Abstrakt Technologie Listopad 2010

“LESS, NOTES and robotic surgery in gynecology: An update and upcoming perspectives.”

Dällenbach, P., P. Petignat, et al. (2010).

Chirurgie LESS, NOTES et robotique en gynécologie: Mise au point et perspectives6(268): 2024-2029.


Laparoscopy revolutionized the gynecological surgical world during the 1980′s and 1990′s and has changed the approach to surgical procedures ever since. Minimal invasive surgery procedures are now the standard of care for many gynecological operations. At the beginning of the 21 st century, robotic gynecological surgery, laparo-endoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) may be on the threshold of another such revolutionary breakthrough. In this article, we review the present place of these new techniques in gynecological surgery and discuss their future perspective.




“Single-site surgery: More oR-LESS?”

Dev, H. S., P. Sooriakumaran, et al. (2010).

European Urology58(6): 849-850.




“Laparoendoscopic single-site surgery (LESS) in gynecology: A multi-institutional evaluation.”

Fader, A. N., L. Rojas-Espaillat, et al. (2010).

American Journal of Obstetrics and Gynecology203(5).


Objective: The study objectives were to determine the surgical outcomes of a large series of gynecology patients treated with laparoendoscopic single-site surgery (LESS). Study Design: This was a retrospective, multi-institutional analysis of gynecology patients treated with LESS in 2009. Patients underwent surgery via a single 1.5- to 2.5-cm umbilical incision with a multichannel single port. Results: A total of 74 women underwent LESS. Procedures were performed for benign pelvic masses (n = 39), endometrial hyperplasia (n = 9), endometrial (n = 15) and ovarian (n = 6) cancers, and nongynecologic malignancies (n = 5). Median patient age and body mass index were 47 years and 28, respectively. A Pearson product-moment correlation coefficient was computed and demonstrated a significant linear relationship between the operating time and number of cases for cancer staging (r = 0.71; n = 26; P < .001) and nonstaging (r = 0.78; n = 48; P < .002) procedures. Perioperative complications were low (3%). Conclusion: LESS is feasible, safe, and reproducible in gynecology patients with benign and cancerous conditions. Operative times are reasonable and can be decreased with experience. © 2010 Mosby, Inc.




“Single-incision sleeve gastrectomy using a novel technique for liver retraction.”

Galvani, C. A., M. Choh, et al. (2010).

Journal of the Society of Laparoendoscopic Surgeons14(2): 228-233.


Introduction: Laparoscopic sleeve gastrectomy has rapidly gained popularity in the field of bariatric surgery, mainly due to its low morbidity and mortality. Traditionally, 4 to 6 trocars are used. Single-access surgery has emerged as an attempt to decrease incisional morbidity and enhance cosmetic benefits. We present our initial 7 patients undergoing single-incision laparoscopic sleeve gastrectomy using a novel technique for liver retraction. Methods: Patients who underwent single-incision laparoscopic sleeve gastrectomy between March 2009 and May 2009 were analyzed. A 4-cm left paramedian incision was used. Laparoscopic sleeve gastrectomy was performed in a standard fashion using a 40 French bougie. Results: Seven patients underwent single-incision sleeve gastrectomy at the University of Illinois at Chicago. They were all female with a mean age of 34 years. Preoperative BMI was 49kg/m<sup>2</sup> (range, 39 to 64). There were no intra-operative complications. Mean operative time was 103 minutes. Estimated blood loss was minimal. All 7 patients were discharged on postoperative day 2 and were doing well without any complications at 3.1±0.7 months after surgery. Conclusion: Single-incision laparoscopic sleeve gastrectomy is safe and feasible and can be performed without changing the existing principles of the procedure. Our technique for internal liver retraction provides adequate exposure and is reproducible. Development of improved standard instrumentation is required for this technique to become popular. © 2010 by JSLS.




“Transumbilical single-incision laparoscopic hysterectomy for large uterus: Feasibility of the technique.”

Gilabert-Estelles, J., J. M. Castello, et al. (2010).

Gynecological Surgery7(2): 143-148.


Total hysterectomy has been shown to have more clinical benefits when performed with a laparoscopic approach in comparison to traditional open surgery. However, multiple puncture sites might increase trocarassociated complications, such as bleeding, hernias, and wound infection and the cosmetic results are not always optimal. The umbilicus, an embryonic natural orifice, is an anatomical structure that may be used to perform advanced gynecological procedures, further reducing the morbidity associated with classical laparoscopic surgery. Leiomyomas are one of the most common indications for hysterectomy in women not wishing to conceive. Uterine size may be a limiting factor for laparoscopic single-incision approach to hysterectomy due to difficulties encountered to achieve a proper operative field. Several practical maneuvers can be used to assure a safe dissection while managing voluminous uteri. Herein we present our preliminary experience of transumbilical single-incision laparoscopic hysterectomy with a multichannel port in a patient affected of myomatous uterus. © Springer-Verlag 2010.




