Laparoendoscopic Single Site Nephrectomy With the SPIDER Surgical System: Engineering Advancements Tested in a Porcine Model

Specific training for LESS surgery results from a prospective study in the animal model

OBJECTIVE

to prospectively evaluate the ability of post-graduate students enrolled in a laparoscopy program of the Institute for Teaching and Research to complete single port total nephrectomies.

MATERIALS AND METHODS

15 post-graduate students were enrolled in the study, which was performed using the SILStm port system for single-port procedures. All participants were already proficient in total nephrectomies in animal models and performed a left followed by a right nephrectomy. Analyzed data comprised incision size, complications, and the time taken to complete each part of the procedure. Statistical significance was set at p<0.05.

RESULTS

All students successfully finished the procedure using the single-port system. A total of 30 nephrectomies were analyzed. Mean incision size was 3.61 cm, mean time to trocar insertion was 9.61 min and to dissect the renal hilum was 25.3 min. Mean time to dissect the kidney was 5.18 min and to complete the whole procedure was 39.4 min. Total renal hilum and operative time was 45.8% (p<0.001) and 38% (p=0.001) faster in the second procedure, respectively. Complications included 3 renal vein lesions, 2 kidney lacerations and 1 lesion of a lumbar artery. All were immediately identified and corrected laparoscopically through the single-port system, except for one renal vein lesion, which required the introduction an auxiliary laparoscopic port.

CONCLUSION

Laparoscopic single-port nephrectomy in the experimental animal model is a feasible but relatively difficult procedure for those with intermediate laparoscopic experience. Intraoperative complications might be successfully treated with the single-port system. Training aids reducing surgical time and improves outcomes.

Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator

Background

The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS).

Methods

Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system.

Results

Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER.

Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005).

Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007).

Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task.

Conclusions

Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.

A state of the art review and categorization of multi-branched instruments for NOTES and SILS

BACKGROUND

Since the advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and single incision laparoscopic surgery (SILS), a variety of multitasking platforms have been under development with the objective to allow for bimanual surgical tasks to be performed. These instruments show large differences in construction, enabled degrees of freedom (DOF), and control aspects.

METHODS

Through a literature review, the absence of an in-depth analysis and structural comparison of these instruments in the literature is addressed. All the designed and prototyped multitasking platforms are identified and categorized with respect to their actively controlled DOF in their shafts and branches. Additionally, a graphical overview of patents, bench test experiments, and animal and/or human trials performed with each instrument is provided.

RESULTS

The large range of instruments, various actuation strategies, and different direct and indirect control methods implemented in the instruments show that an optimal instrument configuration has not been found yet. Moreover, several questions remain unanswered with respect to which DOF are essential for bimanual tasks and which control methods are best suited for the control of these DOF.

CONCLUSIONS

Considering the complexity of the currently prototyped and tested instruments, future NOTES and SILS instrument development will potentially necessitate a reduction of the available DOF to minimize the control complexity, thereby allowing for single surgeon bimanual task execution.

LESS and NOTES instrumentation: future

PURPOSE OF REVIEW

Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are novel techniques with potential to minimize the morbidity of surgery. Challenging ergonomics, instrument clashing, and the lack of true triangluation still remain great concerns.

RECENT FINDINGS

New technological developments in instrument design have been created to enhance clinical applicability of these techniques. Further technological advancements including the incorporation of novel robotic surgical platforms (R-LESS) exploit the ergonomic benefits in an attempt to further advance LESS surgery. Promising devices include magnetic anchoring and guidance systems that have the potential to allow external manoeuvring of intracorporeal instruments while facilitating triangulation and reducing clashing. As well, the benefit of miniature in-vivo robots that can be placed endoscopically intra-abdominally and controlled wirelessly will allow internal manipulation of tissue from internal repositionable platforms.

SUMMARY

It remains to be seen whether LESS or NOTES will prove their clinical benefit over standard laparoscopic or robotic procedures. In this chapter, we review the current LESS and NOTES technology, and focus on new innovations and research in the field.

Pilot laparoscopic ileal cannulation in pigs

Zhang, S. X., Wang, H. B., Zhang, H., Liu, H. F., Zhou, Z. F., Zhang, J. T. and Gao, L. 2014. Pilot laparoscopic ileal cannulation in pigs. Can. J. Anim. Sci. 94: 371–377. Pilot laparoscopic ileal cannulation was performed in eight anesthetized pigs (40.5±1.9 kg) positioned in dorsal recumbency using three portals in the abdomen. The T-shaped ileal cannulation site was located 15 cm anterior to the ileocecal valve on the antimesenteric section of the ileum. A transabdominal suspension suture was placed approximately 3 cm caudal to the ileal cannulation site. A purse-string suture was placed first around the insertion site, and a stab incision was made in the middle of the purse-string suture. The T-shaped cannula was inserted into the ileal lumen through the stab incision, and the purse-string suture was tightened. The T-shaped ileal cannula was pulled out of the abdominal cavity through the exit wound located 3–5 cm lateral and 10–12 cm caudal to the right or left side of the umbilicus. The transabdominal suspension suture was then removed. The T-shaped cannula was secured to the skin with a finger-trap suture. Surgical time and complications were recorded. Repeat laparoscopy was performed 35 d later. No major intraoperative or postoperative complications were encountered. The ileal contents were collected easily. On repeat laparoscopy, firm adhesion between the ileum and the abdominal wall was observed in all pigs, and there was no evidence of digesta leakage or consequential peritonitis.

