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Emerging technology in minimal access surgery
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Technology in Medicine
Emerging technology in minimal access surgery Ashish Dey*, Vinod K. Malik Department of General Surgery, Sir Ganga Ram Hospital, New Delhi, New Delhi, India
abstract Keywords:
Surgical care has undergone a dramatic change over the past couple of decades with the
Emerging
introduction of more advanced technology into patient care. Image guided and video
Technology
endoscopic procedures not only minimize the trauma of access, but also allows more
Laparoscopy
precision in instrumentation through small ‘ports’ or through anatomic conduits (e.g.,
3D
arteries, veins) or natural orifices (e.g., mouth, anus, vagina). The patient benefits substantially in terms of the short term problems of pain and wound infection and also the long term problems related to hernias and adhesions. However the techniques require acquiring an entirely new skill set for the surgeons and getting familiar with the working of the complex devices, notwithstanding the occasionally prohibitive costs. This article will introduce the latest in image-guided surgery, 3D laparoscopy including robotics, the newest energy sources and the latest in simulation based training and operative planning. Copyright ª 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Laparoscopic surgery has brought about a tremendous change in surgical care in the past couple of decades. With new innovations in digitization, optics, instrumentation and recording technology there is now a radical change in how surgical procedures are performed.1 The advantages of laparoscopic surgery in terms of postoperative morbidity are already beyond debate. It greatly diminishes the incidence of postoperative pain, wound infection, incisional hernias and symptomatic adhesive bowel obstruction in the future. It is basically an image-guided surgery through small incisions in the abdominal wall and obviously diminishes the trauma of access to the patient. The smaller size of the surgical incisions however present some real challenges to the operating surgeon. Apart from requiring an entirely novel skill set for the surgeons it also comes with its own set of drawbacks. Recent advances in technology aims at overcoming these limitations and making surgery safe for the patient. Apart from better instrumentation the entire amalgamation of digital display
and storage allows more and more procedures to be performed and achieved for surgical training. The marriage of surgery and technology brought about various innovations and are being considered below.
1.
3D vision
Laparoscopic imaging on the display monitor is generally monocular compared with the binocular and three-dimensional view in open surgery. This is because traditional telescopes have a single-lens system. Binocular imaging currently available in robotic platforms uses provides the surgeon with a truly immersive three-dimensional view. These are also currently being tried out in routine laparoscopic surgery but necessitates 3D monitors and compatible 3D glasses. Although a little cumbersome they are currently being
* Corresponding author. Tel.: þ91 9971007627, þ91 011 42251317; fax: þ91 011 42251288. E-mail addresses: [email protected] (A. Dey), [email protected] (V.K. Malik). 2352-0817/$ e see front matter Copyright ª 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.cmrp.2014.01.003
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
41
Fig. 1 e Integrated OR.
developed and are undergoing trials to demonstrate superior advantages to the surgeon.2
1.1.
Video documentation
With the current state of High Definition video recording there has been a radical change in the way laparoscopic surgery is being performed. Static images or videos of entire procedures can be edited and stored or achieved online for documentation of findings or for surgical training purposes. These images can be attached to the medical record and stored using Radiologic picture archiving and communication system (PACS) images.3 In this way, they are available for the radiologist, pathologist, and other consultants for real time consultation and videoconferencing resulting in better patient care.1,3 An advantage of modern monitors is its ability to display multiple pieces of information on the imaging screen. Most data are nowadays available digitally and can be routed to any display device. This includes real time display of intraoperative ultrasound, flexible endoscopy or fluoroscopy, or preoperatively acquired images (e.g., computed tomography (CT) or Magnetic resonance imaging (MRI) scans) simultaneously with the laparoscopic images using picture-inpicture, split screen, or quad split screen displays.
1.2.
Integrated operating room
This provides digital information on multiple displays and controlled by the operating surgeon either through soft touch buttons on the camera head, touch screen displays or by voice control. The large flat panel displays multiple images on the screen including laparoscope, flexible endoscope, ultrasound, fluoroscopy and even CT and MRI images. The central display in the surgical field is a touch screen, allowing the surgeon to control everything from image routing to the operating room ambience using voice controls or touch screens in the surgical field (Fig. 1). The surgical team has access to multiple monitors that can be moved to ergonomically convenient positions to display the surgical images and other digital information.1
Any image can be recorded to document the surgical findings. The images or video clips can be simultaneously superimposed with voice recordings or texts or can be edited later. This provides valuable documentation of the surgical findings for the medical record that can be accessed remotely with appropriate security and privileges.
