Geometry of laparoscopic suturing and knotting techniques

Optimizing ergonomics during open, laparoscopic, and robotic-assisted surgery: A review of surgical ergonomics literature and development of educational illustrations

BACKGROUND

The surgical profession is plagued with a high prevalence of work-related musculoskeletal disorders. While numerous interventions have been tested over the years, surgical ergonomics education is still uncommon.

METHODS

The available literature on surgical ergonomics was reviewed, and with input from surgeons, recommendations from the review were used to create pictorial reminders for open, laparoscopic, and robot-assisted surgical modalities. These simple pictorial ergonomic recommendations were then assessed for practicality by residents and surgeons.

RESULTS

A review of the current literature on surgical ergonomics covered evidence-based ergonomic recommendations on equipment during open and laparoscopic surgery, as well as proper adjustment of the surgical robot for robot-assisted surgeries. Ergonomic operative postures for the three modalities were examined, illustrated, and assessed.

CONCLUSIONS

The resulting illustrations of ergonomic guidelines across surgical modalities may be employed in developing ergonomic education materials and improving the identification and mitigation of ergonomic risks in the operating room.

Ergonomic Considerations in Urologic Surgery

PURPOSE OF REVIEW

This paper aims to discuss the various work-related musculoskeletal disorders (WRMDs) among urologists and provide an overview of the latest recommendations to improve awareness of ergonomic principles that can be applied in the operating room, with special consideration of challenges faced during pregnancy.

RECENT FINDINGS

Urologists suffer from a large burden of WRMDs. The main drivers of pain associated with the various surgical approaches include repetitive movements, static and awkward body positions, and the use of burdensome equipment. Pregnant surgeons are at an even greater risk of WRMDs and face high rates of pregnancy complications. Laparoscopy, endoscopy, robot-assisted surgeries, and open surgeries present unique ergonomic challenges for the practicing urologist. Proper posture and equipment use, optimal operating room setup, intraoperative stretching breaks, and an emphasis on teaching ergonomic principles can reduce the risk of WRMDs. Surgeons are also at increased risk of WRMDs during pregnancy but may continue to operate while taking measures to limit physical exertion and fatigue. Improving awareness of and incorporating ergonomic principles early in a urologist's career may reduce the risk of injury and improve operative performance and longevity.

Snake Robots for Surgical Applications: A Review

Although substantial advancements have been achieved in robot-assisted surgery, the blueprint to existing snake robotics predominantly focuses on the preliminary structural design, control, and human–robot interfaces, with features which have not been particularly explored in the literature. This paper aims to conduct a review of planning and operation concepts of hyper-redundant serpentine robots for surgical use, as well as any future challenges and solutions for better manipulation. Current researchers in the field of the manufacture and navigation of snake robots have faced issues, such as a low dexterity of the end-effectors around delicate organs, state estimation and the lack of depth perception on two-dimensional screens. A wide range of robots have been analysed, such as the i²Snake robot, inspiring the use of force and position feedback, visual servoing and augmented reality (AR). We present the types of actuation methods, robot kinematics, dynamics, sensing, and prospects of AR integration in snake robots, whilst addressing their shortcomings to facilitate the surgeon’s task. For a smoother gait control, validation and optimization algorithms such as deep learning databases are examined to mitigate redundancy in module linkage backlash and accidental self-collision. In essence, we aim to provide an outlook on robot configurations during motion by enhancing their material compositions within anatomical biocompatibility standards.

Surgical ergonomics for urologists: a practical guide

Poor ergonomics in the operating room can have detrimental effects on a surgeon's physical, psychological and economic well-being. This problem is of particular importance to urologists who are trained in nearly all operative approaches (open, laparoscopic, robotic-assisted, microscopic and endoscopic surgery), each with their own ergonomic considerations. The vast majority of urologists have experienced work-related musculoskeletal pain or injury at some point in their career, which can result in leaves of absence, medical and/or surgical treatment, burnout, changes of specialty and even early retirement. Surgical ergonomics in urology has been understudied and underemphasized. In this Review, we characterize the burden of musculoskeletal injury in urologists and focus on various ergonomic considerations relevant to the urology surgeon. Although the strength of evidence remains limited in this space, we highlight several practical recommendations stratified by operative approach that can be incorporated into practice without interrupting workflow whilst minimizing injury to the surgeon. These recommendations might also serve as the foundation for ergonomics training curricula in residency and continuing medical education programmes. With improved awareness of ergonomic principles and the sequelae of injury related to urological surgery, urologists can be more mindful of their operating room environment and identify ways of reducing their own symptoms and risk of injury.

The endoluminal pressures during flexible gastrointestinal endoscopy

In flexible gastrointestinal (GI) endoscopy, endoscopic insufflation is crucial and directly affects visualization. Optimal visualization enables endoscopists to conduct better examinations and administer optimal treatments. However, endoscopic insufflation is typically performed manually and is subjective. We aimed to measure the GI endoluminal pressure during flexible GI endoscopy. Participants underwent esophagogastroduodenoscopy (EGD) at our endoscopy center. Pressure measurement was conducted after completing diagnostic or follow-up EGD. The endoluminal pressure in the esophagus and stomach was measured at 1-s intervals for 1 min while performing EGD for observational and diagnostic purposes. During the measurements, the endoscopists maintained what they subjectively considered to be adequate exposure for screening for lesions by dilating the lumen. Eighty patients were enrolled in this study. The upper GI endoluminal pressure was assessed during EGD without adverse events. The esophageal endoluminal pressure averaged 8.9 (- 3.0 to 20.7) mmHg, and the gastric endoluminal pressure averaged 10.0 (3.0-17.9) mmHg; the upper GI endoluminal pressures were not affected by patient-related factors or the number of endoscopists' postgraduate years. We have successfully obtained the GI endoluminal pressures during EGD. Further accumulation of these data may lead to more stable and reproducible flexible endoscopic diagnosis and intervention.

No-cable and smartphone/tablet: A functional laparoscopic training box "Fu-Lap T-Box"

Because of the long and variable learning curve of laparoscopic surgery, before its actual application, a well-designed practical simulating instruments like laparoscopic training boxes are needed. But because of unfavourable cost-effectiveness and huge sizes of these boxes, surgeons hardly procure, and carry them. We aimed to design a new, cheap, light and handy laparoscopic training box. Our training box is made of aluminium and used with smartphone or tablet. There is no need for a power unit. Our foldable box has dimensions of 52×38×4 cm, and weighs 2.8 kg and foldable. There are 5 working ports in it. Compared to its alternatives "Fu-Lap T-Box" is much cheaper, lighter and more comfortable. In our opinion it is possible to design and use a new cheaper and portable simulator to gain more hands-on experience before the real surgery.

