Completely transvaginal NOTES cholecystectomy using magnetically anchored instruments

Magnetic anchor technique-assisted thoracoscopic lobectomy in beagles

In single-port thoracoscopic lobectomy, surgical instruments are likely to collide and interfere with each other. We used magnetic anchor technique to design an anchoring device suitable for thoracoscopic surgery, and verified the safety and feasibility of its use in animal experiments. Ten Beagles were used as models, and magnetic anchor technology was used to assist thoracoscopic lobectomy. During the operation, a self-designed magnetic anchored internal grasper was used in place of the traditional laparoscopic grasping forceps. The operation time, intraoperative blood loss, incidence of postoperative complications, and the effect of intraoperative use of the device were analyzed. All 10 beagles were successfully operated; the mean operation time was 19.7 ± 3.53 min (range 15-26 min), and the postoperative blood loss was < 10 mL. No surgical complications occurred. During the operation, the internal grasper was firmly clamped, the auxiliary operation field was well exposed, and the interference of the main operation hole instruments was effectively reduced. We provide preliminary experimental evidence of the safety and feasibility of magnetic anchor technique-assisted thoracoscopic lobectomy.

Gasless single-port laparoscopic cholecystectomy

PURPOSE

Single-port laparoscopic surgery is anticipated to become the future of minimally invasive surgery. We have devised an alternative approach for laparoscopic cholecystectomy by inserting a single port at the umbilicus and using the abdominal wall-lifting method, without establishing pneumoperitoneum.

METHODS

Retrospective analysis of 130 patients undergoing laparoscopic cholecystectomy was done to compare the conventional laparoscopic cholecystectomy (CLC) (n = 69) and the novel single-port laparoscopic cholecystectomy (SLC) using the abdominal wall-lifting method (n = 61). The surgical procedures were as follows. A 2- to 3-cm transumbilical incision was made, and a wound retractor was inserted into the abdomen without difficulty. Abdominal distension was obtained using a fan-shaped retractor without the use of carbon dioxide insufflations. A 5-mm flexible scope and modified curved graspers and dissectors were used to give the feeling of triangulation during dissection.

RESULTS

The SLC group consisted of 25 males and 36 females with a mean age of 58.1 ± 7.2 years and a mean body mass index of 23.1 ± 3.2 kg/m². The two groups were comparable for mean age, sex, disease, American Society of Anesthesiologists physical status classification, and comorbidity. Likewise, the duration of operation, postoperative hospital stays, complications, the number of use of analgesics, and conversion rate to open technique were not significantly different in the two groups.

CONCLUSION

The impaired view in single-port laparoscopic surgery can be improved by using articulating instruments that can be rotated out of the field of view. This novel gasless method is cost-effective and produces minimal postoperative discomfort with no additional scars.

Physical Bases, Indications, and Results of the Use of Magnets in Digestive Surgery: A Narrative Review

Background: The use of magnetic devices in digestive surgery has been a matter of debate in recent years. The aim of this review was to describe the physical bases, indications, and results of the use of magnets in digestive surgery. Methods: A review of the literature was performed using Scopus, PubMed, ScienceDirect, and SciELO databases considering as inclusion criteria all articles published since 2007 to date, describing the physical basis of magnetic assisted surgery and those that describe the surgical procedure, including case reports, as well as, articles on humans and experimental animals. Results: Sixty-four studies were included, 15 detailing aspects on the physical basis and 49 about indications and results. Magnets are currently used to perform fixed traction, mobilizing structures, and anastomosis in humans and experimental animals. Conclusions: The use of magnets in digestive surgery has shown good results, and no complications arising from their use have been reported. However, more prospective and randomized studies that compare magnetic surgery and conventional techniques are needed.

Magnetic-Assisted Robotic and Laparoscopic Renal Surgery: Initial Clinical Experience with the Levita Magnetic Surgical System

Introduction: The Levita™ Magnetic Surgical System (LMSS) is a new device that can provide retraction using magnets and can reduce the number of ports used during laparoscopic and robotic procedure. It is U.S. Food and Drug Administration (FDA) approved for laparoscopic cholecystectomy, bariatric operation, and robotic radical prostatectomy. Our objective was to evaluate the safety and feasibility of the magnetic surgical system during renal procedure. Methods: We performed a prospective, single-center, single-arm, open-label study to assess the safety and performance of the LMSS. The system includes a deployable, single-use magnetic grasper and a reusable external magnet. Selected patients undergoing either laparoscopic or robotic renal procedure from April 2019 to August 2019 were included. Robotic procedures were performed with the da Vinci Xi or single-port (SP) surgical platforms. Preoperative demographic, intraoperative data, and postoperative data were collected and analyzed. Results: Ten procedures were performed using the LMSS. Cases included Xi robotic partial nephrectomy (n = 3), Xi robotic radical nephrectomy (n = 2), SP robotic partial nephrectomy (n = 2), SP robotic pyeloplasty (n = 1), laparoscopic donor nephrectomy (n = 1), and laparoscopic radical nephrectomy (n = 1). No cases required conversion to an open procedure. Issues included one small liver capsular tear from the device jaws necessitating fulguration and occasional robotic "recoverable fault" errors when the external magnet was placed too close to the robotic arms. All patients were discharged home on postoperative day 1 or 2, and there were no readmissions within 30 days. Conclusions: This is the first report on the use of the LMSS for renal procedure. Its use for laparoscopic and robotic renal procedure appears safe and feasible. The grasper is especially useful for exposing the renal hilum during dissection and the ureteropelvic junction during SP robotic procedures, mimicking multiport techniques. Further study is required to optimize use of the LMSS and evaluate its cost effectiveness.

