“Magnetic Anchoring and Guidance System Instrumentation for Laparo-endoscopic Single-site Surgery/Natural Orifice Transluminal Endoscopic Surgery: Lack of Histologic Damage After Prolonged Magnetic Coupling Across the Abdominal Wall.”
Best, S. L., W. Kabbani, et al. (2010).
Objectives: To study the potential pathologic effect of prolonged compression of abdominal wall between the components. Magnetic Anchoring and Guidance System (MAGS) instruments ameliorate some of the challenges in triangulation created by laparo-endoscopic single-site and natural orifice translumenal endoscopic surgery. They consist of an intracorporeal magnetic device coupled to an external hand-held magnet used to anchor and “steer” it around the peritoneal cavity. Methods: Three pigs (45.5-48.6 kg) underwent laparoscopic placement of magnetic devices in 4 quadrants, with the devices left in place for 2 or 4 hours. Full-thickness abdominal wall sections (mean 2.1 cm thick) where each MAGS platform was placed plus a control were harvested at 0, 2, or 14 days after surgery. Histologic assessment was then performed. Results: Beyond mild blanching of the peritoneal surface with a few petechiae immediately after internal component removal, no gross tissue damage was seen. These changes were undetectable by 48 hours and no intra-abdominal adhesions were identified at necropsy. NADH stain for tissue viability in the 4 nonsurvival specimens showed no tissue damage. Hematoxylin and eosin stain showed no necrosis of either superficial or deep muscle, skin, or subcutaneous fat tissue in all 12 specimens when compared with the control. Conclusions: MAGS instruments do not appear to cause tissue damage or adverse clinical outcomes when coupled across thin porcine abdominal walls for up to 4 hours. Because the distance across the abdominal wall is generally greater in adult human beings, these findings support the further clinical development of magnetic instruments to be used in human patients. © 2010 Elsevier Inc. All rights reserved.
“One-port retroperitoneoscopic assisted pyeloplasty versus open dismembered pyeloplasty in young children: Preliminary experience.”
Caione, P., A. Lais, et al. (2010).
Journal of Urology 184(5): 2109-2115.
Purpose We propose 1-port retroperitoneoscopic assisted pyeloplasty as a minimally invasive approach and compare the results to open dismembered pyeloplasty. Materials and Methods All patients 6 months to 5 years old presenting with ureteropelvic junction obstruction between January 2008 and June 2009 were offered 1-port retroperitoneoscopic assisted pyeloplasty. Age matched patients who underwent open dismembered pyeloplasty during 2007 served as controls. The ureteropelvic junction was isolated retroperitoneoscopically and exteriorized through a single operative trocar. Pyeloplasty was performed in an open fashion with Double-J® stenting. Operative time, postoperative pain, surgical complications, hospital stay, ultrasound and mercaptoacetyltriglycine nuclear scan results at 6-month followup were evaluated and compared. Chi-square test and Student’s t test were adopted for statistical analysis, with p <0.05 considered statistically significant. Results A total of 28 children (17 males) with a mean age of 18 months were treated with 1-port retroperitoneoscopic assisted pyeloplasty (18 left side). The control group consisted of 25 patients (11 males) with a mean age of 19 months who underwent open dismembered pyeloplasty (10 left side). Median operative time was 95 minutes (range 70 to 130) in 1-port retroperitoneoscopic assisted pyeloplasty and 72 minutes (58 to 102) in open dismembered pyeloplasty (p <0.05). Median postoperative hospital stay was 2.4 days with the 1-port approach and 6.1 days with the open procedure (p <0.05). Postoperative pain was significantly less in the 1-port group. Skin scar length was 1.4 to 2.9 cm (median 1.7) with 1-port retroperitoneoscopic assisted pyeloplasty and 3.5 to 6.0 cm (4.3) in the open group (p <0.05). Conclusions The 1-port retroperitoneoscopic assisted pyeloplasty represents a safe and effective minimally invasive technique to treat hydronephrosis and could be the treatment of choice in young children. The procedure does not require laparoscopic suturing skills, and combines the advantages of open and laparoscopic pyeloplasty. © 2010 American Urological Association Education and Research, Inc.
“LESSons in minimally invasive urology.”
Dev, H., P. Sooriakumaran, et al. (2010).
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.
“Instrumentation for natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery.”
