The use of magnets with single-site umbilical laparoscopic surgery

Magnets in Paediatric Surgery

Magnetism, recognized in ancient Greece and China, is a fundamental physical force influencing numerous domains, including medicine and surgery. Historically, the medical use of magnets dates back over two millennia. As proof, the ancient Sanskrit medical textbook Sushruta Samhita describes the removal of a metallic arrow lodged in the flesh with a magnet. Modern uses span from diagnostic to therapeutic applications, including in paediatric surgery. High-field magnetism, utilized in Magnetic Resonance Imaging and Transcranial Magnetic Stimulation (TMS), shows promise for various medical conditions, including depression and neurodegenerative diseases. Despite controversy surrounding low-field magnetism, its potential remains a topic of interest. One of the applications in paediatric surgery that has been evaluated in a randomized controlled trial is magnetic acupuncture for supplementary treatment of postoperative pain. As most paediatric surgeons are well aware, the use of magnets also poses risks, particularly in children, where ingested magnets can cause severe gastrointestinal complications. Regulations have tightened in response to increasing cases of magnet ingestion-related injuries but more needs to be done to avoid injury. Currently, magnets play crucial roles in a variety of medical applications, including magnetic cell sorting and therapeutic devices. Notably, magnetic compression anastomosis, which uses magnets to facilitate luminal tissue joining, have seen significant advancements. Innovations include devices for oesophageal atresia repair, with recent studies showing promising results in animal models and early clinical trials. Future research should focus on optimizing magnetic devices, expanding their applications, and ensuring safety. The continued exploration of magnetism's effects on living tissues and the development of new magnetic technologies could revolutionize medical and surgical practices, particularly in paediatric care.

Magnetic anchor technique assisted endoscopic submucosal dissection for early esophageal cancer

BACKGROUND

Esophageal cancer has high incidence globally and is often diagnosed at an advanced stage. With the widespread application of endoscopic technologies, the need for early detection and diagnosis of esophageal cancer has gradually been realized. Endoscopic submucosal dissection (ESD) has become the standard of care for managing early tumors of the esophagus, stomach, and colon. However, due to the steep learning curve, difficult operation, and technically demanding nature of the procedure, ESD has currently been committed to the development of various assistive technologies.

AIM

To explore the feasibility and applicability of magnetic anchor technique (MAT)-assisted ESD for early esophageal cancer.

METHODS

Isolated pig esophagi were used as the experimental model, and the magnetic anchor device was designed by us. The esophagi used were divided into two groups, namely the operational and control groups, and 10 endoscopists completed the procedure. The two groups were evaluated for the following aspects: The total operative time, perforation rate, rate of whole mucosal resection, diameter of the peering mucosa, and scores of endoscopists' feelings with the procedure, including the convenience, mucosal surface exposure degree, and tissue tension. In addition, in the operational group, the soft tissue clip and the target magnet (TM) were connected by a thin wire through a small hole at the tail end of the TM. Under gastroscopic guidance, the soft tissue clip was clamped to the edge of the lesioned mucosa, which was marked in advance. By changing the position of the anchor magnet (AM) outside the esophagus, the pulling force and pulling direction of the TM could be changed, thus exposing the mucosal peeling surface and assisting the ESD.

RESULTS

Herein, each of the two groups comprised 10 isolated esophageal putative mucosal lesions. The diameter of the peering mucosa did not significantly differ between the two groups (2.13 ± 0.06 vs 2.15 ± 0.06, P = 0.882). The total operative time was shorter in the operational group than in the control group (17.04 ± 0.22 min vs 21.94 ± 0.23 min, P < 0.001). During the entire experiment, the TM remained firmly connected with the soft tissue clip and did not affect the opening, closing, and release of the soft tissue clip. The interaction between the TM and AM could provide sufficient tissue tension and completely expose the mucosa, which greatly assists the surgeon with the operation. There was no avulsion of the mucosa, and mucosal lesions were intact when peeled. Therefore, the scores of endoscopists' feelings were higher in the operational group than in the control group in terms of the convenience (9.22 ± 0.19 vs 8.34 ± 0.15, P = 0.002), mucosal surface exposure degree (9.11 ± 0.15 vs 8.25 ± 0.12, P < 0.001), and tissue tension (9.35 ± 0.13 vs 8.02 ± 0.17, P < 0.001). The two groups did not significantly differ in the perforation rate and rate of whole mucosal resection.