A New Needle Holder Design to Facilitate Intracorporeal Knot Tying

PURPOSE

Intracorporeal knot tying in laparoscopic surgery continues to be a problem especially for beginners and inexperienced surgeons. A wide-angle needle holder was designed to make the knot maneuver easier while also ensuring that the knot does not come out of the needle holder. In this study, it was planned to compare the wide-angle needle holder with the classic needle holder in regard to knot tying time.

MATERIAL AND METHOD

A total of 11 male volunteers were randomly selected from freshmen students of the faculty of medicine, who had no experience of surgery or laparoscopic surgery. After the required training and practice, candidates were asked to tie 3 knots each in the training box using a classic needle holder and a wide-angle needle holder. Their knot tying times were recorded.

RESULTS

Although the students had no experience, it was observed that they tied knots more easily and more comfortably using the wide-angle needle holder. It was found that the knot tying times with the wide-angle needle holder were quite short compared with the classic needle holder in all candidates. This difference was also statistically significant ( P = .01).

CONCLUSION

We believe and claim that the use of a wide-angle needle holder during knot tying in laparoscopic surgery can facilitate knot tying and shorten the duration of the knotting, especially for inexperienced surgeons.

Comparison study of consecutive 100 cases of single port vs. multiport laparoscopic myomectomy; technical point of view

We report our experience with single-port and multiple-port laparoscopic myomectomy with operative outcomes and surgical skills. Hundred consecutive patients underwent single-port laparoscopic myomectomy (SP-LM) and 69 multi-port laparoscopic myomectomy (MP-LM). The operative outcomes were compared between the two methods. All procedures were successfully completed without conversion to abdominal myomectomy. The mean maximum diameter of the largest myoma was 7.4 (5-13) vs. 6.8 (5-12) cm and the mean number of myomas was 1.7 vs. 1.6 in SP-LM and MP-LM group, respectively. Mean operative time was 134.2 vs. 122.9 min in SP-LM and MP-LM group (p = .109). We showed that SPL myomectomy is a safe and feasible technique compared to MPL myomectomy with respect to postoperative pain, mean operating time, mean estimated blood loss and length of stay. To improve suturing technique of SP-LM, the working instruments were placed external to the telescope with 'micro-triangulation'.

Advances in laparoscopic surgery in urology

In the past 10 years, laparoscopy has been challenged by robotic surgery; nevertheless, laparoscopic techniques are subject to continuous change. Ultrahigh definition is the next development in video technology, it delivers fourfold more detail than full high definition resulting in improved fine detail, increased texture, and an almost photographic emulsion of smoothness of the image. New 4K ultrahigh-definition technology might remove the current need for the use of polarized glasses. New devices for laparoscopy include advanced sealing devices, instruments with six degrees of freedom, ergonomic platforms with armrests and a chest support, and camera holders. A manually manipulated robot-like device is still at the experimental stage. Robot-assisted surgery has substantially revolutionized laparoscopy, increasing its distribution; however, robot-assisted surgery is associated with considerable costs. All technical improvements of laparoscopic surgery are extremely valuable to further simplify the use of classical laparoscopy.

A Comparative Study in Learning Curves of Two Different Intracorporeal Knot Tying Techniques

Objectives. In our study we are aiming to analyse the learning curves in our surgical trainees by using two standard methods of intracorporeal knot tying. Material and Method. Two randomized groups of trainees are trained with two different intracorporeal knot tying techniques (loop and winding) by single surgeon for eight sessions. In each session participants were allowed to make as many numbers of knots in thirty minutes. The duration for each set of knots and the number of knots for each session were calculated. At the end each session, participants were asked about their frustration level, difficulty in making knot, and dexterity. Results. In winding method the number of knots tied was increasing significantly in each session with less frustration and less difficulty level. Discussion. The suturing and knotting skill improved in every session in both groups. But group B (winding method) trainees made significantly higher number of knots and they took less time for each set of knots than group A (loop method). Although both knotting methods are standard methods, the learning curve is better in loop method. Conclusion. The winding method of knotting is simpler and easier to perform, especially for the surgeons who have limited laparoscopic experience.

The Intraocular Pressure under Deep versus Moderate Neuromuscular Blockade during Low-Pressure Robot Assisted Laparoscopic Radical Prostatectomy in a Randomized Trial

Background

This study aimed to determine whether continuous deep neuromuscular blockade (NMB) improves the surgical conditions and facilitates robotic-assisted laparoscopic radical prostatectomy (RALRP) under low intra-abdominal pressure (IAP) to attenuate the increase in intraocular pressure (IOP) during CO₂ pneumoperitoneum in the steep Trendelenburg (ST) position.

Methods

Sixty-seven patients undergoing RALRP were randomly assigned to a moderate NMB group (Group M), including patients who received atracurium infusion until the end of the ST position, maintaining a train of four count of 1–2; and the deep NMB group (Group D), including patients who received rocuronium infusion, maintaining a post-tetanic count of 1–2. IOP was measured in all patients at nine separate time points. All RALRPs were performed by one surgeon, who rated the overall and worst surgical conditions at the end of the ST position.

Results

The highest IOP value was observed at T4 (60 min after the ST position) in both Group M (23.3 ± 2.7 mmHg) and Group D (19.8 ± 2.1 mmHg). RALRP was accomplished at an IAP of 8 mmHg in 88% Group D patients and 25% Group M patients. The overall surgical condition grade was 4.0 (3.0–5.0) in Group D and 3.0 (2.0–5.0) in Group M (P < 0.001).

Conclusion

The current study demonstrated that continuous deep NMB may improve surgical conditions and facilitate RALRP at a low IAP, resulting in significant attenuation of the increase on IOP. Moreover, low-pressure pneumoperitoneum, facilitated by deep NMB still provided acceptable surgical conditions.

Trial Registration

ClinicalTrials.gov NCT02109133

Optimizing working space in laparoscopy: CT-measurement of the effect of neuromuscular blockade and its reversal in a porcine model

OBJECTIVE

The objective of this paper was to determine the effect of neuromuscular blockade (NMB) on working space in a porcine laparoscopy model.