Granberg, C. F. and M. T. Gettman (2010).
Indian Journal of Urology 26(3): 385-388.
Objective: To describe the evolution of instrumentation and technology for natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) as applied to urologic procedures. Materials and Methods: We performed a search of published reports on PubMed and MEDLINE for the search terms NOTES, single-port, single-incision, single-site, natural orifice + surgery, SPA, LESS, incisionless, and scarless from 1990-2009. Studies relevant to this urologic symposium were chosen for detailed review. Results: Multiple case reports, case series, and review articles relevant to NOTES and LESS utilized for urologic surgery dating from 1991 to 2009 were identified. We were subsequently able to chronicle the technological advances in instrumentation utilized for NOTES, including transvaginal nephrectomy, transvesical NOTES, combination or hybrid NOTES, and robotic-assisted NOTES or R-NOTES. For LESS, we detailed the development of various access ports and operating platforms to facilitate performing urologic procedures through a single-port access site. Conclusions: Significant progress has been made in developing new, multi-lumenal access ports and articulating or curved instruments to aid in triangulation necessary for certain urologic procedures. Magnetic anchoring guidance systems (MAGS) have further enhanced the approach to LESS, with the potential for future application to NOTES. NOTES and LESS have future implications for the armamentarium of urologic surgeons, although much more research is necessary to further improve instrumentation and overcome the learning curve necessary for new technology.
“Novel Robotic da Vinci Instruments for Laparoendoscopic Single-site Surgery.”
Haber, G. P., M. A. White, et al. (2010).
OBJECTIVES: To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS: The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes. RESULTS: All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited. CONCLUSIONS: R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.
“A surgical robot with vision field control for single port endoscopic surgery.”
Kobayashi, Y., Y. Tomono, et al. (2010).
Int J Med Robot.
BACKGROUND: Robotic end-effectors for single port endoscopic surgery (SPS) require a manual change of vision field that slows surgery and increases the degrees of freedom (DOFs) of the manipulator. METHODS: A new surgical prototype robot has dynamic vision field control and a master controller to manipulate the endoscopic view. It uses positioning (4 DOF) and sheath (2 DOF) manipulators for vision field control, and dual tool tissue manipulators (gripping, 5 DOF; cautery, 3 DOF). RESULTS: The robot is feasible in vitro. ‘Cut and vision field control’ (using tool manipulators) was suitable for precise cutting tasks in risky areas; ‘cut by vision field control’ (using the vision field control manipulator) was effective for rapid macro cutting of tissues. A resection was performed using a combination of both methods. CONCLUSIONS: The novel robotic system is feasible, but further studies are needed to address its performance in vivo. Copyright (c) 2010 John Wiley & Sons, Ltd.
“Laparoendoscopic single-site surgery (LESS) prostatectomy – Robotic and conventional approach.”
Kumar, P., S. S. Kommu, et al. (2010).
Minerva Urologica e Nefrologica 62(4): 425-430.
This review deals with the preliminary advances in laparoendoscopic single-site surgery (LESS) as applied to prostate surgery including the simple and radical prostatectomy approaches both robot assisted and robot independent. It analyzed current publications based on animal models and human patients. The authors searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Key word searches included: “prostate”, “prostatectomy”, “radical”, “surgery”, “robot”, “da Vinci”, “scarless”, “scar free”, “single port/trocar/incision”, “intraumbilical”, and “transumbilical”, “natural orifice transluminal endoscopic surgery” (NOTES), “SILS”, “OPUS” and “LESS”. The role of LESS prostatectomy with or without robotic aid has been proven to be technically feasible; however, it is important to note that the approach has significant technical challenges. The da Vinci Surgical System allows some of these ergonomic challenges to be obviated with potentially reduced instrument clash, reduced surgeon and assistant fatigue and better precision with target tasking such as performing the vesicourethral anastomosis. Preliminary consensus regarding oncological control is not yet available on a large scale. Currently, no specific advantage of the LESS approach has been convincingly proven apart from the intuitive improvement in cosmesis. The development, and soon to be launched, flexible robotic platforms towards the end of 2010 will usher with it further refinements making the LESS approach to radical prostatectomy potentially more feasible ergonomically and could see the approach gain a more widespread acceptance.
“Initial experience with laparoendoscopic single-site surgery by use of a homemade transumbilical port in urology.”