Endoscopic applications of magnets for the treatment of gastrointestinal diseases

Endoscopic treatment of gastrointestinal diseases has developed rapidly in recent years, due to its minimally invasive nature. One of the main contributing factors for this progress is the improvement of endoscopic instruments, which are essential for facilitating safe and effective endoscopic interventions. However, the slow learning curve required in the implementation of many advanced endoscopic procedures using standard devices is associated with a high risk of complications. Other routine procedures may also be complicated by unexpected difficulties. Based on the ferromagnetic properties of many objects, both internal and external magnetic devices have been developed and applied for multiple endoscopic interventions. The applications of magnets, mainly including compression, anchoring and traction, facilitate many difficult procedures and make it feasible to operate procedures that were previously impossible. Other novel endoscopic applications, such as magnetic nanoparticles, are also under development. In this article, we reviewed published studies of endoscopic applications of magnets for the treatment of gastrointestinal diseases such as precancerous lesions and cancer, obstruction, stricture, congenital and acquired malformations, motility disorders, and ingestion of foreign bodies. Since several endoscopic applications of magnets may also be relevant to surgery, we included them in this review.

Magnet-Assisted Robotic Prostatectomy Using the da Vinci SP Robot: An Initial Case Series

Introduction: Tissue retraction during minimally invasive surgery has been achieved to date with patient positioning or additional instrumentation. The Levita™ Magnetic Surgical System (San Mateo, CA), a novel, noninvasive, magnetic retraction device for minimally invasive surgery, has been used to facilitate reduced-port robotic prostatectomy using a multiport robotic platform. With the release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA), we now report a multi-institutional initial case series of magnet-assisted robotic prostatectomy using the single-port robotic platform. Materials and Methods: An IRB-approved, retrospective chart review was performed of all patients undergoing robot-assisted radical prostatectomy using the da Vinci SP surgical system and a single Levita magnetic retractor in treatment of prostatic adenocarcinoma at two institutions from November 2018 to January 2019. Preoperative, intraoperative, and postoperative data were collected for descriptive analysis. Results: A total of 15 men, median age 62 years (range 57-71), with mean PSA 7.0 ± 2.3 underwent surgery. The robotic cannula and a single 12-mm assistant port were utilized in all cases, the latter for suction, suture passage, and clip placement; the magnetic retractor aided with posterior dissection, dorsal venous complex stitch placement, bladder neck dissection, and lymphadenectomy. No cases required conversion to a multiport robotic platform, laparoscopy, or open surgery, nor placement of additional assistant ports. No intraoperative or postoperative complications occurred. Average operative time was 224 ± 43 minutes and blood loss was 198 ± 115 mL. All patients were discharged home within 2 days of surgery. Conclusions: Robotic prostatectomy utilizing the da Vinci SP system is feasible, safe, and effective. Use of the magnetic retractor facilitates tissue exposure and improves procedure ergonomics, mimicking the conventional multiport technique. Further exploration of magnet utilization in robotic surgery and optimization of assistant port placement for true single-site surgery is warranted.

Single-Center Experience with Magnetic Retraction in Colorectal Surgery

Background: Appropriate tissue retraction is essential in laparoscopic surgery, and colorectal operations often require an additional incision and trocar that can disturb visualization and maneuverability. Each incision carries an increased risk for complications as well as increased pain and cosmetic issues. Magnetic devices have been developed for a less invasive retraction. The objective of this study is to report our initial experience using magnet retraction. Methods: Ten consecutive patients who underwent laparoscopic colorectal procedures by a single surgeon using a magnetic retractor (Levita Magnetics^® Surgical System, San Mateo, CA) between October 2017 and June 2018 at Duke Regional Hospital in Durham, NC, were included. Results: The cases included four single-port right colectomies, one sigmoidectomy, and five rectopexies. Nine cases were completed laparoscopically, as one right colectomy required conversion due to adhesions and bulky specimen. Indications included adenocarcinoma, diverticular disease, and rectal prolapse. The magnet was successfully used for uterus, colon, or colonic pedicle retraction. No intraoperative or 30-day complications were observed. Conclusion: Magnetic surgical retractors are a safe, dynamic, and incision-less option for surgical field exposure during laparoscopic colorectal surgery. Reduced trocars decrease tissue trauma, enhances maneuverability, and potentially improves outcomes; however, further studies are required.

Use of magnets in gastrointestinal surgery

BACKGROUND

Laparoscopic and endoscopic surgery has undergone vast progress during the last 2 decades, translating into improved patient outcomes. A prime example of this development is the use of magnetic devices in gastrointestinal surgery. Magnetic devices have been developed and implemented for both laparoscopic and endoscopic surgery, providing alternatives for retraction, anchoring, and compression among other critical surgical steps. The purpose of this review is to explore the use of magnetic devices in gastrointestinal surgery, and describe different magnetic technologies, current applications, and future directions.

METHODS

IRB approval and written consent were not required. In this review of the existing literature, we offer a critical examination at the use of magnets for gastrointestinal surgery currently described. We show the experiences done to date, the benefits in laparoscopic and endoscopic surgery, and additional future implications.

RESULTS

Magnetic devices have been tested in the field of gastrointestinal surgery, both in the contexts of animal and human experimentation. Magnets have been mainly used for retraction, anchoring, mobilization, and anastomosis.

CONCLUSION

Research into the use of magnets in gastrointestinal surgery offers promising results. The integration of these technologies in minimally invasive surgery provides benefits in various procedures. However, more research is needed to continually evaluate their impact and implementation into surgical practice.

Magnetic anchor-guided endoscopic submucosal dissection for gastric lesions (with video)

BACKGROUND AND AIMS

The feasibility of magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) using a neodymium magnet for gastric lesions has not been clarified. The aim of study was to evaluate the feasibility of MAG-ESD using neodymium magnets while treating gastric lesions.

METHODS

This prospective trial was conducted at the Yamashita Hospital. MAG-ESD was performed for 50 gastric lesions using an insulated-tip knife. The magnetic anchor consisted of an internal neodymium magnet attached to a hemoclip with 3-0 silk. The external and internal magnets were made from the neodymium magnet. The feasibility of traction using MAG-ESD, en bloc resection rate, complete en bloc resection rate, time required for preparation and attaching the magnetic anchor, procedure time, rate of retrieval of the magnetic anchors, and adverse events were evaluated.