BACKGROUND

Conflicting results on the effect of NMB on laparoscopic working space are found in literature. Almost all studies are limited by absence of objective assessment of working space or use surrogate outcomes.

METHODS

In a standardized porcine laparoscopy model, laparoscopic working-space dimensions with and without NMB were investigated in 16 animals using computed tomography at intra-abdominal pressures of 0, 5, 10, and 15 mmHg during multiple runs of abdominal insufflation.

RESULTS

No statistically significant effect of NMB on abdominal dimensions and laparoscopic working-space volume was found during CO2 pneumoperitoneum. In contrast, the effect of pre-stretching of the abdominal wall by a previous abdominal insufflation was found to be significant.

CONCLUSIONS

This experimental study confirms the results from several clinical studies that NMB does not influence laparoscopic working space. Studies dealing with working space during laparoscopy should take note of pre-stretching bias.

Optimizing working space in laparoscopy: CT measurement of the effect of pre-stretching of the abdominal wall in a porcine model

BACKGROUND

Determinants of working space in minimal access surgery have not been well studied. Using computed tomography (CT) to measure volumes and linear dimensions, we are studying the effect of a number of determinants of CO2 working space in a porcine laparoscopy model. Here we report the effects of pre-stretching of the abdominal wall.

METHODS

Earlier we had noted an increase in CO2 pneumoperitoneum volume at repeat insufflation with an intra-abdominal pressure (IAP) of 5 mmHg after previous stepwise insufflation up to an IAP of 15 mmHg. We reviewed the data of this serendipity group; data of 16 pigs were available. In a new group of eight pigs, we also explored this effect at repeat IAPs of 10 and 15 mmHg. Volumes and linear dimensions of the CO2 pneumoperitoneum were measured on reconstructed CT images and compared between the initial and repeat insufflation runs.

RESULTS

Previous stepwise insufflation of the abdomen with CO2 up to 15 mmHg significantly (p < 0.01) increased subsequent working-space volume at a repeat IAP of 5 mmHg by 21 %, 7 % at a repeat IAP of 10 mmHg and 3 % at a repeat IAP of 15 mmHg. The external anteroposterior diameter significantly (p < 0.01) increased by 0.5 cm (14 %) at repeat 5 mmHg. Other linear dimensions showed a much smaller change. There was no statistically significant correlation between the duration of the insufflation run and the volume increase after pre-stretching at all IAP levels.

CONCLUSIONS

Pre-stretching of the abdominal wall allows for the same surgical-field exposure at lower IAPs, reducing the negative effects of prolonged high-pressure CO2 pneumoperitoneum on the cardiorespiratory system and microcirculation. Pre-stretching has important scientific consequences in studies addressing ways of increasing working space in that its effect may confound the possible effects of other interventions aimed at increasing working space.

Optimizing working-space in laparoscopy: measuring the effect of mechanical bowel preparation in a porcine model

BACKGROUND

Adequate working space is a prerequisite for safe and efficient minimal access surgery. No objective data exist in literature about the effect of mechanical bowel preparation (MBP) on working space in laparoscopic surgery. We objectively measured this effect with computed tomography in a porcine laparoscopy model.

METHODS

Using standardized anesthesia, twelve 20-kg pigs without MBP and eight 20-kg pigs with MBP were studied with computed tomography at intra-abdominal pressure (IAP) levels of 0, 5, 10, and 15 mmHg. Volumes and dimensions of the pneumoperitoneum were measured on reconstructed CT images and compared between the pigs with and those without MBP.

RESULTS

A reproducible and statistically significant increase of approximately 500 ml in pneumoperitoneum volume was found in the MBP group at all levels of IAP. This represents a 43 % relative increase at a pneumoperitoneum pressure of 5 mmHg, 21 % at IAP 10 mmHg, and 18 % at IAP 15 mmHg. Peak inspiratory pressure was lower at IAP 0 and 5 mmHg in the MBP group. Anteroposterior diameter in the group with MBP was lower at 0 mmHg, but abdominal dimensions were similar in both groups at all other IAPs. This shows that the gain in working space is due to a diminished volume of the intra-abdominal content and not to compression or displacement of the bowel.

CONCLUSIONS

MBP increases working space by reducing bowel content. Especially at low intra-abdominal working pressures, the increase in working space associated with MBP could represent an important benefit in challenging laparoscopic surgery.

Optimizing working space in porcine laparoscopy: CT measurement of the effects of intra-abdominal pressure

BACKGROUND

Several factors may affect volume and dimensions of the working space in laparoscopic surgery. The precise impact of these factors has not been well studied. In a porcine model, we used computed tomographic (CT) scanning for measuring working space volume and distances. In a first series of experiments, we studied the relationship between intra-abdominal pressure (IAP) and working space.

METHODS

Eleven 20 kg pigs were studied under standardized anesthesia and volume-controlled ventilation. Cardiorespiratory parameters were monitored continuously, and blood gas samples were taken at different IAP levels. Respiratory rate was increased when ETCO₂ exceeded 7 kPa. Breath-hold CT scans were made at IAP levels of 0, 5, 10, and 15 mmHg. Insufflator volumes were compared to CT-measured volumes. Maximum dimensions of pneumoperitoneum were measured on reconstructed CT images.

RESULTS

Respiratory rate had to be increased in three animals. Mild hypercapnia and acidosis occurred at 15 mmHg IAP. Peak inspiratory pressure rose significantly at 10 and 15 mmHg. CT-measured volume increased relatively by 93 % from 5 to 10 mmHg IAP and by 19 % from 10 to 15 mmHg IAP. Comparing CT volumes to insufflator volumes gave a bias of 76 mL. The limits of agreement were -0.31 to +0.47, a range of 790 mL. The internal anteroposterior diameter increased by 18 % by increasing IAP from 5 to 10 mmHg and by 5 % by increasing IAP from 10 to 15 mmHg. At 15 mmHg, the total relative increase of the pubis-diaphragm distance was only 6 %. Abdominal width did not increase.

CONCLUSIONS

CT allows for precise calculation of the actual CO₂ pneumoperitoneum volume, whereas the volume of CO₂ released by the insufflator does not. Increasing IAP up to 10 mmHg achieved most gain in volume and in internal anteroposterior diameter. At an IAP of 10 mmHg, higher peak inspiratory pressure was significantly elevated.

