Abstrakt Technologie Únor 2011

“Transumbilical single-incision laparoscopic ureterolithotomy.”

Almeida, G. L., N. G. Lima, et al. (2011).

Ureterolitotomía laparoscópica con incisión única transumbilical 35(1): 52-56.


Introduction: laparoendoscopic single-site surgery (LESS) using transumbilical access and conventional laparoscopic instruments is a very attractive alternative to perform ureterolithotomy for ureteral stone with failed endourological management. Material and method: a 29-year-old woman presented with chronic right lumbar pain and a 1.2 cm impacted calculus localized at transition of abdominal to pelvic ureter. Semi-rigid ureteroscopy had failed to fragment the stone and shockwave lithotripsy was not available. Double-J ureteral catheter had been inserted preoperatively. We performed a transumbilical single-incision laparoscopic ureterolithotomy. Three conventional trocars were inserted in a single semi-circular umbilical incision. Right colon was detached and the ureter was identified. Calculus was extracted and the ureteral incision was closed with intracorporal sutures. Results: ureterolithotomy was successfully completed, with all the operative steps performed transumbically. Operative time was 180 minutes. No single-port device or articulating and bent instruments were utilized. Estimated blood loss was less than 50 mL. No intraoperative, access-related and postoperative complications took place. The duration of hospitalization was 24 hours and scarless appearance was observed on postoperative day 15. Conclusion: transumbilical single-incision laparoscopic ureterolithotomy is feasible and safe. This approach offers an inherent cosmetic advantage and few postoperative discomfort. Additional experience and continued investigation are warranted. © 2010 AEU. Publicado por Elsevier Españ, S.L. Todos los derechos reservados.




“Laparoendoscopic single-site surgeries: A single-center experience of 171 consecutive cases.”

Choi, K. H., W. S. Ham, et al. (2011).

Korean Journal of Urology 52(1): 31-38.


Purpose: We report our experience to date with 171 patients who underwent laparoendoscopic single-site surgery for diverse urologic diseases in a single institution. Materials and Methods: Between December 2008 and August 2010, we performed 171 consecutive laparoendoscopic single-site surgeries. These included simple nephrectomy (n=18; robotic surgeries, n=1), radical nephrectomy (n=26; robotic surgeries, n=2), partial nephrectomy (n=59; robotic surgeries, n=56), nephroureterectomy (n=20; robotic surgeries, n=12), pyeloplasty (n=4), renal cyst decortications (n=22), adrenalectomy (n=4; robotic surgeries, n=2), ureterolithotomy (n=10), partial cystectomy (n=3), ureterectomy (n=1), urachal mass excision (n=1), orchiectomy (n=1), seminal vesiculectomy (n=1), and retroperitoneal mass excision (n=1). All procedures were performed by use of a homemade single-port device with a wound retractor and surgical gloves. A prospective study was performed to evaluate outcomes in 171 cases. Results: Of the 171 patients, 98 underwent conventional laparoendoscopic single-site surgery and 73 underwent robotic laparoendoscopic single-site surgery. Mean patient age was 53 years, mean operative time was 190.8 minutes, and mean estimated blood loss was 204 ml. Intraoperative complications occurred in seven cases (4.1%), and post-operative complications in nine cases (5.3%). There were no complications classified as Grade IIIb or higher (Clavien-Dindo classification for surgical complications). Conversion to mini-incision open surgery occurred in seven (4.1%) cases. Regarding oncologic outcomes, no cancer-related events occurred during follow-up other than one aggressive progression of Ewing sarcoma. Conclusions: Laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases; however, surgical experience and long-term follow-up are needed to test the superiority of laparoendoscopic single-site surgery. © The Korean Urological Association, 2011.




“‘LESS’ radical prostatectomy: A pilot feasibility study with a personal original technique.”

Gaboardi, F., A. Gregori, et al. (2011).

BJU International 107(3): 460-464.


