History of endoscopic and laparoscopic surgery

A novel mini-retractor for retroperitoneal laparoscopic partial nephrectomy

BACKGROUND

Retroperitoneal partial nephrectomy (RLPN) is the premier treatment for localized renal tumors despite narrow operation space. Many efforts have been taken to facilitate the operation of RLPN, but the optimal resolution remains debatable.

OBJECTIVE

To explore the feasibility of using Mini-lap to improve workspace and surgical vision in RLPN.

DESIGN, SETTING, AND PARTICIPANTS

A multicenter retrospective review of 51 patients who underwent RLPN with Mini-lap from January 2018 to December 2020 was conducted.

SURGICAL PROCEDURE

Standard RLPN under three poles was performed in all cases. We highlighted the usage of Mini-lap (Teleflex Minilap percutaneous Surgical System) as a novel retractor in RLPN.

OUTCOME AND MEASUREMENTS AND STATICAL ANALYSIS

Demographics, preoperative, intraoperative, and postoperative outcomes were assessed.

RESULTS AND LIMITATIONS

All 51 cases completed RLPN with three ports successfully and no conversion to open surgery. The mean diameter of tumors was (3.53 ± 1.05) cm, in which 62.7% (32/51) were located anteriorly. The operation time and warm ischemic time (WIT) were (86.7 ± 15.9) min and (25.6 ± 5) min respectively. Minor complications (Clavien grade 1-2) occurred in 6 cases. The limitations were small sample size, retrospective design, and absence of control.

CONCLUSIONS

Mini-lap could be used as a mini-retractor in RLPN, sparing extra assistant ports, expanding workspace, and optimizing vision.

PATIENT SUMMARY

With highlights of larger workspace and less instrument interference, mini-lap could be applied in retroperitoneal laparoscopic partial nephrectomy.

Neuroendoscopy: How We Got Here

From its inception in ancient Egyptian rituals, neuroendoscopy always promised a minimally invasive route to the cerebrum. Early visionaries, however, hit the proverbial wall of technical development until the 20th century, when new technologies allowed for light to be transmitted across a tube for visualization of intracranial structures. Despite a hiccupping start, with surgical microscopy hampering initial excitement, the development and transformation of neuroendoscopy continued, and today it is a widespread and reliable surgical option for the treatment of numerous varied and complex pathologies.

Patient-reported outcome, perception and satisfaction after laparoscopic cholecystectomy in Kigali, Rwanda

Background

Laparoscopic surgery is the gold standard for many abdominal surgeries. Laparoscopic programs in low- and middle-income countries (LMICs) and in sub-Saharan Africa face many constraints, although its use is safe, feasible, and clinically beneficial. The authors assessed patient-reported outcomes and the experience of patients operated on at the University Teaching Hospital of Kigali (CHUK).

Methods

This is a retrospective cross-sectional study combining medical data from medical files and information collected from telephone calls to 288 patients who underwent laparoscopic cholecystectomy at CHUK from January 2015 to December 2020.

Results

Among 446 laparoscopic surgeries performed at CHUK over 6 years, cholecystectomies accounted for 64.6 % of cases (288/446). Postoperative complications and mortality after laparoscopic cholecystectomy were low, respectively 1.7 % and 0.7 %, while the median length of stay was 3 days. About 74 % of surveyed patients had never heard of laparoscopic surgery prior to their procedure. Knowledge of laparoscopic surgery was associated with patient education level (p < 0.001). Half of patients had not been involved in the choice of the surgical technique. Overall satisfaction was over 95 % and >90 % of patients consider laparoscopic surgery as the best surgical approach in Rwanda, and for this reason they declared to be ready to promote this new technology despite its higher cost. However, patients reported some weaknesses and made recommendations for improving public awareness of laparoscopy and its benefits, patient-provider relationships, training of surgical workforce, laparoscopic equipment, and infrastructure.

Conclusion

Laparoscopic cholecystectomy can be performed with a low rate of postoperative complications in a resource-limited setting like Rwanda. Patient satisfaction was high, but efforts should be made to improve public awareness of laparoscopic surgery, improve surgical capacity, laparoscopic equipment, and infrastructure.

Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery-a narrative review

Background

Minimally invasive (MI) surgery has revolutionised surgery, becoming the standard of care in many countries around the globe. Observed benefits over traditional open surgery include reduced pain, shorter hospital stay, and decreased recovery time. Gastrointestinal surgery in particular was an early adaptor to both laparoscopic and robotic surgery. Within this review, we provide a comprehensive overview of the evolution of minimally invasive gastrointestinal surgery and a critical outlook on the evidence surrounding its effectiveness and safety.

Methods

A literature review was conducted to identify relevant articles for the topic of this review. The literature search was performed using Medical Subject Heading terms on PubMed. The methodology for evidence synthesis was in line with the four steps for narrative reviews outlined in current literature. The key words used were minimally invasive, robotic, laparoscopic colorectal, colon, rectal surgery.