Current status of robotic surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms "robotic surgery, telesurgery, and laparoscopy." A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

Is there a model to teach and practice retroperitoneoscopic nephrectomy?

INTRODUCTION

Although the retroperitoneal approach has been the preferred choice for open urological procedures, retroperitoneoscopy is not the preferred approach for laparoscopy. This study aims to develop a training model for retroperitoneoscopy and to establish an experimental learning curve.

MATERIAL AND METHODS

Fifteen piglets were operated on to develop a standard retroperitoneoscopic nephrectomy (RPN) training model. All procedures were performed with three ports. Intraoperative data (side, operative time, blood loss, peritoneal opening) were recorded. Animals were divided into groups A, the first eight, and B, the last seven cases. Data were statistically analyzed.

RESULTS

We performed fifteen RPNs. The operative time varied from 15 to 50 minutes (median 30 minutes). Blood loss varied from 5 to 100 mL (median 20 mL). We experienced five peritoneal openings; we had two surgical vascular complications managed laparoscopically. There was statistical difference between groups A and B for peritoneal opening (p = 0.025), operative time (p = 0.0037), and blood loss (p = 0.026).

DISCUSSION

RPN in a porcine model could simulate the whole procedure, from creating the space to nephrectomy completion. Experimental learning curve was eight cases, after statistical data analysis.

CONCLUSION

RPN in a porcine model is feasible and could be very useful for teaching and practicing retroperitoneoscopy.

Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery?

PURPOSE

Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy, such as limited degree of freedom, 2D vision, fulcrum, and pivoting effect. Robotic systems provide corresponding solutions as 3D view, intuitive motion and enable additional degrees of freedom. This review provides an overview of the history of medical robotics, experimental studies, clinical state-of-the-art and economic impact.

METHODS

The Medline database was searched for the terms "robot, telemanipulat, and laparoscop." A total of 2,573 references were found. All references were considered for information on robotic assistance in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work.

RESULTS

In experimental studies, current robotic systems showed superior handling and ergonomics compared to conventional laparoscopic techniques. In gynecology especially for hysterectomy and in urology especially for prostatectomy, two procedures formerly performed via an open approach, the robot enables a laparoscopic approach. This results in reduced need for pain medication, less blood loss, and shorter hospital stay. Within abdominal surgery, clinical studies were generally unable to prove a benefit of the robot. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

CONCLUSION

Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. The most promising procedures are those in which the robot enables a laparoscopic approach where open surgery is usually required.

4 Hands/4 Ports Laparoscopic Radical Prostatectomy

Introduction

Radical laparoscopic prostatectomy is a challenging procedure, which requires a steep learning curve and involves normally three operators. Consequently this is an expensive procedure due both to the time spent for surgery in the operating theatre and the number of operators involved. But time consumption and consequently money costs can be reduced thanks to the learning curve enhancement and, moreover, by reducing the number of operators involved. This work is based on the idea of performing laparoscopic prostatectomy with two operators only.

Material and Methods

Our cases are 124 radical laparoscopic prostatectomies, performed from January 2004 until April 2009; of these, 13 non-consecutive, were carried out with 2 operators and 4 ports. The first attempt - not totally successful due to time spent in the operating theatre and to some operational difficulty - was carried out as 60th procedure (learning curve was not complete). Once the method was applied as 103rd procedure, it could then be constantly implemented.

Results

We demonstrate that this option is feasible once the team performing the laparoscopic radical prostatectomy has acquired a good level in the learning curve. The outcomes are very interesting with regard to time consumption (205’ minutes: one minute more than the 3 operators/5 ports procedure) and early oncological and functional results.

Telepresence surgery: first experiences with laparoscopic radical prostatectomy

The concept of an intelligent steerable surgical instrument system has been described by various authors. Since 1998, telesurgical minimally invasive procedures have been performed with the da Vinci system, mainly for cardiac bypass surgery. We present our initial experience using the device for robot-assisted laparoscopic radical prostatectomy. The intuitive surgical system consists of two main components: the surgeon's viewing and control console with 3D-imaging, and the surgical arm unit that positions and manoeuvres detachable surgical instruments. These instruments are introduced via two 8 mm trocars and allow movements in all six degrees of freedom (DoF). The surgeon performs the procedure while seated at the console holding specially designed instruments. Highly specialised computer software and mechanics transmit the surgeon's hand movements exactly to the microsurgical movements of the manipulators at the operative site. The system used is a W-shaped five trocar arrangement, with the robot's arms at the lateral trocars (8 mm) and two assistant trocars medially (10 mm). A sixth trocar was used in the right suprapubic area for retraction of the gland (Foley catheter). The left assistant used different instruments, such as bipolar forceps, Ultracision, and Endoclip, wheras the right assistant mainly used the suction&#150;irrigation device. The Intuitive System was attached after trocar placement and exposure of Retzius' space. We treated six patients (two pT2, four pT3, median Gleason score 6). The operating room time averaged 315 (range 242&#150;480) min, including pelvic lymph-node dissection. No intra-operative complications occured, one patient required transfusions. There were no positive margins, median catheter time was 5 days. Three patients were completely continent after 1 month. Telerobotic laparoscopic radical prostatectomy is feasible. There is a learning curve with the device, mainly due to the magnification, 3D image and lack of tactile feedback. However, the experienced surgeon can become familiar with the device after a short time. There is still a need for further development of instruments for urological procedures.

