Modified robotic lightweight endoscope (ViKY) validation in vivo in a porcine model

Scoping review: autonomous endoscopic navigation

This is a scoping review of artificial intelligence (AI) in flexible endoscopy (FE), encompassing both computer vision (CV) and autonomous actions (AA). While significant progress has been made in AI and FE, particularly in polyp detection and malignancy prediction, resulting in several available market products, these achievements only scratch the surface potential of AI in flexible endoscopy. Many doctors still do not fully grasp that contemporary robotic FE systems, which operate the endoscope through telemanipulation, represent the most basic autonomy level, specifically categorized as level 1. Although these console systems allow remote control, they lack the more sophisticated forms of autonomy. This manuscript aims to review the current examples of AI applications in FE and hopefully act as a stimulus for more advanced AA in FE.

User interfaces for actuated scope maneuvering in surgical systems: a scoping review

BACKGROUND

A variety of human computer interfaces are used by robotic surgical systems to control and actuate camera scopes during minimally invasive surgery. The purpose of this review is to examine the different user interfaces used in both commercial systems and research prototypes.

METHODS

A comprehensive scoping review of scientific literature was conducted using PubMed and IEEE Xplore databases to identify user interfaces used in commercial products and research prototypes of robotic surgical systems and robotic scope holders. Papers related to actuated scopes with human-computer interfaces were included. Several aspects of user interfaces for scope manipulation in commercial and research systems were reviewed.

RESULTS

Scope assistance was classified into robotic surgical systems (for multiple port, single port, and natural orifice) and robotic scope holders (for rigid, articulated, and flexible endoscopes). Benefits and drawbacks of control by different user interfaces such as foot, hand, voice, head, eye, and tool tracking were outlined. In the review, it was observed that hand control, with its familiarity and intuitiveness, is the most used interface in commercially available systems. Control by foot, head tracking, and tool tracking are increasingly used to address limitations, such as interruptions to surgical workflow, caused by using a hand interface.

CONCLUSION

Integrating a combination of different user interfaces for scope manipulation may provide maximum benefit for the surgeons. However, smooth transition between interfaces might pose a challenge while combining controls.

Preliminary design and evaluation of a generic surgical scope adapter

BACKGROUND

Robotic scope assistant systems are used to visualise and navigate the operative field during a laparoscopic surgery. The objective of this work is to design a surgical scope adapter that enables control of different scope types (zero-degree, angulated, and articulated), and can be connected to any six degree-of-freedom robotic manipulator for usage as a robotic scope assistant system.

METHODS

A surgical scope adapter compatible with different camera heads and scope types was designed and prototyped. The technical performance of the scope adapter was evaluated and a user study was conducted to assess the human-in-the-loop control.

RESULTS

All the subjects were able to navigate the simulated operative field. The scope adapter permits continuous motion to explore the operative field as well as intermittent motion to accurately focus on the targeted anatomical landmarks.

CONCLUSION

The modular and generic nature of the surgical scope adapter may enable its usage across different minimally invasive surgeries.

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Surgical assistant manipulator with diagonal joints and multi-stage telescopic screws for laparoscopic solo surgery

PURPOSE

A surgeon in a sterilized area can perform robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot for view stabilization and a forceps robot for pulling organs. At present, no locally operated surgical assistant manipulator with a mechanical remote center of motion (RCM) is available to operate within a small space while providing a wide range of movement. The present study describes a new locally operated detachable end-effector manipulator (LODEM) with diagonal joints and multi-stage telescopic screws.

METHODS

A forceps manipulator attached to commercial surgical forceps was developed. This manipulator uses RCM diagonal joints for the yaw and pitch axes, providing an intuitive pivot point and free rotation, and telescopic nested screws with multiple sliders clamp the commercial forceps for the axis of insertion. The manipulator placed above the abdominal wall using a fixed arm connected to a bed rail is motor controlled by a handheld interface with button switches for precise traction and is controlled manually for easy rough positioning.