Conclusion

The introduction of minimally surgery has revolutionised patient care. Despite the evidence supporting this technique in gastrointestinal surgery, several controversies remain. Here we discuss some of them; the lack of high level evidence regarding the oncological outcomes of TaTME and lack of supporting evidence for robotic colorectalrectal surgery and upper GI surgery. These controversies open pathways for future research opportunities with RCTs focusing on comparing robotic to laparoscopic with different primary outcomes including ergonomics and surgeon comfort.

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Aligning Incentives for Surgical Innovation: Review of the Literature and Best Practices

Background: Innovation in the clinical surgical space is often generated by the insight and ideas of practicing surgeons whose ideas solve direct and relevant clinical problems with both novel products and reimagined processes. Despite some successes in both product and process development, innovation in the practicing surgical space does not occur with the frequency one might expect and does not consistently result in adoption of profitable or health-improving new products or processes. One barrier to successful innovation is the misalignment of incentives for early-stage innovation in the clinical surgical enterprise. This project was undertaken to determine best innovation practices for clinical Divisions and Departments. Methods: Best practices for innovation in industry were determined by company-specific examples, as well as literature review in the business and medical literature. Concepts were then integrated to determine a viable model that aligns incentives to encourage early-stage innovation. Proposal: The centralized Moderated Innovation Database (MID) of early-stage exploratory ideas integrates best practices of innovation in a low-cost, sustainable model. The MID must be executed in 3 phases to ensure viability in implementation. This model is likely to encourage innovation by both improving stakeholder satisfaction with and engagement in the process, and by increasing capture of early-stage innovation. Conclusion: Infrastructure for early-stage ideas will help align incentives for early-stage innovation, and the MID is consistent with best practices for innovation.

Endoscopy Lifetime Systems Architecture: Scoping Out the Past to Diagnose the Future Technology

Systems engineering captures the desires and needs of the customer to conceptualize a system from the overall goal down to the small details prior to any physical development. While many systems projects tend to be large and complicated (i.e., cloud-based infrastructure, long-term space travel shuttles, missile defense systems), systems engineering can also be applied to smaller, complex systems. Here, the system of interest is the endoscope, a standard biomedical screening device used in laparoscopic surgery, screening of upper and lower gastrointestinal tracts, and inspection of the upper airway. Often, endoscopic inspection is used to identify pre-cancerous and cancerous tissues, and hence, a requirement for endoscopic systems is the ability to provide images with high contrast between areas of normal tissue and neoplasia (early-stage abnormal tissue growth). For this manuscript, the endoscope was reviewed for all the technological advancements thus far to theorize what the next version of the system could be in order to provide improved detection capabilities. Endoscopic technology was decomposed into categories, using systems architecture and systems thinking, to visualize the improvements throughout the system's lifetime from the original to current state-of-the-art. Results from this review were used to identify trends in subsystems and components to estimate the theoretical performance maxima for different subsystems as well as areas for further development. The subsystem analysis indicated that future endoscope systems will focus on more complex imaging and higher computational requirements that will provide improved contrast in order to have higher accuracy in optical diagnoses of early, abnormal tissue growth.

A Novel Sensor for Tissue Mechanical Property Detection During Robotic Surgery

Haptic feedback relays important tissue mechanical properties to surgeons during open surgery. However, this information is lost during Robot-assisted Minimally Invasive Surgery (RMIS). Here we present a proof-of-concept for a novel instrument-integrated sensor that uses fiber Bragg grating (FBG) arrays to identify tissues based on mechanical properties. Subjects were tasked with sorting tissue phantoms based on hardness. When using a conventional surgical robot, the average error for novices (N=5) and the expert user was 22.5% and 12.5% respectively. This reduced to 2.5% and 0% when sorting with direct palpation by hand. In contrast, the senorized instrument with automated analysis was able to perform the task without any error across all trials. Clinical Relevance - The proposed sensor has the potential of identifying different tissues based on mechanical properties and thus characterize tumors and other relevant structures. It is envisaged that this will improve decision making process during RMIS and also provide useful sensory information for autonomous surgery.

A Historical Perspective of The Evolution of Laparoscopic Surgeries in Urology

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology whilst also providing a brief look into its future.

Outcomes for Atypical Tumor Recurrences Following Minimally Invasive Kidney Cancer Operations

Background

We managed a cohort of patients treated with minimally invasive surgery (MIS) for a kidney tumor presenting with atypical tumor recurrence (ATR) involving port sites, intraperitoneal carcinomatosis, and nephrectomy bed/perinephric tumor implants.

Objective

To determine the clinical characteristics, management, and oncologic outcomes for patients with localized renal cell carcinoma (RCC) who develop ATR following curative-intent MIS for partial or radical nephrectomy.