Robotics and telesurgery – an update on their position in laparoscopic radical prostatectomy

Laparoscopy is handicapped by the reduction of the range of motion from six to only four degrees of freedom. In complicated cases (i.e. radical prostatectomy), there is often a crossing of the hands of surgeon and assistant. Finally, standard laparoscopes allow only 2D-vision. This has a major impact on technically difficult reconstructive procedures such as laparoscopic radical prostatectomy. Solutions include the understanding of the geometry of laparoscopy, but also newly developed surgical robots. During the last five years, there has been an increasing development and experience with robotics in urology. This article reviews the actual results focussing on the benefits and problems of robotics in laparoscopic radical prostatectomy. Own experiences with robot-assisted surgery include more than 1200 laparoscopic radical prostatectomies using a voice-controlled camera-arm (AESOP) as well as six telesurgical interventions with the da Vinci-system. Substantial experimental studies have been performed focussing on the geometry of laparoscopy and new training concepts such as perfused pelvitrainers and models for simulation of urethrovesical anastomosis. The recent literature on robotics in urology has been reviewed based on a MEDLINE/PUBMED research. The geometry of laparoscopy includes the angles between the instruments which have to be in a range of 25 degrees to 45 degrees ; the angles between the instrument and the working plane that should not exceed 55 degrees ; and the bi-planar angle between the shaft of the needle holder and the needle which has to be adapted according to the anatomical situation in range of 90 degrees to 110 degrees . 3-D-systems have not yet proved to be effective due to handling problems such as shutter glasses, video helmets or reduced brightness. At the moment, there are only two robotic surgical systems (AESOP, da Vinci) in clinical use, of which only the da Vinci provides stereovision and all six degrees of freedom (DOF). To date, more than 3000 laparoscopic radical prostatectomies have been performed worldwide at 92 centres with this system. The main advantage of the system represents the translation of open surgical skills to laparoscopy. Despite recent development of basic tools (e.g. bipolar forceps) for the da Vinci robot, investment and maintenance costs still represent the major problem of the device. Additionally, the device does not provide any haptic sense (i.e. tactile feedback). Robotic surgery represents a turning point of surgical research. However, broad use of robotic systems is limited mainly because of the high investment and running costs. Interestingly, more than in the field of cardiac surgery, there seems to be a need for telemanipulators in urology, mainly to reduce the learning curve of standard laparoscopy. However, new training concepts used in combination with mono-tasking computerized robots (AESOP) have proved their efficacy associated with a significant cost reduction.

Laparoscopic ureteral reimplantation: prospective evaluation of medium-term results and current developments

OBJECTIVE

Laparoscopic ureteral reimplantation is a feasible method for treating ureteral pathology with good preliminary results in the literature. In this study, we review our medium-term results for laparoscopic ureteral reimplantation and discuss current developments of this procedure.

MATERIALS AND METHODS

Twenty-four laparoscopic ureteral reimplantations were performed between August 2003 and December 2008 for ureteral strictures or ureteral injuries. The mean age was 53.5 years (8 men, 16 women). Patient demographics, preoperative symptoms, radiological imaging, complications, and postoperative outcomes were analyzed. Ten patients underwent vesicopsoas-hitch, nine patients had a vesicopsoas-hitch combined with Boari-flap, and five had Lich-Gregoir extravesical ureteral reimplantations. Success was defined as relief of obstruction on postoperative imaging studies, as well as symptomatic relief.

RESULTS

Laparoscopic ureteral reimplantations were successfully performed in all patients. The mean operative time was 215 min (131-351). Mean estimated blood loss was 283 ml (50-550). One patient had an intraoperative bowel injury which was managed laparoscopically during the same procedure. There were two postoperative complications; two prolonged ileus and one deep venous thrombosis (DVT). Mean hospital stay was 8.7 days. Average time to return to normal activity was 2.6 weeks. Postoperative radiological imaging studies showed good drainage, without hydronephrosis, in 23 patients (success rate 95.8 %) at a median follow up interval of 35 months.

CONCLUSIONS

Laparoscopic ureteral reimplantation is an effective procedure with good medium-term results. We believe that this procedure will become an established treatment option.

Augmented reality: a new tool to improve surgical accuracy during laparoscopic partial nephrectomy? Preliminary in vitro and in vivo results

BACKGROUND

Use of an augmented reality (AR)-based soft tissue navigation system in urologic laparoscopic surgery is an evolving technique.

OBJECTIVE

To evaluate a novel soft tissue navigation system developed to enhance the surgeon's perception and to provide decision-making guidance directly before initiation of kidney resection for laparoscopic partial nephrectomy (LPN).

DESIGN, SETTING, AND PARTICIPANTS

Custom-designed navigation aids, a mobile C-arm capable of cone-beam imaging, and a standard personal computer were used. The feasibility and reproducibility of inside-out tracking principles were evaluated in a porcine model with an artificially created intraparenchymal tumor in vitro. The same algorithm was then incorporated into clinical practice during LPN.

INTERVENTIONS

Evaluation of a fully automated inside-out tracking system was repeated in exactly the same way for 10 different porcine renal units. Additionally, 10 patients underwent retroperitoneal LPNs under manual AR guidance by one surgeon.

MEASUREMENTS

The navigation errors and image-acquisition times were determined in vitro. The mean operative time, time to locate the tumor, and positive surgical margin were assessed in vivo.

RESULTS AND LIMITATIONS

The system was able to navigate and superpose the virtually created images and real-time images with an error margin of only 0.5 mm, and fully automated initial image acquisition took 40 ms. The mean operative time was 165 min (range: 135-195 min), and mean time to locate the tumor was 20 min (range: 13-27 min). None of the cases required conversion to open surgery. Definitive histology revealed tumor-free margins in all 10 cases.

CONCLUSIONS

This novel AR tracking system proved to be functional with a reasonable margin of error and image-to-image registration time. Mounting the pre- or intraoperative imaging properties on real-time videoendoscopic images in a real-time manner will simplify and increase the precision of laparoscopic procedures.

Complications of laparoscopic pyeloplasty in children

INTRODUCTION

Laparoscopic pyeloplasty in children has been proven to be safe and effective, with comparable results to open surgery. Due to the extension of laparoscopic indications from ablative to reconstructive procedures requiring endoscopic suturing, most centres have plateaued within their learning curve. Based on our own experience with a little more than 100 cases, we focus on the complications and the definitive learning curve of laparoscopic pyeloplasty in children.

MATERIALS AND METHODS

A total of 103 laparoscopic pyeloplasties were performed during the period January 2002 to June 2008. Of these, 102 underwent laparoscopic dismembered pyeloplasty and one underwent laparoscopic vascular hitch for crossing lower pole vessels. Intraoperative incidents/complications were analysed using the Satava classification, and the postoperative complications according to the Clavien classification.

RESULTS

Intraoperative incidents occurred in 2.91% of the cases, mostly without consequences for the child including faulty port placement needing placement of an extra port and umbilical port side bleed. Postoperative complications occurred in 11.65% children and included prolonged ileus, prolonged urinary leak, fever, haematuria and recurrent ureteropelvic junction (UPJ) stenosis. Recurrent UPJ stenosis occurred in 4.85% of children needing reoperation.