1.3.
Minilaparoscopy
Having realized the tremendous benefit to the patients of laparoscopy, there has been a desire for diminishing the injury of access to internal body cavities. Several approaches have been developed and are being evaluated to assess potential benefit over traditional laparoscopic surgery. The goals are to diminish postoperative pain, accelerate surgical recovery, and improve cosmetic outcome while maintaining the safety and effectiveness of the surgery. One approach is to miniaturize the diameter of the surgical instruments and telescopes further termed ‘minilaparoscopy’. As camera light sensitivity and image quality improve, high-quality images can be obtained through progressively smaller laparoscopes. In minilaparoscopy, surgeons can insert instruments as small as 2 mm into the body cavity through needle-sized incisions, leaving almost no scar. Unfortunately, the reduced access size necessitates improvement and increased precision in instrument design. These instruments are however less robust and more limited in curvature than 5- or 10-mm instruments. The main advantage of minilaparoscopy appears to be a somewhat improved cosmetic outcome, but various studies did not show much overall advantage compared with the widely used conventional laparoscopic procedures.4
2.
Laparoscopic ultrasound
The use of ultrasound in the operating room by surgeons as well as by endoscopists is increasing. Current guidelines and recommendations in the use of laparoscopic ultrasound (LUS) involve assessment of organ systems including Hepatobiliary,
42
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
Gynecology, Adrenal, Pancreas, Kidney and gastrointestinal Stomach among many others. Current Laparoscopic ultrasound scanners are compact, mobile, have high quality and operate in real-time B-mode system.5 Doppler capabilities, preferably color Doppler, real time 3D visualization and possible combining of the preoperative computed tomography (CT) scan data with the “live” ultrasound data for improved imaging are being developed.6 Laparoscopic ultrasound probes have a diameter of less than 10 mm to allow introduction through an 11 mm laparoscopic port and are 35e50 cm long to allow access to all locations in the abdominal cavity. Most commonly used linear array probes have frequencies of 5 MHze10 MHz, with depth of penetration of approximately 4e10 cm (Fig. 2). A flexible tip allows for improved scanning angles. It is however also important to note that the diagnostic yield of the procedure is highly dependent on operator ability, has a steep learning curve, and depends on the lesion size, the disease process and location in the organ system. The diagnostic yield of the investigation also depends on the accurate interpretation of the images and the experience of the surgeon and hence is greatly observer dependent.
2.1. Reduced port surgery/single-incision laparoscopic surgery (SILS) surgery The quest for reduction or elimination of surgical scars lead to the emergence of single-incision laparoscopic surgery. The umbilicus, a congenital cicatrix is used to conceal the access into the abdominal cavity. Multichannel access devices and articulating instruments were developed to facilitate single incision surgery and eventual coining of the term LaparoEndoscopic Single-site Surgery (LESS). This is feasible through two techniques. The single-incision but multi-port technique aptly described as SIMPLE, involves the use of multiple ports through the same surgical scar where conventional laparoscopic instruments can also be used. The other technique involves the use of a single access device that permits the entry of 3 or 4 instruments through a single opening in the umbilicus into which the device is first inserted. The first of these devices to be available was the R-Port (Advanced Surgical Concepts, Wicklow, United Kingdom). Other devices followed and includes SILS port by Covidien (Fig. 3), SLASS by Ethicon, Air Seal by Surgiquest, Octoport, Daikin Surgical, Korea and X-
Fig. 2 e Laparoscopic ultrasound.
