Use of a Novel Articulating Laparoscopic Needle Driver for Partial nephrectomy: An Initial Experience

Evaluation of the suitability of using ArtiSential in various renal surgery: IDEAL stage 1 study

BACKGROUND

ArtiSential, a new articulating laparoscopic instruments, addresses the limited movement associated with conventional laparoscopic instruments. This study was conducted to assess the clinical effectiveness of ArtiSential in detailed steps of various renal surgery.

METHODS

This study was approved by the Institutional Review Board of our institution and registered on the Clinical Research Information Service site of the Korea Disease Control and Prevention Agency. Participants meeting all inclusion and exclusion criteria were included in the clinical trial and underwent renal surgery. The clinical effectiveness of ArtiSential was assessed in terms of the feasibility and objective and subjective parameters across 9 detailed steps.

RESULTS

Of the 15 potential candidates enrolled from October 2021 to November 2021, 1 patient dropped out due to anaphylaxis from an anesthetic agent, and 14 patients underwent laparoscopic surgery using ArtiSential. Of the 14 patients, 2 patients were converted to laparoscopic surgery using straight-shaped instruments due to the ischemia time exceeding 30 min, and 1 patient due to excessive bleeding. The feasibility for most steps was more than 90%, except the renorrhaphy step. The median total operation time and ischemia time were 161 and 23 min, respectively. The median estimated blood loss was 58.5 mL. Two cases of venous injury occurred during renal pedicle dissection step. The accuracy of the procedure judged by reviewers and usability judged by the operator were acceptable in all steps. The surgeon's quantitatively measured stress score was the highest during renorrhaphy step.

CONCLUSIONS

Laparoscopic surgery using ArtiSential is feasible for most steps except the renorrhaphy step. The difficulty of performing renorrhaphy is attributed to prolonged ischemia time, which could be addressed by overcoming the learning curve.

TRIAL REGISTRATION

Clinical Research Information Service site of the Korea Disease Control and Prevention Agency, KCT0006532. Registered 03/09/2021, https://cris.nih.go.kr/cris/search/detailSearch.do?seq=24071 .

Laparoscopic renal surgery using multi degree-of-freedom articulating laparoscopic instruments in a porcine model

PURPOSE

We evaluated the performance of a new multi-degree-of-freedom articulating laparoscopic instrument, ArtiSential, and compared it with that of a straight-shaped instrument and the da Vinci surgical system, in renal surgery using porcine model.

MATERIALS AND METHODS

Nine female Yorkshire pigs were equally divided into three groups. The three groups were compared at each surgical step in terms of objective and subjective parameters.

RESULTS

The median operative times for renal pedicle clamping and ureter dissection were significantly shorter in ArtiSential group than robotic group (1.3 min vs. 4.7 min, p=0.002; 8.1 min vs. 11.1 min, p=0.015). The median operative time for bladder repair was significantly longer in ArtiSential group than robotic and straight-shaped groups (17.9 min vs. 5.5 min, p=0.002; 17.9 min vs. 9.3 min, p=0.026). There were no significant differences among groups in terms of blood loss or intraoperative complications. ArtiSential device was less useable for renorrhaphy (p=0.009) and bladder repair (p=0.002) compared to the robotic system. ArtiSential group was less accurate than robotic group in terms of tumor resection, renorrhaphy, and bladder repair. During ureter dissection, bladder cuff excision, and bladder repair, the surgeon experienced greater wrist discomfort but lesser back discomfort in ArtiSential group than robotic group.

CONCLUSIONS

For most steps, ArtiSential performed as well as robotic and straight-shaped instruments. The development of specialized surgical techniques for ArtiSential will maximize the advantages of these instruments.

Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery

Objective: Robotic platforms offer articulating needle drivers but are associated with high costs and lack tactile feedback. The recently developed mechanical Laparoscopic Articulating Needle Driver (LAND) (Flexdex^®) for conventional laparoscopy offers enhanced dexterity without these limitations. The goal of this study was to assess safety and efficiency during the implementation of the LAND, and describe its learning curve, in an expert center for laparoscopic surgery. Methods: All LAND-assisted procedures after clinical implementation for a period of 16 months were included into this study. Primary outcome domains were safety (intra- and postoperative complications within 30 days) and efficiency (operative time, suturing, and knot tying time of staple defects of enteroenterostomy). CUmulative SUM (CUSUM) analysis was utilized to describe the enteroenterostomy suturing time learning curve across consecutive cases by plotting the deviation from the series mean. Results: Forty-five procedures (34 Roux-en-Y gastric bypass [of which 7 including diaphragmatic hernia repair], 2 diaphragmatic hernia repair with Nissen fundoplication, and 2 right-sided hemicolectomy) were included into this study. Median (range) operative time and enteroenterostomy suturing time were 68 (46-177) minutes and 161 (112-241) seconds, respectively, comparable with conventional needle driver standards. One procedure was converted to the conventional needle driver due to device malfunctioning and one patients' postoperative course was complicated by a Clavien-Dindo grade 3a complication (intraluminal bleeding requiring gastroscopy). CUSUM chart displays a progression toward the mean from case 22 onward, indicating a limited learning curve. Conclusion: The LAND can be implemented safely and efficiently at a center of excellence for laparoscopic surgery and is associated with a limited learning curve.

