Abstrakt Technologie Prosinec 2009

“Editorial Comment on: Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform.”

Bachmann, A. and S. Wyler (2010).

European Urology 57(1): 136-137.




“Laparo-Endoscopic Single Site (LESS) versus Standard Laparoscopic Left Donor Nephrectomy: Matched-pair Comparison.”

Canes, D., A. Berger, et al. (2010).

European Urology 57(1): 95-101.


Background: Laparo-Endoscopic Single Site (LESS) surgery is a recent development in minimally invasive surgery. Presented herein is the initial comparison of LESS donor nephrectomy (LESS-DN) and standard laparoscopic living donor nephrectomy (LLDN). Objective: To determine whether LESS-DN provides any measurable benefit over LLDN during the perioperative period and subsequent convalescence. Design, setting, and participants: Between November 2007 and November 2008, 18 consecutive patients underwent LESS-DN (17 left DN, 1 right DN). A contemporary matched-pair cohort of 17 patients undergoing standard LLDN was selected for retrospective comparison. Interventions: LESS-DN was performed through an intraumbilical novel multichannel port. The kidney was extracted through a slightly extended umbilical incision. Measurements: All data were prospectively accrued in an institutional review board-approved database. Convalescence data included visual analog pain scores and questionnaires containing patient-reported time to recovery end points. Results and limitations: One right-sided donor was converted to standard laparoscopy and excluded from analysis. Baseline demographics, operating time, blood loss, and hospital stay were comparable between groups. Compared to LLDN, patients undergoing LESS-DN had similar in-hospital analgesic requirements and mean visual analog scores at discharge. After discharge, patient-reported convalescence was faster in the LESS-DN group, including days on oral pain medication (20 vs 6; p = 0.01), days off work (46 vs 18; p = 0.0009), and days to 100% physical recovery (83 vs 29; p = 0.03). Mean warm ischemia time was longer in the LESS-DN group (3 vs 6.1 min; p < 0.0001); however, allograft function was immediate and comparable between groups. One allograft in the LESS-DN group thrombosed postoperatively. Regardless of laparoscopic approach, patients’ global satisfaction with kidney donation and willingness to recommend their procedure to others were favorable and equivalent between groups. Conclusions: This retrospective matched-pair comparison between LESS-DN and LLDN suggests that the single-port approach may be associated with quicker convalescence. In this initial series, LESS-DN had longer ischemia time, yet early allograft outcomes were comparable. © 2009 European Association of Urology.




“Editorial Comment on: Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform.”

Cestari, A. and G. Guazzoni (2010).

European Urology 57(1): 137.




“Natural orifice surgery: The next step in minimal invasiveness towards no scar surgery.”

Forgione, A. (2009).

Minerva Chirurgica 64(4): 355-364.


The possibility to operate into the abdominal cavity by means of flexible endoscopes introduced through natural orifices represents a major step forward in the continuous research for minimal invasive treatment attaining the unimaginable goal of no scar surgery. After several years of investigation in experimental settings, natural orifice surgery is becoming a valuable therapeutic option both as totally transluminal endoscopic approach or with the support of minimal transabdominal assistance. The promising operative results and the great interest determined among the patients always looking for effective treatment associated with less bodily trauma, postoperative pain and faster recovery, are pushing the development of dedicated technological solutions that will make natural orifice – no scar surgery more easy and reproducible to perform and applicable also to more advanced diseases. Natural orifice surgery has the potential to abolish the historical association of surgery to that of scar and pain representing a very appealing surgical option for the patients highly respectful of their body and psychological integrity.




“Consensus statement of the consortium for laparoendoscopic single-site surgery.”

Gill, I. S., A. P. Advincula, et al. (2009).

Surgical Endoscopy: 1-7.




“”Chopstick” surgery: a novel technique improves surgeon performance and eliminates arm collision in robotic single-incision laparoscopic surgery.”

Joseph, R. A., A. C. Goh, et al. (2009).

Surgical Endoscopy: 1-5.