Cone by Karl Storz. Some of the terms used to describe this surgery included SPA (single-port access), SLaPP (single laparoscopic port procedure), SILS (single-incision laparoscopic surgery), OPUS (one-port umbilical surgery), NOTUS (natural orifice transumbilical surgery) and E-NOTES (embryonic natural orifice transumbilical endoscopic surgery) among others.7 One of the main problems of single-port surgery was the lack of triangulation resulting in ‘swordfighting’ or the ‘chopsticks’ effect as the instruments going in close to each other clashed with one another and the camera head and telescope and resulting in loss of maneuverability.1,7 Placing all instruments through a single port creates further challenges because it creates a laparoscopic view that is parallel to the instruments, further impeding the surgeon’s depth perception. Articulating graspers and Roticulating instruments that produced a ‘pseudotriangulation’ allowed surgeons to overcome this difficulty. Flexible Laparoscopy utilizes small, flexible instruments that are controlled by a surgeon through a single site. The flexible instruments allow a surgeon to achieve critical angles and visualize relevant anatomy through a single site port. Using straight, rigid instruments through a single incision often forces the surgeon to cross their handsdusing the left hand to control the right instrument, and the right hand to control the left instrument. Flexible Laparoscopy eliminates these drawbacks through intra-abdominal triangulation, and gives the surgeon true left and right motion to control flexible instruments. Small, flexible instruments are manipulated through steerable channels, giving the surgeon control and dexterity. The SPIDER technology (Fig. 4) by TransEnterix systems, North Carolina utilizes this technique to perform laparoscopic surgeries through a single incision. Natural orifice transluminal endoscopic surgery (NOTES) is a novel approach whereby access to the abdominal cavity is achieved through a natural orifice (mouth, rectum, vagina). This presents an entirely new approach whereby flexible endoscopy is amalgamated with laparoscopic skills to achieve a truly scarless surgery. This however is beyond the realm of truly laparoscopic surgery and will not be discussed here.
Fig. 3 e Spider system.
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
43
console and the instruments; this has therefore opened up the concept of ‘telesurgery’. One drawback of this interface is that the surgeon has no tactile sense of the tissues, but must adapt by using visual information. Currently, minimally invasive surgery robotic systems are widely used in urologic surgery and gynecology and, to a lesser extent in cardiac surgery, otolaryngology, and general surgery. The main drawbacks are the costs, bulkiness, setup time for the equipment, and absence of compelling data to show superiority of robotic operations over those done by well-trained laparoscopic surgeons. The advantages of robotic surgery are compelling to say the least in few selected procedures, if the latest clinical studies are anything to go by.8e11 Fig. 4 e Da vinci robot.
3.
Minimally invasive robotic surgery
The original idea of having a wrist-like movement inside the patient’s abdominal cavity has led to the evolution of the current design of the surgical robot. The robot actually works as an interface between the operating surgeon and patient. In this mastereslave relationship, the master (surgeon) sits at a console, in an ergonomic and comfortable position, and uses movements of both hands and feet to control movement of the laparoscope and instruments (slave) in the patient (Fig. 5). The commercially available robotic system uses a proprietary laparoscope with two optical systems providing binocular (three-dimensional) vision. The surgical instruments are wristed near their distal tips, so the movements of the surgeon’s hands can be reproduced by the instruments without the usual limitations of the fulcrum effect seen with traditional laparoscopic instruments. The degrees of freedom of the instrument are increased, making it easier to carry out fine maneuvers than with traditional laparoscopic surgery. The robot can adjust the gain or the scale of movement. In this way, the surgeon can make larger movements to affect very fine movements of the instrument tip. This can be helpful for surgery that requires fine and precise movements, such as suturing small vessels together. The surgeon can work from within the operating room or even remotely because there is no direct contact between the surgeon at the
3.1.
Newer energy sources
In this era of laparoscopic surgery, monopolar and bipolar energy sources are still being extensively used for hemostasis as in the open era. The search for better and safer hemostatic apparatus and the need to shorten the surgical time by avoiding suture ligation of vessels has prompted the development of newer energy sources like argon beam coagulation, ultrasonic coagulation (Harmonic Ace, Johnson and Johnson), and bipolar vessel sealing systems (LigaSure, Covidien). Although they have improved the efficiency and reduced operative times and have also proved their safety, they have also been associated with distressing complications12 of which bleeding and delayed perforations are the most important. The choice of the energy system rests on the proficiency and choice of the operating surgeon keeping in mind that no energy system is foolproof and adequate vigilance is necessary while using them. Companies selling energy devices have tried to integrate the generators of various energy sources in more compact systems thus increasing their versatility. Examples are the ForceTriad (Covidien, USA), THUNDERBEAT (Olympus, Japan) and the Enseal system (Ethicon, USA). The ForceTriad energy platform delivers both enhanced monopolar and bipolar energy with LigaSure tissue fusion technology in an all-in-one unit. The revolutionary THUNDERBEAT platform also integrates Ultrasonic and Advanced BiPolar energies delivered through a single multifunctional instrument, allowing a surgeon to simultaneously seal and cut vessels up to and including 7 mm in size with minimal thermal spread. The integrated Enseal generator incorporates the Enseal vessel sealing device and the harmonic technology in one unit. Recently Cordless ultrasonic dissectors (Sonicision, Covidien) with inbuilt generators and rechargeable battery have been launched that also promises faster dissection, less thermal spread, better hemostasis, and less blade temperature comparable to the previous systems.