Design, setting, and participants

The study cohort comprised patients from 1999 to 2021 with localized RCC managed at Memorial Sloan Kettering Cancer Center (New York, NY, USA) after MIS for partial or radical nephrectomy who developed ATR. Outcome measurements and statistical analysis: We collected data on clinicopathologic characteristics, treatments, time to ATR, and overall survival.

Results and limitations

The median age of the 58 RCC patients was 61 yr. Forty-one patients (71%) were male, 26 (45%) had robot-assisted operations, and 39 (67%) had clear cell RCC. Twenty-nine patients had stage pT1 disease (50%) and ten (17%) had positive surgical margins. The most common ATR site was perinephric/nephrectomy bed implants (n = 28, 48%). Management included: surgical resection alone (n = 11, 19%), systemic therapy alone (n = 12, 21%), surgical resection and systemic therapy (n = 17, 29%), and palliative care (n = 8, 14%). At median follow-up of 59 mo (interquartile range [IQR] 28–92), the median time to ATR was 12 mo (IQR 5–28). Overall survival at 5 yr was 69.0% (95% confidence interval 57.4–83.1%) with only nine patients alive with no evidence of disease. Limitations include the potential for referral, detection, and selection biases, as well as uncertainty regarding the true incidence of ATR.

Conclusions

ATR following MIS for partial or radical nephrectomy is an understudied, poor prognostic event which leads to a heavy treatment burden. Further investigation into its etiology and means of prevention is warranted.

Patient summary

Patients experiencing recurrence of kidney cancer in an atypical site require a heavy treatment burden and have a guarded overall prognosis. Continued research is needed to determine the precise incidence of these recurrences and identify methods for mitigating them.

Historical Considerations and Surgical Quality Improvement in Robotic Prostatectomy

Laparoscopic prostatectomy was technically challenging and not widely adopted. Robotics led to the widespread adoption of minimally invasive prostatectomy, which has been used heavily, supplanting the open and traditional laparoscopic approach. The benefits of robotic prostatectomy are disputed. Data suggest that robotic prostatectomy outcomes have improved over time.

The endoluminal pressures during flexible gastrointestinal endoscopy

In flexible gastrointestinal (GI) endoscopy, endoscopic insufflation is crucial and directly affects visualization. Optimal visualization enables endoscopists to conduct better examinations and administer optimal treatments. However, endoscopic insufflation is typically performed manually and is subjective. We aimed to measure the GI endoluminal pressure during flexible GI endoscopy. Participants underwent esophagogastroduodenoscopy (EGD) at our endoscopy center. Pressure measurement was conducted after completing diagnostic or follow-up EGD. The endoluminal pressure in the esophagus and stomach was measured at 1-s intervals for 1 min while performing EGD for observational and diagnostic purposes. During the measurements, the endoscopists maintained what they subjectively considered to be adequate exposure for screening for lesions by dilating the lumen. Eighty patients were enrolled in this study. The upper GI endoluminal pressure was assessed during EGD without adverse events. The esophageal endoluminal pressure averaged 8.9 (- 3.0 to 20.7) mmHg, and the gastric endoluminal pressure averaged 10.0 (3.0-17.9) mmHg; the upper GI endoluminal pressures were not affected by patient-related factors or the number of endoscopists' postgraduate years. We have successfully obtained the GI endoluminal pressures during EGD. Further accumulation of these data may lead to more stable and reproducible flexible endoscopic diagnosis and intervention.

Laparoscopic Approach to Rectal Cancer-The New Standard?

Minimally invasive surgery has revolutionized the way surgeons perform colorectal surgery, and new technologies continually upend the way surgeons view and operate within the deep pelvis. Among other benefits, it is associated with decreased lengths of stay, wound and surgical site infections, pain scores, and has an overall lower complication rate vs. open surgery (1). Recently, however, the role of minimally invasive surgery has been called into question in the effective and safe treatment of rectal cancer. This manuscript will outline the history of minimally invasive rectal cancer surgery, examine evidence detailing its safety (compared with alternatives), and discuss important aspects of use, most notably the considerable learning curve required to achieve proficiency, the extent of its current use, and potential pitfalls. The current evidence suggests minimally invasive surgery is a very safe way to treat rectal cancer when performed by experienced and specialty trained surgeons.

Does CO2 pneumoperitoneum in laparoscopy interfere with collagen deposition in abdominal surgical wounds?

