Needlescopic surgery: what’s in the toolbox?

Technical Report and Surgical Outcomes of Needlescopic Totally Extraperitoneal Inguinal Hernia Repair: A Single-center, Retrospective Cohort Study

BACKGROUND

Technical difficulties in totally extraperitoneal inguinal hernia repair (TEP) may be strongly associated with poor operability in a limited operative field. Needlescopic instruments could be helpful in a limited space, and the aim of this study was to evaluate the clinical efficacy of needlescopic TEP.

MATERIALS AND METHODS

The study population constituted 150 consecutive patients undergoing needlescopic TEP, and we compared these patients with 151 consecutive patients who underwent conventional TEP regarding patients' demographic features and operative outcomes. Inclusion criteria were: (1) being treated by an experienced surgeon and (2) replying to our questionnaire regarding postoperative outcomes.

RESULTS

The mean skin opening to closing times for unilateral and bilateral repairs were, respectively, 95.3±30.1 and 130.2±48.7 minutes for conventional TEP and 75.7±24.5 and 114.5±46.3 minutes for needlescopic TEP. The difference for unilateral repairs between the 2 surgical groups was significant (P=0.01). Conversion rates, postoperative hospital stays, and perioperative morbidity rates showed no significant differences between the 2 groups.

CONCLUSIONS

Needlescopic TEP is a useful procedure that decreases operative duration with no significant differences in perioperative morbidity compared with conventional TEP.

Mini-plus percutaneous setting in total laparoscopic hysterectomy

INTRODUCTION

We aimed to analyze the preliminary experience of a mini-plus percutaneous instrument (MpPc) setting in total laparoscopic hysterectomy (TLH).

MATERIAL AND METHODS

Forty-three women who underwent a mini-plus percutaneous total laparoscopic hysterectomy at a tertiary-care university-based teaching hospital and academic affiliated private hospital between May 2017 and 2018 were included. MpPc-TLH was performed through one optical trans-umbilical 5-mm trocar, one 5-mm ancillary port on the right side, either one 2.4-mm percutaneous endoscopic instrument or 3-mm mini-laparoscopic port on the right upper quadrant and if required one 3-mm ancillary port on the left lower quadrant.

RESULTS

A total of 43 patients were included, with a median age of 48 years (range, 38-71 years). Indication for surgery included uterine myomas (n = 20), benign adnexal mass (n = 7), endometrial intraepithelial neoplasia (n = 6), endometrial cancer (n = 5), adenomyosis with abnormal bleeding (n = 3), and high-grade cervical dysplasia (n = 2). The median operating time was 100 min (range, 60-180 min), and the median estimated blood loss was 30 ml (range, 20-60ml). The median postoperative abdominal pain Visual Analog Scale score was 3 (range, 0-6).

CONCLUSIONS

The preliminary data suggest that MpPc approach is a feasible and safe surgical modality for total laparoscopic hysterectomy.

Complete percutaneous laparoscopic cholecystectomy by employing the Percuvance Percutaneous Surgical System

Background

Laparoscopic cholecystectomy (LC) has been the gold standard in the treatment of gallbladder disease. More than 50 different techniques of LC have been developed and performed, which seem to offer much in postoperative outcome and cosmesis. However, each has its limitations in practice mainly due to the long learning curve, or lack of appropriate instruments. The current paper studies the application of percutaneous LC employing the Percuvance Percutaneous Surgical System and reports the first documented complete percutaneous LC in the literature.

Methods

Complete percutaneous LC was performed in fifteen patients diagnosed with cholelithiasis, the Percuvance Percutaneous Surgical System from Teleflex was used. All operations were performed with the use of a single 10 mm Hassan Trocar port and a 30^o degree camera.

Results

Complete percutaneous LC with the use of percutaneous Instruments was applied in all cases. No conversions to open cholecystectomy were reported. Mean operating time was well within the standard for LC. Postoperatively, no complications were observed, while all patients were discharged the next day. Excellent cosmesis and satisfied patients were the long-term results.

Conclusions

Percutaneous LC with the use of a 10 mm Hassan trocar, bears the potential of being a favorable alternative in cholecystectomy.