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 often collide when working coaxially. This study tests a new technique of “chopstick” surgery to enable use of the robotic arms through a single incision without collision. Methods: Experiments were conducted utilizing the da Vinci S® robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a Fundamentals of Laparoscopic Surgery (FLS) box trainer with three laparoscopic ports (1 × 12 mm, 2 × 5 mm) introduced through a single “incision.” Pilot work 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, five experienced robotic surgeons performed three FLS tasks utilizing either a standard robotic arm setup or 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 results in separation of the robotic arms outside the box. 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. Performances were compared while measuring time, errors, number of clutching maneuvers, and degree of instrument collision (Likert scale 1-4). Results: Compared with the standard setup, the chopstick configuration increased surgeon dexterity and global performance through significantly improved performance times, eliminating instrument collision, and decreasing number of camera manipulations, clutching maneuvers, and errors during all tasks. 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. © 2009 Springer Science+Business Media, LLC.




“Pure Natural Orifice Translumenal Endoscopic Surgery (NOTES) Transvaginal Nephrectomy{black small square}.”

Kaouk, J. H., G. P. Haber, et al. (2009).

European Urology.


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.




“NOTES (Natural Orifice Translumenal Endoscopic Surgery).”

Lukovich, P. (2009).

NOTES (Natural Orifice Translumenal Endoscopic Surgery) 62(4): 274-278.




“Feasibility of right and left transvaginal retroperitoneal nephrectomy: From the porcine to the cadaver model.”

Perretta, S., P. Allemann, et al. (2009).

Journal of Endourology 23(11): 1887-1892.


Purpose: Minimally invasive nephrectomy performed through a natural orifice such as the vagina could enhance cosmesis and improve patient acceptance of the procedure and postoperative recovery. As the vagina has already been proposed as a site of specimen extraction in patients undergoing laparoscopic nephrectomy, the aim of this study was to explore the feasibility of transvaginal, retroperitoneal natural orifice transluminal endoscopic surgery (NOTES) nephrectomy for both left- and right-sided kidneys initially in a porcine model and thereafter in a human cadaver model. Materials and Methods: Ten female pigs underwent NOTES nephrectomy (five having a left nephrectomy and five having right nephrectomy). To do this, each pig was anesthetized and placed in a supine position. A retroperitoneal conduit was established by means of a posterior colpotomy and the retroperitoneal space then entered with a conventional double-channel endoscope (StorzTM). Thereafter, careful blunt dissection allowed a passage to be created up to the renal vessels and proximal ureter which were then dissected and divided separately after endoscopic clipping. We then attempted to reproduce the technique in two formaldehyde-preserved female cadavers. Results: All the porcine procedures were accomplished by a totally NOTES approach with a mean operative time of 50 minutes (range 45-60). No bleeding or injury to any of the retroperitoneal structures occurred. In the two cadavers, the retroperitoneal access was reproduced, but a complete dissection of the kidney was not possible because of the rigor of the surrounding tissues. Conclusions: Transvaginal retroperitoneal NOTES right and left nephrectomy is certainly accomplishable in the porcine model, and the feasibility of the access was confirmed in two cadavers. As a retroperitoneal transvaginal dissection preserves the peritoneum and obviates bowel handling, this work should encourage further development of NOTES accesses for renal surgery. © 2009 Mary Ann Liebert, Inc.




“A multitasking platform for natural orifice translumenal endoscopic surgery (NOTES): A benchtop comparison of a new device for flexible endoscopic surgery and a standard dual-channel endoscope.”

Spaun, G. O., B. Zheng, et al. (2009).

Surgical Endoscopy and Other Interventional Techniques 23(12): 2720-2727.


