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Gynecologic Laparoscopic Surgery with a Palm-Controlled Laparoscope Holder
February 2004, Vol. 11, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
Gynecologic Laparoscopic Surgery with a Palm-Controlled Laparoscope Holder Roland Polet, M.D., and Jacques Donnez, M.D., Ph.D.
Abstract
(J Am Assoc Gynecol Laparosc 2004, 11(1):73–78)
During laparoscopic surgery, the operator relies on the skills of an assistant, particularly during laparoscope manipulation. If possible, the surgeon would prefer to hold the scope while at the same time operating with both hands similar to open surgery conditions. A palm electronic interface (Lapman) was developed to allow remote control of a laparoscope manipulator and to make laparoscope displacement and instrument manipulation synchronous for the surgeon. It was tested in gynecologic surgery, where it restored vision and instrument manipulation and allowed laparoscopic surgery to be performed with fewer personnel.
In laparoscopic surgery, the surgeon often delegates endoscope manipulation, and thereby vision control, to the assistant; this is a source of some discomfort and ergonomic constraint. To some extent, however, assistance can be considered a versatile feature, as it is influenced by skill, interest, fatigue levels, and, sometimes, simply availability. That assistant-dependent laparoscopic surgery can be unpredictable and led us to think about how to improve surgeon autonomy in endoscopic surgery. We devised and developed a laparoscope holder, autoremote-controlled by the surgeon (Lapman), and tested it in simple gynecologic laparoscopic procedures.
(up-down, backward-forward) beside the operating table during the setup phase. The overall dimension of the manipulator is 37 × 63 cm at the base, with a base height of 110 cm extending to 150 cm, depending on requirements. The laparoscope is held by the shaft connected by the surgeon to the arm so it can be moved three dimensionally in the pelvis. Based on anatomic landmarks that determine no maximum movements of a laparoscope required during surgery, the parts of the arm are designed with motors and brakes. The speed of the movements is nonlinear, slower at the beginning for safety, then increasing, which smooths displacement. A sound signal (beep) tells the user when the end of a movement is reached in one direction. The hand control (Figure 2) is a tiny electronic circuit embedded in silicone that is molded on the surgeon’s palm to raise the thenar eminence of the nondominant hand toward the last three fingers in their natural flexed position. Six knobs corresponding to the six directions are set out on a pad: three rows of two knobs, using the last three fingers. The unit attaches to the index finger under a sterile glove. Pressing a button activates a radiofrequency emission that is recognized by the receiver. The system will move only when a button is pressed; release of the button leads to an immediate stop of the system. Pressing several buttons at once according to a prescribed scheme enables such setup actions as switching on the laser pointer (for the setup phase), backward-forward, up-down movement of the rolling base, and placing the arm in the neutral position. This control is autoclavable, and batteries allow 100 minutes of uninterrupted activation. As there is a learning curve to become accustomed to the position of the buttons on the pad, software was developed to allow training in three-dimensional manipulation
Lapman Description The device was designed as a dynamic laparoscope holder to hold only the endoscope, not instruments, which are directly manipulated by the surgeon. The project was conducted together with a commercial company (MEDSYS, Gembloux, Belgium) to engineer the manipulator. The ideal laparoscope holder should cause the least possible hindrance to the surgeon and instruments in the operating area, be motorized to enable the laparoscope to move in three planes to cover the whole surgical field (in-out, left-right, up-down), be equipped with a discrete remote hand-control, and meet requirements of cost-effectiveness, taking into account health care constraints. The system consists of two parts: the manipulator that holds the laparoscope, and the hand control that remotely controls the laparoscope’s three-dimensional displacement. The manipulator is composed of a rolling base, supporting the arm, and a shaft (Figure 1). The rolling base is mounted on motorized wheels so that it can move in two planes
From the Department of Gynaecology, Cliniques Universitaires Saint-Luc, Louvain-en-Woluwe, Belgium (both authors). Corresponding author Roland Polet, M.D., Department of Gynaecology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Louvain-enWoluwe, Belgium. Dr. Polet receives royalties from the manufacturer, MEDSYS, Belgium. Submitted January 23, 2003. Accepted for publication July 16, 2003. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, February 2004, Vol. 11 No. 1 © 2004 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
73
Palm-Controlled Laparoscope Holder Polet and Donnez
FIGURE 1. Lapman laparoscope holder.
outside the operating room using a hand-controlled joystick connected to the computer’s serial port.
As the manipulator acts as a linear translator for the laparoscope through the shaft connection, it is mandatory to calibrate it by approximating, as closely as possible, its geometric center (marked by a laser pointer) with the geometric center of the patient (umbilicus) during setup. The working volume can be defined as a trapezoidal cube with an x-y-z axis. First, the x axis of the laparoscope is paralleled to the x axis (inclination) of the assistant by visual approximation. Then, the surgeon determines the laparoscope position that is considered to be the central (z), highest (y), and most cranial points (x) of working volume (Figure 3). A helium-neon laser-pointing system mounted on the manipulator indicates the geometric position of the machine and must coincide with the patient’s umbilicus. The autoclavable sterile shaft is clipped onto the scope and
Surgical Technique The manipulator is placed on the right side of the patient, parallel to the table; it is set in the neutral position. The floor must be free of cables and obstacles that would impede movement of the rolling base. The patient is placed in dorsolithotomy position with the perfused right arm beside her. The Lapman is fully covered with a transparent sterile drape. The laparoscope is introduced with the patient in Trendelenburg position. Once the diagnostic phase of laparoscopy is complete, one proceeds to laser calibration of the manipulator.