Single-Port robot assisted partial nephrectomy: initial experience and technique with the da Vinci Single-Port platform (IDEAL Phase 1)

BACKGROUND

To evaluate the safety and feasibility of robotic-assisted laparoscopic partial nephrectomy (RAPN) performed using the da Vinci Single-Port (SP) platform.

METHODS

A retrospective review was conducted from December 2018 to December 2019 of 14 consecutive patients with localized renal cancer who underwent SP robot-assisted partial nephrectomy at a single institution. The procedures were performed by 2 experienced robotic surgeons, reproducing the steps of the standard multiport robotic approach to partial nephrectomy. A transperitoneal approach was utilized with a 2.5 cm para-rectus incision with one assistant 12 mm laparoscopic port.

RESULTS

No conversions to open or laparoscopic surgery occurred and no additional laparoscopic assistant ports were required. The median total operative time was 202 (162-231) minutes and the median total room time was 258 (215-295) minutes. The warm ischemia time averaged 20 minutes ± 8 minutes. 2 patients required angioembolization due to postoperative acute bleeding (Clavien-Dindo Grade 3a complication). Trifecta outcome (<25 min warm ischemia, no perioperative complications and negative margins) was achieved in 79% of patients. In one case, a positive margin was present. The median length of stay was of 1 day (Interquartile Range 1-2) with a median pain score on postoperative day 1 of 3.5 (Interquartile Range 2.4-5). 1/14 (7%) patient needed narcotic use at one week from discharge. At a median follow up of 5.0 (4.0-8.0) months, no patients have had evidence of disease recurrence.

CONCLUSIONS

In this initial cohort, considering the introduction of a new technology, we observed satisfactory outcomes for several key perioperative variables including operative time, warm ischemia time, surgical margins, hospital stay, pain requirements in patients undergoing RAPN with the SP platform. For experienced robotic surgeons, RAPN with the SP platform is a safe and feasible approach for single site partial nephrectomy.

Evaluation of new motorized articulating laparoscopic instruments by laparoscopic novices using a standardized laparoscopic skills curriculum

Background

Motorized articulating laparoscopic instruments (ALI) offer more degrees of freedom than conventional laparoscopic instruments (CLI). However, a difficult learning curve and complex instrument handling are still a problem of ALI. We compared the performance of new prototypes of motorized ALI with CLI in a series of standardized laparoscopic tasks performed by laparoscopic novices. Further, usability of the new ALI was assessed.

Methods

A randomized cross-over study with 50 laparoscopic novices who either started with CLI and then changed to ALI (CA) or vice versa (AC) was conducted. All participants performed the European training in basic laparoscopic urological skills (E-BLUS) with each instrument in given order. Time and errors were measured for each exercise. Instrument usability was assessed.

Results

Overall, using CLI was significantly faster (CLI 4:27 min vs. ALI 4:50 min; p-value 0.005) and associated with fewer exercise failures in needle guidance (CLI 0 vs. ALI 12; p-value 0.0005) than ALI. Median amount of errors was similar for both instruments. Instrument sequence did not matter, as CA and AC showed comparable completion times. Regarding the learning effect, participants were significantly faster in the second attempt of exercises than in the first. In the needle guidance task, participants using CLI last demonstrated a significant speed improvement, whereas ALI were significantly slower in the second run. Regarding usability, CLI were preferred over ALI due to lighter weight and easier handling. Nevertheless, participants valued ALI’s additional degrees of freedom.

Conclusion

Using new motorized ALI in the E-BLUS examination by laparoscopic novices led to a worse performance compared to CLI. An explanation could be that participants felt overwhelmed by ALI and that ALI have an own distinct learning curve. As participants valued ALI’s additional degrees of freedom, however, a future application of ALI could be for training purposes, ideally in combination with CLI.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08086-2) contains supplementary material, which is available to authorized users.