OBJECTIVE We evaluated the feasibility and the potential advantages of a modification of the single-port laparoscopic radical prostatectomy using a periumbilical multichannel port plus a second port placed in the left fossa with the aim of having an adequate working angle during the most critical steps of the procedure. PATIENTS AND METHODS Between March and September 2009 we operated on five patients with early-stage prostate cancer (T1c) and a normal body mass index (<25). The procedure was carried out with a specially-designed multichannel trocar which contains two 5 mm and one 10 mm ports plus a 5mm port placed in the left iliac fossa in order to have an adequate working angle. The first two patients received a nerve sparing radical prostatectomy. RESULTS All cases were completed successfully in a mean operative time of 225 minutes (range 210-250) with blood losses of less than 100ml. All patients were discharged from the hospital in 3rd postoperative day and the catheter was always removed seven days from surgery. No intraoperative complications occurred. The pathological tumour stage revealed pT2bNo prostate cancer in all five cases without positive surgical margins. After a mean follow-up of 4 months (range 1-7) all patients have an undetectable prostate-specific antigen level and no postoperative early major complications. The first two patients were fully continent respectively after 3 and 8 weeks after surgery, the third patient uses one safety pad after three month from surgery. The last two patients have a moderate incontinence and are currently under rehabilitation. Regarding potency the first patient had intercourses without any therapies after two months from surgery while the second one (6 months follow up) has partial penile tumescence using oral vardenafil. CONCLUSION Two ports laparoscopic radical prostatectomy is feasible in very selected cases. However, our pilot study should be still considered a technical report and the limits of the technique must still be defined in a larger population and by other investigators. © 2010 BJU International.




“The ergonomics of natural orifice translumenal endoscopic surgery (NOTES) navigation in terms of performance, stress, and cognitive behavior.”

James, D. R., F. Orihuela-Espina, et al. (2011).



BACKGROUND: The evolution toward minimally invasive surgery and subsequently to natural orifice translumenal endoscopic surgery (NOTES) poses challenges to the surgeon in terms of increased task complexity requiring greater visuospatial and navigational ability. Neuroergonomics is the study of the brain and behavior at work, and establishing the baseline cortical response for NOTES procedures will help to ascertain whether technological innovation such as navigational aids can alleviate the task-induced cognitive burden. The aims of the current study are to characterize the impact of navigation within a NOTES environment on the subject in terms of (1) performance, (2) stress, (3) prefrontal cortical activity, and (4) how this is influenced by expertise. METHODS: In all, 29 subjects were assessed for performance, stress response, and prefrontal cortical activity during a NOTES navigational task within a validated NOTES simulator. RESULTS: Experts performed significantly better than novices (P < .05). Expertise was not a predictor for overall changes in prefrontal cortical activity. The differences between experts and novices were modulated by the location of prefrontal cortical activity, with experts demonstrating more pronounced lateral prefrontal cortical activation compared with novices. Stress was not an independent predictor of changes in prefrontal cortical hemodynamics. CONCLUSION: This study is the first to characterize the performance, stress, and neurocognitive behavior associated with natural orifice translumenal endoscopic surgery navigation. The results indicate the relevance of visuospatial centers in successful task execution, and they serve as a baseline within the neuroergonomic paradigm for investigating performance-enhancing technology.




“Are bilateral axillary incisions needed or is just a single unilateral incision sufficient for robotic-assisted total thyroidectomy?”

Kandil, E., M. Abdel Khalek, et al. (2011).

Archives of Surgery 146(2): 240-241.




“Can single incision laparoscopic surgery be considered primarily for patients with complicated appendicitis?”

Kim, S. H. and J. M. Kwak (2010).

Journal of the Korean Society of Coloproctology 26(6): 373-374.




“Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: Summary of the working group reports of the Euro-NOTES meeting 2010.”

Meining, A., H. Feussner, et al. (2011).

Endoscopy 43(2): 140-143.


The fourth Euro-NOTES workshop took place in September 2010 and focused on enabling intensive scientific dialogue and interaction between participants to discuss the state of the practice and development of natural-orifice transluminal endoscopic surgery (NOTES) in Europe. Five working groups were formed, consisting of participants with varying scientific and medical backgrounds. Each group was assigned to an important topic: the correct strategy for dealing with bacterial contamination and related complications, the question of the ideal entry point and secure closure, interdisciplinary collaboration and indications, robotics and platforms, and matters related to training and education. This review summarizes consensus statements of the working groups to give an overview of what has been achieved so far and what might be relevant for research related to NOTES in the near future. © Georg Thieme Verlag KG Stuttgart – New York.




“Totally robotic single-position ‘flip’ arm technique for splenic flexure mobilizations and low anterior resections.”

Obias, V., C. Sanchez, et al. (2011).