RESULTS

Fifty patients (median lesion size, 20 mm [range, 5-100]) were enrolled. MAG-ESDs were successfully performed for all 50 gastric lesions. Adequate counter-traction was obtained using the external magnet. En bloc resections were achieved and complete en bloc resections confirmed in all cases without adverse events. Attaching the magnetic anchor required a median of 6 minutes (range, 2-14). The median procedure time was 49 minutes (range, 15-301), and the magnetic anchors could be retrieved in all cases.

CONCLUSIONS

This study clearly demonstrated the feasibility of this MAG-ESD in the stomach. We hope this procedure will facilitate the resection of difficult lesions. (Clinical trial registration number: UMIN000024100.).

A soft multi-module manipulator with variable stiffness for minimally invasive surgery

This work presents a soft manipulator for minimally invasive surgery inspired by the biological capabilities of the octopus arm. The multi-module arm is composed of three identical units, which are able to move thanks to embedded fluidic actuators that allow omnidirectional bending and elongation, typical movements of the octopus. The use of soft materials makes the arm safe, adaptable and compliant with tissues. In addition, a granular jamming-based stiffening mechanism is integrated in each module with the aim of tuning the stiffness of the manipulator and controlling the interactions with biological structures. A miniaturized camera and a pneumatic gripper have been purposely designed and integrated on the tip of the manipulator making it usable in real working conditions. This work reports the design and the fabrication process of the manipulator, the theoretical and experimental evaluation of the stiffness and the analysis of the motion workspace. Finally, pick and place tests with the fully integrated system are shown.

Magnetic anchor guidance for endoscopic submucosal dissection and other endoscopic procedures

Endoscopic submucosal dissection (ESD) is a well-established, minimally invasive treatment for superficial neoplasms of the gastrointestinal tract. The universal adoption of ESD has been limited by its slow learning curve, long procedure times, and high risk of complications. One technical challenge is the lack of a second hand that can provide traction, as in conventional surgery. Reliable tissue retraction that exposes the submucosal plane of dissection would allow for safer and more efficient dissection. Magnetic anchor guided endoscopic submucosal dissection (MAG-ESD) has potential benefits compared to other current traction methods. MAG-ESD offers dynamic tissue retraction independent of the endoscope mimicking a surgeon’s “second hand”. Two types of magnets can be used: electromagnets and permanent magnets. In this article we review the MAG-ESD technology, published work and studies of magnets in ESD. We also review the use of magnetic anchor guidance systems in natural orifice transluminal endoscopic surgery and the idea of magnetic non-contact retraction using surface ferromagentization. We discuss the current limitations, the future potential of MAG-ESD and the developments needed for adoption of this technology.

Current and emerging robotic assisted intervention for Notes

INTRODUCTION

Natural orifices transluminal endoscopic surgery (notes) procedures are limited by a number of factors including closure of the internal entry point, loss of triangulation, and unstable operative platform. Areas covered: In this paper, new technical developments in different aspects of robotic assisted NOTES interventions are reviewed. We further address new research opportunities for more widespread clinical acceptance of robotic assisted NOTES procedures. Expert commentary: The application of robotics in NOTES intervention is still in its infancy. The development of more compact, smart and intuitive robotic NOTES systems holds much promise for the future of NOTES application.

A novel magnetic-driven tissue retraction device for minimally invasive surgery

INTRODUCTION

The purpose of this work is to design and validate an innovative magnetic-based device for tissue retraction for minimally invasive surgery.

MATERIAL AND METHODS

An intra-abdominal magnetic module is coupled with an extracorporeal system for establishing a stable attraction, and consequently a reliable tissue retraction. Once the retractor has been inserted into the abdomen, tissue retraction is not constrained by a fixed access port, thus guaranteeing a more flexible, safer and less invasive operation. The intra-abdominal unit is composed of an axial permanent magnet attached to a stainless-steel non-magnetic alligator clip by a traditional suturing thread. A miniaturized mechanism to adjust the length of the suturing thread for lengthening or shortening the distance between the tissue grasper and the internal magnetic unit is included. A multiphysics approach assured a dedicated design that thoroughly fulfills anatomical, physiological and engineering constraints.

RESULTS

System functionalities were demonstrated both in in-vitro and ex-vivo conditions, reaching good results and promising outcomes in terms of effectiveness and maneuverability. The retractor was successfully tested in an animal model, carrying out a whole retraction procedure.

CONCLUSION

The proposed retraction system resulted to be intuitive, reliable, robust and easy to use, representing a suitable device for MIS procedures.

Two-Port Laparoscopic Cholecystectomy: 18 Patients Human Experience Using the Dynamic Laparoscopic NovaTract Retractor

OBJECTIVE

The concept of reducing the number of transabdominal access ports has been criticized for violating basic tenets of traditional multiport laparoscopy. Potential benefits of reduced port surgery may include decreased pain, improved cosmesis, less hernia formation, and fewer wound complications. However, technical challenges associated with these access methods have not been adequately addressed by advancement in instrumentations. We describe our initial experience with the NovaTract™ Laparoscopic Dynamic Retractor.

METHODS

A retrospective review of all patients who underwent two-port laparoscopic cholecystectomy between 2013 and 2014 using the NovaTract retractor was performed. The patients were equally divided into three groups (Group A, B, C) based on the order of case performed.

RESULTS

Eighteen consecutive patients underwent successful two-port laparoscopic cholecystectomy for symptomatic cholelithiasis. Mean age was 39.9 years and mean body mass index was 28.1 kg/m(2) (range 21-39.4). Overall mean operative time was 65 minutes (range 42-105), with Group A of 70 minutes, Group B of 65 minutes, and Group C of 58 minutes (P = .58). All cases were completed laparoscopically using the retraction system, without a need for additional ports or open conversion. No intra- or postoperative complications were seen. All patients were discharged on the same day of surgery. No mortality found in this series.

