Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

Magnetic anchor technique in laparoscopic cholecystectomy: a single-center, prospective, randomized controlled trial

BACKGROUND

There have been no prospective randomized controlled clinical trials evaluating the advantages of the magnetic anchor technique (MAT) used in reduced-port laparoscopic cholecystectomy (LC). The present study evaluated a novel magnetic anchor device designed by the authors.

METHODS

Between April 2019 and June 2020, 60 patients with gallbladder diseases participated in a single-center, prospective, randomized controlled clinical trial. The patients were randomly apportioned to undergo either 2-port LC assisted by the novel MAT (MAT-2P-LC, experimental group) or conventional 3-port LC (3P-LC, control). The groups were compared regarding operative time, postoperative complications, surgical incision pain score (Wong-Baker), and other indicators. The patients were followed for 2 years.

RESULTS

The test and control groups were comparable in age, gender, body mass index, and primary disease. No patient in the MAT-2P-LC group was converted to 3P-LC. No patients were converted to laparotomy. On the first postoperative day, the Wong-Baker pain score of the experimental group (1.60 ± 0.67) was significantly lower than that of the control (2.20 ± 0.76; P = 0.002). The groups were statistically similar regarding intraoperative blood loss; operative time; time to leave bed; hospital stay; postoperative pain scores at 1 and 4 weeks; and complications.

CONCLUSIONS

This rigorous clinical trial shows that the novel MAT used to assist reduced-port LC significantly reduced postoperative pain, but has no obvious advantages in other terms. Clinical Trails.gov. number, ChiCTR1800019464.

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis

AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.

METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ² test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.

RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.

CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.

A state of the art review and categorization of multi-branched instruments for NOTES and SILS

BACKGROUND

Since the advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and single incision laparoscopic surgery (SILS), a variety of multitasking platforms have been under development with the objective to allow for bimanual surgical tasks to be performed. These instruments show large differences in construction, enabled degrees of freedom (DOF), and control aspects.

METHODS

Through a literature review, the absence of an in-depth analysis and structural comparison of these instruments in the literature is addressed. All the designed and prototyped multitasking platforms are identified and categorized with respect to their actively controlled DOF in their shafts and branches. Additionally, a graphical overview of patents, bench test experiments, and animal and/or human trials performed with each instrument is provided.

RESULTS

The large range of instruments, various actuation strategies, and different direct and indirect control methods implemented in the instruments show that an optimal instrument configuration has not been found yet. Moreover, several questions remain unanswered with respect to which DOF are essential for bimanual tasks and which control methods are best suited for the control of these DOF.

CONCLUSIONS

Considering the complexity of the currently prototyped and tested instruments, future NOTES and SILS instrument development will potentially necessitate a reduction of the available DOF to minimize the control complexity, thereby allowing for single surgeon bimanual task execution.

Toward scar-free surgery: an analysis of the increasing complexity from laparoscopic surgery to NOTES

BACKGROUND

NOTES is an emerging technique for performing surgical procedures, such as cholecystectomy. Debate about its real benefit over the traditional laparoscopic technique is on-going. There have been several clinical studies comparing NOTES to conventional laparoscopic surgery. However, no work has been done to compare these techniques from a Human Factors perspective. This study presents a systematic analysis describing and comparing different existing NOTES methods to laparoscopic cholecystectomy.

METHODS

Videos of endoscopic/laparoscopic views from fifteen live cholecystectomies were analyzed to conduct a detailed task analysis of the NOTES technique. A hierarchical task analysis of laparoscopic cholecystectomy and several hybrid transvaginal NOTES cholecystectomies was performed and validated by expert surgeons. To identify similarities and differences between these techniques, their hierarchical decomposition trees were compared. Finally, a timeline analysis was conducted to compare the steps and substeps.

RESULTS

At least three variations of the NOTES technique were used for cholecystectomy. Differences between the observed techniques at the substep level of hierarchy and on the instruments being used were found. The timeline analysis showed an increase in time to perform some surgical steps and substeps in NOTES compared to laparoscopic cholecystectomy.

CONCLUSION

As pure NOTES is extremely difficult given the current state of development in instrumentation design, most surgeons utilize different hybrid methods-combination of endoscopic and laparoscopic instruments/optics. Results of our hierarchical task analysis yielded an identification of three different hybrid methods to perform cholecystectomy with significant variability among them. The varying degrees to which laparoscopic instruments are utilized to assist in NOTES methods appear to introduce different technical issues and additional tasks leading to an increase in the surgical time. The NOTES continuum of invasiveness is proposed here as a classification scheme for these methods, which was used to construct a clear roadmap for training and technology development.

A technical review of flexible endoscopic multitasking platforms

BACKGROUND

Further development of advanced therapeutic endoscopic techniques and natural orifice translumenal endoscopic surgery (NOTES) requires a powerful flexible endoscopic multitasking platform.

METHODS

Medline search was performed to identify literature relating to flexible endoscopic multitasking platform from year 2004-2011 using keywords: Flexible endoscopic multitasking platform, NOTES, Instrumentation, Endoscopic robotic surgery, and specific names of various endoscopic multitasking platforms. Key articles from articles references were reviewed.

RESULTS

Flexible multitasking platforms can be classified as either mechanical or robotic. Purely mechanical systems include the dual channel endoscope (DCE) (Olympus), R-Scope (Olympus), the EndoSamurai (Olympus), the ANUBIScope (Karl-Storz), Incisionless Operating Platform (IOP) (USGI), and DDES system (Boston Scientific). Robotic systems include the MASTER system (Nanyang University, Singapore) and the Viacath (Hansen Medical). The DCE, the R-Scope, the EndoSamurai and the ANUBIScope have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. The advantage of the access device concept is that it allows optics and instrument dissociation. Due to the anatomical constrains of the pharynx, systems are designed to have a diameter of less than 20 mm. All systems are controlled by traction cable system actuated either by hand or by robotic machinery. In a flexible system, this method of actuation inevitably leads to significant hysteresis. This problem will be accentuated with a long endoscope such as that required in performing colonic procedures. Systems often require multiple operators. To date, the DCE, the R-Scope, the IOP, and the Viacath system have data published relating to their application in human.

CONCLUSION

Alternative forms of instrument actuation, camera control and master console ergonomics should be explored to improve instrument precision, sphere of action, size and minimize assistance required.