“Chopstick surgery: a novel technique enables use of the Da Vinci Robot to perform single-incision laparoscopic surgery.”

Joseph, R. A., N. A. Salas, et al. (2010).

Surgical Endoscopy24(12): 3224.


INTRODUCTION: Single-incision laparoscopic surgery (SILS) is limited by the coaxial arrangement of the instruments. A surgical robot with “wristed” instruments could overcome this limitation but the “arms” collide when working coaxially. This video demonstrates a new technique of “chopstick surgery,” which enables use of the robotic arms through a single incision without collision. METHODS: Experiments were conducted utilizing the da Vinci S((R)) robot (Sunnyvale, CA) in a porcine model with three laparoscopic ports (12 mm, 2-5 mm) introduced through a single “incision.” Pilot work conducted while performing Fundamentals of Laparoscopic Surgery (FLS) tasks determined the optimal setup for SILS to be a triangular port arrangement with 2-cm trocar distance and remote center at the abdominal wall. Using this setup, an experienced robotic surgeon performed a cholecystectomy and nephrectomy in a porcine model utilizing the “chopstick” technique. The chopstick arrangement crosses the instruments at the abdominal wall so that the right instrument is on the left side of the target and the left instrument on the right. This arrangement prevents collision of the external robotic arms. To correct for the change in handedness, the robotic console is instructed to drive the “left” instrument with the right hand effector and the “right” instrument with the left. RESULTS: Both procedures were satisfactorily completed with no external collision of the robotic arms, in acceptable times and with no technical complications. This is consistent with results obtained in the box trainer where the chopstick configuration enabled significantly improved times in all tasks and decreased number of errors and eliminated instrument collisions. CONCLUSION: Chopstick surgery significantly enhances the functionality of the surgical robot when working through a small single incision. This technique will enable surgeons to utilize the robot for SILS and possibly for intraluminal or transluminal surgery.




“Cholecystectomy without visible scar: Single incision laparoscopic surgery.”

Kohnen, L., C. Coimbra, et al. (2010).

La cholécystectomie sans cicatrice visible: La chirurgie laparoscopique par incision ombilicale unique65(10): 543-544.




“Single-port laparoscopic myomectomy using transumbilical GelPort access.”

Lee, J. H., J. S. Choi, et al. (2010).

European Journal of Obstetrics Gynecology and Reproductive Biology153(1): 81-84.


Objective: To describe our initial experience with single-port laparoscopic myomectomy (SP-LM) using transumbilical GelPort access and the surgical technique used, and to evaluate the safety and feasibility of this procedure. Study design: A prospective observational study was performed at a university teaching hospital from January 2009 to December 2009. Fifteen patients with symptomatic subserosal or superficial intramural myomas (≤8 cm) underwent SP-LM. Results: The mean age and body mass index were 35.0 ± 8.6 years and 22.6 ± 2.6 kg/m<sup>2</sup>. Two patients had a history of previous abdominal surgery, consisting of one and two cesarean deliveries. The mean operating time, hemoglobin change, return of bowel activity, and length of hospital stay were 81 ± 21.5 min, 1.1 ± 0.5 g/dL, 34.3 ± 5.9 h, and 3.1 ± 0.5 days, respectively. In one patient (6.7%), SP-LM was converted to two-port LM. There were no surgical or wound complications in any patient, and the histopathological result was leiomyoma in all the cases. Conclusion: SP-LM is feasible in selected patients with symptomatic myoma. © 2010 Elsevier Ireland Ltd All rights reserved.




“Current status of natural orifice trans-endoscopic surgery (NOTES) and laparoendoscopic single site surgery (LESS) in urologic surgery.”

Sanchez-Salas, R. E., E. Barret, et al. (2010).

International Braz J Urol36(4): 385-400.


Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) represent novel approaches in urological surgery. To perform a review of the literature in order describe the current status of LESS and NOTES in Urology. References for this manuscript were obtained by performing a review of the available literature in PubMed from 01-01-02 to 15-05-09. Search terms included single port, single site, NOTES, LESS and single incision. A total of 412 manuscripts were initially identified. Out of these, 64 manuscripts were selected based in their urological content. The manuscript features subheadings for experimental and clinical studies, as NOTES-LESS is a new surgical technique and its future evolution will probably rely in initial verified feasibility. A subheading for reviews presents information regarding common language and consensus for the techniques. The issue of complications published in clinical series and the future needs of NOTES-LESS, are also presented.




“Laparoendoscopic single-site surgery using a multi-functional miniature in vivo robot.”

Wortman, T. D., K. W. Strabala, et al. (2010).

Int J Med Robot.