CONCLUSIONS

The NovaTract laparoscopic dynamic retractor is safe and easy to use, which is reflected by acceptable operative time for a laparoscopic cholecystectomy using only two ports. The system allows surgical approach to mimic the conventional laparoscopic techniques, while eliminating or reducing the number of retraction ports.

An application research on a novel internal grasper platform and magnetic anchoring guide system (MAGS) in laparoscopic surgery

BACKGROUND

Laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery attempt to reduce transabdominal port sites. These require all instruments to pass through a single access point, leading to instruments collide or work at unfamiliar angles. Thus, we designed an internal grasper under magnetic anchoring guide system (MAGS) platform and investigated its utility and operability.

METHODS

We measured the configuration for magnetic force decay over distance using a standardized, ex vivo laboratory testing apparatus. An electronic balance was used to measure the force of the gallbladder pull in ten patients with gallbladder stones. One pig (11 mm abdominal wall thickness) underwent a compressed trial of MAGS platform. The device was left in place for 20 min before tissue sections were harvested, and histologic assessment was performed. The utility and operability were investigated in four pigs (38-280 kg weight).

RESULTS

The magnetic attraction force decayed exponentially over distance; the force of pulling gallbladder was 7.46 ± 0.54 N. This pairing of components allowed for coupling to a theoretical distance of 10 mm. No gross tissue damage was observed. H-E stain showed no necrosis in all specimens. One failed due to wall thickness of 45 mm. Others showed the critical view, triangulation of instruments was obtained, and instrument collision or "sword fighting" was reduced.

CONCLUSIONS

The MAGS platform overcomes limitations such as collisions and lack of triangulation, reduces transabdominal port sites, and is easy to operate. However, our internal grasper requires the abdominal wall thickness below 10 mm.

Transvaginal Laparoscopically Assisted Endoscopic Appendectomy: a major Hybrid Natural Orifice Transluminal Endoscopic Surgery case series in Asia

OBJECTIVE

Evaluation of a Hybrid Approach to NOTES and its performance relative to conventional procedures.

BACKGROUND

Globally, numerous institutions have successfully implemented minimally invasive surgeries by applying natural orifice translumenal endoscopic surgery (NOTES) techniques and achieved decreased morbidity while performing incision-less surgery. However, these techniques are still not common in surgical practice in China and Pakistan. Documenting the experiences and challenges encountered in implementing NOTES in such environments can provide guidance for NOTES implementation elsewhere.

METHODS

From May 2010 to April 2012, 16 human transvaginal appendectomies were carried out applying a hybrid NOTES technique using a solo-umbilical trocar, which provided a safe access for laparoscopic assistance during surgical procedure. After removal of the appendix transvaginally, the colpotomy was sutured under direct vision with absorbable stitches. The outcomes of cases treated with hybrid NOTES techniques were compared to those of conventional laparoscopic appendectomy.

RESULTS

All patients underwent a successful surgical procedure with no intra- or post-operative complications and provided no specific complaints during the tenth day and a monthly follow-up for 2 years. The patients convalesced promptly with healthy and satisfactory cosmetic results. Compared to conventional laparoscopic appendectomy, the hybrid NOTES operation had less post-operative pain, lower cost, and shorter hospitalization.

CONCLUSIONS

Hybrid NOTES procedures can be performed safely using a solo-umbilical trocar. Our initial experience reveals that this hybrid technique is practically feasible and associated with minimal post-operative pain, reasonable convalescence time, and improved cosmetic outcomes.

Study of Individual Characteristic Abdominal Wall Thickness Based on Magnetic Anchored Surgical Instruments

Background:

Magnetic anchored surgical instruments (MASI), relying on magnetic force, can break through the limitations of the single port approach in dexterity. Individual characteristic abdominal wall thickness (ICAWT) deeply influences magnetic force that determines the safety of MASI. The purpose of this study was to research the abdominal wall characteristics in MASI applied environment to find ICAWT, and then construct an artful method to predict ICAWT, resulting in better safety and feasibility for MASI.

Methods:

For MASI, ICAWT is referred to the thickness of thickest point in the applied environment. We determined ICAWT through finding the thickest point in computed tomography scans. We also investigated the traits of abdominal wall thickness to discover the factor that can be used to predict ICAWT.

Results:

Abdominal wall at C point in the middle third lumbar vertebra plane (L3) is the thickest during chosen points. Fat layer thickness plays a more important role in abdominal wall thickness than muscle layer thickness. “BMI-ICAWT” curve was obtained based on abdominal wall thickness of C point in L3 plane, and the expression was as follow: f(x) = P1 × x² + P2 × x + P3, where P1 = 0.03916 (0.01776, 0.06056), P2 = 1.098 (0.03197, 2.164), P3 = −18.52 (−31.64, −5.412), R-square: 0.99.

Conclusions:

Abdominal wall thickness of C point at L3 could be regarded as ICAWT. BMI could be a reliable predictor of ICAWT. In the light of “BMI-ICAWT” curve, we may conveniently predict ICAWT by BMI, resulting a better safety and feasibility for MASI.

Design and Fabrication of an Elastomeric Unit for Soft Modular Robots in Minimally Invasive Surgery

In recent years, soft robotics technologies have aroused increasing interest in the medical field due to their intrinsically safe interaction in unstructured environments. At the same time, new procedures and techniques have been developed to reduce the invasiveness of surgical operations. Minimally Invasive Surgery (MIS) has been successfully employed for abdominal interventions, however standard MIS procedures are mainly based on rigid or semi-rigid tools that limit the dexterity of the clinician. This paper presents a soft and high dexterous manipulator for MIS. The manipulator was inspired by the biological capabilities of the octopus arm, and is designed with a modular approach. Each module presents the same functional characteristics, thus achieving high dexterity and versatility when more modules are integrated. The paper details the design, fabrication process and the materials necessary for the development of a single unit, which is fabricated by casting silicone inside specific molds. The result consists in an elastomeric cylinder including three flexible pneumatic actuators that enable elongation and omni-directional bending of the unit. An external braided sheath improves the motion of the module. In the center of each module a granular jamming-based mechanism varies the stiffness of the structure during the tasks. Tests demonstrate that the module is able to bend up to 120° and to elongate up to 66% of the initial length. The module generates a maximum force of 47 N, and its stiffness can increase up to 36%.