Single-incision cholecystectomy: a comparative study of standard laparoscopic, robotic, and SPIDER platforms

BACKGROUND

Many series have shown the feasibility and safety of single-incision laparoscopic cholecystectomy (SILC), but this technique still has limitations such as instrument collisions and lack of triangulation. Recently, two single-incision platforms, robotic and SPIDER, have attempted to ameliorate such problems. This study aimed to compare three different techniques of single-incision cholecystectomy: standard laparoscopic, robotic, and SPIDER approaches.

METHODS

The authors retrospectively collected data from their first 166 single-incision robotic cholecystectomies (SIRCs) and compared the findings with the data from their first 166 SILCs and the first 166 s-generation SPIDER procedures. All the SILCs were performed with three trocars placed in one umbilical incision and with gallbladder retraction using a Prolene stitch on the right upper quadrant. All the robotic cases were managed using the da Vinci Single-Site Surgical System, and all the SPIDER procedures were performed using the SPIDER Surgical System.

RESULTS

The SILC, SIRC, and SPIDER groups consisted respectively of 129 (76.3%), 131 (78.9%), and 136 (81.9%) women with the respective mean ages of 44.5 ± 14.3, 51.6 ± 15.9, and 46.4 ± 15.2 years. The mean body mass indexes (BMIs) were respectively 29.1 ± 5.6, 29.4 ± 6.2, and 27.5 ± 4.8 kg/m(2), and the mean surgical times were 37.1 ± 13.3, 63.0 ± 25.2, and 52.8 ± 18.7 min. The total hospital stays were respectively 1.3 ± 5.3, 1.2 ± 2.2, and 1.5 ± 2.6 days, and complications were seen respectively in three SILC cases (1.8%), three SIRC cases (1.8%), and two SPIDER cases (1.2%).

CONCLUSIONS

The results of this study demonstrate similar results among the three platforms for most of the parameters measured. The SILC procedure appears to be superior to SIRC and SPIDER in terms of surgical time, but selection bias could be the cause. The SILS, SIRC, and SPIDER procedures all are similar in terms of complication profile. It can be concluded that SILC, SIRC, and SPIDER all are feasible and safe alternatives when used for single-incision cholecystectomy.

Comparison of transrectal and transvaginal hybrid natural orifice transluminal endoscopic surgery partial nephrectomy in the porcine model

OBJECTIVE

To compare the feasibility of porcine transrectal (TR) and transvaginal (TV) hybrid natural orifice transluminal endoscopic surgery (NOTES) partial nephrectomy (PN), as NOTES nephrectomy has recently been performed in the porcine model.

MATERIALS AND METHODS

A total of 10 female pigs (weight 45 kg) underwent TR (n = 5) or TV (n = 5) NOTES PN. The pneumoperitoneum was created by a periumbilical 12-mm trocar, through which a laparoscope was advanced for intra-abdominal visualization. For TV-NOTES PN, a gastroscope was used to obtain TV peritoneal access. For TR-NOTES PN, a horizontal incision was made 2 cm above the dentate line, and a submucosal tunnel was created in the posterior rectal wall. The gastroscope was advanced through the submucosal tunnel and retroperitoneum to the kidney, and a peritoneal window was created. For both TR- and TV-NOTES PN, the gastroscope was exchanged for the SPIDER Surgical System. Flexible dissecting instruments and hook cautery introduced through the SPIDER Surgical System were used to mobilize the kidney. A harmonic scalpel introduced periumbilically was used to excise a portion of the lower pole. LAPRA-TY-secured sutured renorrhaphy was performed, followed by TR or TV specimen extraction.

RESULTS

TR- and TV-NOTES PN was successfully performed in all 10 pigs. A comparison of TR- and TV-NOTES PN revealed no significant differences in the mean access time (29.2 vs 29.6 minutes, P = .944), operative time (196.0 vs 183.0 minutes, P = .631), and estimated blood loss (59.0 vs 54.0 mL, P = .861). Necropsy did not demonstrate abdominal injuries.

CONCLUSION

We have demonstrated proof-of-principle for TR and TV-NOTES PN in swine, with comparable perioperative parameters. Preclinical survival studies are requisite to assess the potential of TR-NOTES as an alternative to TV-NOTES.

Laparo-endoscopic single-site surgery: recent advances in urology

Significant advances have been achieved in the field of urologic laparo-endoscopic single-site surgery (LESS) since the first reported clinical series in 2007. The aim of the present review paper is to summarize and critically analyze the most recent advances in the field of urologic LESS. A literature review was performed using PubMed to retrieve publications related to LESS in urology over the last two years (from January 2011 to May 2012). In the free-text protocol, the following terms were applied: LESS; single port laparoscopy; single incision laparoscopy. Despite unsolved challenges, LESS can be regarded as an emerging trend in minimally invasive urologic surgery and it has significantly evolved, becoming a widely applicable technique in a relatively short time. Outcomes demonstrate that a broad range of procedures can be effectively and safely done, given a solid laparoscopic surgical background and stringent patient-selection criteria. The recent introduction of a purpose-built instrumentation is likely to further foster the application of robotics to LESS. Further improvements are needed before this technique might reach a widespread adoption. Future advances in the field of robotic technology are expected to overcome the current limitations of LESS.