CONCLUSION

We found MAT-assisted ESD safe and feasible for early esophageal cancer. It could greatly improve the endoscopic operation experience and showed good clinical application prospects.

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.

The role of magnetic anchoring and traction technique in thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve

BACKGROUND

Dissecting lymph nodes along the left recurrent laryngeal nerve (LRLN) is the most challenging step in thoracoscopic-assisted esophagectomy. To retract the proximal esophagus in the existing lymphadenectomy methods, either a special trocar is required to insert and take out endoscopic instruments or thoracic punctures are needed to externally retract the esophageal loop. Therefore, advanced skills for esophageal traction are important to facilitate the LRLN lymphadenectomy and to reduce the incidence of trauma to the chest wall. Herein, we present the magnetic anchoring and traction technique, a novel method for LRLN lymphadenectomy during thoracoscopic esophagectomy.

METHODS

The magnetic anchoring traction system was successfully used to retract the upper thoracic esophagus and to help expose the upper mediastinum in 10 cases of thoracoscopic-assisted esophagectomy. When the external magnet was moved outside of body, the internal magnet was coupled with a magnetic force to pull the proximal esophagus to the appropriate direction, which helped to expose the LRLN and adjacent lymph nodes. The lymph nodes adjacent to the LRLN could then be dissected completely without any damage to the nerve.

RESULTS

In all surgeries, the LRLN and adjacent lymph nodes were well visualized, and the number of trocars used to pass endoscopic instruments for retraction of the proximal esophagus or the number of thoracic punctures for external traction of the esophagus during the surgery were reduced.

CONCLUSIONS

In thoracoscopic-assisted esophagectomy, the magnetic anchoring and traction technique can improve the exposure of the LRLN, facilitate LRLN lymphadenectomy, and reduce chest wall trauma.

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.

Internal Grasper and Magnetic Anchoring Guidance System in Gynecologic Laparoendoscopic Single-site Surgery: A Case Series

STUDY OBJECTIVE

To evaluate and report preliminary data after the use of an internal grasper and magnetic anchoring guidance system (MAGS) to allow free movement and optimal triangulation in the abdominal cavity during gynecologic laparoendoscopic single-site surgery (LESS).

DESIGN

A prospective, single-center case series.

SETTING

The First Affiliated Hospital of Xi'an Jiaotong University.

PATIENTS

Eighteen female patients underwent MAGS-assisted LESS with an internal grasper.

INTERVENTIONS

A single surgeon performed MAGS-assisted LESS on patients with benign gynecologic diseases while documenting operative time, device insertion time, surgeon assessment of technical adaptation, patient-evaluated pain and cosmetic outcomes, adverse events, and blood loss.

MEASUREMENTS AND MAIN RESULTS

Eighteen patients underwent transumbilical MAGS-assisted LESS using an internal grasper from November 1, 2019, to December 31, 2019. The mean operative time and insertion time were 98.7 minutes and 1 minute, respectively. The use of MAGS was easily mastered by the surgeon and considered consistently useful in overcoming the limitations of LESS. The patients reported average pain scores of 4.8, 2.3, and 0.5 immediately, 24 hours, and 1 week after surgery, respectively. All patients expressed satisfaction with the postoperative cosmetic results. No serious complications were observed. The mean blood loss was 43.6 mL.

CONCLUSION

MAGS-assisted LESS is easy to deploy and use for benign gynecologic disease and seems to result in positive outcomes. Larger randomized controlled trials are warranted.

