Usefulness of articulating laparoscopic instruments during laparoscopic gastrectomy for gastric adenocarcinoma

Safety and efficacy of flexible articulated instrument (ArtiSential®) in laparoscopic surgery for rectal cancer

BACKGROUND

Laparoscopic surgery for rectal cancer remains challenging because of limited joint motion during dissection in the deep and narrow pelvis. Handheld multiarticulated instruments have been developed to address these limitations. This study aimed to assess the safety and efficacy of a flexible articulated instrument, the ArtiSential® (Livsmed Co, Korea), at reducing the duration of laparoscopic rectal cancer surgery.

STUDY DESIGN

We retrospectively reviewed patients who underwent laparoscopic low or ultralow anterior resection for primary mid to low rectal cancer (tumor distance from anal verge, ≤ 10 cm) performed by a single surgeon in 2012-2022. Patients were divided into groups based on the use of ArtiSential® or straight device, and their clinical characteristics, surgical procedures, pathological findings, postoperative complications, and survival outcomes were analyzed.

RESULTS

The study included 93 patients (articulating group, 32; straight group, 61). Low anterior resection was predominant in both groups, while operative time was significantly shorter in the articulating group (148.08 ± 49.72 vs. 188.13 ± 57.86; p = 0.003). Total mesorectal excision quality and resection margin status did not differ between groups. Postoperative complications, including anastomotic leakage, length of hospital stay, 3-year recurrence-free survival rate (90.6% vs. 88.5%, p = 0.760), and overall survival rate (100% vs. 85.2%, p = 0.092), did not differ between groups.

CONCLUSION

Use of the flexible articulated instrument (ArtiSential®) can reduce operative time without impairing surgical quality or oncologic outcomes. These results suggest that laparoscopic rectal cancer surgery can be performed safely and effectively using a flexible articulated instrument.

CLINICAL TRIAL NUMBER

Not applicable.

A deflectable video camera system for laparoscopic surgery based on shape memory alloy actuators

Laparoscopic instruments are usually not deflectable and therefore have significant usability limitations in minimally invasive surgery. Flexible-tip devices have been introduced, but they are still controlled by manual Bowden cables or conventional motors and are heavy and expensive. An interesting alternative are shape memory alloy (SMA) actuators, because they are lightweight, cost-efficient and offer the potential for a universal actuator platform for laparoscopic and other endoscopic instruments. This paper presents a laparoscopic video camera with electronic deflection control via thumb joystick. Its actuator unit consists of four SMA wires, whose special tensioning mechanism ensures both optimal preload and length compensation. The camera is tiltable in two degrees of freedom, enabled by a laser-cut Nitinol joint. Based on three assembled units and an automated measurement system, the functionality of the camera system was characterised. Deflection angles of more than 178° per degree of freedom were achieved. At operating frequencies of up to 0.5 Hz, the units showed suitable deflection behaviour. Each remained operational for more than 1200 actuation cycles or 4.4 h of continuous operation. Furthermore, the influence of continuous temperature stimulation on characteristic device parameters was investigated. This work contributes to demonstrating the feasibility of SMA actuators for the electrical control of flexible-tip laparoscopic instruments. Temperature control in particular is a challenge for future work.

Integrating minimally invasive bariatric surgery with lessons from gastric cancer surgery