Laparoscopic Tissue Retractor Based on Local Magnetic Actuation

Magnetic instruments for laparoscopic surgery have the potential to enhance triangulation and reduce invasiveness, as they can be rearranged inside the abdominal cavity and do not need a dedicated port during the procedure. Onboard actuators can be used to achieve a controlled and repeatable motion at the interface with the tissue. However, actuators that can fit through a single laparoscopic incision are very limited in power and do not allow performance of surgical tasks such as lifting an organ. In this study, we present a tissue retractor based on local magnetic actuation (LMA). This approach combines two pairs of magnets, one providing anchoring and the other transferring motion to an internal mechanism connected to a retracting lever. Design requirements were derived from clinical considerations, while finite element simulations and static modeling were used to select the permanent magnets, set the mechanism parameters, and predict the lifting and supporting capabilities of the tissue retractor. A three-tier validation was performed to assess the functionality of the device. First, the retracting performance was investigated via a benchtop experiment, by connecting an increasing load to the lever until failure occurred, and repeating this test for different intermagnetic distances. Then, the feasibility of liver resection was studied with an ex vivo experiment, using porcine hepatic tissue. Finally, the usability and the safety of the device were tested in vivo on an anesthetized porcine model. The developed retractor is 154 mm long, 12.5 mm in diameter, and weights 39.16 g. When abdominal wall thickness is 2 cm, the retractor is able to lift more than ten times its own weight. The model is able to predict the performance with a relative error of 9.06 ± 0.52%. Liver retraction trials demonstrate that the device can be inserted via laparoscopic access, does not require a dedicated port, and can perform organ retraction. The main limitation is the reduced mobility due to the length of the device. In designing robotic instrument for laparoscopic surgery, LMA can enable the transfer of a larger amount of mechanical power than what is possible to achieve by embedding actuators on board. This study shows the feasibility of implementing a tissue retractor based on this approach and provides an illustration of the main steps that should be followed in designing a LMA laparoscopic instrument.

A miniaturized robotic platform for natural orifice transluminal endoscopic surgery: in vivo validation

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) involves accessing the abdominal cavity via one of the body natural orifices for enabling minimally invasive surgical procedures. However, the constraints imposed by the access modality and the limited available technology make NOTES very challenging for surgeons. Tools redesign and introduction of novel surgical instruments are imperative in order to make NOTES operative in a real surgical scenario, reproducible and reliable. Robotic technology has major potential to overcome current limitations.

METHODS

The robotic platform described here consists of a magnetic anchoring frame equipped with dedicated docking/undocking mechanisms to house up to three modular robots for surgical interventions. The magnetic anchoring frame guarantees the required stability for surgical tasks execution, whilst dedicated modular robots provide the platform with adequate vision, stability and manipulation capabilities.

RESULTS

Platform potentialities were demonstrated in a porcine model. Assessment was organized into two consecutive experimental steps, with a hybrid testing modality. First, platform deployment, anchoring and assembly through transoral-transgastric access were demonstrated in order to assess protocol feasibility and guarantee the safe achievement of the following experimental session. Second, transabdominal deployment, anchoring, assembly and robotic module actuation were carried out.

CONCLUSIONS

This study has demonstrated the feasibility of inserting an endoluminal robotic platform composed of an anchoring frame and modular robotic units into a porcine model through a natural orifice. Once inserted into the peritoneal cavity, the platform provides proper visualization from multiple orientations. For the first time, a platform with interchangeable modules has been deployed and its components have been connected, demonstrating in vivo the feasibility of intra-abdominal assembly. Furthermore, increased dexterity employing different robotic units will enhance future system capabilities.

Miniature Surgical Robots in the Era of NOTES and LESS

Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.

Simplified magnetic anchor-guided endoscopic submucosal dissection in dogs (with videos)

BACKGROUND

Magnetic anchor-guided endoscopic submucosal dissection (MAG-ESD) was developed to reduce adverse events such as bleeding and perforation and to facilitate ESD. However, the external electromagnet required miniaturization to make it suitable for daily clinical practice.

OBJECTIVE

To evaluate the feasibility of simplified MAG-ESD using permanent magnets.

DESIGN

Case series.

SETTING

Nagoya University Hospital.

SUBJECTS

Beagle dogs.

INTERVENTIONS

The simplified MAG-ESD was performed on 10 representative areas of the stomachs of beagle dogs. The magnetic anchor consisted of an internal magnet attached to a hemoclip. The external and internal magnets were made from the rare earth neodymium.

MAIN OUTCOME MEASUREMENTS

The feasibility of countertraction with good visualization using simplified MAG-ESD. The rate of perforation, the time required for preparation, and attaching the magnetic anchor were also evaluated.

RESULTS

All lesions were successfully resected without perforation. The magnetic anchor could be controlled easily, and direct visualization was maintained by adequate counter traction. Preparing the magnetic anchor and grasping the mucosal edge using the hemoclip was easy and required a median of only 4 minutes (range, 2-7 minutes).

LIMITATIONS

Animal experiment, low number and lesion size.

CONCLUSIONS

This simplified MAG-ESD is feasible and allowed excellent visualization in the dog stomach. The feasibility of this system should be assessed in humans.