Needlescopic-assisted uniportal video-assisted thoracoscopic pulmonary anatomical segmentectomy

BACKGROUND

Pulmonary segmentectomy can be an oncologic equivalent of lobectomy for small non-small cell lung cancer. Uniportal video-assisted thoracoscopic surgery (VATS) has recently showed favorable surgical outcomes, but remains technical demanding, especially in a complex procedure like anatomic segmentectomy. This manuscript demonstrates the surgical techniques for uniportal VATS segmentectomies with the assistance of additional needlescopic instruments.

METHODS

Data of 22 consecutive patients who underwent 24 needlescopic-assisted uniportal VATS segmentectomies between December 2016 and June 2017 was analyzed.

RESULTS

There were 12 uni-segmentectomies, 10 bi-segmentectomies, and 2 tri-segmentectomies. The mean operation time was 178.3 minutes. The mean duration of chest tube drainage was 5.2 days, and the mean duration of hospital stay was 7.4 days. There were two episodes of major bleeding and one case that required conversion to lobectomy.

CONCLUSIONS

Under the assistance of additional needlescopic instruments, segmentectomy can be performed more easily and safely with uniportal VATS.

New Hybrid Mini-laparoendoscopic Single-site Partial Nephrectomy With Early Unclamped Technique for Renal Tumors With Intermediate PADUA Score (IDEAL Phase 2a)

OBJECTIVE

To evaluate a new hybrid technique, which we defined as mini-laparoendoscopic single-site partial nephrectomy (MILESS-PN), for renal masses presenting an intermediate PADUA score.

MATERIALS AND METHODS

Forty consecutive cases of MILESS-PN performed between April 2013 and November 2015 were included in this study. Mini-laparoendoscopic single-site surgery consisted of the simultaneous use of two 3-mm pararectal trocars and an umbilical SILS trocar; the sequence of steps of MILESS-PN was comparable with standard laparoscopic partial nephrectomy. Demographic data and the main perioperative and oncological outcome parameters were gathered and analyzed.

RESULTS

The median operative time was 134.6 (interquartile range [IQR] 110-180) minutes with a median warm ischemia time of 12.1 (IQR 9.5-15.5) minutes. Postoperatively, 4 early complications were recorded and the median hospital stay was 4.2 (IQR 3.5-6.0) days. The median renal tumor size was 3.6 (IQR 2.4-5.3) cm with a median PADUA score of 8.3 (IQR 8-9). The definitive pathologic results revealed a renal cell carcinoma in 32 cases (80%), an angiomyolipoma in 3 cases (7.5%), and an oncocytoma in 5 cases (12.5%). All tumors were removed with negative surgical margins, and at the median follow-up of 34.5 (IQR 24-48) months, all patients were alive without evidence of tumor recurrence or port-site metastasis. A statistically significant decrease in the estimated glomerular filtration rate (eGFR) was observed postoperatively (postoperative vs preoperative median eGFR: 87.6 [IQR 70.4-101.8] and 104.7 [IQR 82.7-123.3], P <.0001) and at 6 months (6 months vs preoperative eGFR 93.6 [IQR 79.1-110.2] and 104.7 [IQR 82.7-123.3], P <.0001).

CONCLUSION

MILESS-PN for renal tumors with an intermediate PADUA score in well-selected patients is not associated with increased risks for the patients, presenting excellent oncological and functional results at the midterm follow-up. Mini-laparoendoscopic single-site surgery could represent a valid alternative to laparoendoscopic single-site surgery or minilaparoscopy because of its higher surgical reproducibility.

Concept design of robotic modules for needlescopic surgery

BACKGROUND

Many minimally invasive surgical procedures and assisting robotic systems have been developed to further minimize the number and size of incisions in the body surface. This paper presents a new idea combining the advantages of modular robotic surgery, single incision laparoscopic surgery and needlescopic surgery.

MATERIAL AND METHODS

In the proposed concept, modules carrying therapeutic or diagnostic tools are inserted in the abdominal cavity from the navel as in single incision laparoscopic surgery and assembled to 3-mm needle shafts penetrating the abdominal wall.

RESULTS

A three degree-of-freedom robotic module measuring 16 mm in diameter and 51 mm in length was designed and prototyped. The performance of the three connected robotic modules was evaluated.

CONCLUSION

A new idea of modular robotic surgery was proposed, and demonstrated by prototyping a 3-DOF robotic module. The performance of the connected robotic modules was evaluated, and the challenges and future work were summarized.

