“Single-port, single-operator-light endoscopic robot-assisted laparoscopic urology: pilot study in a pig model.”
Crouzet, S., G. P. Haber, et al. (2010).
BJU Int 105(5): 682-685.
OBJECTIVES: To present our initial operative experience in which single-port-light endoscopic robot-assisted reconstructive and extirpative urological surgery was performed by one surgeon, using a pig model. MATERIALS AND METHODS: This pilot study was conducted in male farm pigs to determine the feasibility and safety of single-port, single-surgeon urological surgery. All pigs had a general anaesthetic and were placed in the flank position. A 2-cm umbilical incision was made, through which a single port was placed and pneumoperitoneum obtained. An operative laparoscope was introduced and securely held using a novel low-profile robot under foot and/or voice control. Using articulating instruments, each pig had bilateral reconstructive and extirpative renal surgery. Salient intraoperative and postmortem data were recorded. Results were analysed statistically to determine if outcomes improved with surgeon experience. RESULTS: Five male farm pigs underwent bilateral partial nephrectomy and bilateral pyeloplasty before a completion bilateral radical nephrectomy. There were no intraoperative complications and there was no need for additional ports to be placed. The mean (range) operative duration for partial nephrectomy, pyeloplasty, and nephrectomy were 120 (100-150), 110 (95-130) and 20 (15-30) min, respectively. The mean (range) estimated blood loss for all procedures was 240 (200-280) mL. The preparation time decreased with increasing number of cases (P = 0.002). CONCLUSIONS: The combination of a single-port, a robotic endoscope holder and articulated instruments operated by one surgeon is feasible. With a single-port access, the robot allows more room to the surgeon than an assistant.
“Use of a flexible robotic transgastric natural orifice translumenal endoscopic surgery (NOTES) platform in a cadaver to test access, navigation, maneuverability, and stability.”
Eisenberg, D., E. Storne, et al. (2010).
Surg Endosc.
BACKGROUND: The advancement of natural orifice translumenal endoscopic surgery (NOTES) depends on the availability of a suitable platform. A 2008 Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Working Group identified access, navigation, maneuverability, and stability to withstand instrument forces as the essential requirements for a successful NOTES platform [1]. No single NOTES platform can adequately achieve all four of these key capabilities. In this study, the authors tested a novel flexible endoscopic robotic platform in a cadaver to determine how it performs with respect to these specific requirements. METHODS: A highly maneuverable multichannel flexible robotic endoscopic platform developed for NOTES was used transgastrically in an adult cadaver to test the platform’s ability to reach multiple intraabdominal targets. The device was under the control of the surgeon throughout the test. The surgeon was blinded to a control laparoscopic view. At each target organ, the platform was maneuvered via a joystick to provide different camera views and tool access orientation appropriate for the surgical tasks of each procedure. Standard endoscopic tools were used in the platform’s two working channels to demonstrate the platform’s ability to withstand the forces generated during tissue manipulation and clipping. RESULTS: The platform reached each target organ site without difficulty, relying on the endoscopic view only. The platform’s unique ability to maintain stability in two- and three-dimensional space resisted forces exerted by tools in the tool channels used for tissue manipulation and clipping. Endoscopic visualization allowed the surgeon to reposition the platform easily to gain a different camera view or tool access orientation about an organ (see video in Supplementary material). CONCLUSION: The authors demonstrated that the four capabilities identified by NOSCAR can be provided by the flexible robotic endoscopic platform. These essential capabilities for the clinical implementation of NOTES were addressed specifically by this platform. The provision of these capabilities in a single device may further the advancement and adoption of NOTES.
“Laparoendoscopic single-site surgery in urology.”
Eisenberg, M. S., J. A. Cadeddu, et al. (2010).
Current Opinion in Urology 20(2): 141-147.
Purpose of Review: To analyze the current literature regarding advances in laparoscopic single-site (LESS) surgery in urology. Recent Findings: Since its initial urologic description in 2007, there has been a surge of interest in LESS surgery. Published descriptions of LESS procedures now include virtually all extirpative and reconstructive urologic procedures. Novel instrumentation and techniques have been developed that offset many of the inherent increased technical demands with LESS surgery. Substantial clinical data have recently been reported that attest to the safety and efficacy of LESS surgery in select patients. Initial data have also been reported comparing morbidity outcomes with standard laparoscopy. Summary: LESS is now an established technique within the field of minimally invasive urologic surgery. Further study is needed to determine the true benefits of the technique and the extent of its clinical application. Further refinements in technology will likely be needed before the widespread adoption of LESS. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“Laparo-endoscopic single-site surgery hysterectomy using robotic lightweight endoscope assistants.”
Kane, S. and K. J. Stepp (2010).
Journal of Robotic Surgery 3(4): 253-255.
Current laparoscopic and robotic hysterectomy techniques require three to five small incisions in the abdominal wall. Each additional port contributes an additional risk for port site complications. Because of these risks, and in an effort to improve cosmesis, surgery through a single incision is being explored. New versatile robot devices can provide a less cumbersome and less expensive alternative to the conventional multi-arm robot devices. In the case reported here, that of a 37-year-old female undergoing hysterectomy, we combined the use of these two technologies in a novel way. By utilizing a single laparoscopic port site in addition to two lightweight robotic endoscope assistants, we were able to decrease risk and improve cosmesis while allowing single-operator control of all instrumentation. The novel use of this robotic device demonstrates a potential decrease in the need for surgical assistants and thus a decrease in cost. When combined with single-site laparoscopy, it also allows the surgeon complete control of the operative environment and may enable more surgeons to embrace the single-incision technique. © Springer-Verlag London Ltd 2010.