Purpose To determine by histomorphometric analysis whether CO2 pneumoperitoneum interferes with collagen deposition in surgical wounds in the aponeurosis of rats. Methods This experiment involved 80 male Wistar rats, randomly allocated into four groups according to pneumoperitoneum period (PRE: 30 min preoperatively; POST: 30 min postoperatively; PP: 30 min pre- and postoperatively; C: control group). CO2 pneumoperitoneum was insufflated to 5 mmHg of pressure. A laparotomy was performed; 1 cm of the left colon was then resected, and an end-to-end anastomosis was performed to simulate surgical trauma, after which the abdominal wall was closed. On postoperative days 7 or 14, a sample of the abdominal wall was collected, stained with picrosirius red and observed under polarized light in an optical microscope. The amount of collagen was estimated by computerized histomorphometric analysis. Results There were no significant differences in collagen deposition between the control and experimental groups on postoperative days 7 (p=0.720) or 14 (p=0.933). The amount of collagen increased as expected in all groups between postoperative days 7 and 14 (p=0.0003). Conclusion At 5 mmHg, CO2 pneumoperitoneum does not interfere with collagen deposition in abdominal wall surgical wounds in rats.

Laparoscopy & robotics: a historical parallel

ABSTRACT The evolution of robotic platforms has brought up ethical, economic, educational, and clinical applicability issues that refer to the early 1990s, when laparoscopy began its dissemination as a technology that would revolutionize surgery. Introduced in Brazil since 1990, laparoscopy has received a lot of resistance from different sectors, including the medical academy itself. The technique was considered expensive, complex, poorly available and with limited clinical applications. However, in a short time, it was established as the gold standard for the treatment of most diseases in different organ systems and surgical specialties. At this time, similarly to laparoscopy, robotic surgery is expressed as a disruptive technology, determining an important breakdown of paradigms, and moving the wheel of history forward. The author draws a parallel in relation to the use of both technologies in the surgeon’s armamentarium. The fear of the “new technology”, seen when laparoscopy appeared, is repeated with the advent of robotic surgery. Laparoscopy and robotic surgery, at the same time, imposed new knowledge challenges for surgeons, anesthetists, nurses, engineers - the need to learn again, to develop new skills. The previous experience of implementing laparoscopy should always be remembered and considered, optimizing the current scenario of the robotic platform, in its introduction and dissemination with the surgical community. The advent of the “robotic era” and its evolutionary potential will continue to assist surgeons in their mission to serve their patients with quality and safety.

Transluminal Cancer Surgery

Transluminal surgery, also known as natural orifices endoluminal surgery, can be considered the most minimally invasive approach of gaining access to an organ. Although some approaches, such as transgastric or transvaginal cholecystectomy, have remained experimental, peroral endoscopic myotomy to treat achalasia and transanal total mesorectal excision to treat low rectal cancer have become accepted, safe, and feasible approaches by trained surgeons for selected patients. This article recapitulates the development of transluminal surgery from its experimental beginnings to the validated procedure it has become today.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) in Gynecology

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is an emerging field in minimally invasive surgery. NOTES can be performed via a variety of approaches, including through the stomach, esophagus, bladder, and rectum, but the majority of cases have been performed transvaginally. Potential advantages of natural orifice surgery in gynecology include the lack of abdominal incisions, less operative pain, shorter hospital stay, improved visibility, and the possibility to circumvent extensive lysis of adhesion to reach the pelvic cavity. This chapter provides a historical overview and the potential application of NOTES.

Practice, training and safety of laparoscopic surgery in low and middle-income countries

Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.

Past, present, and future of laparoscopic renal surgery

Although laparoscopic renal surgery dates to almost 30 years ago, in which the first laparoscopic nephrectomy was performed in 1990, the history of laparoscopy extends back over 100 years, when laparoscopy was first performed on dogs. Over the last 30 years, laparoscopic renal surgery has seen many advancements in technology and technique. With the introduction of robotics and new instruments, renal surgery is becoming increasingly less invasive, and patients are having improved operative outcomes. As new technology develops, the envelope will continue to be pushed by urologists with the hope of improvement of patient outcomes and satisfaction.

Current status of residency training in laparoscopic surgery in Brazil: a critical review

Introduction

The surgeon's formation process has changed in recent decades. The increase in medical schools, new specialties and modern technologies induce an overhaul of medical education. Medical residency in surgery has established itself as a key step in the formation of the surgeon, and represents the ideal and natural way for teaching laparoscopy. However, the introduction of laparoscopic surgery in the medical residency programs in surgical specialties is insufficient, creating the need for additional training after its termination.

Objective

To review the surgical teaching ways used in services that published their results.

Methods

Survey of relevant publications in books, internet and databases in PubMed, Lilacs and Scielo through july 2014 using the headings: laparoscopy; simulation; education, medical; learning; internship and residency.

Results

The training method for medical residency in surgery focused on surgical procedures in patients under supervision, has proven successful in the era of open surgery. However, conceptually turns as a process of experimentation in humans. Psychomotor learning must not be developed directly to the patient. Training in laparoscopic surgery requires the acquisition of psychomotor skills through training conducted initially with surgical simulation. Platforms based teaching problem solving as the Fundamentals of Laparoscopic Surgery, developed by the American Society of Gastrointestinal Endoscopic Surgery and the Laparoscopic Surgical Skills proposed by the European Society of Endoscopic Surgery has been widely used both for education and for the accreditation of surgeons worldwide.