RESULTS

Positional accuracy at the tip with a load of 5 N was under 0.5 mm. Mechanical deflection was under 2.1 mm. The manually controlled force was under 4.4 N. Successful simulated laparoscopic cholecystectomy using the prototype manipulator to handle the target and maintain stability was performed on a surgically realistic gallbladder model.

CONCLUSIONS

A LODEM with diagonal joints and multi-stage telescopic screws was developed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a surgeon working near the patient. This electric motor-controlled laparoscopic instrument holder by the surgeon in the surgical field could be used for such applications.

The experience of the minimally invasive (MI) fellowship-trained (FT) hepatic-pancreatic and biliary (HPB) surgeon: could the outcome of MI pancreatoduodenectomy for peri-ampullary tumors be better than open?

BACKGROUND

Although early series focused on benign disease, minimally invasive pancreatoduodenectomy (MIPD) might be particularly suited for malignancy. Unlike their predecessors, fellowship-trained (FT) Hepatic-Pancreatic and Biliary (HPB) surgeons usually have equal skills in approaching peri-ampullary tumors (PT) either openly or via minimally invasive (MI) techniques.

METHOD

We retrospectively reviewed a MI-HPB-FT surgeon's 10-year experience with PD. A sub-analysis of malignant PT was also done (MIPD-PT vs. OPD-PT). The primary endpoint was to assess postoperative mortality and morbidity. Secondary endpoints included operative parameters, length of hospital stay, and survival analysis. Moreover, we addressed practice pattern changes for a surgeon straight out of training with no previous experience of independent surgery.

RESULTS

From December 2007-February 2018, one MI-HPB-FT performed a total of 100 PDs, including 57 MIPDs and 43 open PDs (OPDs). In both groups, over 70% of PDs were undertaken for malignancy. Eight patients with borderline resectable pancreatic ductal cancer (PDC) were in the OPD-PT group (as compared to only 2 in the MIPD-PT group) (p = 0.07). Estimated mean blood loss and length of stay were less in the MIPD-PT group (345 mL and 12 days) as compared to the OPD-PT group (971 mL and 16 days), p < 0.001 and p = 0.007, respectively. However, the mean operative time was longer for the MIPD-PT (456 min) as compared to the OPD-PT (371 min), p < 0.001. Thirty and 90-day mortality was 2.6%/5.1% after MIPD-PT compared to 0%/3.2% after OPD-PT, respectively, p = 1. Overall 30-/90-day morbidity rates were similar at 41.0%/43.6% after MIPD-PT and 35.5%/41.9% after OPD-PT, respectively, p = 0.8 and 1. Complete resection (R0) rates were not statistically different, 97.4% after MIPD-PT compared to 87.0% after OPD-PT (p = 0.2). After MIPD and OPD for malignant PT, overall 1, 3 and 5-year survival rates, and median survival were 82.5%, 59.6% and 46.3% and 38 months as compared to 52.5%, 15.7% and 10.5% and 13 months, respectively (p = 0.01). In the MIDP-PT group, recurrence free survival (RFS) at 1, 3 and 5 years and median RFS were 69.1%, 41.9% and 33.5% and 26 months as compared to 50.4%, 6.3% and 6.3% and 13 months, in the OPD-PT group, respectively (p = 0.03).

CONCLUSION

FT HPB Surgeons who begin their practice with the ability to do both MI and OPD may preferentially approach resectable peri-ampullary tumors minimally invasively. This may result in decreased blood loss decreased length of hospital stays. Despite longer operative time, the improved visualization of MI techniques may enable superior R0 rates when compared to historical open controls. Moreover, combined with quicker initiation of adjuvant chemotherapeutic treatments, this may eventually result in improved survival.

Artificial Intelligence Surgery: How Do We Get to Autonomous Actions in Surgery?