CONCLUSIONS

Laparoscopic pyeloplasty in children is not only feasible, but safe and effective. Intraoperative incidents occur in up to 3% of the cases, and complications in 12.9-15.8%. Increased experience, training and knowledge regarding the incidence and management of complications will be able to further reduce these in the future.

Three-dimensional visualisation and articulating instrumentation: Impact on simulated laparoscopic tasks

Laparoscopy requires the development of technical skills distinct from those used in open procedures. Several factors extending the learning curve of laparoscopy include ergonomic and technical difficulties, such as the fulcrum effect and limited degrees of freedom. This study aimed to establish the impact of four variables on performance of two simulated laparoscopic tasks.

METHODS

Six subjects including novice (n=2), intermediate (n=2) and expert surgeons completed two tasks: 1) four running sutures, 2) simple suture followed by surgeon's knot plus four square knots. Task variables were suturing angle (left/right), needle holder type (standard/articulating) and visualisation (2D/3D). Each task with a given set of variables was completed twice in random order. The endpoints included suturing task completion time, average and maximum distance from marks and knot tying task completion time.

RESULTS

Suturing task completion time was prolonged by 45-degree right angle suturing, articulating needle holder use and lower skill levels (all P < 0.0001). Accuracy also decreased with articulating needle holder use (both P < 0.0001). 3D vision affected only maximum distance (P=0.0108). For the knot tying task, completion time was greater with 45-degree right angle suturing (P=0.0015), articulating needle holder use (P < 0.0001), 3D vision (P=0.0014) and novice skill level (P=0.0003). Participants felt that 3D visualisation offered subjective advantages during training.

CONCLUSIONS

Results suggest construct validity. A 3D personal head display and articulating needle holder do not immediately improve task completion times or accuracy and may increase the training burden of laparoscopic suturing and knot tying.

Mechanical Simulators for Training for Laparoscopic Surgery in Urology

BACKGROUND AND PURPOSE

The introduction of laparoscopic surgery into urology has led to new training concepts differing significantly from previous concepts of training for open surgery. This paper focuses on the type and importance of mechanical simulators in laparoscopic training.

MATERIALS AND METHODS

On the basis of our own studies and experience with the development of various concepts of laparoscopic training, including different modules (i.e., Pelvi-trainer, animal models, clinical mentoring) since 1991, we reviewed the current literature concerning all types of simulators. We focused on training for laparoscopic ablative and reconstructive surgery using mechanical simulators.

RESULTS

The principle of a mechanical simulator (i.e., a box with the possibility of trocar insertion) has not changed during the last decade. However, the types of Pelvi-trainers and the models used inside have been improved significantly. According to the task of the simulator, various sophisticated models have been developed, including standardized phantoms, animal organs, and even perfused segments of porcine organs. For laparoscopic suturing, various step-by-step training concepts have been presented. These can be used for determination of the ability of a physician with an interest in laparoscopic surgery, but also to classify the training status of a laparosopic surgeon.

CONCLUSIONS

Training in laparoscopic surgery has become an important topic, not only in learning a procedure, but also in maintaining skills and preparing for the management of complications. For these purposes, mechanical simulators will definitely play an important role in the future.

Laparoscopic intestinal exploration and full-thickness intestinal biopsy in standing horses: a pilot study

OBJECTIVE

To assess a laparoscopic technique for equine intestinal biopsy.

STUDY DESIGN

Experimental study.

ANIMALS

Seven adult horses.

METHODS

Food but not water was withheld for 36 hours before laparoscopy. In 3 horses (group A) standing, right laparoscopic access to different small intestinal segments was compared with ventral median celiotomy access. Inaccessible segments were identified at necropsy. In 4 horses (group B), the feasibility of obtaining full-thickness duodenal and cecal biopsies and any associated morbidity were evaluated. Biopsy specimens were collected during standing right laparoscopy using a 2-step procedure and intracorporeal suturing technique, and abdominal lavage was performed. Horses were monitored clinically and by abdominal fluid cytology and microbial culture, and repeat laparoscopy was performed on day 6.

RESULTS

Standing right flank laparoscopy provided good observation of small intestinal segments and enabled manipulation of all but 15-20 cm of the duodenum and approximately 40 cm more ileum compared with ventral median celiotomy. Group B horses had no complications, no adhesions, and no bacterial growth from peritoneal fluid samples. None of the horses had signs of abdominal pain.

CONCLUSION

A 2-stage intestinal biopsy technique performed during standing, right flank laparoscopy may be a safe alternative to exploratory celiotomy and biopsy in normal horses.

CLINICAL RELEVANCE

Right flank laparoscopy allows biopsy of intestinal segments including duodenum and 50% more of the ileum than is accessible by ventral median celiotomy. This technique should be evaluated in clinical patients.

[Reconstructive procedures in laparoscopic urology]

The introduction of laparoscopic pyeloplasty was the first step towards the development of suturing and knotting techniques. The final breakthrough came with the development of radical prostatectomy since the performance of the urethrovesical anastomosis required highly developed skills in reconstructive surgery. For most laparoscopic surgeons suturing and knot tying became quite familiar henceforth. As a consequence, the interest for other reconstructive procedures has increased tremendously since. Within a very short time pyeloplasty was developed to a surgical standard, and the results compare very favorably with open surgery. A very attractive method is the ureteral reimplantation according to the psoas hitch technique, which, however, does not completely duplicate the open surgical operation. Many patients can potentially be attracted by sacrocolpopexy to treat genital prolapse. The long-term success rate is 92% which is excellent for this indication. Urinary diversion following cystectomy is usually not performed completely intracorporeally, but laparoscopically assisted.

Methods of training using pelvic trainers

During the past decade, the clinical applications of laparoscopic surgery in urology have been growing steadily. The laparoscopic version of various procedures, such as nephrectomy, is becoming the standard of care. This has led to an increased need for laparoscopic training in urology and focused the attention on the various modalities for laparoscopic skill acquisition. The common training modalities for laparoscopy are box trainers, animal and cadaveric laparoscopy, and virtual reality simulators. Each modality carries its own benefits to the practicing surgeon. The box trainers are the first practiced and are basic training simulators. They were first designed to help with training in basic laparoscopic skills and to assist surgeons in getting acquainted with instruments. However, these simple boxes are being upgraded constantly by tissue- and organ-specific models, allowing the surgeon to train in a convenient and cost-effective environment. This article describes the ways to work with box trainers, from basic skills to advanced laparoscopic tasks, and discusses the contribution of these trainers to real surgery as well as their role in defining criterion levels of surgical performance.