BACKGROUND: Existing methods used to perform laparoendoscopic single-site surgery (LESS) require multiple laparoscopic tools that are inserted into the peritoneal cavity through a single, specialized port. These methods are inherently limited in visualization and dextrous capabilities by working through a single access point. A miniature in vivo robotic platform that is completely inserted into the peritoneal cavity through a single incision can address these limitations, providing more intuitive manipulation capabilities and improved visualization. METHODS: The miniature in vivo robotic platform for LESS consists of a multi-functional robot and a remote surgeon interface. The robot has two arms and specialized end effectors that can be interchanged to provide monopolar cautery, tissue manipulation, and intracorporeal suturing capabilities. RESULTS: This robot has been demonstrated in multiple non-survival procedures in a porcine model, including four cholecystectomies. CONCLUSION: This study demonstrates the effectiveness of using a multi-functional miniature in vivo robot platform to perform LESS. Copyright (c) 2010 John Wiley & Sons, Ltd.




“Micro-force sensing in robot assisted membrane peeling for vitreoretinal surgery.”

Balicki, M., A. Uneri, et al. (2010).

Medical image computing and computer-assisted intervention : MICCAI … International Conference on Medical Image Computing and Computer-Assisted Intervention13(Pt 3): 303-310.


Vitreoretinal surgeons use 0.5 mm diameter instruments to manipulate delicate tissue inside the eye while applying imperceptible forces that can cause damage to the retina. We present a system which robotically regulates user-applied forces to the tissue, to minimize the risk of retinal hemorrhage or tear during membrane peeling, a common task in vitreoretinal surgery. Our research platform is based on a cooperatively controlled microsurgery robot. It integrates a custom micro-force sensing surgical pick, which provides conventional surgical function and real time force information. We report the development of a new phantom, which is used to assess robot control, force feedback methods, and our newly implemented auditory sensory substitution to specifically assist membrane peeling. Our findings show that auditory sensory substitution decreased peeling forces in all tests, and that robotic force scaling with audio feedback is the most promising aid in reducing peeling forces and task completion time.




“Fused video and ultrasound images for minimally invasive partial nephrectomy: a phantom study.” Cheung, C. L., C. Wedlake, et al. (2010).

Medical image computing and computer-assisted intervention : MICCAI … International Conference on Medical Image Computing and Computer-Assisted Intervention13(Pt 3): 408-415.


The shift to minimally invasive abdominal surgery has increased reliance on image guidance during surgical procedures. However, these images are most often presented independently, increasing the cognitive workload for the surgeon and potentially increasing procedure time. When warm ischemia of an organ is involved, time is an important factor to consider. To address these limitations, we present a more intuitive visualization that combines images in a common augmented reality environment. In this paper, we assess surgeon performance under the guidance of the conventional visualization system and our fusion system using a phantom study that mimics the tumour resection of partial nephrectomy. The RMS error between the fused images was 2.43mm, which is sufficient for our purposes. A faster planning time for the resection was achieved using our fusion visualization system. This result is a positive step towards decreasing risks associated with long procedure times in minimally invasive abdominal interventions.




“Dynamic guidance for robotic surgery using image-constrained biomechanical models.”

Pratt, P., D. Stoyanov, et al. (2010).

Medical image computing and computer-assisted intervention : MICCAI … International Conference on Medical Image Computing and Computer-Assisted Intervention13(Pt 1): 77-85.


The use of physically-based models combined with image constraints for intraoperative guidance is important for surgical procedures that involve large-scale tissue deformation. A biomechanical model of tissue deformation is described in which surface positional constraints and internally generated forces are derived from endoscopic images and preoperative 4D CT data, respectively. Considering cardiac motion, a novel technique is presented which minimises the average registration error over one or more complete cycles. Features tracked in the stereo video stream provide surface constraints, and an inverse finite element simulation is presented which allows internal forces to be recovered from known preoperative displacements. The accuracy of surface texture, segmented mesh and volumetrically rendered overlays is evaluated with detailed phantom experiments. Results indicate that by combining preoperative and intraoperative images in this manner, accurate intraoperative tissue deformation modelling can be achieved.




“Collaborative tracking for MRI-guided robotic intervention on the beating heart.”

Zhou, Y., E. Yeniaras, et al. (2010).

Medical image computing and computer-assisted intervention : MICCAI … International Conference on Medical Image Computing and Computer-Assisted Intervention13(Pt 3): 351-358.

Magnetic Resonance Imaging (MRI)-guided robotic interventions for aortic valve repair promise to dramatically reduce time and cost of operations when compared to endoscopically guided (EG) procedures. A challenging issue is real-time and robust tracking of anatomical landmark points. The interventional tool should be constantly adjusted via a closed feedback control loop to avoid harming these points while valve repair is taking place in the beating heart. A Bayesian network of particle filter trackers proves capable to produce real-time, yet robust behavior. The algorithm is extremely flexible and general–more sophisticated behaviors can be produced by simply increasing the cardinality of the tracking network. Experimental results on 16 MRI cine sequences highlight the promise of the method.