Conclusion

The establishment of a more appropriate pedagogical process for teaching laparoscopic surgery in the medical residency programs is mandatory in order to give a solid surgical education and to determine a structured and safe professional activity.

Effectiveness of a reusable low-cost balloon trocar dissection device in the creation of preperitoneal space during endoscopic surgery. An experimental study in swine

PURPOSE

To evaluate a new, low-cost, reusable balloon trocar device for dissection of the preperitoneal space during endoscopic surgery.

METHODS

Twenty swine (weight: 15-37 kg) were randomized to two groups, according to whether the preperitoneal space was created with a new balloon device manufactured by Bhio-Supply (group B) or with the commercially available OMSPDB 1000® balloon device manufactured by Covidien (group C). Quality and size of the created preperitoneal space, identification of anatomic structures, balloon dissection time, total procedure time, balloon resistance and internal pressure after insufflation with 300 mL of ambient air, balloon-related complications, and procedure cost were assessed.

RESULTS

No significant differences in dissection time, total procedure time, or size of the created preperitoneal space were found between the groups. Balloons in group B had a significantly higher internal pressure compared to balloons in group C. None of the balloons ruptured during the experiment. Three animals in group C had balloon-related peritoneal lacerations. Despite a higher individual device cost, group B had a lower procedure cost over the entire experiment.

CONCLUSION

The new balloon device is not inferior to the commercially available device in terms of the safety and effectiveness for creating a preperitoneal space in swine.

The Twin Forceps: A New Instrument for SILS

In the last ten years, the single incision laparoscopic surgery (SILS) is gaining more interest than the traditional laparoscopic surgery (LAP). Many studies make a comparison between the performances of the SILS and the LAP. The results show that the single incision laparoscopic surgery reduces pain, length of period of postoperative hospitalization, and loss of blood. This technique is also able to reduce the infection sites. In spite of many advantages, SILS reveals some problems: laparoscopic instruments triangulation and small workspace. The surgeon has to be more skillful to make a surgery in SILS because the surgeon has only three laparoscopic instruments and only one hole in the abdomen cavity. In this paper, a novel laparoscopic instrument to help the surgeon during a SILS operation is presented. This instrument is innovative forceps with double graspers. Different designs of this instrument are presented, with the final one which greatly simplifies both construction and operation. The initial experience in the laboratory with the innovative instrument is presented. The surgeon experienced in laparoscopic surgery and with the help of assistants performed a training program based on predetermined task performed in simulation box (laparoscopic box-trainer).

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Enhanced signal coupling in wide-field fiber-coupled imagers

Some high-performance imaging systems, including wide angle "monocentric" lenses made of concentric spherical shells, form a deeply curved image surface coupled to focal plane sensors by optical fiber bundles with a curved input and flat output face. However, refraction at the angled input facet limits the range of input angles, even for fiber bundles with numerical aperture 1. Here we investigate using a curved beam deflector near the focal surface to increase the field of view and improve spatial resolution at the edges of the field of view. We show the field of view of such an imager can be increased from approximately 60° (full width at half maximum intensity) to over 90° using an embossed refractive microprism array, where the prism angle varies across the aperture to maintain coupling. We describe a proof-of-principle experiment using a f = 17.8mm fiber-coupled monocentric singlet lens, and show that a local region of microprisms embossed into a thin layer of SU-8 photopolymer can increase the field of view by 50%.

Saline-filled laparoscopic surgery: A basic study on partial hepatectomy in a rabbit model

BACKGROUND

There is still a poor understanding of the effects of pneumoperitoneum with insufflation of carbon dioxide gas (CO2) on malignant cells, and pneumoperitoneum has a negative impact on cardiopulmonary responses. A novel saline-filled laparoscopic surgery (SAFLS) is proposed, and the technical feasibility of performing saline-filled laparoscopic partial hepatectomy (LPH) was evaluated in a rabbit model.

MATERIAL AND METHODS

Twelve LPH were performed in rabbits, with six procedures performed using an ultrasonic device with CO2 pneumoperitoneum (CO2 group) and six procedures performed using a bipolar resectoscope (RS) in a saline-filled environment (saline group). Resection time, CO2 and saline consumption, vital signs, blood gas analysis, complications, interleukin-1 beta (IL-1β) and C-reactive protein (CRP) levels were measured. The effectiveness of the resections was evaluated by the pathological findings.

RESULTS

LPH was successfully performed with clear observation by irrigation and good control of bleeding by coagulation with RS. There were no significant differences in all perioperative values, IL-1βand CRP levels between the two groups. All pathological specimens of the saline group showed that the resected lesions were coagulated and regenerated as well as in the CO2 group.