In silico investigation of a surgical interface for remote control of modular miniature robots in minimally invasive surgery

Aim. Modular mini-robots can be used in novel minimally invasive surgery techniques like natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single site (LESS) surgery. The control of these miniature assistants is complicated. The aim of this study is the in silico investigation of a remote controlling interface for modular miniature robots which can be used in minimally invasive surgery. Methods. The conceptual controlling system was developed, programmed, and simulated using professional robotics simulation software. Three different modes of control were programmed. The remote controlling surgical interface was virtually designed as a high scale representation of the respective modular mini-robot, therefore a modular controlling system itself. Results. With the proposed modular controlling system the user could easily identify the conformation of the modular mini-robot and adequately modify it as needed. The arrangement of each module was always known. The in silico investigation gave useful information regarding the controlling mode, the adequate speed of rearrangements, and the number of modules needed for efficient working tasks. Conclusions. The proposed conceptual model may promote the research and development of more sophisticated modular controlling systems. Modular surgical interfaces may improve the handling and the dexterity of modular miniature robots during minimally invasive procedures.

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.

Miniature Surgical Robots in the Era of NOTES and LESS

Laparoscopy is an established method for the treatment of numerous surgical conditions. Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body as entrances to the abdominal cavity. An alternative concept of minimally invasive approach to the abdominal cavity is to insert all the laparoscopic instruments through ports using a single small incision on the abdominal wall. A suggested name for this technique is laparoendoscopic single-site surgery (LESS). Considering the technical difficulties in NOTES and LESS and the progress in informatics and robotics, the use of robots seems ideal. The aim of this study is to investigate if there is at present, a realistic possibility of using miniature robots in NOTES or LESS in daily clinical practice. An up-to-date review on in vivo surgical miniature robots is made. A Web-based research of the English literature up to March 2013 using PubMed, Scopus, and Google Scholar as search engines was performed. The development of in vivo miniature robots for use in NOTES or LESS is a reality with great advancements, potential advantages, and possible application in minimally invasive surgery in the future. However, true totally NOTES or LESS procedures on humans using miniature robots either solely or as assistance, remain a dream at present.

The influence on immunologic parameters during NOTES in a porcine survival model

OBJECTIVE

To analyze the effect of natural orifice transluminal endoscopic surgery (NOTES) on the survival of animals, by comparing the change of intraoperative and postoperative immunologic parameters of NOTES with laparoscopy.

MATERIALS AND METHODS

Twenty pigs were randomized to treatment with NOTES or standard laparoscopy. Each group underwent diagnostic peritoneoscopy by laparoscopy or NOTES in 90 minutes. Laboratory values, including interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-α), were obtained at baseline, at intraoperative minute (IOM) 30, 60, and 90, and on postoperative day (POD) 1, 3, and 7.

RESULTS

All procedures were successfully completed and all animals (except one in the NOTES group) survived to POD 14. The level of IL-1 and TNF-α was not significantly different compared with the preoperative level of IL-1 and TNF-α in both groups at IOM 30 and 60. It increased significantly at IOM 90 and POD 1 and 3 in both groups. Although levels of both IL-1 and TNF-α were higher in the NOTES group compared with the other group, there was no significant difference between the groups. At POD 7, the level of IL-1 and TNF-α decreased to near-normal levels in both groups.

CONCLUSIONS

Although preliminary, the findings in this study do not currently support the assumption that NOTES is less invasive than laparoscopy. Further research is required to confirm these findings.

Natural-orifice translumenal endoscopic surgery (NOTES): minimally invasive evolution or revolution?

Since the first animal experimental laparoscopy in 1902, minimal access techniques have revolutionized surgery. Using the natural orifice dates back to at least the second century when Soranus performed a vaginal hysterectomy. The main difference between traditional endolumenal surgery and the translumenal approach of natural-orifice translumenal endoscopic surgery (NOTES) is the intentional puncture of a healthy organ in NOTES to access a cavity or other organ. The aim of this review was to examine the past, present, and potential future role of NOTES in the context of other developments in minimal access surgery. NOTES is at an early stage in its development and a convincing benefit over laparoscopy has not been demonstrated. Concerns regarding complications, for example of viscerotomy closure, have limited the widespread uptake of pure NOTES. However, it is likely that technological advances for NOTES surgery will enhance conventional laparoscopic and endoscopic techniques.

Initial experiences of a novel self-retaining intracorporeal retractor device for urologic laparoendoscopic single-site surgery

BACKGROUND AND PURPOSE

Laparoendoscopic single-site surgery (LESS) is a surgical option for a number of urologic operations, although it does carry technical limitations. One of the major obstacles in performing LESS is accomplishing optimal retraction of adjacent organs. The aim of this study was to investigate the feasibility of a novel self-retaining intracorporeal retractor device, the Internal Organ Retractor (IOR), and to describe our experience using this device in LESS.

PATIENTS AND METHODS

A total of 23 patients who underwent LESS using IOR between December 2012 and July 2013 were identified. Among these patients, 11 nephrectomies, 9 adrenalectomies, 1 pyeloplasty, and 2 nephroureterectomies were performed. Perioperative outcomes including operative time, complications related to use of the IOR, and amount of time needed for the application and removal of the IOR were measured during each operation.

RESULTS

Adequate retraction was accomplished in all surgical cases. The IOR helped to maintain a consistent operative field throughout the surgery. A median application time of a single IOR was 85.0 (range 44.5-187.5) seconds and removal time was 50.0 (20-400) seconds. The median number of IOR sets used was 2.0 (range 1-4), and the median total application and removal time in a single operation were 170.0 (45-750) seconds and 95.0 (20-400) seconds, respectively. There were no perioperative complications associated with use of the IOR.

CONCLUSIONS

The IOR provided satisfactory retraction during LESS, and its application/removal was uncomplicated and needed a minimal amount of time. The IOR reduced the need for additional laparoscopic ports for retraction. We believe that the IOR is a useful retraction tool for LESS and possibly multiport laparoscopic surgeries.