Most surgeons are skeptical as to the feasibility of autonomous actions in surgery. Interestingly, many examples of autonomous actions already exist and have been around for years. Since the beginning of this millennium, the field of artificial intelligence (AI) has grown exponentially with the development of machine learning (ML), deep learning (DL), computer vision (CV) and natural language processing (NLP). All of these facets of AI will be fundamental to the development of more autonomous actions in surgery, unfortunately, only a limited number of surgeons have or seek expertise in this rapidly evolving field. As opposed to AI in medicine, AI surgery (AIS) involves autonomous movements. Fortuitously, as the field of robotics in surgery has improved, more surgeons are becoming interested in technology and the potential of autonomous actions in procedures such as interventional radiology, endoscopy and surgery. The lack of haptics, or the sensation of touch, has hindered the wider adoption of robotics by many surgeons; however, now that the true potential of robotics can be comprehended, the embracing of AI by the surgical community is more important than ever before. Although current complete surgical systems are mainly only examples of tele-manipulation, for surgeons to get to more autonomously functioning robots, haptics is perhaps not the most important aspect. If the goal is for robots to ultimately become more and more independent, perhaps research should not focus on the concept of haptics as it is perceived by humans, and the focus should be on haptics as it is perceived by robots/computers. This article will discuss aspects of ML, DL, CV and NLP as they pertain to the modern practice of surgery, with a focus on current AI issues and advances that will enable us to get to more autonomous actions in surgery. Ultimately, there may be a paradigm shift that needs to occur in the surgical community as more surgeons with expertise in AI may be needed to fully unlock the potential of AIS in a safe, efficacious and timely manner.

Locally operated assistant manipulators with selectable connection system for robotically assisted laparoscopic solo surgery

PURPOSE

By integrating locally operated surgical assistant robots in a sterilized area, a surgeon can perform safe robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot and a forceps robot. At present, there is no leader-follower control system with switchable connection for the leader device in which each assistant follower robot can provide the manipulation intuitively and easily. In the present study, a new locally operated leader-follower selectable control system has been developed.

METHODS

The leader-follower system was developed to connect one leader operating device and one of two selectable follower assistant manipulator devices with different numbers of axes, kinematics models, sensors, and actuators for view stabilization and pulling organs. The system is constructed using the middleware of the ORiN-based medical robot architecture MRLink. The system is regulated by the robot integrator application with unilateral leader-follower PTP using the relative displacement between the leader device and the selected follower device through providers of device interface including the information and control commands.

RESULTS

The execution cycle for updating the position was 50 ms, and the time delay to catch up with the same position was 100 ms. Two assistant manipulators controlled by the leader-follower selectable system could successfully produce the desired view and handle the target organ model for 17 min in a simulated laparoscopic cholecystectomy.

CONCLUSIONS

A locally operated leader-follower selectable control system was constructed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a doctor working near the patient. This system could be used for such applications.

A novel hybrid 3D endoscope zooming and repositioning system: Design and feasibility study

BACKGROUND

Manipulation of the endoscope during minimally invasive surgery is a major source of inconvenience and discomfort. This report elucidates the architecture of a novel one-hand controlled endoscope positioning device and presents a practicability evaluation.

METHODS AND MATERIALS

Setup time and total surgery time, number and duration of the manipulations, side effects of three-dimensional (3D) imaging, and ergonomic complaints were assessed by three surgeons during cadaveric and in vivo porcine trials.

RESULTS

Setup was accomplished in an average (SD) of 230 (120) seconds. The manipulation time was 3.87 (1.77) seconds for angular movements and 0.83 (0.24) seconds for zooming, with an average (SD) of 30.5 (16.3) manipulations per procedure. No side effects of 3D imaging or ergonomic complaints were reported.

CONCLUSIONS

The integration of an active zoom into a passive endoscope holder delivers a convenient synergy between a human and a machine-controlled holding device. It is shown to be safe, simple, and intuitive to use and allows unrestrained autonomic control of the endoscope by the surgeon.