Laparoscopic procedures in bariatric surgery are evolving to enhance cosmetic outcomes and minimize postoperative complications. This study demonstrates the results of bariatric surgery achieved through the application of surgical techniques derived from gastric cancer surgery. Several surgical techniques from gastric cancer surgery were implemented in bariatric surgery, including: (1) V-shaped liver retraction, (2) Reduced port surgery, (3) Intraoperative endoscopy and (4) Multi-degree-of-freedom articulating device. A single surgeon, with experience in over 1000 gastric cancer surgeries, performed consecutive bariatric surgeries starting from the initial case. The study analyzed short-term results, including operation details, postoperative complications, outcomes of weight loss, and the learning curve. A total 94 consecutive laparoscopic sleeve gastrectomy cases were performed from 2019 to 2022. The mean age of 94 patients was 35.9 ± 9.7 years, with 58 (61.7%) being female. The mean body mass index (BMI) was 40.9 ± 6.2. Type 2 diabetes was prevalent in 46.8% of the patients. On average, 3.3 ± 0.5 trocars were used per surgery. The mean estimated blood loss and hospital stay after surgery were 20.1 ± 36.3 cc and 3.3 ± 0.6 days, respectively. There were no complications reported for postoperative leakage, bleeding, or passage disturbance, and no mortality occurred. At 12 months, the mean percentage total weight loss (%TWL) and excess BMI loss (%EBMIL) were 28.5% and 79.7%, respectively. The mean operation times was 109.5 ± 27.4 min, with a plateau observed at around the 30th case. Bariatric surgery can be effectively performed by a gastric cancer expert surgeon using techniques derived from gastric cancer surgery.

ArtiSential® laparoscopic cholecystectomy versus singlefulcrum laparoscopic cholecystectomy: Which minimally invasive surgery is better?

Backgrounds/Aims

In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential® LC with those of single-fulcrum LC.

Methods

This retrospective study compared ArtiSential® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain.

Results

A total of 88 and 63 patients underwent ArtiSential® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01).

Conclusions

ArtiSential® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential® LC is considered the better option for patients, compared to single-fulcrum LC.

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.

Artisential®-assisted pancreatoduodenectomy: a comparative analysis with Robot(Da Vinci®)-assisted pancreatoduodenectomy

BACKGROUND

Robot-assisted pancreaticoduodenectomy (R-PD) helps further improve the safety and efficacy of minimally invasive pancreaticoduodenectomy. However, it faces challenges such as high costs and limitations in availability at different centers, making it difficult for patients to access. In this study, we evaluate the initial experience of Artisential®-assisted PD (A-PD) and compare its perioperative outcomes with R-PD, discussing the clinical applicability of A-PD.

METHODS

This study reviewed cases of R-PD and A-PD conducted between 2022 and 2023. A total of 34 patients underwent R-PD, while 26 patients underwent A-PD. Statistical analysis was conducted based on factors related to the patient's surgical procedure and postoperative prognostic indicators.

RESULTS

There were no significant differences observed between the two groups in terms of surgical factors. There were also no differences in the occurrence of postoperative complications. However, there was a significant difference in the length of hospital stay, with the Artisential® group having an average of 11.50 ± 5.54 days and the Robot group having 15.06 ± 5.34 days (p = 0.001).

CONCLUSIONS

R-PD and A-PD showed no differences in procedures or outcomes. Using a multi-articulated device is beneficial where robot use is challenging.

Myomectomy with ArtiSential fully articulating laparoscopic instruments: A prospective multicenter study

BACKGROUND

ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°-unrestricted movement of the wrist joint, as in robotic surgery.

OBJECTIVE

The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes.

METHODS

A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized.

RESULTS

The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m2; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments.

CONCLUSIONS

Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy.

Commentary: A New Frontier: Exploring Novel Articulating Hand-Held Instruments in Video-Assisted Thoracoscopic Surgery

See Article page 329.

Early Clinical Outcomes of Thoracoscopic Major Pulmonary Resection and Thymectomy Using Novel Articulating Endoscopic Forceps

Background

Video-assisted thoracoscopic surgery (VATS) is recognized as a safe and effective treatment modality for early-stage lung cancer and anterior mediastinal masses. Recently, novel articulating instruments have been developed and introduced to endoscopic surgery. Here, we share our early experiences with VATS major pulmonary resection and thymectomy performed using ArtiSential articulating instruments.