4. Simulation for surgical training and operative planning
Fig. 5 e SILS port.
Image-guided surgery, whether performed by laparoscopy, robotics, flexible endoscopy, transcatheter methods, or other techniques generally requires a set of specific technical skills distinct from those required for traditional open surgical procedures. The very idea of simulation in surgical training is
44
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
to reduce the learning curve and has many practical advantages. Repeated practice of the specific skills allows the surgeon to make errors and efforts to correct them. The learner can be allowed to progress at his or her own pace, go beyond the comfort level, and experiment with different techniques or approaches. Performance can be measured in a standardized and objective way and compared with an accepted performance standard (proficiency level).13 The advent of the laparoscopic era, with the shift to imagebased surgical technologies, has required abdominal surgeons to learn new skills. Adaptation to the two-dimensional environment, with the reduction in tactile feedback and increased hand-eye coordination was required and was not easy. Similarly, training programs struggled with how best to prepare residents for laparoscopic surgery. Other factors including an increased focus on patient safety, rising operating room costs, and limitations in resident work hours led to the development of models to allow the acquisition and assessment of fundamental laparoscopic skills outside the operating room, through simulation. Simulation is costly in terms of technologic and human resources. However it is expected that improvement in laparoscopic training and skill acquisition through simulation techniques will ultimately result in improved overall patient care.14
5.
Conclusion
Laparoscopic surgery has been going through a rapid growth spurt as current advancements in technology have been integrated into the operating room. The marriage of technology and medicine should ultimately result in improved patient safety and delivering optimal surgical care.
4. Thakur V, Schlachta CM, Jayaraman S. Systematic review and meta-analysis: minilaparoscopic versus conventional laparoscopic cholecystectomy: a systematic review. Ann Surg. 2011;253:244e258. 5. Jakimowicz JJ. Technical and clinical aspects of intraoperative ultrasound applicable to laparoscopic ultrasound. Endosc Surg Allied Technol. 1994;2:119e126. 6. Bao P, Warmath J, Galloway Jr R, Herline A. Ultrasound-tocomputer-tomography registration for image-guided laparoscopic liver surgery. Surg Endosc. 2005;19:424e429. 7. Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery e current status and controversies. J Minim Access Surg. 2011;7:6e16. 8. Braga LH, Pace K, Demaria J, Lorenzo AJ. Systematic review and meta-analysis of robotic-assisted versus conventional laparoscopic pyeloplasty for patients with ureteropelvic junction obstruction: effect on operative time, length of hospital stay, postoperative complications, and success rate. Eur Urol. 2009;56:848e857. 9. Davis JW, Castle EP, Pruthi RS, Ornstein DK, Guru KA. Robotassisted radical cystectomy: an expert panel review of the current status and future direction. Urol Oncol. 2010;28:480e486. 10. Idrees K, Bartlett DL. Robotic liver surgery. Surg Clin North Am. 2010;90:761e774. 11. Reza M, Maeso S, Blasco JA, Andradas E. Meta-analysis of observational studies on the safety and effectiveness of robotic gynaecological surgery. Br J Surg. 2010;97:1772e1783. 12. Harrell AG, Kercher KW, Heniford BT. Energy sources in laparoscopy. Semin Laparosc Surg. 2004;11:201e209. 13. Faulkner H, Regehr G, Martin J, Reznick R. Validation of an objective structured assessment of technical skill for surgical residents. Acad Med. 1996;71:1363e1365. 14. Sroka G, Feldman LS, Vassiliou MC, Kaneva PA, Fayez R, Fried GM. Fundamentals of laparoscopic surgery simulator training to proficiency improves laparoscopic performance in the operating room e A randomized controlled trial. Am J Surg. 2010;199:115e120.
