“LESSons in minimally invasive urology.”
Dev, H., P. Sooriakumaran, et al. (2011).
BJU International 107(10): 1555-1559.
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.
“Single-port hysterectomy with pelvic lymph node dissection in the porcine model: feasibility and validation of a novel robotic lightweight endoscope positioner.”
Escobar, P. F., J. Knight, et al. (2011).
Gynecological Surgery: 1-5.
The purpose of this study was to evaluate the feasibility and validity of a modified single-port robotic lightweight endoscope in the performance of single-port hysterectomy with pelvic lymph node dissection in the porcine model. Task completion times were recorded for each component of the procedure: port placement, docking of the surgical robot, operative time for the procedures. For each task, linear regression modeling was performed using SPSS to determine whether a correlation existed between task completion time and increasing surgeon experience. All robotic-assisted LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Regression analysis demonstrated a strong correlation between the number of procedures and task completion time for robot docking and pelvic lymph node dissection, correlation coefficients 0.74 and 0.77, p = 0.001, respectively. This study demonstrated the feasibility and effectiveness of a new, compact single-port robotic voice-activated endoscope at improving laparoscope guidance during the performance of single-port hysterectomy with pelvic lymph node dissection in the porcine model. Further work is needed to better define the ideal operative procedure for single-site surgery in oncology and integration of new single-port robotic platforms into clinical practice. © 2011 Springer-Verlag.
“Single plus one port laparoscopic radical prostatectomy: A report of 8 cases in one center.”
Gao, Y., D. F. Xu, et al. (2011).
Chinese Medical Journal 124(10): 1580-1582.
Laparoscopic radical prostatectomy is considered the first treatment of choice for local prostate cancer due to its minimal invasion advantage. To further achieve the goal of minimal invasion, single port laparoscopic radical prostatectomy has been developed to minimize the complications associated with puncture tracks. The aim of this study was to illustrate the technique for single port laparoscopic radical prostatectomy and evaluate its efficacy and safety. We reported 8 cases of radical prostatectomy with excellent early outcome carried out in Shanghai Changzheng Hospital from June 2009 to August 2009 using a home-made multiple instrument access port and adding an additional small incision at McBurney point.
“Laparoendoscopic Single-site Surgery in Urology: Worldwide Multi-institutional Analysis of 1076 Cases.”
Kaouk, J. H., R. Autorino, et al. (2011).
Background: Laparoendoscopic single-site surgery (LESS) has gained popularity in urology over the last few years. Objective: To report a large multi-institutional worldwide series of LESS in urology. Design, setting, and participants: Consecutive cases of LESS done between August 2007 and November 2010 at 18 participating institutions were included in this retrospective analysis. Intervention: Each group performed a variety of LESS procedures according to its own protocols, entry criteria, and techniques. Measurements: Demographic data, main perioperative outcome parameters, and information related to the surgical technique were gathered and analyzed. Conversions to reduced-port laparoscopy, conventional laparoscopy, or open surgery were evaluated, as were intraoperative and postoperative complications. Results and limitations: Overall, 1076 patients were included in the analysis. The most common procedures were extirpative or ablative operations in the upper urinary tract. The da Vinci robot was used to operate on 143 patients (13%). A single-port technique was most commonly used and the umbilicus represented the most common access site. Overall, operative time was 160 ± 93 min and estimated blood loss was 148 ± 234 ml. Skin incision length at closure was 3.5 ± 1.5 cm. Mean hospital stay was 3.6 ± 2.7 d with a visual analog pain score at discharge of 1.5 ± 1.4. An additional port was used in 23% of cases. The overall conversion rate was 20.8%; 15.8% of patients were converted to reduced-port laparoscopy, 4% to conventional laparoscopy/robotic surgery, and 1% to open surgery. The intraoperative complication rate was 3.3%. Postoperative complications, mostly low grade, were encountered in 9.5% of cases. Conclusions: This study provides a global view of the evolution of LESS in the field of minimally invasive urologic surgery. A broad range of procedures have been effectively performed, primarily in the academic setting, within diverse health care systems around the world. Since LESS is performed by experienced laparoscopic surgeons, the risk of complications remains low when stringent patient-selection criteria are applied. © 2011 European Association of Urology.
“Single port laparoscopic surgery and transanal specimen retrieval for sigmoid colon cancer.”
Kim, S. H., J. I. Lee, et al. (2011).
Journal of the Korean Surgical Society 80(2): 77-83.