“Urologic laparoendoscopic single-site surgery.”
Liatsikos, E., P. Kallidonis, et al. (2009).
Nature Reviews Urology 6(12): 654-659.
Laparoendoscopic single-site surgery (LESS) probably represents the next evolutionary step in laparoscopic surgery. Although most urologic procedures are feasible by the LESS approach, significant challenges in terms of intraoperative ergonomics and requirement for laparoscopic skill are present. New, specially designed instruments and ports represent a solution for combating ergonomic problems during surgery. Documentation of the advantages of LESS over other approaches is currently lacking, as comparative clinical trials are scarce in the literature; in the absence of such information, the technique has been accepted at centers of laparoscopic expertise. Thus, further prospective randomized clinical trials are necessary to fully characterize the outcomes of LESS. © 2009 Macmillan Publishers Limited. All rights reserved.
“Single-setting robotic radical nephrectomy and radical prostatectomy.”
Madi, R. (2009).
Journal of Robotic Surgery 3(3): 195-198.
“Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER).”
Phee, S. J., K. Y. Ho, et al. (2010).
Surg Endosc.
BACKGROUND: The lack of triangulation of standard endoscopic devices limits the degree of freedom for surgical maneuvers during natural orifice transluminal endoscopic surgery (NOTES). This study explored the feasibility of adapting an intuitively controlled master and slave transluminal endoscopic robot (MASTER) the authors developed to facilitate wedge hepatic resection in NOTES. METHODS: The MASTER consists of a master controller, a telesurgical workstation, and a slave manipulator that holds two end-effectors: a grasper, and a monopolar electrocautery hook. The master controller is attached to the wrist and fingers of the operator and connected to the manipulator by electrical and wire cables. Movements of the operator are detected and converted into control signals driving the slave manipulator via a tendon-sheath power transmission mechanism allowing nine degrees of freedom. Using this system, wedge hepatic resection was performed through the transgastric route on two female pigs under general anesthesia. Entry into the peritoneal cavity was via a 10-mm incision made on the anterior wall of the stomach by the electrocautery hook. Wedge hepatic resection was performed using the robotic grasper and hook. Hemostasis was achieved with the electrocautery hook. After the procedure, the resected liver tissue was retrieved through the mouth using the grasper. RESULTS: Using the MASTER, transgastric wedge hepatic resection was successfully performed on two pigs with no laparoscopic assistance. The entire procedure took 9.4 min (range, 8.5-10.2 min), with 7.1 min (range, 6-8.2 min) spent on excision of the liver tissue. The robotics-controlled device was able to grasp, retract, and excise the liver specimen successfully in the desired plane. CONCLUSION: This study demonstrated for the first time that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures. With it, the triangulation of surgical tools and the manipulation of tissue became easy, and wedge hepatic resection could be accomplished successfully without the need for assistance using laparoscopic instruments.
“Early experience with sils port laparoscopic sleeve gastrectomy.”
Saber, A. A. and T. H. El-Ghazaly (2009).
Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 19(6): 428-430.
Background: Ever since single-incision laparoscopic surgery was introduced 12 years ago, it has undergone many attempts to improve its feasibility and accessibility. We herein are reporting our early experience with SILS Port as a multichannel single-port access to perform laparoscopic sleeve gastrectomy. Methods: Six morbidly obese patients underwent laparoscopic sleeve gastrectomy using the SILS Port as a common point of entry for 3 trocars. The same perioperative protocol was implemented for all 6 patients. Results: All 6 SILS Port laparoscopic sleeve gastrectomies were successfully performed using this technique. The 3 super-obese male patients with central obesity required the insertion of a 5-mm subxiphoid trocar. The mean operating time was 123 minutes. There were no mortalities or postoperative complications noted during the immediate follow-up period of all 6 patients. Conclusion: SILS gastrectomy using SILS Port is safe and feasible. © 2009 by Lippincott Williams & Wilkins.
“Comparative assessment of laparoscopic single-site surgery instruments to conventional laparoscopic in laboratory setting.”
Stolzenburg, J. U., P. Kallidonis, et al. (2010).
Journal of Endourology 24(2): 239-245.
Introduction: Laparoendoscopic single-site surgery (LESS) represents the latest innovation in laparoscopic surgery. We compare in dry and animal laboratory the efficacy of recently introduced pre-bent instruments with conventional laparoscopic and flexible instruments in terms of time requirement, maneuvrability, and ease of handling. Materials and Methods: Participants of varying laparoscopic experience were included in the study and divided in groups according to their experience. The participants performed predetermined tasks in dry laboratory using all sets of instruments. An experienced laparoscopic surgeon performed 24 nephrectomies in 12 pigs using all sets of instruments. Single port was used for all instrument sets except for the conventional instruments, which were inserted through three ports. The time required for the performance of dry laboratory tasks and the porcine nephrectomies was recorded. Errors in the performance of dry laboratory tasks of each instrument type were also recorded. Results: Pre-bent instruments had a significant advantage over flexible instruments in terms of time requirement to accomplish tasks and procedures as well as maneuvrability. Flexible instruments were more time consuming in comparison to the conventional laparoscopic instruments during the performance of the tasks. There were no significant differences in the time required for the accomplishment of dry laboratory tasks or steps of nephrectomy using conventional instruments through appropriate number of ports in comparison to pre-bent instruments through single port. Discussion: Pre-bent instruments were less time consuming and with better maneuvrability in comparison to flexible instruments in experimental single-port access surgery. Further clinical investigations would elucidate the efficacy of pre-bent instruments. © 2010, Mary Ann Liebert, Inc.