Conflicts of interest internet references All authors have none to declare.
references
1. Courtney M, Townsend R, Daniel Beauchamp B, Evers M, Mattox Kenneth L. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 19th ed. Philadelphia: Saunders, an Imprint of Elsevier Inc.; 2012:418e428 [chapter 17]. 2. Chan AC, Chung SC, Yim AP, Lau JY, Ng EK, Li AK. Comparison of two-dimensional vs three-dimensional camera systems in laparoscopic surgery. Surg Endosc. 1997;11:438e440. 3. Bitterman N. Technologies and solutions for data display in the operating room. J Clin Monit Comput. 2006;20:165e173.
1. VTS Medical Systems “Custom OR Integration”. Photo. vtsmedical.com 2008 19 July 2013. http://www.vtsmedical.com. 2. Jerby Brian “Laparoscopic Ultrasound Probe”. Photo. cancernetwork.com September 1, 1998 July 19 2013. http:// www.cancernetwork.com. 3. SILS Port. Photo. autosuture.com. 2012, September 24 2013. http://www.autosuture.com/image. 4. Ostrovsky Gene “TransEnterix SPIDER Surgical System”. Photo. medgadget.com Oct 22, 2010 July 19 2013. http://www. medgadget.com. 5. da vinci “da Vinci Surgical System”. Photo. davincisurgery.com 2013 July 2013. http://www. davincisurgery.com.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/cmrp
Technology in Medicine
Emerging technology in minimal access surgery Ashish Dey*, Vinod K. Malik Department of General Surgery, Sir Ganga Ram Hospital, New Delhi, New Delhi, India
abstract Keywords:
Surgical care has undergone a dramatic change over the past couple of decades with the
Emerging
introduction of more advanced technology into patient care. Image guided and video
Technology
endoscopic procedures not only minimize the trauma of access, but also allows more
Laparoscopy
precision in instrumentation through small ‘ports’ or through anatomic conduits (e.g.,
3D
arteries, veins) or natural orifices (e.g., mouth, anus, vagina). The patient benefits substantially in terms of the short term problems of pain and wound infection and also the long term problems related to hernias and adhesions. However the techniques require acquiring an entirely new skill set for the surgeons and getting familiar with the working of the complex devices, notwithstanding the occasionally prohibitive costs. This article will introduce the latest in image-guided surgery, 3D laparoscopy including robotics, the newest energy sources and the latest in simulation based training and operative planning. Copyright ª 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Laparoscopic surgery has brought about a tremendous change in surgical care in the past couple of decades. With new innovations in digitization, optics, instrumentation and recording technology there is now a radical change in how surgical procedures are performed.1 The advantages of laparoscopic surgery in terms of postoperative morbidity are already beyond debate. It greatly diminishes the incidence of postoperative pain, wound infection, incisional hernias and symptomatic adhesive bowel obstruction in the future. It is basically an image-guided surgery through small incisions in the abdominal wall and obviously diminishes the trauma of access to the patient. The smaller size of the surgical incisions however present some real challenges to the operating surgeon. Apart from requiring an entirely novel skill set for the surgeons it also comes with its own set of drawbacks. Recent advances in technology aims at overcoming these limitations and making surgery safe for the patient. Apart from better instrumentation the entire amalgamation of digital display
and storage allows more and more procedures to be performed and achieved for surgical training. The marriage of surgery and technology brought about various innovations and are being considered below.
1.
3D vision
Laparoscopic imaging on the display monitor is generally monocular compared with the binocular and three-dimensional view in open surgery. This is because traditional telescopes have a single-lens system. Binocular imaging currently available in robotic platforms uses provides the surgeon with a truly immersive three-dimensional view. These are also currently being tried out in routine laparoscopic surgery but necessitates 3D monitors and compatible 3D glasses. Although a little cumbersome they are currently being
* Corresponding author. Tel.: þ91 9971007627, þ91 011 42251317; fax: þ91 011 42251288. E-mail addresses: [email protected] (A. Dey), [email protected] (V.K. Malik). 2352-0817/$ e see front matter Copyright ª 2014, Sir Ganga Ram Hospital. Published by Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.cmrp.2014.01.003
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
41
Fig. 1 e Integrated OR.
developed and are undergoing trials to demonstrate superior advantages to the surgeon.2
1.1.