Modular Assembly Micro-Robots for Natural Orifice Transluminal Endoscopic Surgery

Surgical operations are progressively being performed using minimally invasive techniques. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body in order to approach the peritoneal cavity. There are two basic types of robotics for NOTES; the external robots that stay outside the patient but act inside the abdominal cavity, and the internal robots that stay and act in the abdomen. The internal robots could only be mini-robots. The development of modular assembling reconfigurable micro-robots is a revolutionary idea for the NOTES. Modular micro-robots consist of small subunits which could be assembled and construct a functional miniature robot. These surgical micro-robots may increase the possibility for true scarless tele-surgery. Although specific applications of intrabdominal surgical micro-robots are still in an early concept stage, the field is rapidly evolving. In the future, patients may be operated by specialized micro-robotic intrabdominal surgeons.

NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model

BACKGROUND

We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure.

METHODS

We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy.

RESULTS

We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications.

CONCLUSION

Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.

Safety and feasibility for single-incision laparoscopic cholecystectomy in local community hospital: a retrospective comparison with conventional 4-port laparoscopic cholecystectomy

BACKGROUND

The aim of this study was to evaluate the safety and feasibility for single-incision laparoscopic cholecystectomy (SILC) by retrospective comparison with conventional laparoscopic cholecystectomy (CLC) in a local community hospital.

METHODS

SILC was introduced and performed in 57 patients for benign gallbladder diseases. Their clinical data were compared with those of 62 patients treated with CLC. They included patient demographic data and operative outcomes.

RESULTS

SILC was attempted in 57 patients and 52 cases (91.2%) were successfully completed. There were no statistical differences between the 2 groups in terms of operative time, blood loss, and postoperative complications. The length of hospital stay in the SILC group was significantly shorter compared with CLC (P < 0.0001).

CONCLUSIONS

SILC has been successfully introduced in a local community hospital. The safety and feasibility was also confirmed. The SILC procedure may become 1 standard option for the treatment of benign gallbladder diseases.

Transvaginal liver surgery using a tethered magnet and a laparoscopic rein

Hybrid transvaginal endoscopic surgery can be facilitated with additional instruments, techniques, and a flexible endoscope. Magnets are an aid to exposure using a laparoscopic rein.

Introduction:

A novel technique was used to remove a large liver cyst via culdolaparoscopy.

Case Description:

We used laparoscopic instruments, a gastroscope, a laparoscopic rein, and magnets. The magnets consist of an external magnet and a specially modified tethered neodymium internal magnet, safe for use in transvaginal endoscopic surgery.

Discussion:

These technologies offer some advantages when they are used together: magnets and the rein to aid in exposure, traction–retraction, and triangulation. Previous reports have been published on the removal of benign liver lesions transvaginally, but none to date has involved the use of magnets. This article reports on the role of magnets and reins in an incision reduction approach to the removal of a liver cyst.

Magnetic compression in gastrointestinal and bilioenteric anastomosis: how much force?

AIM

The concept of compression alimentary anastomosis is well established. Recently, magnetic axial alignment pressures have been encompassed within such device constructs. We quantify the magnetic compression force and pressure required to successfully achieve gastrointestinal and bilioenteric anastomosis by in-depth interrogation of the reported literature.

METHODS

Reports of successful deployment and proof of anastomotic patency on survival were scrutinized to quantify the necessary dimensions and strengths of magnetic devices in (a) gastroenteral anastomosis in live porcine models and (b) bilioenteric anastomosis in the clinical setting. Using a calculatory tool developed for this work (magnetic force determination algorithm, MAGDA), ideal magnetic force and compression pressure were quantified from successful reports with regard to their variance by intermagnet separation.

RESULTS

Optimized ranges for both compression force and pressure were determined for successful porcine gastroenteral and clinical bilioenteric anastomoses. For gastroenteral anastomoses (porcine investigations), an optimized compression force between 2.55 and 3.57 kg at 2-mm intermagnet separation is recommended. The associated compression pressure should not exceed 60 N/cm(2). Successful bilioenteric anastomoses is best clinically achieved with intermagnet compression of 18 to 31 g and associated pressures between 1 and 3.5 N/mm(2) (at 2-mm intermagnet separation).

CONCLUSION

The creation of magnetic compression anastomoses using permanent magnets demonstrates a remarkable resilience to variations in magnetic force and pressure exertion. However, inappropriate selection of compression characteristics and magnet dimensions may incur difficulties. Recommendations of this work and the availability of the free online tool (http://magda.ucc.ie/) may facilitate a factor of robustness in the design and refinement of future devices.

Anchoring frame for intra-abdominal surgery

Natural orifice transluminal endoscopic surgery (NOTES) is one of the modern surgical techniques that led to the miniaturization of surgical tools and brings the concept of inserting many robotic units into the peritoneal cavity for executing “scarless” surgical tasks. However, the development of transabdominal anchoring systems that guarantee stability is recognized as a challenging issue in the design of miniature intra-abdominal robotic devices. A dedicated platform, exploiting magnetic coupling for anchoring, has been designed by respecting anatomical constraints, maximizing the volume to increase the number of embedded magnets, and consequently incrementing operating distance. The device is equipped with a SMA (shape memory alloy) mechanism that allows configuration change from an extended cylindrical (compliant for deployment) to a compact triangular (rigid for providing stability) design. The feasibility and the potential of the proposed platform have been demonstrated both in in vitro and in in vivo conditions on a human phantom and a porcine model, respectively.

A modular magnetic platform for Natural Orifice Transluminal Endoscopic Surgery

Modern surgery is currently developing NOTES (Natural Orifice Translumenal Endoscopic Surgery) robotic approaches to enable scarless surgical procedures. Despite of the variegated devices proposed, they still have several limitations. In this work, we propose a surgical platform composed of specialized modules, in order to provide the overall system with adequate stability, dexterity and force generation. The concept behind the platform, the main modules and their performance are described to highlight the system potential to outperform current NOTES procedures.