Lessons Learned After 101 Cases of Single-Site Magnetic-Assisted Cholecystectomy in Children

BACKGROUND / PURPOSE

The aim of this report is to present our experience with a magnetic-assisted single-site cholecystectomy technique ("magnachole") in pediatric patients.

METHODS

We performed a retrospective chart review of all patients who underwent magnachole between 2009 and 2019. We evaluated patients' demographics, diagnosis, operative time, complications, conversion rate and length of stay. Additionally, simple lineal regression analysis was conducted to determine if the surgeon's experience, the patient's age at surgery, the patient's gender or the patient's body weight affected operative time.

RESULTS

A total of 101 patients were operated during the analyzed period. The mean age at surgery was 12.6 (range 4 to 19) years, and the mean body weight was 53.7 (range 13.5 to 123) kg. The most frequent indication (91%) was symptomatic cholelithiasis. Mean operative time was 85 (range 45 to 240) min. The mean operative time decreased by 22.7 min (p < 0.001, 95% [CI] 10.35 to 35.13) when we compared the first 51 cases to the last 50 cases. Simple lineal regression showed a reduction of 2.6 min in operative time per year. Age at surgery, gender, and weight did not influence operative time. There were no intraoperative complications. Only 1 case required an additional port to complete the operation. There were no conversions to open cholecystectomy. Median length of stay was 26 h (range 10 to 168).

CONCLUSION

The magnachole technique is safe and effective, and has become our preferred surgical approach for children who need a cholecystectomy. As expected, the operative time decreased as surgeons gain experience with the technique. The technique is feasible regardless of the patient's body habitus.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Single-Port Laparoscopic Cholecystectomy Assisted with Neodymium Magnets: Initial Prospective Experience with 60 Cases

Introduction: Laparoscopic cholecystectomy (LC) is the gold standard performed by the majority of surgeons worldwide, and the use of single-port cholecystectomy remains a matter of debate. Single-port magnetic-assisted cholecystectomy (SPMAC) was described as an alternative because of its ability for proper triangulation and the advantage of reducing port surgery. The objective of this study is to describe the initial experience of SPMAC and evaluate the surgical learning curve. Materials and Methods: A prospective cohort was conducted between February 2017 and August 2018; 60 patients completed the inclusion criteria. Variables analyzed were gender, age, body mass index, American Society of Anesthesiologist (ASA) classification, operative time, hospital stay, intraoperative bleeding, and conversion rate. Postoperative pain was measured with a visual analogue scale (VAS). Aesthetic perception was measured by the cosmetic visual analogue scale (CVAS). The postoperative complications were graded according to Clavien-Dindo classification, and the cumulative sum (CUSUM) model was used for evaluating the learning curve. Results: The mean operatory time was 56.1 minutes. With regard to the postoperative pain variable, the VAS value was 2 out of 10 in 78.33% of patients. With regard to aesthetic satisfaction, CVAS was reported to be 10 out of 10 in 96.67% of patients. Conversion rate was 0%. The learning curve of operative time was reached at the 22nd patient, according to the CUSUM chart. Conclusions: SPMAC is feasible and effective; in our consideration, an acceptable learning curve considering benign gallbladder pathology is one of the most prevalent in general surgery. Further comparative studies with conventional LC and SPMAC need to be performed to conduct a proper comparison.

The use of neodymium magnets in healthcare and their effects on health

The strong magnetic field properties of magnets have led to their use in many modern technologies, as well as in the fields of medicine and dentistry. Neodymium magnets are a powerful type of magnet that has been the subject of recent research. This review provides a brief explanation of the definition, history, and characteristics of rare earth magnets. In addition, a broad overview of results obtained in studies performed to date on the effects of magnets, and neodymium magnets in particular, on body systems, tissues, organs, diseases, and treatment is provided. Though they are used in the health sector in various diagnostic devices and as therapeutic tools, there is some potential for harmful effects, as well as the risk of accident. The research is still insufficient; however, neodymium magnets appear to hold great promise for both diagnostic and therapeutic purposes.