Video documentation
With the current state of High Definition video recording there has been a radical change in the way laparoscopic surgery is being performed. Static images or videos of entire procedures can be edited and stored or achieved online for documentation of findings or for surgical training purposes. These images can be attached to the medical record and stored using Radiologic picture archiving and communication system (PACS) images.3 In this way, they are available for the radiologist, pathologist, and other consultants for real time consultation and videoconferencing resulting in better patient care.1,3 An advantage of modern monitors is its ability to display multiple pieces of information on the imaging screen. Most data are nowadays available digitally and can be routed to any display device. This includes real time display of intraoperative ultrasound, flexible endoscopy or fluoroscopy, or preoperatively acquired images (e.g., computed tomography (CT) or Magnetic resonance imaging (MRI) scans) simultaneously with the laparoscopic images using picture-inpicture, split screen, or quad split screen displays.
1.2.
Integrated operating room
This provides digital information on multiple displays and controlled by the operating surgeon either through soft touch buttons on the camera head, touch screen displays or by voice control. The large flat panel displays multiple images on the screen including laparoscope, flexible endoscope, ultrasound, fluoroscopy and even CT and MRI images. The central display in the surgical field is a touch screen, allowing the surgeon to control everything from image routing to the operating room ambience using voice controls or touch screens in the surgical field (Fig. 1). The surgical team has access to multiple monitors that can be moved to ergonomically convenient positions to display the surgical images and other digital information.1
Any image can be recorded to document the surgical findings. The images or video clips can be simultaneously superimposed with voice recordings or texts or can be edited later. This provides valuable documentation of the surgical findings for the medical record that can be accessed remotely with appropriate security and privileges.
1.3.
Minilaparoscopy
Having realized the tremendous benefit to the patients of laparoscopy, there has been a desire for diminishing the injury of access to internal body cavities. Several approaches have been developed and are being evaluated to assess potential benefit over traditional laparoscopic surgery. The goals are to diminish postoperative pain, accelerate surgical recovery, and improve cosmetic outcome while maintaining the safety and effectiveness of the surgery. One approach is to miniaturize the diameter of the surgical instruments and telescopes further termed ‘minilaparoscopy’. As camera light sensitivity and image quality improve, high-quality images can be obtained through progressively smaller laparoscopes. In minilaparoscopy, surgeons can insert instruments as small as 2 mm into the body cavity through needle-sized incisions, leaving almost no scar. Unfortunately, the reduced access size necessitates improvement and increased precision in instrument design. These instruments are however less robust and more limited in curvature than 5- or 10-mm instruments. The main advantage of minilaparoscopy appears to be a somewhat improved cosmetic outcome, but various studies did not show much overall advantage compared with the widely used conventional laparoscopic procedures.4
2.
Laparoscopic ultrasound
The use of ultrasound in the operating room by surgeons as well as by endoscopists is increasing. Current guidelines and recommendations in the use of laparoscopic ultrasound (LUS) involve assessment of organ systems including Hepatobiliary,
42
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
Gynecology, Adrenal, Pancreas, Kidney and gastrointestinal Stomach among many others. Current Laparoscopic ultrasound scanners are compact, mobile, have high quality and operate in real-time B-mode system.5 Doppler capabilities, preferably color Doppler, real time 3D visualization and possible combining of the preoperative computed tomography (CT) scan data with the “live” ultrasound data for improved imaging are being developed.6 Laparoscopic ultrasound probes have a diameter of less than 10 mm to allow introduction through an 11 mm laparoscopic port and are 35e50 cm long to allow access to all locations in the abdominal cavity. Most commonly used linear array probes have frequencies of 5 MHze10 MHz, with depth of penetration of approximately 4e10 cm (Fig. 2). A flexible tip allows for improved scanning angles. It is however also important to note that the diagnostic yield of the procedure is highly dependent on operator ability, has a steep learning curve, and depends on the lesion size, the disease process and location in the organ system. The diagnostic yield of the investigation also depends on the accurate interpretation of the images and the experience of the surgeon and hence is greatly observer dependent.