Int J Med Robot.


BACKGROUND: Using the da Vinci robot in low anterior resection (LAR) has not been widely adopted due to limited range of motion of the robotic arms and the need to move the robot during operations. Our technique uses all three arms for both the splenic flexure and the pelvis, but with only one docking position. METHODS: The robot is placed to the left of the patient. The camera port is 3 cm to the right of the umbilicus. Arm 1 is placed in the RLQ. Arm 2 is placed midepigastric. Arm 3 is placed in the LLQ. Arm 3 starts off on the left side of the robot, on the same side as Arm 1 aimed cephalad. During mobilization of colon and splenic flexure, Arms 2 and 3 help retract the colon while Arm 1 dissects. Our pelvic dissection begins with Arm 3 “flipped” to the right side of the robot and redocked to the same left sided port aimed caudally. The robot does not need to be repositioned and the patient does not need to be moved. The pelvic dissection can now be done in the standard fashion. RESULTS: Our early experience includes four patients: two LARs and two left hemicolectomies. Mean operative time = 347 minutes, docking time = 20 minutes, and robotic surgical time = 195 minutes. Two complications occurred: post-operative ileus and high ostomy output. Mean LOS = 5. CONCLUSIONS: The robotic “flip” arm technique allows the surgeon to fully utilize all the robotic arms in LAR, which is unique versus other techniques. Copyright (c) 2011 John Wiley & Sons, Ltd.




“Laparo-endoscopic single site (LESS) management of benign kidney diseases: Evaluation of complications.”

Permpongkosol, S., P. Ungbhakorn, et al. (2011).

Journal of the Medical Association of Thailand 94(1): 43-49.


Background: To present our experience with Laparo-Endoscopic Single Site (LESS) management of benign kidney diseases. Material and Method: Between September 2008 and November 2009, 18 patients underwent single port transumbilical laparoscopic surgery for nephrectomy for a nonfunctioning kidney (7 cases), cyst decortications for symptomatic renal cyst (10 cases), and redo-dismembered pyeloplasty with previously failed laparoscopic surgical repair (1 case). Patients underwent surgery through a single 2-cm infraumbilical incision with the triport laparoscopic-port. All pathological reports of LESS nephrectomy and cyst decortications confirmed with chronic pyelonephritis and simple cysts, respectively. Histology of xanthogranulomotus pyelonephritis showed two cases of the nephrectomy procedure. Results: Mean patient age and BMI were 61 ± SD 14.2 years and 24.75 ± SD 11.2 kg/m2, respectively. Mean operating time was 187.7 ± SD 71.4 min. LESS was a possible and safe approach in 77.8% of patients. All LESS cyst decortications and redo-pyeloplasty were completed without major complications or conversion to open surgery. However, there was one case each of LESS cyst decortication and pyeloplasty requiring an additional 3-mm port for suturing due to bleeding and an instrument error. For LESS nephrectomy, two (28.6%) with higher waist circumference were converted to standard laparoscopic nephrectomy due to failure to progress. One post operative complication of incisional hernia occurred in a patient with chronic bronchitis and asthma. Conclusion: LESS for the management of benign kidney diseases is an effective and safe treatment option with selected patients and experienced surgeon.




“Single incision mid-urethral sling for treatment of female stress urinary incontinence.”

Pickens, R. B., F. A. Klein, et al. (2011).

Urology 77(2): 321-325.


Objectives To present the longitudinal outcomes in an observational cohort of patients who had undergone treatment of stress urinary incontinence with a single incision mid-urethral sling (MUS). Methods A prospective, observational study of all female patients who had undergone surgical intervention with the MiniArc MUS was performed. The surgical candidates underwent history and physical examination and urodynamic testing, as indicated. Quality of life questionnaires (Urogenital Distress Inventory [UDI-6] and Incontinence Impact Questionnaire [IIQ-7]) were administered preoperatively. The salient operative data were recorded. The patients were followed up postoperatively for evidence of treatment success and adverse events. The patients completed the UDI-6, IIQ-7, and Female Sexual Function Index questionnaires at 1 and 12 months after treatment. Results From September 2007 to October 2008, 120 patients underwent placement of the MiniArc MUS for the treatment of stress urinary incontinence. The mean patient age was 58.4 years. The mean body mass index was 27.2 kg/m 2. The mean preoperative daily pad use was 2.4. The mean preoperative IIQ-7 and UDI-6 score was 86.58 and 62.5, respectively. Of the 120 patients, 108 (90%) completed a minimum follow-up period of 12 months. Of these 108 patients, 101 (94%) were cured/dry. The mean postoperative pad use was 0.2 (P &lt; .001). The mean IIQ-7 and UDI-6 score was 13.32 (P &lt; .001) and 12.5 (P &lt; .001), respectively. The Female Sexual Function Index results demonstrated no discomfort with intercourse in 49%, occasional discomfort in 9%, and frequent discomfort in 2%. The remaining 40% of our patients were not sexually active. Conclusions Our results have shown that the MiniArc MUS offers excellent outcomes that are durable at 1 year after treatment. © 2011 Elsevier Inc.