The Heilbronn Laparoscopic Training Program for Laparoscopic Suturing: Concept and Validation

BACKGROUND AND PURPOSE

More than a decade after the first description of laparoscopic nephrectomy, an increasing number of laparoscopic procedures are being performed worldwide. Nevertheless, there still exists a significant lack of standardized training programs to teach ablative and, most important, reconstructive laparoscopic operations (i.e., pyeloplasty, radical prostatectomy). We evaluated and validated a new standardized step-by-step program to improve laparoscopic skills and enable trainees not experienced in laparoscopy to perform a urethrovesical anastomosis.

MATERIALS AND METHODS

In an inanimate model (pelvic trainer) with defined trocar positions, the 10 participants were exposed to six reconstructive exercises. The steps consist of improvement of hand-eye coordination (two-row metal-pin model; step I), linear and curved suturing with changing angles of the needle (chicken leg and catheter model; steps II-V), and performance of an anastomosis in a porcine bladder (step VI). Times of 3, 15, 15, 10, 20, and 30 minutes for steps I, II, III, IV,V, and VI, respectively, were defined as the goal before proceeding to the next stage. The time required to succeed in each step and the increase in the speed of suturing and knotting activities were analyzed with the Wilcoxon signed-rank test.

RESULTS

After a mean of 40 hours of training, all participants were able to perform all steps within the specified times and complete an accurate urethrovesical anastomosis in 30 minutes. The time required to succeed before and after training showed a significant decrease (P < 0.05). Continual training in reconstructive procedures decreased the time needed for suturing activities by between 66.3% and 72.2%. The time needed for the knotting activities decreased by between 34.3% and 38.3%.

CONCLUSIONS

Our program enabled participants not experienced in laparoscopy to increase reproducible performance in reconstructive laparoscopy. These results indicate that the challenging parts of reconstructive laparoscopy such as intracorporeal suturing can be taught using a standardized concept. This experience could be incorporated easily by every department developing a laparoscopic training program.

Newly designed laparoscopic retractable dissector and suture passer

We introduce a novel laparoscopic instrument that performs as a dissector and retractable suture passer in preparation for intracorporeal knot tying. The newly designed instrument was developed at our institution to duplicate techniques of vessel ligation in open surgery.

Hand movements in laparoscopic suturing: a simple vector analysis

BACKGROUND

Laparoscopic suturing is a complex task that is vital to the performance of many advanced laparoscopic procedures. Mastery can be difficult and problematic for surgical trainees.

METHODS

We present a description of hand movements in laparoscopic suturing. Complex maneuvers are simplified into linear motions using vectors. The analysis is intended to be a tool for training in the art of laparoscopic surgery.

RESULTS

Linear hand movements in the x and y axes produce opposite motions at the instrument tip. Position along the z axis influences the extent of hand movement relative to the instrument tip. Rotational movements of the hand produce an equal rotation of the instrument tip. Revolution is a complex motion that combines movements in x and y axes. Vector analysis reveals that the arc of revolution must be reversed to produce the desired needle motion.

CONCLUSIONS

A conceptual understanding of hand-movement vectors facilitates the efficient mastery of the complex skills required for laparoscopic suturing.

One-Knot Pyeloplasty

Laparoscopic pyeloplasty represents one of the more advanced reconstructive procedures for the urologist. While early reports were replete with long operative times, there have been several changes that have added to the efficiency of the procedure. In our practice, we have found three changes to be of greatest value: (1) an upper-midline port placement; (2) use of a continuous suture for the anastomosis with a double-armed, knotted suture; and (3) antegrade stent placement.

Acquiring Surgical Skills: A Comparative Study of Open versus Laparoscopic Surgery

OBJECTIVES

A preliminary study to evaluate the feasibility of a protocol for comparing the learning curves for open and laparoscopic surgical procedures.

PARTICIPANTS AND METHODS

Thirteen pre-clinical medical students with no previous surgical training were given intensive coaching in open and laparoscopic surgical techniques for 12 weeks. At the end of this period, their open and laparoscopic skills were assessed by three independent examiners. Individual and aggregate ability scores in various aspects of open and laparoscopic surgery and the time taken to perform the procedures were compared using Student's t-test.

RESULTS

There was no statistically significant difference in the overall scores by the two different techniques ( p=0.057 ). However, differences between the two techniques were significant in certain criteria including tissue dissection (p=0.024), tidiness of gall bladder (p=0.034 ) and liver ( p=0.016 ) specimens and the time taken for the two techniques ( p < or = 0.001 ).

CONCLUSIONS

This study suggests that when inexperienced subjects are given equal training in laparoscopy and open surgery, the overall skills acquired were similar by both methods when assessed after 6 weeks. However, on detailed analysis of the different components of surgery, the laparoscopic skills were deficient in finer dissection, identification of correct planes and two-dimensional perception when compared to open surgery and required more operative time. Our study group perceived that laparoscopy was more difficult to learn than open surgery even after the training. The study group also felt that the training in basic surgical skills during their undergraduate careers would make them more interested in studying surgery and choosing it as a career.

Laparoscopic radical prostatectomy: perioperative complications in an initial and consecutive series of 80 cases

OBJECTIVES

We retrospectively evaluated the intraoperative and early postoperative complications of the initial experience with the first 80 laparoscopic radical prostatectomies performed at our institution.

METHODS

Between January 17, 2001 and July 24, 2002, 80 patients between 53 and 78 years old (mean age 63.8) with clinically localized prostate cancer underwent laparoscopic radical prostatectomy with the Montsouris technique. A total of 24 (30%) staging pelvic lymphadenectomy were performed. The inpatient and outpatient medical records as well as all complications were reviewed.

