception of basic laparoscopy to endoscopic surgery through natural orifices, and it continues to evolve by leaps and bounds with computer‐assisted surgery and improved robotics in surgery. Without question, laparoscopy has revolutionized the way we perform standard surgery, especially relative to the techniques that had been used for hundreds of years. Despite the development of multiple novel technologies since the 1980s, very little has changed with regard to basic conceptualizations and practice of laparoscopy. In this review article, we will describe the highlights of recent advanced laparoscopic surgery procedures, their potential applications within the field of surgery, and how these advances may impact and improve future quality and patient outcomes.     

Flexible endoscopic robot

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endoscope passed through a natural orifice through an internal incision in the stomach, vagina, bladder or colon. NOTES is still evolving and many barriers stand on its way before it can gain acceptance in modern surgical practice. Effective access to the peritoneal cavity, closure techniques of the natural orifice access sites, development of a multitasking platform to accomplish procedures and support for special orientation are only a handful of its known limitations. Although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of degree of freedom (DOF) of the end effectors. We have developed a Master and Slave Transluminal Endoscopic Robot (MASTER) with nine degrees of freedom (DOF) in end effectors, which are long and flexible so as to enhance endoscopic procedures and NOTES. Using MASTER we have successfully performed endoscopic sub-mucosal dissections (ESD) to segmental hepatectomies in animal models. Thus, the MASTER robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools.     

Training for NOTES

The foundation of skills for the performance of natural orifice translumenal endoscopic surgery (NOTES) lies in the training for general surgery (especially laparoscopy) and flexible gastrointestinal endoscopy. Physicians wishing to practice NOTES need to acquire or have both skill sets, or need to partner together to blend complementary capabilities with colleagues. In the future, however, a new cadre of NOTES specialists may emerge who will have developed individual expertise in the full spectrum of NOTES knowledge base requirements. This article highlights a body of knowledge and skills needed to become a NOTES proceduralist and review the current training paradigms for gastrointestinal endoscopists and surgeons.     

Principle and history of Natural Orifice Translumenal Endoscopic Surgery (NOTES)

The field of gastrointestinal endoscopy has been witnessing major advances over the last five decades. Developing from flexible endoscopy to endoscopic retrograde cholangiopancreatography (ERCP) in the 1950's and 70's to endoscopic ultrasound in the 80's, endoscopic technology has been transformed from serving purely diagnostic purposes to therapeutic applications. One recent major advance is the notion of using the flexible endoscope, taking it beyond the gastrointestinal lumen into what lies beyond the confines of the gastrointestinal tract. Natural orifice translumenal surgery offers the exciting potential to be safer, less invasive and possibly more cost‐effective than the traditional open surgical or laparoscopic approach. The history and principles of natural orifice translumenal endoscopic surgery (NOTES), along with future implications, are outlined in this article.     

Current status of robotic surgery in urology

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot‐assisted surgery in the field of urology and following the success of robot‐assisted prostatectomy and robot‐assisted partial nephrectomy, robot‐assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.     

Principle and history of Natural Orifice Translumenal Endoscopic Surgery (NOTES).

The field of gastrointestinal endoscopy has been witnessing major advances over the last five decades. Developing from flexible endoscopy to endoscopic retrograde cholangiopancreatography (ERCP) in the 1950's and 70's to endoscopic ultrasound in the 80's, endoscopic technology has been transformed from serving purely diagnostic purposes to therapeutic applications. One recent major advance is the notion of using the flexible endoscope, taking it beyond the gastrointestinal lumen into what lies beyond the confines of the gastrointestinal tract. Natural orifice translumenal surgery offers the exciting potential to be safer, less invasive and possibly more cost-effective than the traditional open surgical or laparoscopic approach. The history and principles of natural orifice translumenal endoscopic surgery (NOTES), along with future implications, are outlined in this article.     

Techniques for transgastric access to the peritoneal cavity

Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. So far, NOTES surgeries have been reported by modifying laparoscopic surgery. The peroral transgastric route was chosen to access the peritoneal cavity in initial trials because of a potentially lower risk for surrounding organ injury using the anterior wall percutaneous endoscopic gastrostomy-style gastrotomy. This article reviews and describes techniques of transgastric access to the peritoneal cavity used in published animal studies.     