“A new technique for robotic thyroidectomy: “the daVinci gasless single-incision axillary approach”.”

Rodriguez, F. N. S., R. A. Low, et al. (2011).

Journal of Robotic Surgery: 1-6.


Robotic thyroidectomy has been recently introduced as a new modality of treatment for selected benign and malignant thyroid lesions. The standard technique, popularized by a leading Korean group, combines an axillary and a thoracic approach to accomplish thyroid resection without neck incision. We recently introduced a modified technique that has enabled us to complete robotic thyroidectomy through a single axillary incision. We herein report our initial successful experience in 35 cases with the modified technique. © 2011 Springer-Verlag London Ltd.




“Robotic Laparoendoscopic Single-Site Radical Nephrectomy: Surgical Technique and Comparative Outcomes.”

White, M. A., R. Autorino, et al. (2011).

European Urology.


BACKGROUND: Recent reports have suggested that robotic laparoendoscopic single-site surgery (R-LESS) is feasible, yet comparative studies to conventional laparoscopy are lacking. OBJECTIVE: To report our early experience with R-LESS radical nephrectomy (RN). DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of R-LESS RN data was performed between May 2008 and November 2010. A total of 10 procedures were performed and subsequently matched to 10 conventional laparoscopic RN procedures (controls). The control group was matched with respect to patient age, body mass index (BMI), American Society of Anesthesiologists score, surgical indication, and tumor size. SURGICAL PROCEDURE: R-LESS RN was performed using methods outlined in the manuscript and supplemental video material. All patients underwent R-LESS RN by a single surgeon. Single-port access was achieved via two commercially available multichannel ports, and robotic trocars were inserted either through separate fascial stabs or through the port, depending on the type used. The da Vinci S and da Vinci-Si Surgical Systems (Intuitive Surgical, Sunnyvale, CA, USA) with pediatric and standard instruments were used. MEASUREMENTS: Preoperative, perioperative, pathologic, and functional outcomes data were analyzed. RESULTS AND LIMITATIONS: The mean patient age was 64.0 yr of age for both groups, and BMI was 29.2kg/m(2). There was no difference between R-LESS and conventional laparoscopy cases in median operative time, estimated blood loss, visual analogue scale, or complication rate. The R-LESS group had a lower median narcotic requirement during hospital admission (25.3 morphine equivalents vs 37.5 morphine equivalents; p=0.049) and a shorter length of stay (2.5 d vs 3.0 d; p=0.03). Study limitations include the small sample size, short follow-up period, and all the inherent biases introduced by a retrospective study design. CONCLUSIONS: R-LESS RN offers comparable perioperative outcomes to conventional laparoscopic RN. Prospective comparison is needed to definitively establish the position of R-LESS in minimally invasive urologic surgery.




“Maximizing coupling strength of magnetically anchored surgical instruments: How thick can we go?”

Best, S. L., R. Bergs, et al. (2011).

Surgical Endoscopy and Other Interventional Techniques 25(1): 153-159.