Initial Japanese Experience of Laparoscopic Cholecystectomy Using a New Robot-Assisted System

The object of this paper is to clarify the feasibility and safety of robot-assisted laparoscopic cholecystectomy. Acute or chronic cholecystitis is the most common disease in patients, caused by cholecystolithiasis. Minimally invasive laparoscopic surgery is often performed for treatment of cholelithiasis. We performed robot-assisted laparoscopic cholecystectomy for the treatment of 5 patients with cholecystolithiasis. The patient underwent laparoscopic cholecystectomy using the ViKY Endo-Control System (ViKY, EndoControl, Grenoble, France). The robot-controlled laparoscopic holder was placed at the right axilla. The laparoscopic operation was performed via conventional 4-port access using the ViKY system with voice activation. All patients were treated successfully by this robot-assisted laparoscopic procedure, without any complications. Mean docking time using the ViKY was 16 minutes, mean resection time of the gallbladder was 62.2 minutes, operative time was 94.6 minutes, and the mean amount of the blood loss was minimal. Our initial experience demonstrated that robot-assisted laparoscopy was feasible and safe in patients with cholecystolithiasis, providing patient advantages. We also discuss the advantages and disadvantages of robot-assisted laparoscopic surgery.

Image recognition of triangular tissue of an organ pulled by forceps in surgical working area for laparoscope robot

An image processing method using selected corner points and ridge lines to recognize triangular tissue of an organ pulled by forceps in a laparoscopic view has been developed. The proposed method could be used for semi-automatic control of a laparoscope robot. It makes use of a masking process based on the recognition of the forceps and clots, detection of corner points for a Delaunay diagram, detection of ridge lines oriented in the same direction, and recognition of the triangular working area. Triangles recognized in laparoscopic surgical videos using this method were similar to the correct triangles made by an endoscopic specialist.

Compact forceps manipulator with a spherical-coordinate linear and circular telescopic rail mechanism for endoscopic surgery

PURPOSE

By integrating locally operated small surgical robots in a sterilized area, a surgeon can perform safe and accurate robotically assisted laparoscopic surgery. At present, there is no locally operated compact forceps robot that can operate within a small space while providing a wide working area on the abdominal wall. In the present study, a new spherical-coordinate manipulator with a linear telescopic rail and two circular telescopic rails that can act as a third arm for the surgeon has been developed.

METHODS

A compact locally operated detachable end-effector manipulator (LODEM) was developed. This manipulator uses circular telescopic rails with linkage mechanisms for the yaw and pitch axes, and a linear telescopic rail for the insertion/extraction axis is attached to forceps. The dimensions of the manipulator are [Formula: see text] when contracted and [Formula: see text] when expanded. The positional accuracy, mechanical deflection, and backlash of the prototype were evaluated while performing simulated in vivo laparoscopic surgery.

RESULTS

The positional accuracy, deflection, and backlash of the telescopic rail mechanism were 2.1, 1.8, and 5.1 mm, respectively. The manipulator could successfully handle the target and maintain stability, while the arms of the endoscope specialist were free from collisions with the manipulator during an in vivo laparoscopic surgery.

CONCLUSIONS

A compact LODEM was designed to facilitate minimally invasive, robotically assisted laparoscopic surgery by a doctor working near the patient. This device could be used for such applications.

Concurrent use of a robotic uterine manipulator and a robotic laparoscope holder to achieve assistant-less solo laparoscopy: the double ViKY

Three patients requiring gynecological surgery had uterine manipulation using a VCare(®) controlled by a ViKY(®) at the same time as having a ViKY(®) robotic arm controlling the laparoscope. The setup time for each varied from 6-9 min for the uterine manipulator and 3-5 min for the laparoscope holder. In all cases (one endometriosis and two dermoid cysts) the operative field was good. Two patients were discharged within 24 h of surgery. One patient required an extra day in hospital after she went into acute urinary retention once the catheter was removed. This work demonstrated that assistant-less solo gynecological surgery is feasible using two ViKY robotic arms for both uterine manipulation and laparoscope holding.

