Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery

A review of wrist mechanism design and the application in gastrointestinal minimally invasive surgery of multi-degree-of-freedom surgical laparoscopic instruments

BACKGROUND

This paper aims to comprehensively review current designs of Multi-degree-of-freedom (Multi-DOF) wrist mechanisms and the applications of Multi-DOF surgical instruments in gastrointestinal minimally invasive surgery (MIS).

METHODS

By reviewing the advantages and limitations of traditional laparoscopic and robotic surgical instruments, we present the development of Multi-DOF surgical instruments. Then, we summarize the Multi-DOF wrist mechanisms, delineating their pros and cons. Finally, the surgical outcomes and efficiency of Multi-DOF surgical instruments are reviewed.

RESULTS

The utilization of Multi-DOF surgical instruments for both benign and malignant gastrointestinal diseases demonstrates perioperative outcomes comparable to traditional laparoscopic and robotic surgeries. In certain aspects, it exhibits advantages such as shorter operative times and faster gastrointestinal function recovery.

CONCLUSION

Further research is needed to effectively combine these driving mechanisms to achieve a new type of transmission mechanism with high rigidity and precision, ample working space, and decoupled degrees of freedom. Multi-DOF surgical instruments offer the advantages of high flexibility and lower costs, displaying good feasibility and safety in practical clinical applications within gastrointestinal surgery. Their promotion in primary care hospitals could benefit a larger patient population. However, more extensive sample-sized multicenter studies are still warranted to elucidate such surgical instruments' advantages further.

Comparison of surgical performance using articulated (ArtiSential®) and conventional instruments for colorectal laparoscopic surgery: A single-centre, open, before-and-after, prospective study

AIM

Rigid surgical instruments limit movement whereas articulated instruments offer better control in small spaces and allow for intuitive and ergonomic movements. However, the effectiveness of the use of articulated instruments in improving colorectal laparoscopic outcomes remains unclear. The aim of this work was to determine whether colorectal laparoscopic surgical proficiency improved when multijoint instruments were used instead of conventional ones.

METHOD

We enrolled 70 consecutive patients (n = 20 for conventional instruments) aged 19-80 years who underwent elective laparoscopic surgery for colorectal diseases. Unedited surgery videos were validated using the modified Global Operative Assessment of Laparoscopic Skills (mGOALS) scale. Learning curves were analysed using a cumulative sum control chart for mGOALS grades.

RESULTS

The surgery type, length of hospital stay and 30-day postoperative complication rates were comparable between the groups, and the surgeon's mGOALS grades were similar (p = 0.190). However, in the articulated group, the scores were significantly higher for depth perception (p = 0.012) and tissue-handling domains (p = 0.046), while surgical duration was significantly shorter and intraoperative blood loss was significantly lower (p = 0.022), compared with those in the conventional (p = 0.002) group. Learning curve findings indicated that the first 10 and subsequent 40 surgeries in the articulated group were within the inexperienced and experienced phases, respectively. The mGOALS score in the experienced phase improved in the articulated group compared with that in the conventional group (p = 0.036).

CONCLUSIONS

The use of articulated instruments in laparoscopic colorectal surgery showed potential benefits. Further studies are needed to confirm these findings.

Initial Application of Fluorescence Imaging for Intraoperative Localization of Small Neuroendocrine Tumors in the Pancreas: Case Report and Review of the Literature

BACKGROUND

Indocyanine green is commonly used for laparoscopic hepatectomy but remains uncommon in pancreatic surgery. Given the increasing number of small neuroendocrine tumors found in the pancreas and the heavy reliance on laparoscopic ultrasound for intraoperative localization, we attempted to use indocyanine green for these tumors. Our results show good localization and have the potential to provide a valuable clinical aid.

CASE PRESENTATION

This case report details five patients with preoperative diagnosis of pancreatic neuroendocrine tumors of small endocrine tumors, intraoperative successful localization, and successful completion of laparoscopic partial resection of pancreatic tumors by indocyanine green fluorescence staining; none of the patients experienced serious complications after surgery and were discharged from the hospital, and routine pathology confirmed that four cases were pancreatic neuroendocrine tumors of G1 stage, and one case was pancreatic neuroendocrine cell hyperplasia.

CONCLUSION

Fluorescence imaging technology safely aids in the intraoperative localization of small pancreatic neuroendocrine tumors.