A Soft Retraction System for Surgery Based on Ferromagnetic Materials and Granular Jamming

In recent years, minimally invasive surgery (MIS) has gained wider acceptance among surgeons. MIS requires high skills for the operators, mainly due to its intrinsic technical limitations. Tissue manipulation and retraction remain the most challenging tasks; more specifically liver, stomach, and intestine are the organs mostly involved in retraction tasks for abdominal procedures. The literature reports an increasing interest toward dedicated solutions for abdominal tissue retraction tasks. To overcome the limitations of commercial systems and research prototypes, the aim of this study is the design, the realization, and the validation of a retraction system that is simple, reliable, easy to use, safe, and broadly compatible with MIS. The proposed retractor has two main components: (1) a soft central part with variable stiffness obtained by exploiting the granular jamming phenomenon for assuring, at the same time, safe introduction into the abdominal cavity and stable retraction and (2) two iron cylinders located at the two extremities of the device for anchoring the retractor to the abdominal wall by using the magnetic attraction force between these components and two external permanent magnets. System design has been performed by deeply investigating granular jamming principle and ferromagnetic properties of iron elements. Ex vivo and in vivo assessment has been carried out with the final aim to identify the most appropriate design of each retractor component and to demonstrate the advantages of using a soft system with variable stiffness during a retraction task.

If I had a hammer

We present the case of a 64-year-old man who was referred to our service after sustaining a self-inflicted nail-gun injury to his chest. He received three nails penetrated into his chest. Computer tomography revealed no massive haemorrhage or damage to major vessels. He underwent an emergency sternotomy, two nails caused pericardial perforation and myocardial injury were noted easily and removed easily via sternotomy. Myocardial injury showed a trajectory near the junction of the left anterior descending artery and the diagonal artery with no significant bleeding appreciated. The third nail was deep in the lung parenchyma at the hilum. A pacemaker magnet was used to locate the third nail, which was subsequently removed. Our case demonstrates the use of magnets in emergency surgery, to locate and remove metallic foreign bodies.

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.

Operative and Immediate Postoperative Differences Between Traditional Multiport and Reduced Port Laparoscopic Total Splenectomy in Pediatric Patients

BACKGROUND

Laparoscopy offers many benefits to splenectomy, such as reduced incisional pain and shortened hospital duration. The purpose of this study is to evaluate procedural and outcome differences between multiport (MP) and reduced port (RP) splenectomy when utilized to treat children.

PATIENTS AND METHODS

An institutional review board approved retrospective analysis of all consecutive laparoscopic total splenectomies performed at a single institution between January 2010 and October 2015 was conducted. We evaluated demographics, surgical technique, instance of conversion, operative duration, estimated blood loss, need for intraoperative blood transfusion, postoperative length of stay, time to full feeds, complications, and follow-up duration.

RESULTS

Over a 5-year period, 66 patients less than 20 years of age underwent laparoscopic total splenectomy. RP splenectomy was attempted in 14 patients. The remaining 52 were MP operations. Populations were comparable with regard to demographics. Preoperative splenic volumes (mL) were greater in the RP population (median [IQR]: 1377 [747-1508] versus 452 [242-710], P = .039). RP splenectomy demonstrated no difference compared to MP splenectomy in operative time (153 versus 138 minutes, P = .360), estimated blood loss (120 versus 154 mL, P = .634), or percent of cases requiring intraoperative blood transfusion (14 versus 23, P = .716). By the first postoperative day, 57% of RP and 17% of MP patients could be discharged (P = .005). Thirty-day readmission rates were similar, at 7% for RP and 8% for MP operations. Fever was the indication for all readmissions. Mean duration of follow-up is 28 months for MP and 13 months for RP cases.

CONCLUSION

A reduced number of ports can be safely utilized for total splenectomy in pediatric patients without increasing procedural duration or need for intraoperative blood transfusion. In addition, rate of discharge on the first postoperative day was significantly higher in the RP splenectomy group.