200 consecutive laparoscopic pancreatic resections performed with a robotically controlled laparoscope holder

INTRODUCTION

Because of the potential benefit of robotics in pancreatic surgery, we review our experience at two minimally invasive pancreatic surgery centers that utilize a robotically controlled laparoscope holder to see if smaller robots that enable the operating surgeon to maintain contact with the patient may have a role in the treatment of pancreatic disease.

METHODS

From March 1994 to June 2011, a total of 200 laparoscopic pancreatic procedures utilizing a robotically controlled laparoscope holder were performed.

RESULTS

A total of 72 duodenopancreatectomies, 67 distal pancreatectomies, 23 enucleations, 20 pancreatic cyst drainage procedures, 5 necrosectomies, 5 atypical pancreatic resections, 4 total pancreatectomies, and 4 central pancreatectomies were performed. Fourteen patients required conversion to an open approach and eight a hand-assisted one. A total of 24 patients suffered a major complication. Sixteen patients developed a pancreatic leak and 19 patients required reoperation. Major complications occurred in 14 patients and pancreatic leaks occurred in 13 patients. Ten patients required conversion to a lap-assisted or open approach and six patients required reoperation.

CONCLUSIONS

Currently, a robotically assisted approach using a camera holder seems the only way to incorporate some of the benefits of robotics in pancreatic surgery while maintaining haptics and contact with the patient.

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

BACKGROUND

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

METHODS

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

RESULTS

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.

CONCLUSION

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.

Adopting Gayet's Techniques of Totally Laparoscopic Liver Surgery in the United States

Professor Brice Gayet of the Institut Mutualiste Montsouris in Paris, France, has developed totally laparoscopic techniques for all segments of the liver. As a pioneer in the field of minimally invasive hepato-pancreato-biliary surgery, he started a Minimally Invasive Hepato-Pancreato-Biliary Fellowship in 2006. A retrospective review of all hepatic cases performed by a single surgeon since completing this Fellowship was undertaken. From November 2007 to October 2012, a total of 80 liver resections were done, of which 73 were begun with the intention of completing the case laparoscopically. Of these, more than 90% were completed laparoscopically and 88% were for malignant disease. One of the foundations of Professor Gayet's techniques is the low lithotomy or 'French' position and the utilization of a small robotically controlled laparoscope holder that is sterilizeable and considerably more economic than complete surgical systems. Prototypes exist of robotically controlled hand-held laparoscopic instruments that, unlike the complete surgical system, enable surgeons to maintain a sense of touch (haptics). Proper training in minimally invasive hepato-pancreato-biliary techniques can be obtained with surgeons able to independently perform laparoscopic major hepatectomies without senior minimally invasive backup. Furthermore, miniature and more affordable robotics may enable more surgeons to enjoy the benefits of minimally invasive surgery while maintaining patient safety and minimizing the rising burden of health-care costs worldwide.

Initial experience with laparoscopic hepatic resection at a comprehensive cancer center

BACKGROUND

Over the past few years, surgeons have been able to obtain training in advanced minimally invasive surgery (MIS) for hepatic, pancreatic, and biliary (HPB) cases instead of having to teach themselves these complex techniques. As a result, the initial experience of a surgeon with advanced MIS HPB training at a national cancer center was reviewed.

METHODS

The experience of a surgeon with the first 50 laparoscopic hepatectomies for cancer was reviewed retrospectively. All cases begun with the intention to complete the hepatectomy laparoscopically were included in the laparoscopic group.

RESULTS

From November 2008 to October 2010, a total of 57 hepatectomies were performed, with 53 attempted laparoscopically. Of these 57 hepatectomies, 46 (87%) were completed laparoscopically, 4 (7%) required hand assistance, and 3 (6%) were converted to an open approach. Laparoscopic minor hepatectomies were performed for 28 patients and laparoscopic major hepatectomies for 25 patients. The mean operative time was 265 min, and the mean estimated blood loss was 300 ml. The mean hospital stay was 7 days. Complications occurred for six patients (11%) (2 bile leaks, 2 hemorrhages requiring conversion, 1 hernia requiring a hernia repair on postoperative day 7, and 1 ileus managed nonoperatively).

