A randomized comparison of conventional vs articulating laparoscopic needle-drivers for performing standardized suturing tasks by laparoscopy-naive subjects

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of an Articulating Laparoscopic Needle Holder (FlexDex™) Compared to a Conventional Rigid Needle Holder in 2-Dimension Vision Amongst Novices: A Randomised Controlled Study

Aim

This study aims to compare novice performance of advanced bimanual laparoscopic skills using an articulating laparoscopic device (FlexDex™) compared to a standard rigid needle holder amongst surgical novices in 2-dimension (2D) visualisation.

Methods

In this prospective randomised trial, novices (n = 40) without laparoscopic experience were recruited and randomised into two groups, which used either traditional rigid needle holders or the FlexDex™. Both groups performed 10 repetitions of a validated assessment task. Times taken and error rates were recorded, and results were evaluated based on completion times, error rates, and learning curves.

Results

The intervention group that used the FlexDex™ completed 10 attempts of the standardised laparoscopic task slower than the control group that used traditional rigid needle holder (415 s versus 267 s taken for the first three attempts and 283 s versus 187 s taken for the last three attempts, respectively). The difference in average time for the first three and last three attempts reached statistical significance (P < 0.001). Furthermore, the intervention group demonstrated a higher error rate when compared to the control group (9.3 versus 6.2 errors per individual).

Conclusion

When compared to the FlexDex™, the traditional rigid needle holder was observed to be superior in task performance speed, leading to shorter completion times and quicker learning effect, as well as fewer errors.

Key Statement

Traditional rigid needle holder leads to faster task completion times and lower error rates when compared with an articulating laparoscopic needle holder in 2D vision.

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

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

Advances and Trends in Pediatric Minimally Invasive Surgery

As many meta-analyses comparing pediatric minimally invasive to open surgery can be found in the literature, the aim of this review is to summarize the current state of minimally invasive pediatric surgery and specifically focus on the trends and developments which we expect in the upcoming years. Print and electronic databases were systematically searched for specific keywords, and cross-link searches with references found in the literature were added. Full-text articles were obtained, and eligibility criteria were applied independently. Pediatric minimally invasive surgery is a wide field, ranging from minimally invasive fetal surgery over microlaparoscopy in newborns to robotic surgery in adolescents. New techniques and devices, like natural orifice transluminal endoscopic surgery (NOTES), single-incision and endoscopic surgery, as well as the artificial uterus as a backup for surgery in preterm fetuses, all contribute to the development of less invasive procedures for children. In spite of all promising technical developments which will definitely change the way pediatric surgeons will perform minimally invasive procedures in the upcoming years, one must bear in mind that only hard data of prospective randomized controlled and double-blind trials can validate whether these techniques and devices really improve the surgical outcome of our patients.

Robotic-like suturing with FlexDex Surgical System® for difficult laparoscopic suture

The field of laparoscopic surgery has experienced an exponential growth in recent years. Despite great progress in this field, standard laparoscopic tools have not been optimally developed and still has some deficiencies when it comes to mobility and ergonomics. Robotic surgery has attempted to solve these problems by improving the articulation of surgical instruments. However, it presents a series of disadvantages, among which are its high cost, low availability and the need of a specific training, which conditions its profitability and hinders a widespread use. We present the results of a prospective clinical series of 20 cases in which the safety, efficacy and ergonomics of FlexDex® have been tested for performing laparoscopic intracorporeal sutures. The result is a safe and functional tool that offers both control and precision in its handling, while improves the ergonomics of the surgeon. This device represents an alternative that combines the precision and range of movements of robotic surgery with the greater availability of conventional laparoscopy.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Is the Human Brain Capable of Controlling Seven Degrees of Freedom?

BACKGROUND

Conventional rigid laparoscopic instruments offer five degrees of freedom (DOF). Robotic instruments add two independent DOFs allowing unconstrained directional steering. Several nonrobotic instruments have been developed with the additional DOFs, but with these devices, surgeon's wrist movements are not intuitively transmitted into tip movements. In this study, a new articulated instrument has been evaluated. The aim of the study was to compare learning curves and performances of conventional laparoscopic instruments, the da Vinci system and Steerable devices in a crossover study.

MATERIALS AND METHODS

A total of 16 medical students without any laparoscopic experience were trained for 27 h to operate all of a rigid, a robotic, and a new Steerable instrument in a random order. Learning curves and ultimate experience scores were determined for each instrument. Strain in wrist and shoulders was assessed with a visual analog score.

RESULTS

Performing the suturing task with rigid and robot instruments required 4 h of training, compared with 6 h to master the Steerable instrument. After 9 h of training with each instrument, completing the complex suturing pattern required 662 ± 308 s with rigid instruments, 279 ± 90 s with the da Vinci system, and 279 ± 53 s with the Steerable instrument. Pain scores were significantly higher after using the rigid instruments compared with the Steerable instruments.

CONCLUSIONS

Transmission of torque and the presence of additional two DOFs in combination with reduced crosstalk significantly improved the instrument dexterity where the Steerable platform is concerned. Although the learning curve is longer, once mastered, it provides enhanced surgical freedom.

A Novel Intuitively Controlled Articulating Instrument for Reoperative Foregut Surgery: A Case Report

The field of laparoscopic surgery has continued to grow exponentially over the years, prompting new innovative technologies. Despite substantial advancements, standard laparoscopic tools have undergone little design changes and fail to optimize mobility in limited spaces. Advancements in robotics have attempted to address this, allowing for increasing degrees of freedom and articulation of instruments. Even so, this system has proven to be cumbersome with questionable cost-effectiveness. In this study, we present the first use of a solely mechanical intuitively controlled articulating laparoscopic needle driver. The ability to naturally articulate allowed for ease during suturing and knot tying during the critical portions of the operation. The FlexDex surgical instrument demonstrates promise in the field of foregut surgery in addition to other areas of minimally invasive specialties.

Minimally invasive single-site surgery for the digestive system: A technological review

Minimally Invasive Single Site (MISS) surgery is a better terminology to explain the novel concept of scarless surgery, which is increasingly making its way into clinical practice. But, there are some difficulties. We review the existing technologies for MISS surgery with regards to single-port devices, endoscope and camera, instruments, retractors and also the future perspectives for the evolution of MISS surgery. While we need to move ahead cautiously and wait for the development of appropriate technology, we believe that the “Ultimate form of Minimally Invasive Surgery” will be a hybrid form of MISS surgery and Natural Orifice Transluminal Endoscopic Surgery, complimented by technological innovations from the fields of robotics and computer-assisted surgery.

Laparoendoscopic single-site surgery and natural orifice transluminal endoscopic surgery: future perspectives

Hundreds of laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) cases have been reported in the literature across a broad span of urological procedures. Despite this, many hurdles to widespread adoption of these techniques exist, including technical challenges, such as decreased triangulation and unfamiliar viewing angles, and more philosophical issues, such as the necessity of demonstrating benefits of these techniques over conventional laparoscopy. Future research will seek to overcome these obstacles. This may be accomplished with further instrument development, including robotic instrumentation, as well as clinical studies evaluating outcomes of LESS/NOTES operations that may demonstrate advantages in these techniques.