Methods

At the Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 500 patients underwent VATS pulmonary resection between July 2020 and April 2023, while 43 patients underwent VATS thymectomy between January 2020 and April 2023. After exclusion, 224 patients were enrolled for VATS major pulmonary resection, and 38 were enrolled for VATS thymectomy. ArtiSential forceps were utilized in 35 of the 224 patients undergoing pulmonary resection and in 12 of the 38 individuals undergoing thymectomy. Early clinical outcomes were retrospectively analyzed.

Results

No significant differences were observed in sex, age, surgical approach, operation time, histological diagnosis, or additional procedures between the patients who underwent surgery using novel articulating instruments and the group treated with conventional endoscopic instruments for both VATS major pulmonary resection and thymectomy. However, the use of the novel articulating endoscopic forceps was associated with a significantly larger number of dissected lymph nodes (p=0.028) and lower estimated blood loss (p=0.009) in VATS major pulmonary resection.

Conclusion

Major pulmonary resection and thymectomy via VATS using ArtiSential forceps were found to be safe and effective, with early clinical outcomes comparable to established methods. Further research into long-term clinical outcomes and cost-effectiveness is warranted.

Augmenting Veterinary Minimally Invasive Surgery: Evidence-based Review of Foundational and Novel Devices and Technology

Veterinary minimally invasive surgery continues to grow as a specialty. With increasing experience in this field, comes improved accessibility as well as progressive complexity of procedures performed. Advancement in technology has been both a response to the growth and a necessary driver of continued refinement of this field. Innovative research leading to advancements in surgical equipment has led to the development of novel image acquisition platforms, cannulas, smoke evacuation systems, antifog devices, instrumentation, and ligating/hemostatic devices. These innovations will be reviewed and potential clinical applications are discussed.

Perioperative outcomes of laparoscopic low anterior resection using ArtiSential® versus robotic approach in patients with rectal cancer: a propensity score matching analysis

BACKGROUND

Total mesorectal excision using conventional straight fixed devices may be technically difficult because of the narrow and concave pelvis. Several laparoscopic articulating tools have been introduced as an alternative to robotic systems. The aim of this study was to compare perioperative outcomes between laparoscopic low anterior resection using ArtiSential® and robot-assisted surgery for rectal cancer.

METHODS

This retrospective study included 682 patients who underwent laparoscopic or robotic low anterior resection  for rectal cancer from September 2018 to December 2021. Among them, 82 underwent laparoscopic surgery using ArtiSential® (group A) and 201 underwent robotic surgery (group B). A total of 73 [group A; 66.37 ± 11.62; group B 65.79 ± 11.34] patients were selected for each group using a propensity score matching analysis.

RESULTS

There was no significant difference in the baseline characteristics between group A and B. Mean operative time was longer in group B than A (163.5 ± 61.9 vs 250.1 ± 77.6 min, p < 0.001). Mean length of hospital stay was not significantly different between the two groups (6.2 ± 4.7 vs 6.7 ± 6.1 days, p = 0.617). Postoperative complications, reoperation, and readmission within 30 days after surgery were similar between the two groups. Pathological findings revealed that the circumferential resection margins were above 10 mm in both groups (11.00 ± 7.47 vs 10.17 ± 6.25 mm, p = 0.960). At least 12 lymph nodes were sufficiently harvested, with no significant difference in the number harvested between the groups (20.5 ± 9.9 vs 19.7 ± 7.3, p = 0.753).

CONCLUSIONS

Laparoscopic low anterior resection using ArtiSential® can achieve acceptable clinical and oncologic outcomes. ArtiSential®, a multi-joint and articulating device, may serve a feasible alternative approach to robotic surgery in rectal cancer.

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.