Single-incision versus conventional laparoscopic cholecystectomy: a systematic review of available data

To evaluate the feasibility and limitation of single-incision laparoscopic cholecystectomy (SILC), we performed a systematic literature search and 11 studies were included. SILC was successfully performed in 91.9% participants and conventional instruments were used mostly. Although longer operative time was required for this novel procedure than the conventional laparoscopic cholecystectomy, mean difference was 18.54 minutes (P=0.0001) and a learning curve was noted. There was no significant discrepancy in overall complications and severe complications (P=0.51 and 0.82, respectively). No difference in the length of hospital stay between the 2 groups was detected (P=0.09). No consensus has reached on the postoperative pain score between the 2 techniques. SILC with conventional instruments was a feasible and safe approach. It may be offered as an alternative for cholecystectomy in carefully selected patients.

Fine Tilt Tuning of a Laparoscopic Camera by Local Magnetic Actuation

Background. The magnetic surgical camera is an emerging technology having the potential to improve visualization without taking up port site space. However, tilting the point of view downward/upward can be done only by constantly applying a pressure on the abdomen. This study aims to test the hypothesis that the novel concept of local magnetic actuation (LMA) is able to increase the tilt range available for a magnetic camera without the need for deforming the abdominal wall. The hypothesis that 2-port laparoscopic nephrectomy in fresh tissue human cadavers could be performed by using the LMA camera is also tested. Methods. First, the 2 cameras were separately inserted, anchored, and moved inside the inflated abdomen. Tilting angles were quantified by image analysis while intra-abdominal pressure changes were monitored. Then, 5 two-port nephrectomies were performed by using the LMA camera while collecting quantitative outcomes. Results. The magnetic camera required a constant pressure on the magnetic handle to achieve an average ±20° tilt from the horizontal position, with an average of 7 mm Hg loss of intra-abdominal pressure. The LMA camera allowed for 75° of tilt from the horizontal position with a resolution of ±1°, without any need to deform the abdomen. All the nephrectomies were completed successfully within an average time of 11 minutes. Conclusion. LMA is an effective strategy to provide magnetic cameras with wide-range and high-resolution vertical motion without the need to deform the abdominal wall.

Modular Assembly Micro-Robots for Natural Orifice Transluminal Endoscopic Surgery, the Future of Minimal Invasive Surgery

Surgical operations are progressively being performed using minimally invasive techniques. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a novel surgical technique that uses the natural orifices of the human body in order to approach the peritoneal cavity. There are two basic types of robotics for NOTES; the external robots that stay outside the patient but act inside the abdominal cavity, and the internal robots that stay and act in the abdomen. The internal robots could only be mini-robots. The development of modular assembling reconfigurable micro-robots is a revolutionary idea for the NOTES. Modular micro-robots consist of small subunits which could be assembled and construct a functional miniature robot. These surgical micro-robots may increase the possibility for true scarless tele-surgery. Although specific applications of intrabdominal surgical micro-robots are still in an early concept stage, the field is rapidly evolving. In the future, patients may be operated by specialized micro-robotic intrabdominal surgeons.

Magnetically anchored cautery dissector improves triangulation, depth perception, and workload during single-site laparoscopic cholecystectomy

INTRODUCTION

This study evaluated operative outcomes and workload during single-site laparoscopy (SSL) using a magnetically anchored cautery dissector (MAGS) compared with a conventional laparoscopic hook cautery (LAP).

METHODS

Each cautery was used to perform six SSL porcine cholecystectomies. For MAGS, the cautery device was inserted through the umbilical incision, magnetically coupled, and deployed; two graspers and a laparoscope were used. For LAP, two percutaneous retraction sutures, one grasper, a hook cautery dissector, and a laparoscope were used. Operative outcomes, surgeon ratings (scale, 1-5; 1 = superior), and workload (scale, 1-10; 1 = superior) were evaluated.

RESULTS

No significant differences were detected for operative outcomes and surgeon ratings, however, trends were detected favoring MAGS. Surgeon workload ratings were significantly better for MAGS (2.6 ± 0.2) vs. LAP (5.6 ± 1.1; p < 0.05). For MAGS, depth perception and triangulation were excellent and the safe handling protocol was followed with no complications. For LAP, the parallelism of instruments and lack of triangulation hindered depth perception, caused instrument conflicts, and resulted in two minor complications (one superficial liver laceration and one inadvertent burn to the diaphragm).

CONCLUSION

These data suggest that using the MAGS device for SSL cholecystectomy results in equivalent (or better) operative outcomes and less workload compared with LAP.

Single-port laparoscopic adhesiolysis for torsion ileus

Single-incisional laparoscopic surgery (SILS) has emerged as an attempt to further enhance the cosmetic benefits and reduce the morbidity of minimally invasive surgery. We present an approach of SILS adhesiolysis to adhesive strangulated ileus. A 70-year-old female patient, who had undergone laparoscopic low anterior resection 6 years before, underwent SILS adhesiolysis to a midline surgical incision wound adhesion site. The surgery was performed with only a 2.5-cm left-side transrectus incision using the SILS port. Laparoscopy revealed intestinal torsion and congestion with adhesion of the ileum to the previous surgical incision wound. SILS adhesiolysis was successfully carried out. The patient was discharged 4 days after surgery. SILS adhesiolysis is a feasible and efficient procedure in certain cases.

NOTES, MANOS, SILS and other new laparoendoscopic techniques

A new way of opening a body cavity can be a revolution in surgery. In 1980s, laparoscopy changed how surgeons had been working for years. Natural orifice translumenal endoscopic surgery (NOTES), minilaparoscopy-assisted natural orifice surgery (MANOS), single incision laparoscopic surgery (SILS) and other new techniques are the new paradigm in our way of operating in the 21^st century. The development of these techniques began in the late 90s but they have not had enough impact to develop and evolve. Parallels between the first years of laparoscopy and NOTES can be made. Working for an invisible surgery, not only for cosmesis but for a less invasive surgery, is the target of NOTES, MANOS and SILS performed by surgeons and endoscopists over the last 10 years. The future flexible endoscopic platforms and the fusion between laparoscopic instruments and devices and robotic surgery will be a great advance for “scarless surgery”.