[Minilaparoscopy with 5 mm optics and 3 mm trocars]

Minilaparoscopy was introduced already 20 years ago. In spite of reduced diameter, technical performance of modern trocars and instruments has improved substantially. While carrying out a minilaparoscopic procedure, the required position of the trocars and the surgical strategy remain the same. The most important step towards minilaparoscopy is reduction of the diameter of the laparoscopes from 10 to 5 mm. The 5 mm laparoscopes show high resolution and transport enough energy to properly illuminate the surgical field. Minilaparoscopic procedures help to improve cosmetic results and reduce postoperative pain, but postoperative complication rates are not affected. Use of one 5 mm trocar causes higher tissue tension than two 3 mm trocars and an additionally placed 3 mm trocar will not increase the complication rate. Therefore, a reduced risk of trocar hernia formation may be expected when a minilaparoscopic approach is used. Efficiency has been proven for minilaparoscopic cholecystectomy, appendectomy, and hernioplasty (TAPP/TEP) whereas overall available evidence across the literature remains poor. Further miniaturization is linked directly to video editing: physical limitations in classic optic systems have already been reached; therefore, reduction of optical chip systems could be a possible alternative.

A Comparative Assessment of Novel Mini-Laparoscopic Tools

Background: Mini-laparoscopy, or needlescopy, is an emerging minimally invasive technique that aims to improve on standard laparoscopy in the areas of tissue trauma, pain, and cosmesis. The objective of this study was to determine if there was a difference in functionality between 2 novel mini-laparoscopic instruments when compared to standard laparoscopic tools. Differences were assessed in a simulated surgical environment. Methods: Twenty participants (5 novices, 10 intermediate, 5 expert) were recruited for this institutional review board–approved study in a surgical simulation training center. Group A tools were assembled intracorporeally, and Group B tools were assembled extracorporeally. Using standard laparoscopic graspers, mini-laparoscopic graspers, or a combination of both, each participant performed 3 basic laparoscopic training tasks: a Peg Transfer, Rubber Band Stretch, and Tootsie Roll Unwrapping. Following each round of tasks, participants completed a survey evaluating the mini-laparoscopic graspers with respect to standard laparoscopic graspers. Data were analyzed using Kruskal-Wallis test with Dunn’s test for post hoc comparisons. Results: When comparing task times, both mini tools performed at the level of standard laparoscopic graspers in all participant groups. Group A tools were quicker to assemble and disassemble versus Group B tools. According to posttask surveys, all participant groups indicated that both sets of mini-laparoscopic graspers were comparable to the standard graspers. Conclusion: In a nonclinical setting, mini-laparoscopic instruments perform at the level of standard laparoscopic tools. Based on these results, clinical trials would be a reasonable next step in assessing feasibility and safety.

Resection of Sentinel Lymph Nodes by an Extraperitoneal Minilaparoscopic Approach Using Indocyanine Green for Uterine Malignancies

Background. The sentinel lymph node (SLN) concept might minimize surgical aggressiveness in cervical and endometrial malignancies. The aim of the study was to test the feasibility and reliability of minilaparoscopic extraperitoneal SLN excision after indocyanine green (ICG) cervical injection using a high-definition near infrared (NIR) imaging system in an in vivo porcine model. The same procedure was performed using conventional laparoscopic instruments and both outcomes were compared. Methods. Twenty-four animals were equally and randomly divided into a minilaparoscopic group (group A) and a 5-mm conventional laparoscopic group (group B). A high-definition NIR imaging system and a 30° ICG endoscope were used. First, ICG (0.5 mL) was injected in the paracervical region. The SLN coloring time was recorded. An extraperitoneal approach to the SLN was executed with the same CO2 retropneumoperitoneum pressures (10 mm Hg). In both groups, the times for SLN localization and excision, as well as complications, were registered. Finally, a laparotomy was then done to evaluate whether any stained SLN still remained. The same surgical team performed all experiments. Results. SLNs were identified and extraperitoneally excised in all animals without major complications. The SLN localization varied between animals from external iliac to preaortic regions. The surgical times were shorter with minilaparoscopy (39.3 ± 13 minutes) than with conventional 5-mm instruments (51.3 ± 14.17 minutes; P = .042). In group B, one stained SLN remained and was only detected by laparotomy. Conclusions. We confirmed the feasibility and reliability of extraperitoneal minilaparoscopic approach for identification, dissection, and excision of SLN using an NIR imaging system and ICG.