Background: A unique endoscopic platform with two independent end-effectors, each with five degrees of freedom, and an ergonomic user interface has been developed to address the needs of complex endolumenal and natural orifice translumenal endoscopic surgery (NOTES) procedures. This study aimed to measure the amount this new platform would improve performance for bimanual coordination compared with a standard dual-channel scope using a benchtop simulation. Methods: Task 1 involved 12 individuals performing an identical bimanual coordination task with two different devices: a dual-channel endoscope (DCE) and the EndoSAMURAI prototype. The participants were separated into three groups with different levels of endoscopy and NOTES experience. A complex bimanual coordination task (pin transfer) was used. For this task, 12 pins had to be manipulated in a predetermined order. Performance was measured by movement speed, and accuracy. Comparisons were made between the two devices and the three groups of subjects. Task 2 required the same 12 participants to perform a standardized intracorporeal suture in a NOTES simulation. Results: In the pin transfer task, overall performance speed was significantly faster using the EndoSAMURAI (304 ± 125 s) rather than the DCE (867 ± 312 s; P < 0.001). The difference between the two operating systems was more pronounced in the student group than in the surgeon group: experts (226 ± 41 vs. 620 ± 277 s), surgeons (333 ± 152 vs. 930 ± 283 s), students (318 ± 83 vs. 1021 ± 423 s). Accuracy, as indicated by the number of pin drops, also was significantly better using the EndoSAMURAI (0.4) rather than the DCE (1.8 drops; P = 0.006). In addition, all 12 participants were able to complete a suture using the EndoSAMURAI, but none could complete a suture using the DCE. Conclusions: The EndoSAMURAI enhances performance times and accuracy in complex surgical tasks compared with the conventional therapeutic endoscope. © 2009 Springer Science+Business Media, LLC.




“Robotic Laparoendoscopic Single-Site Surgery Using GelPort as the Access Platform.”

Stein, R. J., W. M. White, et al. (2010).

European Urology 57(1): 132-137.


Background: Laparoendoscopic single-site surgery (LESS) allows for the performance of major urologic procedures with a single small incision and minimal scarring. The da Vinci Surgical System provides advantages of easy articulation and improved ergonomics; however, an ideal platform for these procedures has not been identified. Objective: To evaluate the GelPort laparoscopic system as an access platform for robotic LESS (R-LESS) procedures. Design, setting, and participants: Since April 2008, 11 R-LESS procedures have been completed successfully in a single institutional referral center. For the last four consecutive cases, the GelPort has been used as an access platform through a 2.5-5-cm umbilical incision. Intervention: R-LESS cases performed with the GelPort included pyeloplasty (n = 2), radical nephrectomy (n = 1), and partial nephrectomy (n = 1). Measurements: Perioperative data were obtained for all patients including demographic data, operative indications, operative records, length of stay, complications, and pathologic analysis. Results and limitations: For both pyeloplasty cases, average operative time (OR time) was 235 min and estimated blood loss (EBL) was 38 cm3. For the patient undergoing radical nephrectomy for a 5.1-cm renal tumor, OR time was 200 min and EBL was 250 cm3. The final patient underwent partial nephrectomy without renal hilar clamping for an 11-cm angiomyolipoma with OR time of 180 min and EBL of 600 cm3. All R-LESS procedures attempted with the GelPort were completed successfully and without complication. Average length of hospital stay was 1.75 d (range: 1-2). The partial nephrectomy patient required transfusion of 1 U of packed red blood cells. Conclusions: Use of the GelPort as an access platform for R-LESS procedures provides adequate spacing and flexibility of port placement and acceptable access to the surgical field for the assistant, especially during procedures that require a specimen extraction incision. Additional platform and instrumentation development will likely simplify R-LESS procedures further as experience grows. © 2009.




“Current status of laparoendoscopic single-site surgery in urology.”

Stolzenburg, J. U., P. Kallidonis, et al. (2009).

World Journal of Urology 27(6): 767-773.


Purpose: Laparoendoscopic single-site surgery (LESS) uses single incisions for the introduction of instruments through a specially designed multi-lumen single port (multi-port) for the performance of several urologic procedures. Methods: Literature review regarding the LESS approach took place on May 2009 and the experiences of our institutions were also included. Results: Almost all urologic intra-abdominal and pelvic procedures have been successfully and safely performed with the LESS approach. Nevertheless, current experience is limited and there are significant technical challenges to the performance of LESS techniques. Conclusions: Wider adaptation of the approach requires refinement of LESS instrumentation to overcome the technical challenges of the approach. The improved outcome should also be documented with further clinical evaluation. © 2009 Springer-Verlag.