CONCLUSIONS

Surgeons with advanced MIS HPB training may be able to perform a higher percentage of their hepatectomies laparoscopically. Training in both open and laparoscopic HPB surgery is advisable before these techniques are performed.

Kinematic design considerations for minimally invasive surgical robots: an overview

BACKGROUND

Kinematic design is a predominant phase in the design of robotic manipulators for minimally invasive surgery (MIS). However, an extensive overview of the kinematic design issues for MIS robots is not yet available to both mechanisms and robotics communities.

METHODS

Hundreds of archival reports and articles on robotic systems for MIS are reviewed and studied. In particular, the kinematic design considerations and mechanism development described in the literature for existing robots are focused on.

RESULTS

The general kinematic design goals, design requirements, and design preferences for MIS robots are defined. An MIS-specialized mechanism, namely the remote center-of-motion (RCM) mechanism, is revisited and studied. Accordingly, based on the RCM mechanism types, a classification for MIS robots is provided. A comparison between eight different RCM types is given. Finally, several open challenges for the kinematic design of MIS robotic manipulators are discussed.

CONCLUSIONS

This work provides a detailed survey of the kinematic design of MIS robots, addresses the research opportunity in MIS robots for kinematicians, and clarifies the kinematic point of view to MIS robots as a reference for the medical community.

Video: laparoscopic right hepatectomy and partial resection of the diaphragm for liver metastases

BACKGROUND

Indications for minimally invasive major hepatectomies have been increasing as experience with these techniques grows. Invasion into the diaphragm is considered a contraindication to the laparoscopic approach. At their institution, the authors have begun approaching all tumors laparoscopically. This report presents the techniques necessary to perform right hepatectomy, partial diaphragm resection, and repair using totally laparoscopic techniques.

METHODS

Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. The hepatic inflow is taken extraparenchymally before transection of the hepatic parenchyma in an anterior-to-posterior fashion. The hepatic inflow then is transected, and the involved portion of diaphragm is transected with ultrasonic shears. Next, the diaphragm is repaired primarily and buttressed with an absorbable material to decrease the incidence of recurrent diaphragmatic hernia.

RESULTS

Laparoscopic treatment was attempted for ten patients and successfully completed for nine of these patients (90%). All 10 patients had secondary liver tumors. Three patients required concomitant partial diaphragm resection. The median estimated blood loss (EBL) was 500 ml (range, 300-3,000 ml). All margins were negative, and the average hospital stay was 8 days (range, 5-17 days). Two patients (20%) experienced complications, which consisted of biliary leaks, which were treated with percutaneous drainage. One of these patients underwent conversion to an open procedure due to an inferior vena cava injury. No mortality occurred at 30 or 90 days of follow-up evaluation.

CONCLUSION

The minimally invasive approach to secondary tumors requiring right hepatectomy is feasible and safe even when there is diaphragmatic involvement. Larger series with long-term follow-up evaluation are needed to determine whether these short-term results translate into durable benefits.

Laparoscopic pancreatoduodenectomy: a review of 285 published cases

BACKGROUND

Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed.

METHODS

All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins.

RESULTS

Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease.

CONCLUSIONS

This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Totally transumbilical laparoscopic cholecystectomy

A recently convened Consortium at the Cleveland Clinic agreed on the term Laparo-Endoscopic Single-Site (LESS) surgery to describe minimally invasive techniques that use a single incision to accomplish laparoscopic procedures. These procedures are done by using either a single port through one fascial incision or multiple ports placed through separate fascial incisions. Because of cost containment issues and the lack of widespread availability of a single port, we currently use multiple reusable ports placed through three separate fascial incisions via a transumbilical incision. As opposed to standard laparoscopic cholecystectomy, a deflecting laparoscope and one articulating instrument are utilized to improve the safety and ease of this procedure. Presented in this video are the steps necessary to perform a LESS cholecystectomy via a transumbilical incision with commercially available instruments.

Laparoscopic liver resection: when to use the laparoscopic stapler device

Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.