CONCLUSIONS

SAFLS is feasible and provides a good surgical view with irrigation and identification of bleeding sites.

Heuristic reevaluation of the bacterial hypothesis of peptic ulcer disease in the 1950s

Throughout the first half of the twentieth century the research on peptic ulcer disease (PUD) focused on two rivaling hypothesis: the "acidity" and the "bacterial" one. According to the received view, the latter was dismissed during the 1950s only to be revived with Warren's and Marshall's discovery of Helicobacter pylori in the 1980s. In this paper we investigate why the bacterial hypothesis was largely abandoned in the 1950s, and whether there were good epistemic reasons for its dismissal. Of special interest for our research question is Palmer's 1954 large-scale study, which challenged the bacterial hypothesis with serious counter-evidence, and which by many scholars is considered as the shifting point in the research on PUD. However, we show that: (1) The perceived refutatory impact of Palmer's study was disproportionate to its methodological rigor. This undermines its perceived status as a crucial experiment against the bacterial hypothesis. (2) In view of this and other considerations we argue that the bacterial hypothesis was worthy of pursuit in the 1950s.

Evolution and future of laparoscopic colorectal surgery

The advances of laparoscopic surgery since the early 1990s have caused one of the largest technical revolutions in medicine since the detection of antibiotics (1922, Flemming), the discovery of DNA structure (1953, Watson and Crick), and solid organ transplantation (1954, Murray). Perseverance through a rocky start and increased familiarity with the chop-stick surgery in conjunction with technical refinements has resulted in a rapid expansion of the indications for minimally invasive surgery. Procedure-related factors initially contributed to this success and included the improved postoperative recovery and cosmesis, fewer wound complications, lower risk for incisional hernias and for subsequent adhesion-related small bowel obstructions; the major breakthrough however came with favorable long-term outcomes data on oncological parameters. The future will have to determine the specific role of various technical approaches, define prognostic factors of success and true progress, and consider directing further innovation while potentially limiting approaches that do not add to patient outcomes.

Single incision laparoscopic hepatectomy: A systematic review

Single incision laparoscopic surgery is a rather innovative surgical technique. A systematic literature review was performed with the intention to evaluate the till now clinical evidence regarding the application of single incision technique on liver resections as a method of management in hepatic lesions. Twelve relative studies were found in the field including 30 patients with a age range from 29 to 90 years and a body mass index from 20.1 to 36.5 kg/m². Primary hepatic carcinoma (40%), metastatic nodules (26.7%), hepatic cysts (16.7%), hepatic haemangiomas (13.3%) and hepatic adenoma (3.3%) were the most common indications of the lesions resected. The types of hepatectomy performed included partial hepatectomy (43.3%), segmentectomy (30%) and lobectomy (26.7%). In the majority of the patients, left lateral segments (II-III-IV) (76.7%) were resected. The median operative time was 110 min (range: 55-235) while the median quantity of blood loss was 50 ml (range: 0-100). No conversion to open surgery and no transfusion were needed. The duration of hospital stay ranged between 2 and 11 days. No complications, no cases of disease recurrence or death of patients were reported. None of the studies included described data on the cosmesis of the application of single incision laparoscopic technique on hepatic resections. Moreover, the surgical technique, as well as the different type of ports used is also presented in this review. Single site port laparoscopic surgery is a promising minimally invasive procedure for liver resections.

Laparoscopic paracostal herniorrhaphy in a dog: case report

Traumatic paracostal hernia is classified as an abdominal hernia that protrudes from the abdomen to a non physiologic space over the ribs. Treatment requires surgical reconstruction of the disrupted musculature in the thoracoabdominal region. Laparoscopic paracostal herniorrhaphy was performed in an eight-month-old male Teckel, presented after a car accident injury. A three-portal laparoscopic access was used for definitive diagnosis and hernia correction. After traction of the herniated omentum, a thoracoabdominal communication caused a left side pneumothorax, which was successfully drained with a chest tube placement. The herniorrhaphy was accomplished with intracorporeal sutures by a combination of Ford interlocking and cross mattress patterns. The postoperative period was uneventful. The laparoscopic paracostal herniorrhaphy was satisfactory, allowing both diagnosis and correction of the paracostal defect, showing to be a feasible alternative to the open surgery.

Endoscopy and laparoscopy: a historical aspect of medical terminology

INTRODUCTION

The history of medical terminology is interrelated with the scientific advances in the field. Efforts to explore human cavities for diagnostic and therapeutic purposes began as early as the 5th century BC. The evolution of laparoscopy at the beginning of the past century has been a major step toward minimization of surgical trauma. The present article investigates the terminological origin and the evolution of the terms endoscopy and laparoscopy.

METHODS

A search of ancient bibliographical archives and a review of the modern medical literature was undertaken.