2.1. Reduced port surgery/single-incision laparoscopic surgery (SILS) surgery The quest for reduction or elimination of surgical scars lead to the emergence of single-incision laparoscopic surgery. The umbilicus, a congenital cicatrix is used to conceal the access into the abdominal cavity. Multichannel access devices and articulating instruments were developed to facilitate single incision surgery and eventual coining of the term LaparoEndoscopic Single-site Surgery (LESS). This is feasible through two techniques. The single-incision but multi-port technique aptly described as SIMPLE, involves the use of multiple ports through the same surgical scar where conventional laparoscopic instruments can also be used. The other technique involves the use of a single access device that permits the entry of 3 or 4 instruments through a single opening in the umbilicus into which the device is first inserted. The first of these devices to be available was the R-Port (Advanced Surgical Concepts, Wicklow, United Kingdom). Other devices followed and includes SILS port by Covidien (Fig. 3), SLASS by Ethicon, Air Seal by Surgiquest, Octoport, Daikin Surgical, Korea and X-
Fig. 2 e Laparoscopic ultrasound.
Cone by Karl Storz. Some of the terms used to describe this surgery included SPA (single-port access), SLaPP (single laparoscopic port procedure), SILS (single-incision laparoscopic surgery), OPUS (one-port umbilical surgery), NOTUS (natural orifice transumbilical surgery) and E-NOTES (embryonic natural orifice transumbilical endoscopic surgery) among others.7 One of the main problems of single-port surgery was the lack of triangulation resulting in ‘swordfighting’ or the ‘chopsticks’ effect as the instruments going in close to each other clashed with one another and the camera head and telescope and resulting in loss of maneuverability.1,7 Placing all instruments through a single port creates further challenges because it creates a laparoscopic view that is parallel to the instruments, further impeding the surgeon’s depth perception. Articulating graspers and Roticulating instruments that produced a ‘pseudotriangulation’ allowed surgeons to overcome this difficulty. Flexible Laparoscopy utilizes small, flexible instruments that are controlled by a surgeon through a single site. The flexible instruments allow a surgeon to achieve critical angles and visualize relevant anatomy through a single site port. Using straight, rigid instruments through a single incision often forces the surgeon to cross their handsdusing the left hand to control the right instrument, and the right hand to control the left instrument. Flexible Laparoscopy eliminates these drawbacks through intra-abdominal triangulation, and gives the surgeon true left and right motion to control flexible instruments. Small, flexible instruments are manipulated through steerable channels, giving the surgeon control and dexterity. The SPIDER technology (Fig. 4) by TransEnterix systems, North Carolina utilizes this technique to perform laparoscopic surgeries through a single incision. Natural orifice transluminal endoscopic surgery (NOTES) is a novel approach whereby access to the abdominal cavity is achieved through a natural orifice (mouth, rectum, vagina). This presents an entirely new approach whereby flexible endoscopy is amalgamated with laparoscopic skills to achieve a truly scarless surgery. This however is beyond the realm of truly laparoscopic surgery and will not be discussed here.
Fig. 3 e Spider system.
c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
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console and the instruments; this has therefore opened up the concept of ‘telesurgery’. One drawback of this interface is that the surgeon has no tactile sense of the tissues, but must adapt by using visual information. Currently, minimally invasive surgery robotic systems are widely used in urologic surgery and gynecology and, to a lesser extent in cardiac surgery, otolaryngology, and general surgery. The main drawbacks are the costs, bulkiness, setup time for the equipment, and absence of compelling data to show superiority of robotic operations over those done by well-trained laparoscopic surgeons. The advantages of robotic surgery are compelling to say the least in few selected procedures, if the latest clinical studies are anything to go by.8e11 Fig. 4 e Da vinci robot.
3.