Transumbilical single-port laparoscopic surgery (SPLS) is a newly emerged and rapidly evolving, minimally invasive treatment method. Transumbilical SPLS produces minimal parietal injury and can achieve cosmetic advantages by reducing additional trocar placement. The in-line or chopstick arrangement of laparoscopic instruments can make the operative procedures somewhat strange and inconvenient at first, but experienced laparoscopic surgeons can achieve the same coverage as conventional laparoscopic surgery with time. Here, we report the first case of transumbilical SPLS anterior resection (SPLS-AR) with transanal retrieval of aspecimen and intracorporeal single stapling anastomosis. The operating time was 270 min. There were no intraoperative or postoperative complications. Transumbilical SPLS resulted in a 1.5-cm wound with early recovery. Transumbilical SPLS-AR with transanal retrieval and intracorporeal anastomosis for sigmoid colon cancer is feasible by experienced laparoscopic colorectal surgeons based on careful evaluation and selection of patients. This operation fulfills both oncological principles and cosmetic demand.
“First human surgery with a novel single-port robotic system: cholecystectomy using the da Vinci Single-Site platform.”
Kroh, M., K. El-Hayek, et al. (2011).
Surgical Endoscopy: 1-8.
Background: Interest in single-incision laparoscopic techniques continues to grow. A learning curve certainly exists, and although the techniques have improved, technical considerations including external clashes, poor visualization of critical structures, and surgeon fatigue remain. Applications of robotics to these newer techniques are evolving. The da Vinci Single-Site robotic surgery platform is a new semi-rigid robotic operative system designed to work with the Intuitive Surgical da Vinci Si operative system. The authors present the first human experience with this new device used to perform single-incision laparoscopic cholecystectomy. This study aimed to present the first human experience performing cholecystectomy with a novel robotic single-port platform. Methods: After Cleveland Clinic Institutional Review Board approval, patients with symptomatic biliary disease fitting standard criteria for cholecystectomy were enrolled in the study. A total of 13 consecutive single-port, robotic cholecystectomy operations were performed. Patient demographics and operative results were evaluated. Results: All 13 operations were completed successfully with the Single-Site platform. A critical view of safety as determined by the operative surgeon was obtained in all cases. One patient required placement of an additional extra-umbilical trocar for appropriate visualization secondary to gallbladder necrosis, and this incision also was used for eventual drain placement. For two patients, an intraoperative choloangiogram was performed. The mean operative time was 107 ± 54 min, and the mean docking time was 15 ± 9 min. Discharge for 11 patients was within 24 h. No significant complications occurred. Conclusion: Cholecystectomy using the da Vinci Single-Site system is feasible. Availability of this new semi-rigid, robotic surgery platform may increase access to the potential advantages of single-site surgery. Additional advantages of single-site surgery may be elucidated with further studies. © 2011 Springer Science+Business Media, LLC.
“Laparoendoscopic single site nephrectomy with the SPIDER surgical system: Engineering advancements tested in a porcine model.”
Salas, N., M. A. Gorin, et al. (2011).
Journal of Endourology 25(5): 739-742.
Background and Purpose: The Single Port Instrument Delivery Extended Reach (SPIDER) surgical system was developed for true continuous instrument triangulation during laparoendoscopic single site (LESS) surgery. We present our initial preclinical experience with the SPIDER surgical system during renal surgery. Material and Methods: Bilateral laparoscopic nephrectomies were performed in a live adult porcine animal model using the SPIDER device. A standard surgical approach was used via direct video guidance. Results: The procedure was successfully performed without surgical error or complication. The SPIDER system proved easy to use with only a minimal learning curve. Intracorporeal surgical knots were tied without difficulty using this single site system. Conclusions: Our initial experience with the SPIDER surgical system during renal surgery is promising. SPIDER allows for true single port instrument triangulation offering a superior operative experience to currently available LESS surgical systems. © 2011, Mary Ann Liebert, Inc. 2011.
“Enhancement of a master-slave robotic system for natural orifice transluminal endoscopic surgery.”
Sun, Z., R. Y. Ang, et al. (2011).
Annals of the Academy of Medicine, Singapore 40(5): 223-228.
Introduction: A novel robotic platform for Natural Orifi ce Transluminal Endoscopic Surgery (NOTES) is presented in this paper. It aims to tackle two crucial technical barriers which hinder its smooth transition from animal studies to clinical trials: providing effective instrumentations to perform complex NOTES procedures and maintaining the spatial orientation for endoscopic navigation. Materials and Methods: The technical barriers are overcome by the design of the robotic system considering size, triangulation, dexterity, maneuverability and complexity. It is also shown that haptic feedback and interventional navigation system could solve the problem of off-axis manipulation of the camera angle and loss of spatial orientation upon entering the peritoneal cavity in transgastric NOTES procedure, respectively. Results: Successful ESD (endoscopic submucosal dissection) and wedge hepatic resection have been performed on live pigs with our Master And Slave Transluminal Endoscopic Robot (MASTER) system, showing its capability to perform advanced endoscopic surgical and NOTES procedures. It is found that the MASTER exhibited good grasping and cutting effi ciency. And the lesion resection time could be signifi cantly reduced with more practice between the endoscopist and the robot operator. Conclusion: This study evaluates the feasibility of MASTER system as a platform overcoming the barriers to NOTES. It is also demonstrated that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures.