Lee, S. Y., Y. T. Kim, et al. (2010).
Korean Journal of Urology 51(9): 613-618.
Purpose: We present our initial experience with laparoendoscopic single-site surgery (LESS) by a single surgeon in the urologic field. Materials and Methods: From May 2009 to April 2010, 30 consecutive patients underwent LESS including seven cases of nephrectomy, five cases of nephroureterectomy with bladder cuff excision, four cases of ureterolithotomy, eight cases of marsupialization, and six cases of varicocelectomy. We performed a retrospective analysis of the medical records of the above patients. The single port was made with a surgical glove and an Alexis® wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA). The wound retractor was put into the peritoneal space through an umbilical incision, and a laparoscopic triangle was secured by crossing both instruments. All operations were performed by the transperitoneal approach. Results: Mean patient age was 54.8 years. Mean operative time was 171.2±109.1 minutes. Mean estimated blood loss was 265.0±395.5 ml. Mean incision length was 3.2±1.4 cm. Mean length of hospitalization was 5.2±2.9 days. There was one laparoscopic conversion and two open conversions. There were two cases of transient ileus that improved with conservative treatment. Mean visual analogue pain scales on the operative day and first postoperative day were 6.3/10 and 3.1/10, respectively. Conclusions: In our experience, LESS for urologic surgery is feasible, safe, and clinically applicable. We consider the homemade single-port device to be a relatively cost-effective and convenient device. If surgical instruments for LESS and appropriate ports specified for LESS are developed, LESS would be a surgical treatment technique that could be used as an alternative to the conventional types of laparoscopic surgery. © The Korean Urological Association, 2010.
“Single port laparoscopic surgery.”
Lee, W. J. (2010).
Journal of the Korean Medical Association 53(9): 793-806.
Minimally invasive surgery and laparoscopic surgery have been used for more than 30 years, and are now popular even for some malignant diseases. There have been two developments in technology; one is robotic surgery and the other is less minimally invasive surgery like natural orifice transluminal endoscopic surgery (NOTES) and single port laparoscopic surgery. NOTES, using the current platform of a conventional fiberscope and side channel instruments for surgery, suffers many limitations, including image quality, flexibility of the fiberscope, size of the side channel, and difficulty of closing the opening. Due to the above-mentioned limitations, single port laparoscopic surgery has many advantages over. This review aims to define single port laparoscopic surgery and describe its terminology and technology. To perform single port laparoscopic surgery efficiently, new instruments (e.g., a laparoscopic camera, ports, laparoscopic instruments) and combining other innovative methods into surgery are both helpful. Even though there have been many developments in laparoscopic cameras, ports, and laparoscopic instruments to enhance single port laparoscopic surgery, further improvements are needed. Motorized instruments or using a robotic platform in combination with single port laparoscopic surgery will be another way to overcome the limitations of current single port laparoscopic surgery. Single port laparoscopic surgery is a technique that has recently emerged, but will be performed in a wider range of surgical procedures based on developments in laparoscopic cameras, ports and laparoscopic instalment technology. © Korean Medical Association.
“Robotic natural orifice translumenal endoscopic surgery and laparoendoscopic single-site surgery: current status.”
Rane, A. and R. Autorino (2010).
Current Opinion in Urology.
PURPOSE OF REVIEW: To analyse the evidence supporting current and future application of robotic technology in natural orifice translumenal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). RECENT FINDINGS: Early clinical experience with the application of currently available da Vinci robotic system to LESS has been encouraging, as some of the constraints encountered during conventional LESS can be overcome. Robotic devices that are currently being developed for NOTES and LESS focus on improving either tissue manipulation capabilities for externally actuated robotic and flexible endoscopy systems or visualization for robots that are inserted completely into the peritoneal cavity. SUMMARY: Robotic technology is rapidly evolving and is expected to drive several aspects of minimally invasive surgery forward in the near future with the ultimate goal of minimizing complications and improving outcomes.
“Single-incision laparoscopic surgery for right hemicolectomy: Our initial experience with 10 cases.”
Wong, M. T. C., K. H. Ng, et al. (2010).
Techniques in Coloproctology 14(3): 225-228.