Feasibility of articulating laparoscopic instruments in laparoscopic gastrectomy using propensity score matching

Advancements in minimally invasive surgery has led to the development of several surgical instruments, including the ArtiSential®. This new instrument provides a greater range of motion and improved dexterity to laparoscopic procedures, making it an alternative option to traditional straight instruments, and the Da Vinci robot system. The purpose of this study is to compare the postoperative outcomes of a prospective cohort of patients who underwent laparoscopic gastrectomy using articulating instruments with those of a historical cohort of patients who underwent the same procedure using straight instruments. The study was designed as a prospective observational cohort study matched to a retrospective historical cohort using propensity score matching. The primary outcome was the rate of early complications within 90 days of surgery. Other outcomes included the operation time, estimated blood loss, time to first flatus, time to first soft fluid diet, hospital stay, and mortality. After propensity score matching, 41 patients were enrolled in both groups. The mean age was 62.4 ± 12.3 years in the conventional group and 63.5 ± 9.6 years in the artisential group (p = 0.647). Mean operative time was significantly shorter in the artisential group compared to the conventional group (136.1 min vs. 163.9 min, p = 0.032). The time to first soft fluid diet was also significantly shorter in the artisential group (2.2 days vs. 2.8 days, p = 0.030), but there was no significant difference in the time to first flatus and overall hospital stay. The incidence of early complications was lower in the artisential group, but the difference was not significant (24.4% vs 7.3%, p = 0.070). There was no mortality in either group. The use of articulating instruments for laparoscopic gastrectomy did not increase postoperative morbidity compared to straight laparoscopic instruments. The use of articulating instruments may be associated with faster bowel recovery and less early complications.

Initial Experience of Articulating Laparoscopic Instruments for Benign Gynecologic Disease: A Single-Arm Multicenter Prospective Study (Korean Gynecologic Oncology Group 4002)

Laparoscopic surgery has evolved with technological advances in many aspects and increasing demand for its benefits in cosmetics, fast recovery, reduced complication rates and pain. However, it still possesses drawbacks such as limited surgical movement due to the nature of rigid laparoscopic instruments. In order to overcome such limitations, several laparoscopic jointed instruments have been developed. In this prospective multicenter, single-arm cohort study, we investigated the short-term safety and feasibility of the new articulating laparoscopic instruments in benign gynecologic surgery. A total of 113 patients who were diagnosed with benign gynecologic adnexal diseases underwent laparoscopic surgery with articulating laparoscopic instruments. Surgical outcomes, including intra/postoperative complication rates, operation time and estimated blood loss, as well as surgeon's subjective evaluation of the usage of the instruments, were evaluated. The results demonstrated that the articulating laparoscopic instruments had comparable usability and produced similar surgical outcomes to conventional laparoscopic surgery. The objective parameters, such as the operative time and complication rates, as well as the subjective parameters, such as the surgeon's own evaluation of the surgical instruments' usability, demonstrated potential benefits of the instruments in benign gynecological diseases. Overall, the study demonstrated that the use of this novel articulating device is feasible in gynecologic laparoscopic surgery.

Early experience with the ARTISENTIAL® articulated instruments in laparoscopic low anterior resection with TME

Background

The notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL^® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL^®.

Methods

Between September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL^® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed.

Results

Seventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m² (range 23–33 kg/m²). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality.

Conclusions

Low anterior resection with ARTISENTIAL^® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL^® in comparison with standard laparoscopic instruments through a larger study.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02588-y.

Preoperative and intraoperative gastric tumor localization

As the incidence of early gastric cancer increases, gastric tumor localization has become an important issue. Several diagnostic methods have been proposed for preoperative and intraoperative gastric tumor localization. These include endoscopic metal clipping, computed tomographic gastrography, endoscopic tattooing, and intraoperative endoscopy. However, in spite of various methods, tumor localization has its limitations; thus, new diagnostic alternatives need to be developed.

Articulating laparoscopic instruments: are they a breakthrough that can overcome current limitations in laparoscopic gastric cancer surgery?

Laparoscopic surgery is rapidly evolving with technological advances, but there are several drawbacks. An articulating device, with freedom of a perfect 360°, is attractive as a solution to overcome the restriction of instrument movement caused by straight tools. Its usefulness or efficacy should be supported by relevant scientific evidence. However, it is sometimes difficult to prove it because the factors influencing the surgical outcomes are complex and closely related to each other.