RESULTS

The pathological tumor stage revealed 18 pT2a (22.5%), 29 pT2b (36.25%), 21 pT3a (26.25%), 10 pT3b (12.5%), 1 pT4 (1.25%), 1 pT4 N1 (1.25%). No conversion was necessary in all cases. Mean operative time was 218 minutes (range 150-420) overall, mean blood loss was 376 ml (range 50-1000) and the mean postoperative hospital stay was 4.5 days (range 3-9). The mean and the median duration of bladder catheterization were respectively 11 and 10 days (range 7-23). Injury to the epigastric vessels was detected intraoperatively in 5 cases (6.25%) with immediate hemostasis achieved. There was 1 death (1.25%) 35 days after a cerebrovascular accident occurred on postoperative day 3. We observed 1 (1.25%) postoperative ileus, hemoperitoneum in 5 cases (6.25%), 2 (2.5%) acute urinary retentions, 6 (7.5%) anastomotic leakages, 1 (1.25%) anastomotic stricture, 1 (1.25%) hydrocele and 2 (2.5%) urinary tract infections.

CONCLUSIONS

In our initial experience laparoscopic radical prostatectomy was performed with no complications in 77.5% of patients. We observed major and minor complications respectively in 16.25% and 6.25% of the patients. Our series provides evidence that the laparoscopic approach is feasible and associated with acceptable perioperative morbidity.

Functional reconstruction and minimally invasive techniques

Recent years have seen notable advances in imaging technologies. Three-dimensional computer-rendered techniques with rapid image acquisition have led to the development of virtual reality imaging. Virtual reality imaging allows interactive intraluminal navigation through any hollow viscus, simulating conventional endoscopy. This technique of virtual endoscopy has been applied to many organs, including the urinary tract. Virtual reality endoscopy is beginning to challenge the gold standard of conventional endoscopic evaluation. Recent advances in laparoscopic surgery are largely attributable to technological improvements in imaging equipment. Laparoscopic ultrasound has become a common adjunct in laparoscopic surgery. In particular, advances in video cameras and digital imaging technology have decreased the steep learning curve associated with laparoscopic procedures. Telerobotic systems offer several advantages to laparoscopic surgery, such as all six degrees of freedom, dexterity enhancement, tremor filtering, and stereovision. In addition, technological breakthroughs allow many procedures to evolve from open operations involving lengthy hospital stays to imaging-guided minimally invasive procedures performed on an outpatient basis. Finally, Internet-based imaging is changing the way in which urology services are delivered, by allowing rapid communication between remote locations.

Robotic and telesurgery: will they change our future?

In urology, at the end of the last millennium, there was an increasing use of computerized technology, extracorporeal shock wave lithotripsy, microwave therapy and high-energy focused ultrasound. However, experience with manipulating robots in urological surgery is still very limited. Laparoscopic surgery is handicapped by a reduction of the range of motion because of the fixed trocar position. The da Vinci system is the first surgical system to address all these problems adequately. The system consists of two main components: the surgeon's viewing and control console with three-dimensional imaging and the surgical arm unit that positions and manoeuvres detachable surgical instruments. The surgeon performs the procedure seated at the console holding specially designed instruments. Telerobotic laparoscopic radical prostatectomy provides advantages such as stereovision, dexterity and tremor filtering, but there is a learning curve with the device, mainly because of the magnification, the three-dimensional image and the lack of tactile feedback. However, after only a short period of time, the experienced surgeon is able to become familiar with the device. The impact of robotics in urological surgery is therefore very promising, and we are convinced that it will totally change the future of urological surgery.

Ergonomic problems associated with laparoscopy

PURPOSE

Failure to understand the ergonomics of laparoscopic surgery has a potential to pose health problems for the surgeons. This study was planned to assess the prevalence, significance, and awareness of ergonomic problems associated with laparoscopy.

MATERIAL AND METHODS

A questionnaire designed to assess the frequency and degree of physical discomfort practicing surgeons experienced and their awareness of the responsible factors was distributed to approximately 350 attendees of the Live International Workshop and CME on Laparoscopic Urologic Surgery. The response sheets were analyzed.

RESULTS

Two hundred four attendees completed the questionnaire, of whom 131 were performing laparoscopic surgery (Group A). The rest (N = 73) were practicing only conventional surgery (Group B). The correct answer to the pictorial question, which tested the correct grip technique, was 81% and 56% in Group A and B, respectively (P = 0.0003). Group A surgeons were significantly (P = 0.04) better at answering the questions on neurapraxia. There was a statistically significant (P = 0.004) increase in the frequency of finger numbness and eye strain in Group A surgeons compared with Group B. Within Group A, finger numbness (P = 0.03) and eye strain (P = 0.002) were significantly greater in the junior laparoscopic surgeons than in senior laparoscopic surgeons. Surgeons having <2 years of laparoscopic surgical experience were significantly more affected.

CONCLUSIONS

Surgeons performing laparoscopy have significant ergonomic problems, especially finger numbness and eye strain. Junior laparoscopic surgeons and surgeons with <2 years of laparoscopic surgical experience are more affected.

Retroperitoneoscopic and laparoscopic suturing: tips and strategies for improving efficiency

BACKGROUND

The difficulties of minimally invasive reconstructive surgery, laparoscopically or retroperitoneoscopically, are caused by spatial limitation and fixed trocar positions and, therefore, restricted movement and handling of the instruments. In addition to a standardization of the technique, continual training, and improved instrument technologies, optimization of the geometry of reconstructive surgery, such as angles and distances between the working ports or the camera and needle position, are imperative to providing an optimal clinical performance.

MATERIALS AND METHODS

After designing a standardized suturing technique and conducting an experimental analysis of the geometric factors important in reconstructive surgery, we transferred these results to our clinical setting. A series of 116 reconstructive laparoscopic and retroperitoneoscopic procedures (nephropexy, pyeloplasty, bladder neck suspension, and radical prostatectomy) were analyzed according to the technical realization and quality of reconstruction. Trocar and table positions were adjusted according to our preliminary results, as were the position of the instruments and camera.

RESULTS

The trocar and instrument positions are critical for the clinical outcome of reconstructive surgery. Continual training in a standardized suturing technique, together with the clinical application of the important geometric rules, can reduce surgery time by 50%. The time required for suturing single knots could be decreased even more: as much as 75%, thus ensuring efficient and safe reconstructive surgery.

CONCLUSION

Reconstructive procedures such as pyeloplasty or radical prostatectomy can be standardized and performed in an acceptable amount of time with adequate quality when adhering to a standardized technique and the important geometric rules. Improved performance in terms of time and quality will increase the acceptance of these procedures, which can help to solve the problem associated with a low total number of indications for laparoscopy and retroperitoneoscopy.