RESULTS

The word endoscopy derives from the Greek word endoscópesis, a compound word consisting of éndon, which means inside and scopeín, which means to watch carefully. Laparoscopy also is a compound word, consisting of the words lapára, which means abdomen or abdominal wall, and scopeín. The word lapára derives from the adjective laparós, which means soft. The word lapára may be traced back to the Linear B syllabic script (17th to 13th century BC), as well as in descriptions of fights by the epic poet Homer (8th century BC). Although endoscopic examinations had been performed since the 5th century BC, the term endoscopy is first encountered in medical manuscripts of the 19th century AC, after the evolution of novel instruments and following the advent of artificial light. Similarly, the word laparothoracoscopy was first used in the early 20th century.

CONCLUSIONS

The origins of the words laparoscopy and endoscopy are traced back to the archaic period and later to the classical years of ancient Greece. The everlasting semantic of these origins is revisited in the 21st century, as minimization of surgical trauma with the aid of modern technology substantiates the diachronic objective "to do no harm."

NOTES, MANOS, SILS and other new laparoendoscopic techniques

A new way of opening a body cavity can be a revolution in surgery. In 1980s, laparoscopy changed how surgeons had been working for years. Natural orifice translumenal endoscopic surgery (NOTES), minilaparoscopy-assisted natural orifice surgery (MANOS), single incision laparoscopic surgery (SILS) and other new techniques are the new paradigm in our way of operating in the 21^st century. The development of these techniques began in the late 90s but they have not had enough impact to develop and evolve. Parallels between the first years of laparoscopy and NOTES can be made. Working for an invisible surgery, not only for cosmesis but for a less invasive surgery, is the target of NOTES, MANOS and SILS performed by surgeons and endoscopists over the last 10 years. The future flexible endoscopic platforms and the fusion between laparoscopic instruments and devices and robotic surgery will be a great advance for “scarless surgery”.

Single-Incision Laparoscopic Surgery (SILS) in Biliary and Pancreatic Diseases

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to 'scarless' surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, single-incision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single- or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.

Intraperitoneal temperature and desiccation during endoscopic surgery. Intraoperative humidification and cooling of the peritoneal cavity can reduce adhesions

This study was conducted to document quantitatively the intraperitoneal temperature and desiccation during laparoscopic surgery. The temperature, relative humidity, and flow rate were measured in vitro and during laparoscopic surgery, at the entrance and at the exit of the abdomen. This permitted us to calculate desiccation for various flow rates using either dry CO(2) or CO(2) humidified with 100% relative humidity at any preset temperature between 25 and 37°C. The study showed that desiccation, both in vitro and in vivo, varies as expected with the flow rates and relative humidity while intraperitoneal temperature varies mainly with desiccation. Temperature regulation of bowels is specific and drops to the intraperitoneal temperature without affecting core body temperature. With a modified humidifier, desiccation could be eliminated while maintaining the intraperitoneal temperature between 31 to 32°C.

[Application of electrogastrography to public health]

In general, gastrointestinal motility tests cause pain; therefore, the establishment of noninvasive methods is desired. Noninvasive methods facilitate the measurement of motility close to the normal physiological state, can provide new findings, and may contribute to the development of associated fields. Electrogastrography (EGG) is a gastrointestinal motility test in which gastrointestinal electric activity is measured. Compared with other gastrointestinal motility measurement methods such as the gastric emptying and internal pressure measurement methods, EGG is noninvasive and allows measurement under minimum restriction; therefore, measurement for a long time is also possible. In addition, since gastrointestinal electric activity, which cannot be quantified using other methods, can be measured, EGG is applicable to the evaluation of the state of the body and pathological conditions, and may provide new findings such as those useful for the prevention of gastrointestinal dysfunction associated with various disorders. EGG is also useful for preventing disorders associated with abnormal gastrointestinal activity such as functional dyspepsia, which has been more frequently observed in recent years, and constipation, which is an extremely frequent complaint in the elderly. Thus, EGG is of marked importance in public health. However, the range of EGG utilizations and applications is still limited at present. Therefore, we outlined the measurement/analysis methods, the advantages and problems of EGG and electrogastroenterography (EGEG), described their clinical importance, and also commented on forefront studies on EGG and evaluated its prospects.

Novel technique for a single-incision laparoscopic surgery (SILS) approach to cholecystectomy: single-institution case series

BACKGROUND

Multiple case series managed by a single-incision laparoscopic surgery (SILS) approach to cholecystectomy have been published, reporting that this new procedure is easily reproducible and safe. Currently, variations on surgical technique are being tested. This report describes the largest series of single-skin- and single-fascial-incision cholecystectomies using a multichannel port.

METHODS

Between July 2008 and December 2009, 55 patients underwent SILS cholecystectomy by two experienced general surgeons at a single institution. The operative time, surgical technique, conversion rate, specimen pathology, and postoperative complications were reported.