Single-Port Laparoscopic Cholecystectomy for Gall Bladder Polyps

Background and Objectives:

Single-port laparoscopic cholecystectomy (SPLC) was introduced to improve patients' postoperative quality of life and cosmesis over the conventional approach (CLC). The purpose of this case–control study was to compare the outcome of SPLC with that of CLC in a specific disease: gall bladder (GB) polyps.

Methods:

Eligible for the study were all patients with GB polyps who underwent laparoscopic cholecystectomy between June 1, 2009, and June 30, 2011. The 112 patients studied (56 each for SPLC and CLC) were matched by using a propensity score that included gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, history of previous abdominal operation, and pathology outcome. To avoid selection bias caused by the surgeon's choice (often dependent on the degree of inflammation) and to investigate the efficacy of SPLC for a single disease, GB polyps, we excluded patients with acute or chronic cholecystitis.

Results:

Characteristics of the patients matched by a propensity score between SPLC and CLC showed no significant difference. Incidentally detected malignancy was in postoperative pathology in cases in both groups. Although operative time was shorter for SPLC, there was no significant difference in time between the 2 groups. There were 3 open conversions in the CLC group, and an additional port was used in the SPLC group. There was no difference between the groups in hospital stay and postoperative complications.

Conclusion:

In the management of GB polyps, the operative results of SPLC are comparable to those of CLC. We conclude that SPLC is as safe as CLC and has the potential for greater cosmetic satisfaction for patients than CLC. Further trials for objective appraisal of cosmetic outcomes are needed.

Magnetic Surgical Instruments for Robotic Abdominal Surgery

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

Single-incision pediatric endosurgery in newborns and infants

This study focuses on the successful application of single-incision pediatric endosurgery in the treatment of congenital anomalies and acquired diseases in neonates and infants. The purpose of this scientific review consists in highlighting the spectrum, indications, applicability, and effectiveness of single-port endosurgery in children during the first 3 postnatal months.

Validation of a pediatric single-port laparoscopic surgery simulator

BACKGROUND

This study aims to adapt an existing multiport pediatric laparoscopic surgery simulator to be suitable for pediatric single-port laparoscopy and to investigate construct validity for its use as a resource for skills training and assessment.

METHODS

An existing pediatric-sized box trainer was modified to accommodate a commercially available port. A total of 41 participants (18 novices, 16 intermediates and 7 experts) were recruited to complete four curriculum tasks via a single-port access approach. Objective task performance scores were evaluated.

RESULTS

Task completion times and performance scores were significantly different between novices and experts for the peg transfer (P = 0.02, P = 0.008 respectively), pattern cut (P < 0.001, P < 0.001 respectively) and ligating loop (P = 0.038, P = 0.035 respectively). There were significant differences in outcomes between novices and intermediates for all tasks, including the intracorporeal suture task (P ≤ 0.001). There were no significant differences in outcomes between intermediates and experts for all tasks.

CONCLUSIONS

The Pediatric Laparoscopic Surgery (PLS) simulator can be easily adapted for single-port laparoscopic surgery to be construct valid for the peg transfer, ligating loop and pattern cut tasks. There is scope for additional tasks to be developed that focus on the unique technical challenges and skills associated with single-port techniques.

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.

Feasibility and safety of single-incision laparoscopic splenectomy: a systematic review

OBJECTIVE

The aim of this review was to evaluate the feasibility, safety, and potential benefits of single-incision laparoscopic splenectomy (SILS-Sp).

METHODS

We conducted a systemic review of literature between 2009 and 2012 to retrieve all relevant articles.