Background: Published data has confirmed the oncological safety and efficacy of laparoscopic colorectal surgery. Continued surgical innovation has seen the recent resurgence of single-port laparoscopic surgery. We present a series of 10 cases of single-incision laparoscopic surgery (SILS) for right hemicolectomy, with the aim of reaffirming the feasibility and favourable short-term results of this technique. Methods: Ten patients underwent SILS for right hemicolectomy using the SILSTM port, between June 2009 and August 2009. A longitudinal periumbilical incision was used as the access point for all cases. Data analysed included age, gender, American Society of Anaesthesiology score, body mass index (BMI), location of disease, duration of surgery, length of incision and duration of hospital stay. Inclusion criteria were no prior abdominal surgery, no intra-abdominal sepsis, no distant metastases and a BMI of <30. Results: All 10 cases of right hemicolectomy were successfully performed using the SILSTM port through a single periumbilical incision. The median age of patients was 64 years (range 48-83 years), with a median body mass index of 21.5 kg/m<sup>2</sup> (range 18.9-25.6 kg/m<sup>2</sup>). The median duration of surgery and hospital stay was 83 min (range 60-125 min) and 6 days (range 5-11 days), respectively. No morbidity or mortality was associated with this technique, and all patients recovered uneventfully. Conclusion: This case series illustrates that SILS for right hemicolectomy is feasible and safe. However, the routine use of this innovative technique in malignant disease cannot be recommended without further large-scale prospective trials. © 2010 Springer-Verlag.
“Design and fabrication of a novel tactile sensory system applicable in artificial palpation.”
Afshari, E., S. Najarian, et al. (2010).
Minim Invasive Ther Allied Technol.
Abstract Force and position feedback are the two important parameters that are employed in different medical diagnoses and more specifically surgical operations. Furthermore, during different minimally invasive procedures, the ability of touch and force and position feedback are absent. In this regard, artificial palpation is a new technology that is employed to obtain tactile data in situations where physicians/surgeons cannot use their tactile sense. One of the most valuable achievements of artificial palpation are tactile sensory systems that have various applications in the detection of hard objects inside the soft tissue. Considering the present problems and limitations of kidney stone removal laparoscopy, the aim of this research is to design and fabricate a novel tactile sensory system capable of determining the exact location of stones during laparoscopy. This new tactile sensory system consists of four main parts: The sensory part, the mechanical part, the electrical part, and the display part. In this new system, due to the use of both displacement and force sensors, the usage limitations of previous tactile sensory systems are eliminated. The new tactile sensory system is well capable of finding the stone in the laboratory models through physical contact with the model’s surface.
“The ANUBISTM project.”
Dallemagne, B. and J. Marescaux (2010).
Minimally Invasive Therapy and Allied Technologies 19(5): 257-261.
The aims of the ANUBISTM project developed in IRCAD-Strasbourg were to evaluate the concept and the potentialities of natural orifices transluminal endoscopic surgery (NOTES), to develop a specific instrumentation, to translate the research work into clinical settings and to provide education and training. To achieve these goals, an intensive collaboration was established between IRCAD, which comprises medical staff (surgeons, gastroenterologists, gynaecologists), computer scientists and robotics engineers, and industrial partners. Between 2005 and 2008, more than 400 experimental procedures were performed on inanimate models, ex-vivo tissues, animal models and human cadavers. Cholecystectomy was defined as the procedure that would realize the translation of experimental work into the clinical setting. The first human transvaginal cholecystectomy was performed at the end of the second year of the project. Transgastric cholecystectomy followed six months later. A new concept of therapeutic flexible endoscope (AnubiscopeTM, Storz Endoskope,Tutlingen, Germany) was developed, and different modalities of closure of the viscerotomies were elaborated. Implementation of the experimental program into the clinical setting and translation of technological research into a finalized industrial product were achieved thanks to a rigorous, extensive and stepwise study of the potentialities of NOTES. Education and training were organized and 500 participants attended the specific courses and hands-on sessions organized at IRCAD-EITS. © 2010 Informa Healthcare.
“Toward construct validity for a novel sensorized instrument-based minimally invasive surgery simulation system.”
Jayaraman, S., A. L. Trejos, et al. (2010).
Surgical Endoscopy: 1-7.