“Robotics: Past, Present, and Future Considerations.”

Curet, M. J. (2009).

Seminars in Colon and Rectal Surgery 20(4): 156-161.


Surgical robots, although relatively new, have developed quickly. The development of surgical robots is reviewed in this article. The surgical robots have applications in many surgical specialties. The most widely used surgical robotic system is the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) that is based on an immersive, “master-slave” paradigm which enhances the surgeon’s abilities. Surgical robotics is changing rapidly, and any development in surgical robots in future will allow greater application of robotic devices to increasingly more difficult procedures and hard to access anatomical sites, with significant improvement in patient outcomes. © 2009 Elsevier Inc. All rights reserved.




“Darwin’s theory and robotic surgery.”

De Badajoz, E. S. (2009).

La teoría de darwin y la cirugía robótica 62(8): 611-613.




“Failure and Malfunction of da Vinci Surgical Systems During Various Robotic Surgeries: Experience From Six Departments at a Single Institute.”

Kim, W. T., W. S. Ham, et al. (2009).

Urology 74(6): 1234-1237.


Objectives: To analyze the mechanical failures and malfunctions of the da Vinci Surgical (S) System during various robotic surgeries in 6 different departments at our institute and also evaluated the solutions for the failures and malfunctions. Methods: From July 2005 to December 2008, a total of 1797 robotic surgeries were performed at our institute. The surgeries were performed using 4 da Vinci surgical systems (1 standard da Vinci system from July 2005 to July 2007 and 3 da Vinci S systems from July 2007 to December 2008). Mechanical failures or malfunctions occurred in 43 cases. We evaluated the robotic surgeries according to the type of surgery and the department. We analyzed the cases involving conversion to open or laparoscopic surgeries and those in which there was a malfunction with the instrument. Results: There were 43 cases (2.4%) of mechanical failure with the da Vinci system from a total of 1797 robotic surgeries. This included 24 (1.3%) cases of mechanical failure or malfunction and 19 cases (1.1%) of instrument malfunction. The mechanical malfunction included 1 on/off failure, 5 console malfunctions, 6 robotic arm malfunctions, 2 optic system malfunctions, and 10 system errors. One open and 2 laparoscopic conversions (3 cases; 0.17%) were performed. Conclusions: Mechanical failure or malfunction occurred during robotic surgery in 43 cases (2.4%), and the open or laparoscopic conversion rate during surgery was very low (0.17%). We found the mechanical failure or malfunction to be rare. © 2009 Elsevier Inc. All rights reserved.




“Optimization of a novel mechanism for a minimally invasive surgery robot.”

Li, J., S. Wang, et al. (2009).

Int J Med Robot.


BACKGROUND: Minimally invasive surgery (MIS) has many advantages compared with open surgery, but there are still many drawbacks in performing MIS. Using robotic technologies, many problems caused by human restrictions, such as fatigue and low precision, can be solved. In this paper, a novel mechanism for a MIS robot is proposed. METHODS: Kinematics analysis was carried out and singularity and isotropy configurations were also investigated, based on kinematics equations. In order to evaluate the performance of the robot, a combined measure gave attention to the mean value and standard deviation of the reciprocal of the condition number. Optimization was achieved by maximizing the combined measure subjected to a set of constraints in the task workspace. The effectiveness of the measure was demonstrated by comparing the performance and volume of the optimized mechanism with those of the mechanism optimized by the Global Condition Index (GCI). RESULTS: The robot met the volume constraints with the dimensional parameter a </= 115 mm. The combined measure varphi was maximized when a is 100 mm. The robots optimized by the GCI and the combined measure showed similar performance in terms of condition number, but the latter had advantages on volume compared with the former. CONCLUSIONS: A novel mechanism that satisfied the incision point constraint of MIS was proposed. A systematic methodology for optimizing the mechanism was developed and the combined measure was effective to evaluate the performance. A prototype was set up based on the outcomes mentioned in the paper. Copyright (c) 2009 John Wiley & Sons, Ltd.