Minimally invasive robotic surgery
The original idea of having a wrist-like movement inside the patient’s abdominal cavity has led to the evolution of the current design of the surgical robot. The robot actually works as an interface between the operating surgeon and patient. In this mastereslave relationship, the master (surgeon) sits at a console, in an ergonomic and comfortable position, and uses movements of both hands and feet to control movement of the laparoscope and instruments (slave) in the patient (Fig. 5). The commercially available robotic system uses a proprietary laparoscope with two optical systems providing binocular (three-dimensional) vision. The surgical instruments are wristed near their distal tips, so the movements of the surgeon’s hands can be reproduced by the instruments without the usual limitations of the fulcrum effect seen with traditional laparoscopic instruments. The degrees of freedom of the instrument are increased, making it easier to carry out fine maneuvers than with traditional laparoscopic surgery. The robot can adjust the gain or the scale of movement. In this way, the surgeon can make larger movements to affect very fine movements of the instrument tip. This can be helpful for surgery that requires fine and precise movements, such as suturing small vessels together. The surgeon can work from within the operating room or even remotely because there is no direct contact between the surgeon at the
3.1.
Newer energy sources
In this era of laparoscopic surgery, monopolar and bipolar energy sources are still being extensively used for hemostasis as in the open era. The search for better and safer hemostatic apparatus and the need to shorten the surgical time by avoiding suture ligation of vessels has prompted the development of newer energy sources like argon beam coagulation, ultrasonic coagulation (Harmonic Ace, Johnson and Johnson), and bipolar vessel sealing systems (LigaSure, Covidien). Although they have improved the efficiency and reduced operative times and have also proved their safety, they have also been associated with distressing complications12 of which bleeding and delayed perforations are the most important. The choice of the energy system rests on the proficiency and choice of the operating surgeon keeping in mind that no energy system is foolproof and adequate vigilance is necessary while using them. Companies selling energy devices have tried to integrate the generators of various energy sources in more compact systems thus increasing their versatility. Examples are the ForceTriad (Covidien, USA), THUNDERBEAT (Olympus, Japan) and the Enseal system (Ethicon, USA). The ForceTriad energy platform delivers both enhanced monopolar and bipolar energy with LigaSure tissue fusion technology in an all-in-one unit. The revolutionary THUNDERBEAT platform also integrates Ultrasonic and Advanced BiPolar energies delivered through a single multifunctional instrument, allowing a surgeon to simultaneously seal and cut vessels up to and including 7 mm in size with minimal thermal spread. The integrated Enseal generator incorporates the Enseal vessel sealing device and the harmonic technology in one unit. Recently Cordless ultrasonic dissectors (Sonicision, Covidien) with inbuilt generators and rechargeable battery have been launched that also promises faster dissection, less thermal spread, better hemostasis, and less blade temperature comparable to the previous systems.
4. Simulation for surgical training and operative planning
Fig. 5 e SILS port.
Image-guided surgery, whether performed by laparoscopy, robotics, flexible endoscopy, transcatheter methods, or other techniques generally requires a set of specific technical skills distinct from those required for traditional open surgical procedures. The very idea of simulation in surgical training is
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c u r r e n t m e d i c i n e r e s e a r c h a n d p r a c t i c e 4 ( 2 0 1 4 ) 4 0 e4 4
to reduce the learning curve and has many practical advantages. Repeated practice of the specific skills allows the surgeon to make errors and efforts to correct them. The learner can be allowed to progress at his or her own pace, go beyond the comfort level, and experiment with different techniques or approaches. Performance can be measured in a standardized and objective way and compared with an accepted performance standard (proficiency level).13 The advent of the laparoscopic era, with the shift to imagebased surgical technologies, has required abdominal surgeons to learn new skills. Adaptation to the two-dimensional environment, with the reduction in tactile feedback and increased hand-eye coordination was required and was not easy. Similarly, training programs struggled with how best to prepare residents for laparoscopic surgery. Other factors including an increased focus on patient safety, rising operating room costs, and limitations in resident work hours led to the development of models to allow the acquisition and assessment of fundamental laparoscopic skills outside the operating room, through simulation. Simulation is costly in terms of technologic and human resources. However it is expected that improvement in laparoscopic training and skill acquisition through simulation techniques will ultimately result in improved overall patient care.14
5.
Conclusion
Laparoscopic surgery has been going through a rapid growth spurt as current advancements in technology have been integrated into the operating room. The marriage of technology and medicine should ultimately result in improved patient safety and delivering optimal surgical care.
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Conflicts of interest internet references All authors have none to declare.
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