Minimally invasive surgical training is complicated due to the constraints imposed by the surgical environment. Sensorized laparoscopic instruments capable of sensing force in five degrees of freedom and position in six degrees of freedom were evaluated. Novice and expert laparoscopists performed the complex minimally invasive surgical task of suturing using the novel instruments. Their force and position profiles were compared. The novel minimally invasive surgical instrument proved to be construct valid and capable of detecting differences between novices and experts in a laparoscopic suturing task with respect to force and position. Further evaluation is mandated for a better understanding of the ability to predict performance based on force and position as well as the potential for new metrics in minimally invasive surgical education. © 2010 Springer Science+Business Media, LLC.
“Vacuum grasping as a manipulation technique for minimally invasive surgery.”
Vonck, D., R. H. M. Goossens, et al. (2010).
Surgical Endoscopy and Other Interventional Techniques 24(10): 2418-2423.
Background: Laparoscopic surgery requires specially designed instruments. Bowel tissue damage is considered one of the most serious forms of lesion, specifically perforation of the bowel. Methods: An experimental setting was used to manipulate healthy pig bowel tissue via two vacuum instruments. During the experiments, two simple manipulations were performed for both prototypes by two experienced surgeons. Each manipulation was repeated 20 times for each prototype at a vacuum level of 60 kPa and 20 times for each prototype at a vacuum level of 20 kPa. All the manipulations were macroscopically assessed by two experienced surgeons in terms of damage to the bowel. Results: In 160 observations, 63 ecchymoses were observed. All 63 ecchymoses were classified as not relevant and negligible. No serosa or seromuscular damages and no perforations were observed. Conclusion: Vacuum instruments such as the tested prototypes have the potential to be used as grasper instruments in minimally invasive surgery. © 2010 The Author(s).
An integrated MEMS tactile tri-axial micro-force probe sensor for Minimally Invasive Surgery.
Wang, W., Y. Zhao, et al. (2009).
In this paper, we describes an integrated MEMS tactile tri-axial micro-force probe sensor based on piezoresistive for Minimally Invasive Surgery (MIS) as it’s micro-structure, three-dimensional measurement and high resolution up to be micronewton (μN) scale. The sensor is 4×4×20.9mm <sup>3</sup>. The sensing element of the sensor is fabricated on Silicon on Insulator (SOI) wafer by surface and bulk micromachining technology. It uses four cantilever beams supporting the suspended mass. Twelve relief pieoresisters formed by iron implant and Inductive Couple Plasmas (ICP) etching technology are placed on the beams to detect the applied force. The pyrex glass bonded on the bottom of the SOI wafer by anodic bonding technology is the overload protection element. The tactile element is the quartz fiber probe which is no-pollution, low cost, small size and easy to process. It is glued on suspended mass of the sensing element by epoxy resin. After fabrication, the sensor is packaged and tested by precision test bench and analytical balance. The experimental results illustrate that the sensor has excellent characteristics especially with resolution better than 3μN. © 2009 IEEE.
“An object-based visual attention model for robotic applications.”
Yu, Y., G. K. Mann, et al. (2010).
IEEE Trans Syst Man Cybern B Cybern 40(5): 1398-1412.
By extending integrated competition hypothesis, this paper presents an object-based visual attention model, which selects one object of interest using low-dimensional features, resulting that visual perception starts from a fast attentional selection procedure. The proposed attention model involves seven modules: learning of object representations stored in a long-term memory (LTM), preattentive processing, top-down biasing, bottom-up competition, mediation between top-down and bottom-up ways, generation of saliency maps, and perceptual completion processing. It works in two phases: learning phase and attending phase. In the learning phase, the corresponding object representation is trained statistically when one object is attended. A dual-coding object representation consisting of local and global codings is proposed. Intensity, color, and orientation features are used to build the local coding, and a contour feature is employed to constitute the global coding. In the attending phase, the model preattentively segments the visual field into discrete proto-objects using Gestalt rules at first. If a task-specific object is given, the model recalls the corresponding representation from LTM and deduces the task-relevant feature(s) to evaluate top-down biases. The mediation between automatic bottom-up competition and conscious top-down biasing is then performed to yield a location-based saliency map. By combination of location-based saliency within each proto-object, the proto-object-based saliency is evaluated. The most salient proto-object is selected for attention, and it is finally put into the perceptual completion processing module to yield a complete object region. This model has been applied into distinct tasks of robots: detection of task-specific stationary and moving objects. Experimental results under different conditions are shown to validate this model.