[Reduced port surgery : Developing a safe pathway to single port access surgery]

Development of a human machine interface for robotically assisted surgery optimized for laparoscopic workflows

INTRODUCTION

In robotic-assisted surgery (RAS), the input device is the primary site for the flow of information between the user and the robot. Most RAS systems remove the surgeon's console from the sterile surgical site. Beneficial for performing lengthy procedures with complex systems, this ultimately lacks the flexibility that comes with the surgeon being able to remain at the sterile site.

METHODS

A prototype of an input device for RAS is constructed. The focus lies on intuitive control for surgeons and a seamless integration into the surgical workflow within the sterile environment. The kinematic design is translated from the kinematics of laparoscopic surgery. The input device uses three degrees of freedom from a flexible instrument as input. The prototype's performance is compared to that of a commercially available device in an evaluation. Metrics are used to evaluate the surgeons' performance with the respective input device in a virtual environment implemented for the evaluation.

RESULTS

The evaluation of the two input devices shows statistically significant differences in the performance metrics. With the proposed prototype, the surgeons perform the tasks faster, more precisely, and with fewer errors.

CONCLUSION

The prototype is an efficient and intuitive input device for surgeons with laparoscopic experience. The placement in the sterile working area allows for seamless integration into the surgical workflow and can potentially enable new robotic approaches.

[Clinical value of alternative technologies to standard laparoscopic cholecystectomy - single port, reduced port, robotics, NOTES]

Surgical interventions should ideally treat an existing disease curatively and achieve this with a low complication rate and minimal trauma. In this sense, laparoscopic cholecystectomy has become established as the recognized standard for the treatment of cholecystolithiasis. Newer procedures, such as single-port surgery or natural orifice transluminal endoscopic surgery (NOTES) have recently emerged to reduce the already low interventional trauma even further and to provide a better cosmetic outcome. With all new methods the main aim is the reduction of the transabdominal access points. Based on published results and diagnosis-related groups (DRG) data, this article examines whether this goal has been achieved, also with respect to the overall quality of treatment and the complication rates. In this context and in addition to the already mentioned approaches, robotic cholecystectomy and the reduced port approach are also considered.

Evaluation of hands-on seminar for reduced port surgery using fresh porcine cadaver model

BACKGROUND

The use of various biological and non-biological simulators is playing an important role in training modern surgeons with laparoscopic skills. However, there have been few reports of the use of a fresh porcine cadaver model for training in laparoscopic surgical skills. The purpose of this study was to report on a surgical training seminar on reduced port surgery using a fresh cadaver porcine model and to assess its feasibility and efficacy.

MATERIALS AND METHODS

The hands-on seminar had 10 fresh porcine cadaver models and two dry boxes. Each table was provided with a unique access port and devices used in reduced port surgery. Each group of 2 surgeons spent 30 min at each station, performing different tasks assisted by the instructor. The questionnaire survey was done immediately after the seminar and 8 months after the seminar.

RESULTS

All the tasks were completed as planned. Both instructors and participants were highly satisfied with the seminar. There was a concern about the time allocated for the seminar. In the post-seminar survey, the participants felt that the number of reduced port surgeries performed by them had increased.

CONCLUSION

The fresh cadaver porcine model requires no special animal facility and can be used for training in laparoscopic procedures.

Reduced port laparoscopic gastrectomy for gastric cancer

The use of reduced port laparoscopic surgery (RPS) has become increasingly popular. The concept of RPS includes all procedures derived from various efforts minimizing the invasiveness of surgery, with single-incision laparoscopic surgery (SILS) being the ultimate reduced port technique. Reduced-port laparoscopic gastrectomy (RPLG) for gastric cancer has not yet been fully established and still has issues such as feasibility, oncological validity, training, and education. The short-term results of reported studies are acceptable. However, long-term results that verify positive results or radical cure even in cases of cancer have not yet been published. Patients for whom RPLG is indicated should be selected carefully. Prospective multicenter studies should be conducted to establish RPS as a truly evidence-based practice that addresses not only cosmesis but also the appropriate balance between minimal invasiveness and radical cure.

Impact of single-incision laparoscopic cholecystectomy (SILC) versus conventional laparoscopic cholecystectomy (CLC) procedures on surgeon stress and workload: a randomized controlled trial

INTRODUCTION

Single-incision laparoscopic cholecystectomy (SILC) may lead to higher patient satisfaction; however, SILC may expose the surgeon to increased workload. The goal of this study was to compare surgeon stress and workload between SILC and conventional laparoscopic cholecystectomy (CLC).

METHODS

During a double-blind randomized controlled trial comparing patient outcomes for SILC versus CLC (NCT0148943), surgeon workload was assessed by four measures: surgery task load index questionnaire (Surg-TLX), maximum heart rate, salivary cortisol level, and instruments usability survey. The maximum heart rate and salivary cortisol levels were sampled from the surgeon before the random assignment of the surgical procedure, intraoperatively after the cystic duct was clipped, and at skin closure. After each procedure, the surgeon completed the Surg-TLX and an instrument usability survey. Student's t tests, Wilcoxon rank sum test, and Kruskal-Wallis nonparametric ANOVAs on the dependent variables by the technique (SILC vs. CLC) were performed with α = 0.05.