“Horizon Stabilized-Dynamic View Expansion for Robotic Assisted Surgery (HS-DVE).”
Warren, A., P. Mountney, et al. (2011).
International Journal of Computer Assisted Radiology and Surgery: 1-8.
Purpose: New surgical approaches based on natural orifice transluminal surgery (NOTES) have the potential to further decrease morbidity and hospital stay. However, a number of key challenges have been identified preventing its clinical adoption, including inadequate instrument design and spatial disorientation. Furthermore, retroflexion, missing fixed anatomical references, and limited field-of-view are key factors contributing to disorientation in NOTES. Methods: A hybrid approach of integrated orientation sensing and real-time vision processing is proposed to restore orientation cues for improved surgical navigation. The distal tip of an articulated robotic endoscope is equipped with an inertial measurement unit (IMU) enabling video images to be reoriented and stabilized with respect to the horizon. This is performed by measuring the direction of gravity in relation to the cameras. Dynamic view expansion is used to increase the field-of-view of the endoscope. The method registers past video images to the current image and creates an enlarged visualization of the anatomy through simultaneous localization and mapping (SLAM). Results: The clinical potential of the system is demonstrated on a NOTES appendectomy procedure performed on the NOSsE phantom. This involves an articulated robotic endoscope navigating to visualize the appendix while retroflexed. The horizon stabilization is additionally evaluated quantitatively against known ground truth. Conclusions: The combination of horizon stabilization and dynamic view expansion presents a realistic approach for reintroducing orientation and navigation cues during NOTES. The platform allows real-time implementation, which is an important prerequisite for further clinical evaluation. © 2011 CARS.
“Single-Port Robotic Cholecystectomy: Results From a First Human Use Clinical Study of the New da Vinci Single-Site Surgical Platform.”
Wren, S. M. and M. J. Curet (2011).
Archives of Surgery.
OBJECTIVES: To report our results from a first human use clinical study with the da Vinci Surgical single-site instrumentation in patients with gallbladder disease and to perform a retrospective comparison with traditional multiport laparoscopic cholecystectomy. DESIGN: Ten patients underwent robotic single-port cholecystectomy performed with the da Vinci Si robot and novel da Vinci single-site instrumentation. Outcomes and operative times were compared with patients undergoing traditional multiport laparoscopic cholecystectomy during the same period. SETTING: Tertiary care Veterans Administration hospital. PATIENTS: Outpatients older than 18 years with an American Society of Anesthesiologists class of 1 to 3, no prior upper abdominal surgery, and diagnosis of noninflammatory biliary disease. INTERVENTION: Single-site robotic cholecystectomy. MAIN OUTCOME MEASURES: Operative time, complications up to 30 days, pain scores, and overall satisfaction. RESULTS: Nine of 10 patients had completion of robotic single-site cholecystectomy. Average operating room time was 105.3 minutes compared with an average of 106.1 minutes in the standard laparoscopic group. There were no serious adverse events in the robotic surgery group, with an average follow-up of 3 or more months. CONCLUSION: Robotic single-port cholecystectomy is feasible and comparable with standard laparoscopic cholecystectomy in the Veterans Administration medical center setting.
“Force field adaptation can be learned using vision in the absence of proprioceptive error.”
Melendez-Calderon, A., L. Masia, et al. (2011).
IEEE Transactions on Neural Systems and Rehabilitation Engineering 19(3): 298-306.
It has been shown that people can learn to perform a variety of motor tasks in novel dynamic environments without visual feedback, highlighting the importance of proprioceptive feedback in motor learning. However, our results show that it is possible to learn a viscous curl force field without proprioceptive error to drive adaptation, by providing visual information about the position error. Subjects performed reaching movements in a constraining channel created by a robotic interface. The force that subjects applied against the haptic channel was used to predict the unconstrained hand trajectory under a viscous curl force field. This trajectory was provided as visual feedback to the subjects during movement (virtual dynamics). Subjects were able to use this visual information (discrepant with proprioception) and gradually learned to compensate for the virtual dynamics. Unconstrained catch trials, performed without the haptic channel after learning the virtual dynamics, exhibited similar trajectories to those of subjects who learned to move in the force field in the unconstrained environment. Our results demonstrate that the internal model of the external dynamics that was formed through learning without proprioceptive error was accurate enough to allow compensation for the force field in the unconstrained environment. They suggest a method to overcome limitations in learning resulting from mechanical constraints of robotic trainers by providing suitable visual feedback, potentially enabling efficient physical training and rehabilitation using simple robotic devices with few degrees-of-freedom.