RESULTS

A total of 29 studies with 105 patients undergoing SILS-Sp were reviewed. Fifteen studies used a commercially available single-port device. The range of body mass index was 14.7-41.4 kg/m(2). Six studies described combined operations including cholecystectomy (n = 8), mesh-pexy (n = 1), and pericardial devascularizaion (n = 1). The ranges of operative times and estimated blood losses were 28-420 min and 0-350 mL, respectively. Of 105 patients, three patients (2.9%) required additional ports, two patients (1.9%) were converted to open, and three patients (2.9%) to conventional multiport laparoscopic splenectomy (overall conversion rate, 4.8%). Postoperative bleeding occurred in two patients (1.9%) who both required reoperation. Overall mortality was 0% (0/105). The length of postoperative stay varied across reports (1-11 d). Among four comparative studies, one showed greater estimated blood loss and lower numeric pain rating scale score in the SILS-Sp group than in the multiport laparoscopic splenectomy group (206.25 ± 142.45 versus 111.11 ± 99.58 mL) and (3.81 ± 0.91 versus 4.56 ± 1.29), respectively. Another comparative study showed that SILS-Sp was associated with a shorter operative time (92.5 versus 172 min; P = 0.003), lower conversion rate, equivalent length of hospital stay, reduced mortality, similar morbidity, and comparable postoperative narcotic requirements.

CONCLUSIONS

In early series of highly selected patients, SILS-Sp appears to be feasible and safe when performed by experienced laparoscopic surgeons. However, as an emerging operation, publication bias is a factor that should be considered before we can draw an objective conclusion.

Novel hybrid (magnet plus curve grasper) technique during transumbilical cholecystectomy: initial experience of a promising approach

OBJECTIVES

The use of magnets in transumbilical cholecystectomy (TUC) improves triangulation and achieves an optimal critical view. Nonetheless, the tendency of the magnets to collide hinders the process. In order to simplify the surgical technique, we developed a hybrid model with a single magnet and a curved grasper.

PATIENTS AND METHODS

All TUCs performed with a hybrid strategy in our pediatric population between September 2009 and July 2012 were retrospectively reviewed. Of 260 surgical procedures in which at least one magnet was used, 87 were TUCs. Of those, 62 were hybrid: 33 in adults and 29 in pediatric patients. The technique combines a magnet and a curved grasper. Through a transumbilical incision, we placed a 12-mm trocar and another flexible 5-mm trocar. The laparoscope with the working channel used the 12-mm trocar. The magnetic grasper was introduced to the abdominal cavity using the working channel to provide cephalic retraction of the gallbladder fundus. Across the flexible trocar, the assistant manipulated the curved grasper to mobilize the infundibulum. The surgeon operated through the working channel of the laparoscope.

RESULTS

In this pediatric population, the mean age was 14 years (range, 4-17 years), and mean weight was 50 kg (range, 18-90 kg); 65% were girls. Mean operative time was 62 minutes. All procedures achieved a critical view of safety with no instrumental collision. There were no intraoperative or postoperative complications. The hospital stay was 1.4±0.6 days, and the median follow-up was 201 days.

CONCLUSIONS

A hybrid technique, combining magnets and a curved grasper, simplifies transumbilical surgery. It seems feasible and safe for TUC and potentially reproducible.

New methods of magnet-based instrumentation for NOTES

INTRODUCTION

Laparoscopic surgery has displaced open surgery as the standard of care for many clinical conditions. NOTES has been described as the next surgical frontier with the objective of incision-free abdominal surgery. The principal challenge of NOTES procedures is the loss of triangulation and instrument rigidity, which is one of the fundamental concepts of laparoscopic surgery. To overcome these problems necessitates the development of new instrumentation. material and methods: We aimed to assess the use of a very simple combination of internal and external magnets that might allow the vigorous multiaxial traction/counter-traction required in NOTES procedures. The magnet retraction system consisted of an external magnetic assembly and either small internal magnets attached by endoscopic clips to the designated tissue (magnet-clip-approach) or an endoscopic grasping forceps in a magnetic deflector roll (magnet-trocar-approach).

RESULTS

We compared both methods regarding precision, time and efficacy by performing transgastric partial uterus resections with better results for the magnet-trocar-approach.