Background: The Magnetic Anchoring and Guidance System (MAGS) includes an external magnet that controls intra-abdominal surgical instruments via magnetic attraction forces. We have performed NOTES (Natural Orifice Transluminal Endoscopic Surgery) and LESS (Laparoendoscopic Single Site) procedures using MAGS instruments in porcine models with up to 2.5-cm-thick abdominal walls, but this distance may not be sufficient in some humans. The purpose of this study was to determine the maximal abdominal wall thickness for which the current MAGS platform is suitable. Methods: Successive iterations of prototype instruments were developed; those evaluated in this study include external (134-583 g, 38-61 mm diameter) and internal (8-39 g, 10-22 mm diameter) components using various grades, diameters, thicknesses, and stacking/shielding/focusing configurations of permanent Neodymium-iron-boron (NdFeB) magnets. Nine configurations were tested for coupling strength across distances of 0.1-10 cm. The force-distance tests across an air medium were conducted at 0.5-mm increments using a robotic arm fitted with a force sensor. A minimum theoretical instrument drop-off (decoupling) threshold was defined as the separation distance at which force decreased below the weight of the heaviest internal component (39 g). Results: Magnetic attraction forces decreased exponentially over distance. For the nine configurations tested, the average forces were 3,334 ± 1,239 gf at 0.1 cm, 158 ± 98 gf at 2.5 cm, and 8.7 ± 12 gf at 5 cm; the drop-off threshold was 3.64 ± 0.8 cm. The larger stacking configurations and magnets yielded up to a 592% increase in attraction force at 2.5 cm and extended the drop-off threshold distance by up to 107% over single-stack anchors. For the strongest configuration, coupling force ranged from 5,337 gf at 0.1 cm to 0 gf at 6.95 cm and yielded a drop-off threshold distance of 4.78 cm. Conclusions: This study suggests that the strongest configuration of currently available MAGS instruments is suitable for clinically relevant abdominal wall thicknesses. Further platform development and optimization are warranted. © 2010 Springer Science+Business Media, LLC.




“A pilot study on a new anchoring mechanism for surgical applications based on mucoadhesives.”

Tognarelli, S., V. Pensabene, et al. (2011).

Minimally Invasive Therapy and Allied Technologies 20(1): 3-13.


In order to minimize the invasiveness of laparoscopic surgery, different techniques are emerging from research to clinical practice. Whether the incision is performed on the outside as in Single Port Laparoscopy (SPL) or on the inside as in Natural Orifice Transluminal Endoscopic Surgery (NOTES) of the patient’s body, inserting and operating all the instruments from a single access site seems to be the next challenge in surgery. Magnetic guidance has been recently proposed for controlling surgical tools deployed from a single access. However, the exponential drop of magnetic field with distance makes this solution suitable only for the upper side of the abdominal cavity in nonobese patients. In the present paper we introduce a polymeric anchoring mechanism to lock surgical assistive tools inside the gastric cavity, based on the use of mucoadhesive films. Mucoadhesive properties of four formulations, with different chemical components and concentration, are evaluated by using both in vitro and ex vivo test benches on porcine stomach samples. Hydration of mucoadhesive films by contact with the aqueous mucous layer is analyzed by means of in vitro swelling tests, whereas optimal preloading conditions and adhesion performances, in terms of detachment force, supported weight and size are investigated ex vivo. Mucoadhesion is observed with all the four formulations. For a contact area of 113 mm2, the maximum normal and shear detachment forces withstood by the adhesive film are 2,6 N and 1 N respectively. These values grow up to 12,14 N and 4,5 N when the contact area increases to 706 mm2. Lifetime of the bonding on the inner side of the stomach wall was around two hours. Mucoadhesive anchoring represents a fully biocompatible and safe approach to deploy multiple assistive surgical tools on mucosal tissues by minimizing the number of access ports. This technique has been quantitatively assessed ex vivo for anchoring on the inner wall of the gastric cavity or in gastroscopic surgery. By properly varying the chemical formulation, this approach can be extended to other cavities of the human body. © 2011 Informa Healthcare.




“Analysis of wormlike robotic locomotion on compliant surfaces.”

Zarrouk, D., I. Sharf, et al. (2011).

IEEE Transactions on Biomedical Engineering 58(2): 301-309.


An inherent characteristic of biological vessels and tissues is that they exhibit significant compliance or flexibility, both in the normal and tangential directions. The latter in particular is atypical of standard engineering materials and presents additional challenges for designing robotic mechanisms for navigation inside biological vessels by crawling on the tissue. Several studies aimed at designing and building wormlike robots have been carried out, but little was done on analyzing the interactions between the robots and their flexible environment. In this study, we will analyze the interaction between earthworm robots and biological tissues where contact mechanics is the dominant factor. Specifically, the efficiency of locomotion of earthworm robots is derived as a function of the tangential flexibility, friction coefficients, number of cells in the robot, and external forces.