RESULTS

The reported series consisted of 43 women (78%) and 12 men (22%) with a mean age of 44.2 years (range, 22-89 years). The body mass index (BMI) of the patients ranged from 16.1 to 46.8 kg/m2 (mean, 29.1 kg/m2). The mean operating room (OR) time was 66.5 min (range, 30-140 min). An improvement in OR time was observed over the course of the study. The first 19 cases were managed through a single incision but with two fascial defects for port placement. The last 36 cases were performed through a single skin incision with a single fascial incision. In five cases, an extra port had to be placed, and one case was converted to open surgery. To date, no port-site hernias, wound infections, small bowel obstructions, or other postoperative complications have been observed.

CONCLUSION

The authors believe that the single-skin- and single-fascial-incision technique will prove superior to creation of multiple fascial defects in terms of future port-site hernias and will replace prior techniques using multiple fascial incisions.

Safety and learning curve in robotic colorectal surgery

Robotic surgery has recently started to be used for minimally invasive colorectal surgery. Because of limited access and high cost, very few colorectal units are available in the US. We describe our experience with benign and malignant disease since September 2008 in a dedicated colorectal practice. A prospective collected robotic database was queried for colon and rectal procedures. Anonymized demographic, intraoperative, and postoperative data, and pathology information, were collected and analyzed. A total of 48 robotic procedures for colorectal maladies were performed in the study period. There were 35 females and 13 males. The average age was 57 years. Twenty-two cases were performed for diverticulitis, 13 for malignancy (10 distal rectum (<8 cm anal verge), two rectosigmoid, and one ascending colon cancer), 10 for rectal prolapse, two for rectovaginal fistula, and one for incidental appendiceal mucocele found during a gynecologic resection. The average operating room time (OR) was 162 min and there were no conversions to open procedures. Blood loss averaged 104 mL. Mean length of hospital stay (LOS) was 5.4 days. Patient readmission occurred in 27.3% of cases. The anastamotic leak rate was 2.1% (one patient). No mortalities were reported. When the analysis was performed for colorectal malignancies (13 procedures), there were nine females and four males. Average age was 59 years. The mean OR time was 191.1 min. Mean intraoperative blood loss was 123 mL and there were no conversions to open surgery. Average LOS was 7.0 days. There was one anastamotic leak (7.7%). The length of stay was increased for the patient with anastamotic leak (18 days) and for a patient with high stoma output and postoperative ileus (17 days). Readmission rate was 30.1%. The total number of lymph nodes retrieved averaged 19.5, with a mean distal margin of 3.0 cm and in all cases negative radial margins. Robotic colorectal surgery for benign and malignant disease is safe, and short-term outcomes are comparable with those of traditional and laparoscopic surgery. Oncologic resections were adequate with excellent lymph node sampling and radial and distal margins.

Robotic-assisted laparoscopic surgery for recurrent diverticulitis: experience in consecutive cases and a review of the literature

BACKGROUND

Robotic-assisted laparoscopic surgery has recently gained enthusiasm for application in colorectal surgery. We present the safety and feasibility of using the da Vinci® robotic system for the surgical treatment of sigmoid diverticulitis.

METHODS

Between August 2008 and November 2009, robotic-assisted laparoscopic anterior rectosigmoid resection (RALS-AR) for diverticulitis was performed in 24 consecutive patients. Demographic data, intraoperative parameters, and postoperative outcomes were assessed.

RESULTS

RALS-AR was performed in 14 male (58.3%) and 10 female (41.7%) patients with a diagnosis of recurrent diverticulitis. The mean patient age and BMI were 49.8 ± 9.3 years (range = 30-62 years) and 29.9 ± 6.3 kg/m(2) (range = 15.9-46.9 kg/m(2)), respectively. Disease stratification identified 15 cases of uncomplicated (62.5%) and 9 cases of complicated (37.5%) disease. The procedures required 14.1 ± 6.7 min (range = 6-30 min) for robotic docking, 100.5 ± 31.0 min (range = 50-180 min) for surgeon console time, and 224.2 ± 47.1 min (range = 150-330 min) for the total operative time. Robotic docking and surgeon console time represented 51.9% of the total operative time. A primary colorectal anastomosis was fashioned with avoidance of colostomy in all patients. There were no significant intraoperative complications, and none of the procedures required conversion to open, hand-assisted, or conventional laparoscopic technique. The length of hospital stay was 3.4 ± 2.6 days (range = 2-14 days), and the postoperative complication rate was 12.5% (n = 3). There were no anastomotic leaks, secondary surgical interventions, or hospital readmissions.

CONCLUSIONS

Robotic-assisted laparoscopic technique is a safe and feasible option for the surgical treatment of diverticulitis. The approach may be offered to patients with uncomplicated or complicated disease, and it results in a short hospital stay and low complication rate.