Abstrakt Technologie Březen 2010

“Robotics may overcome technical limitations of single-trocar surgery: an experimental prospective study of Nissen fundoplication.”

Allemann, P., J. Leroy, et al. (2010).

Archives of Surgery 145(3): 267-271.


OBJECTIVE: To compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeon’s hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments. DESIGN: Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. SETTING: A research institute. PARTICIPANTS: Three surgeons with different experience. MAIN OUTCOME MEASURES: Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. RESULTS: All of the procedures were successfully completed. Mean operative time (45.6 +/- 11.2 vs 65.4 +/- 10.7 minutes; P = .03) and number of conflicts (1.0 +/- 0.9 vs 3.8 +/- 1.2; P < .001) were significantly reduced in the robotic series. CONCLUSIONS: Use of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.




“Current status and future perspectives in laparoendoscopic single-site and natural orifice transluminal endoscopic urological surgery.”

Autorino, R., R. J. Stein, et al. (2010).

International Journal of Urology.


Abstract Objective of this study is to provide an evidence-based analysis of the current status and future perspectives of scarless urological surgery. A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). In addition, experience with LESS and NOTES at our own institution has been considered. All clinical and investigative reports for LESS and NOTES procedures in the urological literature have been considered. A wide variety of clinical procedures in urology have been succesfully completed by using LESS techniques. Thus far, experience with NOTES has largely been investigational, although early clinical reports are emerging. Further development of instrumentation and platforms is necessary for both techniques to become more widely adopted throughout the urological community.




“Natural orifice translumenal endoscopic surgery (NOTES) partial nephrectomy in a porcine model.”

Boylu, U., M. Oommen, et al. (2010).

Surgical Endoscopy and Other Interventional Techniques 24(2): 485-489.


Background This study aimed to evaluate the feasibility of natural orifice translumenal endoscopic surgery (NOTES) transgastric partial nephrectomy without hilar clamping in a porcine model. Methods A 45-kg male pig was placed in the supine position after endotracheal general anesthesia. A therapeutic gastroscope was introduced through the esophagus, and a 2-cm gastrotomy was performed using a diathermy electrocautery needle at the junction of the fundus and the proximal body. After incision of Gerotas fascia, the left kidneys upper pole was excised using the thulium laser without hilar dissection or clamping. An endoscopic wire loop was used to entrap and extract the specimen into the stomach. The gastroscope was subsequently withdrawn with the intact specimen. After hemostasis via reinsertion of the endoscope was ensured, metal clips were applied endoscopically to close the gastrotomy. Results The total operative time for the NOTES transgastric partial nephrectomy was 240 min. Use of the therapeutic double-channel gastroscope allowed for scarless NOTES. The available 3.7- and 2.8-mm gastroscope ports were used for gastrotomy, excision, removal of the specimen, and endoscopic clip application. The procedure was performed in a nonischemic fashion with application of the thulium laser, which provided adequate hemostasis. No further interventions such as suturing of the renal capsule or use of hemostatic agents were required. The final specimen was 3 cm in size, and the estimated blood loss was 200 ml. A major drawback of the thulium laser was excessive smoke produced by vaporization of the tissue, which was minimized with the use of external irrigation. Conclusion The findings show that NOTES transgastric partial nephrectomy with thulium laser is feasible. Further studies are needed to demonstrate long-term efficacy and provide additional data regarding practical applications of this novel approach and technique. Copyright © 2009 Springer Science+Business Media, LLC.




“Transumbilical single-port laparoscopic partial nephrectomy in a pig model.”

Boylu, U., M. Oommen, et al. (2010).

BJU International 105(5): 686-690.


OBJECTIVE To determine the feasibility, instrumentation, and learning curve for single-port laparoscopic partial nephrectomy (SPLPN) in a pig model. MATERIALS AND METHODS Ten transumbilical SPLPN were performed using the R-Port (Advanced Surgical Concepts, Wicklow, Ireland) multi-instrument port, a 5-mm flexible laparoscope (Olympus Surgical, Orangeburg, NY, USA), and custom-engineered articulating needle drivers, graspers, and scissors (Cambridge Endo, Framingham, MA, USA). After general anaesthesia, the pig was placed in the flank position. After umbilical placement of the R-Port, Gerota’s fascia was incised and hilar dissection performed with the newly engineered articulating instruments. Either the upper or lower pole of the kidney was scored and excised after placing a bulldog clamp on the renal pedicle. The bolsters were prepared with absorbable haemostat, placed at the site of excision, and secured with polyglactin sutures. RESULTS A fascial incision of ≥2.5 cm should be made to allow adequate room for passing the instruments. Also, use of the 5 mm flexible laparoscope minimizes instrument crowding and allows for optimal visualization. The mean (sd, range) time for hilum dissection was 12.2 (4.3, 7-20) min, while that for total excision was 9.8 (1.7, 8-12) min. Modified suturing techniques were developed to achieve reconstruction in a small working space. Specialized instrumentation is essential for a successful SPLPN with no need for an additional port for triangulation. The mean duration of intracorporeal suturing was 27.7 min (declining from 40 to 15 min). The total ischaemia time decreased from 50 min in the first case to 27 min in the last (mean 37.4 min). The mean estimated blood loss was 81.1 (31.7, 50-150) mL. CONCLUSIONS SPLPN is technically feasible but further refinement of instrumentation and techniques is needed to decrease the ischaemia time and optimize the procedure. © 2009 BJU International.