Development of scar-less laparoscopic hernia repair (TAPP-252) facilitated by new 2mm instruments

INTRODUCTION

To minimize the invasiveness of laparoscopic transabdominal preperitoneal hernia repair (TAPP) for the treatment of adult inguinal hernia, we developed a new operative technique with the use of only one 5 mm port and two 2 mm punctures (TAPP-252).

MATERIAL AND METHODS

To facilitate TAPP-252, we developed seven kinds of new 2 mm instruments, including grasping forceps, hook shaped electrode, mesh pusher, needle driver, scissors, laparoscope and port.

RESULTS

TAPP-252 was stably performed in 35 patients with minimal abdominal wall destruction and excellent cosmetic result without any recurrence or morbidity.

CONCLUSIONS

The newly developed 2 mm devices showed sufficient performance and durability in TAPP-252. Further investigation is necessary to assess durability and long-term outcomes.

Low-Friction Minilaparoscopy Outperforms Regular 5-mm and 3-mm Instruments for Precise Tasks

Background and Objectives:

Therapeutic laparoscopy was incorporated into surgical practice more than 25 y ago. Several modifications have since been developed to further minimize surgical trauma and improve results. Minilaparoscopy, performed with 2- to 3-mm instruments was introduced in the mid 1990s but failed to attain mainstream use, mostly because of the limitations of the early devices. Buoyed by a renewed interest, new generations of mini instruments are being developed with improved functionality and durability. This study is an objective evaluation of a new set of mini instruments with a novel low-friction design.

Method:

Twenty-two medical students and 22 surgical residents served as study participants. Three designs of laparoscopic instruments were evaluated: conventional 5 mm, traditional 3 mm, and low-friction 3 mm. The instruments were evaluated with a standard surgical simulator, emulating 4 exercises of various complexities, testing grasping, precise 2-handed movements, and suturing. The metric measured was time to task completion, with 5 replicates for every combination of instrument–exercise–participant.

Results:

For all 4 tasks, the instrument design that performed the best was the same in both the medical student and surgical resident groups. For the gross-grasping task, the 5-mm conventional instruments performed best, followed by the low-friction mini instruments. For the 3 more complex and precise tasks, the low-friction mini instruments outperformed both of the other instrument designs.

Conclusion:

In standard surgical simulator exercises, low-friction minilaparoscopic instruments outperformed both conventional 3- and 5-mm laparoscopic instruments for precise tasks.

Minilaparoscopy with Interchangeable, Full 5-mm End Effectors: First Human Use of a New Minimally Invasive Operating Platform

BACKGROUND

The most common paradigm in minimally invasive surgery is entry of a single trocar through separate incisions in the abdomen. However, in an effort to decrease postoperative pain and minimize scarring, alternative techniques have been described. Needlescopic surgery uses instruments that are 3 mm or less in diameter. Prior uses of needlescopic instruments have been hindered somewhat by diminished shaft strength and small end-effector size. The Percuvance™ (Teleflex, Wayne, PA) system uses a 2.9-mm shaft with interchangeable 5-mm end effectors in order to minimize abdominal wall trauma while maintaining the functionality of traditional laparoscopic instruments.

MATERIALS AND METHODS

All patients evaluated for laparoscopic surgery by two surgeons with a foregut and general surgery practice at the Cleveland Clinic (Cleveland, OH) were included in the study. Fifteen consecutive patients were enrolled in the study. Patient demographics and operative results were reviewed.

RESULTS

In March 2015, 15 patients underwent surgery using the Percuvance surgical system at the Cleveland Clinic. There was one conversion to open surgery due to extensive intraabdominal adhesions and unclear anatomy. There was one re-exploration for presumed anastomotic leak, which was negative. Operative time and length of hospital stay were similar to those of standard laparoscopic procedures. There were no deaths in this series. Subjective surgeon experience was overall positive, and functionality of the Percuvance system seemed equal to that of standard 5-mm laparoscopic instrumentation.

CONCLUSIONS

This initial experience with the Percuvance system demonstrated effective exchange of 5-mm port sites for needlescopic instruments with similar handling to traditional laparoscopic instruments. This interchangeable system may allow performance similar to standard laparoscopic port instrument orientation and principles in the setting of decreased-caliber access.

Mini-laparoscopic versus robotic radical hysterectomy plus systematic pelvic lymphadenectomy in early cervical cancer patients. A multi-institutional study

OBJECTIVE

The aim of this study was to verify possible differences in terms of perioperative outcomes and complications between mini-laparoscopic radical hysterectomy with lymphadenectomy (mLRH) and robotic radical hysterectomy with lymphadenectomy (RRH) in patients with early cervical cancer (ECC).