DISCUSSION

This proof-of-principle animal study showed that the combination of external and internal magnets generates sufficient coupling forces at clinically relevant abdominal wall thicknesses, making them suitable for use and evaluation in NOTES procedures, and provides the vigorous multiaxial traction/counter-traction required by the lack of additional abdominal trocars.

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.

Single-incision pediatric endosurgery: a systematic review

BACKGROUND

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes.

MATERIALS AND METHODS

We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed.

RESULTS

We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used.

CONCLUSIONS

A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.

Single-access laparoscopic colectomy utilizing gravity in the lateral decubitus position

BACKGROUND

Only a limited number of instruments can be used in single-access laparoscopic colectomy, and triangulation must be forfeited to avoid instrument collision. We investigated whether this problem could be overcome by performing laparoscopic colectomy by the use of the lateral decubitus position, making full use of gravity.

OBJECTIVE

The aim of this study was to determine whether single-access laparoscopic colectomy could be achieved while maintaining patients in the lateral decubitus position.

DESIGN

This was a prospective study.

SETTING

This single-center study was conducted in a hospital.

PATIENTS

Ten consecutive patients (4 men and 6 women) with stage II or III colon cancer were included.

INTERVENTIONS

Each patient was placed in the lateral decubitus position. Single-port access to the abdomen was provided by a 3.0-cm incision at the umbilicus. The roots of the supplying or draining vessels were isolated and divided for lymphadenectomy. Next, the colon was dissected from a lateral approach, without the help of the assistant. The specimen was extracted from the single-access incision. Extracorporeal or intracorporeal anastomosis was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the feasibility of single-access laparoscopic colectomy in the lateral decubitus position.

RESULTS

There were no intraoperative complications and no need for conversions to conventional laparoscopic surgery, open surgery, or the supine position. The median total surgical time was 154 minutes (interquartile range, 135-220 minutes). Surgical blood loss was slight (<20 mL) in all patients. No postoperative complications occurred. The median postoperative hospital stay was 7 days (interquartile range, 5-7 days).

LIMITATIONS

The sample size was small.

CONCLUSIONS

Our results show that single-access laparoscopic colectomy in the lateral decubitus position is safe and feasible.

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.

SILS: Is It Cost- and Time-Effective Compared to Standard Pediatric Laparoscopic Surgery?

The aim of the study was to review our experience with single-incision laparoscopic surgery (SILS) and to compare costs and operative time to standard laparoscopic surgery (SLS). A prospectively collected database of operative times and costs was analysed for the years 2008–2011. SILS cases were compared to standard laparoscopy on a procedure-matched basis. Patient demographics, on-table time and consumable costs were collated. Descriptive statistics and Mann-Whitney U-test were utilized with SPSS for windows. Analysis of the data demonstrate that neither consumable costs nor operative time were significantly different in each group. Comparing operative costs, SILS appendicectomy, nephrectomy/heminephrectomy, and ovarian cystectomy/oophorectomy showed cost benefit over SLS (£397 versus £467; £942 versus £1127; £394 versus £495). A trend toward higher cost for SILS Palomo procedure is noted (£734 versus £400). Operative time for SILS appendicectomy, nephrectomy/heminephrectomy, and Palomo was lower compared to SLS (60 versus 103 minutes[mins.]; 130 versus 60 mins.; 60 versus 80 mins.). In conclusion, SILS appears to be cost-effective for the common pediatric surgical operations. There is no significant difference in operating time in this series, but small sample size is a limiting factor. Studies with larger numbers will be necessary to validate these initial observations.

Single-port laparoscopic surgery in children: concept and controversies of the new technique

Single-incision laparoscopic surgery (SILS) is emerging as an alternative technique to conventional laparoscopy for the treatment of common surgical diseases. Despite its wide use, the adoption of SILS in children has been slower since the broad application of minimally invasive techniques in children, in general, has historically lagged behind those in adults. This paper reviews the evolution of SILS from its original conception and its application in the field of pediatric surgery.