Clinical applications of handheld robotic devices in general surgery: A mini-review

Laparoscopy has evolved the surgical field around the world. Although this has defined minimally invasive surgery, there are limitations. Lack of articulating instrument tips restricts their use in difficult cases. Ergonomic challenges risk occupational injury. Although there is now an increasing use of robotics, these platforms have significant costs. Articulating laparoscopic instruments, termed handheld robotic devices, pose a potential solution to this problem. We aimed to perform a mini-review the clinical applications of handheld robotic devices in general surgery. A limited literature search of the MEDLINE, EMBASE, and Cochrane databases were performed to identify handheld robotic devices with clinical trial data. Primary outcomes were operative time, complication rate, and conversion to laparoscopy or open surgery. Three devices were identified. Noninferiority was demonstrated with respect to laparoscopic instruments in terms of operative time and postoperative complications. This is despite the devices being in their relative infancy with learning curves. Subgroup analysis in a comparative trial with robotics for inguinal hernia repair revealed no significant difference in operative duration during unilateral flap closure. There were no cases requiring conversion. The need for cost-effective robotic devices is clear. Handheld robotic devices have been engineered to provide articulating instrument tips while using existing laparoscopic equipment. They have been demonstrated to be safe and effective. The amalgamation of precision-enhancing robotic instruments with the fiscal advantages of laparoscopic tools has the potential to fundamentally alter the field of minimally invasive surgery.

Literature Review of Handheld Articulating Instruments in Minimally Invasive Surgery

Background: Minimally invasive surgery (MIS) using handheld articulating instruments (HAIs) has emerged as an innovative approach, offering enhanced dexterity and accessibility compared with conventional straight tools. There has been a significant surge in market interest surrounding HAIs. However, the question about the potential benefits of these devices for surgeons and patients in clinical applications remains unclear. Methods: We thoroughly searched relevant literature about the HAIs with clinical applications. This article reviews the feasibility, safety, outcomes, ergonomics, and learning curve associated with utilizing HAIs, including notable commercial products FlexDex, ArtiSential, and HandX. This study also investigates the comparisons of the use of HAIs with traditional laparoscopy and the da Vinci robotic system in terms of surgical outcomes and operational efficiency. Results: Early clinical studies demonstrate the applicability of HAIs across gastrointestinal, urologic, cardiothoracic, and general surgery, with promising results and few complications reported. Comparisons with conventional laparoscopy reveal no significant differences in surgical outcomes. However, HAIs present a more prolonged learning curve than robotic surgery for novice users. Combining three-dimensional visualization techniques facilitate performance. Further research with larger sample sizes is warranted to establish definitive superiority in surgical efficiency and characterize optimal training methodology. Conclusions: Overall, the maneuverability and lower cost of HAIs present new possibilities in MIS, potentially expanding accessibility for smaller health care organizations and benefiting more patients.

Can a Fully Articulating Electromechanical Laparoscopic Needle Driver Compare with a Robotic Platform in Transabdominal Preperitoneal Inguinal Hernia Repair?

Background: Enhanced laparoscopic instruments are filling the gap between straight-stick laparoscopic equipment and robotic platforms. We sought to evaluate the performance and cost of the HandX™ device during mesh fixation and peritoneal flap closure of transabdominal preperitoneal (TAPP) inguinal hernia repairs. Methods: The video recordings of a consecutive series of TAPP surgeries using the articulated needle driver device were compared with a series of surgeries on the DaVinci robotic platform by a single surgeon. Two critical steps of the procedure were analyzed: mesh fixation and peritoneal closure. A cost analysis between the two platforms was completed. Results: We analyzed 27 cases using the new needle driver and 27 cases using the DaVinci Surgical Robotic system. To evaluate the learning curve (LC) with the HandX device, we created three groups (G1, G2, and G3). The two latter groups were combined and called after LC. Mean fixation time using the DaVinci system was 258.1 seconds (±100.4) compared with 391.5 (±95.9) using the articulating handheld laparoscopic needle driver after LC (P < .001). The average time for peritoneal closure was 418.6 (±192.1) seconds for DaVinci and 634.5 (±159.5) seconds for HandX (P < .001). When comparing the after-LC HandX cases and the DaVinci system stratified by side, there was no significant difference in peritoneal closure in the right side (520.1 seconds (84.3) with the HandX versus 444.2 seconds (229.7) using the DaVinci system (P = .353). When evaluating direct cost of the instruments, HandX cases had a lower cost (310 USD) when compared with the cost of using DaVinci (973 USD). Conclusions: The new smart articulating needle driver may be a cost-effective means of bringing some of the benefits of the robotic platform to laparoscopy.