MATERIAL AND METHODS

In this retrospective study, thirty women with early stage cervical cancer who underwent mini-laparoscopic radical hysterectomy plus lymphadenectomy (mLRH) were compared with a cohort of thirty women who underwent robotic multiport radical hysterectomy (RRH). The study involved patients, between August 2010 and December 2012, from three Italian institutions: National Cancer Institute of Rome, University of Insubria, Varese, and the Catholic University of the Sacred Heart of Rome.

RESULTS

No significant differences between groups were observed in terms of age, BMI, previous abdominal surgery or FIGO stage. Operative time, blood loss, need of blood transfusion, risk of intra- and post-operative complications, and lymph nodes yield were similar between mLRH and RRH in patients with ECC. The median length of hospital stay was 2 days in the mLRH group and 3 days in the RRH group (p < 0.05).

CONCLUSIONS

The few differences we registered do not seem clinically relevant, thus making the two procedures comparable. The decision on how to gain best access for radical hysterectomy considers the surgeon's skill and experience with the different possible approaches. Further randomized trials are needed to determine whether mini-laparoscopic techniques truly offer any advantages.

Contemporary urologic minilaparoscopy: indications, techniques, and surgical outcomes in a multi-institutional European cohort

OBJECTIVES

To provide an analytical overview of contemporary indications, techniques, and outcomes of urologic minilaparoscopy (ML) in multiple European centers.

METHODS

Data of patients who had undergone a minilaparoscopic urologic procedure at nine European institutions between 2009 and 2012 were retrospectively gathered. Surgical procedures were classified as upper or lower urinary tract and as ablative or extirpative and reconstructive. The main surgical outcome parameters were analyzed and relevant operative data related to the surgical technique were recorded.

RESULTS

Overall, 192 patients (mean age 45.25±17.8 years) were included in the analysis. Most of them were nonobese (mean body mass index [BMI] 24.7±3.6 kg/m(2)) at low estimated surgical risk (mean American Society of Anesthesiologists [ASA] 1.69±0.68). Indications for surgery were mostly nononcologic (132 cases, 68.8%). Most of the procedures were done in the upper urinary tract (133 cases, 69.2%) and were mostly with a reconstructive intent (109 cases, 56.7%). Overall operative time was 132.7±52.3 minutes with an estimated blood loss of 60.9±47.6 mL while the mean hospital stay was 5±2.1 days. Most of the postoperative complications were low Clavien grade (1 and 2), with only one (0.5%) grade 3 and one (0.5%) grade 4 complications recorded.

CONCLUSIONS

A broad range of common procedures can be safely and effectively performed with ML techniques. By duplicating the principles of standard laparoscopy, but potentially offering less surgical scar and trauma, ML can be regarded as a viable option when looking for a virtually "scarless" surgery.

[Further technical and digital development in minimally invasive and conventional surgery]

Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment "surgical operating room" has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.

Changing our view of minimally invasive gynecologic surgery: a review of laparoendoscopic single-site surgery and a report on new approaches

The recent emergence of laparoendoscopic single-site surgery (LESS) has had a great impact on gynecology. As LESS grows in popularity, attention has been paid to the procedure's cosmetic benefits. Although in theory LESS is an ideal approach that leaves no visible scars and improves patients' quality of life, the outcomes are not always ideal according to recently published data. Therefore, alternative approaches, such as mini-laparoscopy, are also becoming more popular. Herein, we review randomized trials studying the benefits of LESS in gynecology and discuss alternative approaches. Finally, we propose the mimic approach as the next generation for non-visible scar surgery.

Laparoendoscopic single-site surgery in kidney surgery: clinical experience and future perspectives

Laparoscopic surgery of the upper urinary tract has reduced the morbidity related to large abdominal incisions and has resulted in significant advantages over open surgery. Nevertheless, the pursuit for even more minimally invasive alternatives to laparoscopy has led to the concept of scarless surgery and the approach of laparoendoscopic single-site surgery (LESS). LESS is currently a feasible approach for the majority of kidney surgical procedures, and there is intense debate regarding its efficiency and advantages. In the present review of the literature, the current status of upper urinary LESS and its advantages and disadvantages, as well the technological and technical evolution, are presented.