“Initial Experience With 50 Laparoendoscopic Single Site Surgeries Using a Homemade, Single Port Device at a Single Center.”

Jeon, H. G., W. Jeong, et al. (2010).

Journal of Urology.


PURPOSE: We report our technique of and initial experience with 50 patients who underwent laparoendoscopic single site surgery using a homemade single port device at a single institution. MATERIALS AND METHODS: Between December 2008 and August 2009 we performed 50 laparoendoscopic single site surgeries using the Alexis(R) wound retractor, which was inserted at the umbilical incision. A homemade single port device was made by fixing a size 7(1/2) surgical glove to the retractor outer ring and securing the glove fingers to the end of 3 or 4 trocars with a tie and a rubber band. A prospective study was performed in 50 patients to evaluate outcomes. RESULTS: Of 50 patients 34 underwent conventional laparoendoscopic single site surgery, including radical and simple nephrectomy, and cyst decortication in 8 each, nephroureterectomy in 3, partial nephrectomy and adrenalectomy in 2 each, and partial cystectomy, ureterectomy and ureterolithotomy in 1 each, while 16 underwent robotic laparoendoscopic single site surgery, including partial nephrectomy in 11, nephroureterectomy in 3, and simple and radical nephrectomy in 1 each. Mean patient age was 52 years, mean body mass index was 23.4 kg/m(2), mean operative time was 201 minutes and mean estimated blood loss was 201 ml. Four intraoperative complications occurred, including 2 bowel serosal tears, diaphragm partial tearing and conversion to open radical nephrectomy. One case of postoperative bleeding was managed by transfusion. Surgical margins were negative in the 13 patients who underwent partial nephrectomy. Mean hospital stay was 4.5 days (range 1 to 16). CONCLUSIONS: Our homemade single port device is cost-effective, provides adequate range of motion and is more flexible in port placement for laparoendoscopic single site surgery than the current multichannel port.




“Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy.”

Kaouk, J. H., G. P. Haber, et al. (2010).

European Urology 57(4): 723-726.


Natural orifice translumenal endoscopic surgery (NOTES) within urology has largely been limited to experimental animal studies and diagnostic procedures in humans. Attempts to complete a pure NOTES transvaginal nephrectomy have thus far been unsuccessful. We report the first clinical experience with pure NOTES transvaginal nephrectomy. A 58-year-old woman presented with recurrent urinary tract infections and an atrophic right kidney. Transvaginal access was obtained through a 3-cm posterior colpotomy. The right kidney was mobilized, the renal hilum was divided, and the specimen was removed through the vaginal incision. Operative time was 420 min. Estimated blood loss was 50 ml. There were no perioperative complications. © 2009 European Association of Urology.




“Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments.”

Mereu, L., S. Angioni, et al. (2010).

International Journal of Gynecology and Obstetrics 109(1): 78-80.


Objective: To present our initial experience using single access laparoscopic surgery for the treatment of benign adnexal pathologies. Methods: Sixteen patients with benign adnexal pathologies underwent salpingoophorectomy (n = 9), ovarian cyst enucleation (n = 5), or salpingectomy (n = 2) using a laparoendoscopic single site approach with a new multiport reusable trocar and flexible and curved-as well as standard-laparoscopic instruments. Results: Conversion to a multi-access standard laparoscopic technique was not required in any patient and no intraoperative complications were observed. Postoperatively, one umbilical scar infection was detected. Mean operative time was 42 minutes. Conclusion: Laparoscopic single site enucleation for adnexal pathologies is feasible, safe, and effective, and has good results for cosmetic appearance and postoperative pain. Use of specialized instruments and standardization of the technique affect surgical ergonomy and operating time. © 2009 International Federation of Gynecology and Obstetrics.




“Editorial comment to laparoendoscopic single-site urological surgery: Initial experience in Japan.”

Rane, A. (2010).

International Journal of Urology 17(3): 293.




“Single port laparoscopic ureterolithotomy: An initial report of 6 cases.”

Xu, D. F., J. P. Che, et al. (2010).

Academic Journal of Second Military Medical University 31(2): 183-185.


Objective: To summarize our initial experience on single-incision laparoscopic ureterolithotomy in 6 patients, and to evaluate the efficacy and safety of this procedure. Methods: From Jun. 2009 to Jul. 2009, single-incision laparoscopic ureterolithotomies were performed in 6 patients who had a ureteral calculus. The clinical data and operative results were summarized retrospectively. Results: All 6 operations were performed successfully, with no conversion to an open procedure; neither an extra trocar for assistance was needed. No intraoperative complications were noticed. The average operative time was (93.5±30.4) min, the average estimated blood loss was (28.5±16.2) ml, and the average postoperative hospital stay was (5.4±1.1) d. Conclusion: Single-incision ureterolithotomy appears to be safe and effective, and has less trauma and better cosmetic outcomes; but it seems to be more difficult for the surgeon to operate.