RESULTS

Twenty-three SILC and 25 CLC procedures were included in the intent-to-treat analysis. No significant differences were observed between SILC and CLC for patient demographics and procedure duration. SILC had significantly higher post-surgery surgeon maximum heart rates than CLC (p < 0.05). SILC also had significantly higher mean change in the maximum heart rate between during and post-procedure (p < 0.05) than CLC. Salivary cortisol level was significantly higher during SILC than CLC (p < 0.01). Awkward manipulation of the instruments and limited fine motions were reported significantly more frequently with SILC than CLC (p < 0.01). In the surgeon-reported Surg-TLX, subscale of physical demand was significantly more demanding for SILC than CLC (p < 0.05).

CONCLUSIONS

Surgeon heart rate, salivary cortisol level, instrument usability, and Surg-TLX ratings indicate that SILC is significantly more stressful and physically demanding than the CLC. Surgeon stress and workload may impact patients' outcomes; thus, ergonomic improvement on SILC is necessary.

Reduced port laparoscopic gastrectomy: a review, techniques, and perspective

Reduced port laparoscopic surgery has been used increasingly. It is a concept that has grown out of the various efforts aimed at minimally invasive surgery, with SILS being the ultimate reduced port technique. Reduced port laparoscopic surgery has been used to perform sleeve gastrectomy in bariatric surgery and excision of benign gastric submucosal tumor, applications that generally do not require lymph node dissection or complicated reconstruction. It can be done safely, result in a permanent cure, and offer good cosmetic outcomes. Reduced port laparoscopic surgery for gastric cancer has a short history, and its usefulness has not yet been fully established. This review describes the present situation and challenges faced as well as standardized procedures and the future prospects of reduced port laparoscopic gastrectomy for gastric cancer, which my team performs almost daily. These aspects of reduced port laparoscopic surgery are presented in light of the literature.

Laparoscopic spleen-preserving resection of the pancreatic body and tail via the left anterior pararenal approach

AIM: To investigate the safety and efficacy of laparoscopic spleen preserving pancreatic resection via the left anterior pararenal approach.

METHODS: Clinical data for 40 patients who underwent spleen-preserving resection of the pancreatic body and tail from January 2012 to December 2013 at Nanyang Central Hospital were analyzed retrospectively.

RESULTS: The surgery was successful in all the 40 patients, and there was no conversion to open surgery. The operative time was 57.1 min ± 14.6 min. Intraoperative blood loss was 82.4 mL ± 23.5 mL. Hospital stay was 7.1 d ± 0.4 d. After surgery, no bleeding, splenic infarction, pancreatic leakage, intra-abdominal infections or other complications occurred. Blood sugar returned to normal after surgery. Follow-up time was 8.4 mo ± 2.1 mo, and blood and kidney function, blood sugar and abdominal B ultrasound findings were all normal during the follow-up period. No recurrence occurred.

CONCLUSION: Laparoscopic spleen-preserving resection of the pancreatic body and tail via the left anterior pararenal approach is feasible and associated with fast postoperative recovery and few complications.

Single-port cholecystectomy versus multi-port cholecystectomy: a prospective cohort study with 222 patients

BACKGROUND

The aim of this study was to compare single-port access cholecystectomy (SPA) with the standard laparoscopic technique (LC) regarding the duration of the operation, complications, learning curve, late postoperative quality of life (QoL) and the incidence of incisional hernias.

METHODS

Between June 2009 and December 2011, a total of 122 SPA cholecystectomies were performed in our hospital. Simultaneously, 310 patients were operated on with the LC technique. In the LC group, 100 patients met the same criteria defined for SPA surgery. The two groups (SPA and LC) were compared by multivariable regression analysis. Endpoints of this study were quality of life (QoL) after 6 months by the EQ-5D questionnaire 5L and the incidence of incisional hernia 1 year after surgery. Operating time, hospital stay, and perioperative complications were also measured and compared. The median follow-up was 9.2 months (3-25 months).

RESULTS

The patients in the SPA group were younger and more often female. The mean operating time for group SPA was 73 min (35-136 min)-significantly longer than that for group LC with 60 min (33-190 min) (p < 0.001). Additional trocars were used in 8 of 122 (6.5 %) SPA patients. A conversion to open cholecystectomy was not necessary in SPA patients. The conversion rate in the LC group to open cholecystectomy was 2 % (2/100). The perioperative and postoperative complications and incisional hernia (5.5 %) were the same in both groups. QoL was significantly better in the SPA group in terms of mobility (p = 0,002), usual activity (p = 0.036), and overall anxiety (p = 0.026).

CONCLUSIONS

SPA cholecystectomy is safe, although the operation is significantly longer. No differences in terms of major complications or the incidence of incisional hernia were seen after 1 year. QoL was significantly better in patients operated on with the SPA technique.