Spectrally encoded fiber-based structured lighting probe for intraoperative 3D imaging

Three dimensional quantification of organ shape and structure during minimally invasive surgery (MIS) could enhance precision by allowing the registration of multi-modal or pre-operative image data (US/MRI/CT) with the live optical image. Structured illumination is one technique to obtain 3D information through the projection of a known pattern onto the tissue, although currently these systems tend to be used only for macroscopic imaging or open procedures rather than in endoscopy. To account for occlusions, where a projected feature may be hidden from view and/or confused with a neighboring point, a flexible multispectral structured illumination probe has been developed that labels each projected point with a specific wavelength using a supercontinuum laser. When imaged by a standard endoscope camera they can then be segmented using their RGB values, and their 3D coordinates calculated after camera calibration. The probe itself is sufficiently small (1.7 mm diameter) to allow it to be used in the biopsy channel of commonly used medical endoscopes. Surgical robots could therefore also employ this technology to solve navigation and visualization problems in MIS, and help to develop advanced surgical procedures such as natural orifice translumenal endoscopic surgery.     

Concept design of robotic modules for needlescopic surgery

Background: Many minimally invasive surgical procedures and assisting robotic systems have been developed to further minimize the number and size of incisions in the body surface. This paper presents a new idea combining the advantages of modular robotic surgery, single incision laparoscopic surgery and needlescopic surgery.

Material and methods: In the proposed concept, modules carrying therapeutic or diagnostic tools are inserted in the abdominal cavity from the navel as in single incision laparoscopic surgery and assembled to 3-mm needle shafts penetrating the abdominal wall.

Results: A three degree-of-freedom robotic module measuring 16?mm in diameter and 51?mm in length was designed and prototyped. The performance of the three connected robotic modules was evaluated.

Conclusion: A new idea of modular robotic surgery was proposed, and demonstrated by prototyping a 3-DOF robotic module. The performance of the connected robotic modules was evaluated, and the challenges and future work were summarized.     

NOTES: past,present and future

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about that field. Natural Orifices Translumenal Endoscopic Surgery (NOTES) has the potential to break the physical barrier between bodily trauma and surgery. At the dawn of surgery, excellence was associated with big incisions: “big scar ‐ big surgeon”. In the 80s, minimally invasive surgery was born representing one of the greatest surgical evolutions of the 20th century. After Kalloo's first report in 2004 on transgastric peritoneoscopy in a porcine model, the interest in natural orifice transluminal endoscopic surgery (NOTES) has blossomed. Theoretically the same operation performed laparoscopically could be carried out through natural orifices without any abdominal incision avoiding pain and scarring. The lesson learned from the advent of laparoscopic surgery, thought us that we could be witnessing the birth of another surgical revolution. Since 2004 many abdominal procedures that use a NOTES approach have been successfully performed in animal models. However, the initial excitement for NOTES has been somewhat tempered by the reality that a NOTES procedure in human without laparoscopic assistance has not been performed by most groups. Indeed, a major issue is the lack of stable operative platform and flexible instruments that allow retraction and exposure of the organs, such as appendix or gallbladder. Will this issue change the future of NOTES?     

Submucosal endoscopy with mucosal flap safety valve (SEMF) technique: A safe access method into the peritoneal cavity and mediastinum

Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. Our colleagues at the Mayo Clinic have explored, over several years, the concept of using the submucosa as a working space for endoscopic interventions, such as resection of mucosal neoplasias and submucosal tumors, as well as for the acquisition of muscular tissue for etiologic analysis of motility disorders. The submucosal space can also be utilized as a protective tunnel preventing peritoneal soiling by using the free overlying mucosa, as a sealant flap, and permitting a safer offset entry into the peritoneal and thoracic cavities for NOTES. In the SEMF technique, the submucosal space is mechanically created by balloon dissection facilitated by either high‐pressure CO2 gas injection or chemically ‘softening’ the submucosal connective tissues. This article reviews and describes SEMF in detail along with applications involving in vivo porcine models.     

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.     

Endoluminal resection of gastric intestinal stromal tumors (GIST)

Summary

Endoluminal surgery, the combination of flexible endoscopy and percutaneous transgastric laparoscopy, has expanded the role of minimally invasive surgery in treating foregut diseases. This imaginative technique blends the skills of endoscopist and laparoscopist. The stomach is well-suited for this technique as it is an expandable, large volume organ readily accessible to a flexible endoscope, and the relative ease of placing endoscopically or laparoscopically-guided percutaneous, transgastric ports provides access for laparoscopic instrumentation. The resection of gastric stromal tumors provides one of the few opportunities to integrate flexible endoscopy and laparoscopy. Proper training in the appropriate indications to utilize endoluminal techniques and familiarity with the multiple modifications from the original intragastric techniques described nearly a decade ago will allow surgeons to approach small, predominately endoluminal gastric stromal tumors with low malignant potential located in the cardia, along the posterior gastric wall, near the gastroesophageal junction or proximal to the pylorus.