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February 2004, Vol. 11, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 2. Lapman hand control under glove of surgeon’s left hand.
FIGURE 3. Working volume of Lapman manipulator.
75
Palm-Controlled Laparoscope Holder Polet and Donnez
controlled robot, and the Endosista (Armstrong, High Wycombe, UK)2 moves in accordance with the surgeon’s head, which it tracks using a headband pointer. Imagtrack (Olympus, Tokyo, Japan)3 is an immobile 13-mm cameralaparoscope, inside which a mobile chip is displaced in the x-y axis, under voice or fingertip control, through a unit attached to the handle of the left instrument. These dynamic laparoscope holders must be clearly distinguished from the fully integrated and most expensive robots4 (Zeus, Computer Motion, Santa Barbara, CA; Intuitive, Intuitive Surgical, Sunnyvale, CA), which manipulate not only the endoscope but also the instruments themselves, allowing telesurgery among other things. The surgeon’s and assistant’s positions around the manipulator are peculiar to each speciality. In gynecology, the assistant, if available, is best placed between the patient’s legs (Figure 4); a longer shaft allows interpositioning of the assistant to the right of the patient, in front of the operator. The importance of correct calibration of the system cannot be overemphasized; it is essential to obtain clean movements. The device was conceived to rotate and slide along a central axis called the zero point. Neglecting to approximate the umbilicus carefully with the zero point can cause the system to generate minor disturbances in movements due to a lever arm effect. This laparoscope manipulator has several advantages. Like any other, it provides the surgeon with a steady image, which is useful for suturing and helps in orientation. Latent response to the surgeon’s command is virtually nil. The device allows one to work with fewer personnel; in straightforward operations it is possible to operate alone in comfortable conditions, the only function assigned to the circulating nurse being manipulation of the uterus from below. Upper abdominal surgery can be performed by rotating the device cranially. Finally, this instrument is likely to be cost effective, as many insurance carriers do not pay for an assistant in some laparoscopic procedures. The present version of the Lapman does have some limitations. Fog formation could force the surgeon to put down the instruments, disconnect the laparoscope, retrieve it, wipe it, and reintroduce it, thus interfering with fluency of the operation. Practically, the simple use of antifog solution is enough to avoid this problem. Cleaning the lens in such conditions takes less than 15 seconds. Investigative literature5 on dynamic laparoscope positioning noted that the frequency of lens wiping due to fog formation is significantly reduced compared with human manipulation of the laparoscope. Obliquity is possible in the x-y axis but not in the y-z and x-z axes; in the latter axes, displacement is sequential and requires separate activation of the knobs. Generally, as movements obtained with most laparoscope holders are sequential, not oblique, these systems do not cope well with the need to move around a lot on the target. Extensive adhesiolysis, bulky targets (large uteri, large ovarian cysts), and two distant operative fields in the same operation (laparoscopic promontofixation) are not ideally served by this manipulator and should give preference to human assistance.
inserted into the arm of the manipulator through the sterile drape covering the scope holder. The complete setup takes less than 3 minutes. Surgery can then begin. Discussion The general organization and positioning of the surgical team around the operating table is a matter of surgeon’s preference. Formerly, the telescope was manipulated by the surgeon who was thus sacrificing one hand for visual control of surgery. Manipulation of laparoscopic instruments one by one was performed with the remaining hand, other instruments being delegated to an assistant. Alternatively, and most commonly, manipulation of the laparoscope can be assigned to an assistant, which affords the surgeon fluency and speed during surgery by restoring symbiotic control of both hands. However, management of the optical field is directly dependent on the qualities of the assistant, whose ability to anticipate may not always be optimal; indeed, not uncommonly, the assistant may be unaware of the next step of the operation. The ideal and most comfortable solution would be to restore the surgeon’s control of both hands and eyes without intermediaries. Development of an adequate user-friendly interface to pilot navigation of the scope is of crucial ergonomic importance to the surgeon. The task was to find which neuromuscular function could be used to achieve command of six degrees of freedom without interfering with other functions. We chose to regulate control of the laparoscope holder with the last fingers of the left hand, which is usually the nondominant hand whose function in dissection is limited to traction, retraction, and irrigation, relatively trivial tasks. A foot pedal such as the Aesop robot (Computer Motion, Santa Barbara, CA) requires eye control and can be uncomfortable to use over time1. Besides, the foot is often used to accomplish intermittent actions such as coagulation. Voice interface is an attractive idea but limited by two drawbacks: latent response to the order, slowing down the operation when the surgeon has to move about frequently, and the impossibility of moving obliquely. The idea of scope holders is not new; static laparoscope holders have existed for a long time. Although they give the most stable image on the video screen, they are unable to follow dynamically, in real time, changes in the operative field required by the surgeon, unless the surgeon puts down one instrument in order to move the scope holder, interrupting concentration and impeding the general fluency of the operation. Besides providing steadiness and a substitute for human assistance, dynamic versions of these devices were developed to offer simultaneous visual control and instrument manipulation. In an open surgical field, the surgeon’s eyes and hands work in simultaneous interrelation. These machines differ in technology (influencing the price) and the interface used for command. Ideal characteristics should take into account cost, robustness, awkwardness, setup time, user-friendliness of the control unit, and response time to command. For example, the Aesop 30001 is a voice-
76
February 2004, Vol. 11, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Indications for the Lapman in Laparoscopic Surgery Lapman Function Single or first assistant
Second assistant (laparoscope stability)
Indication Adnexal surgery (ovariectomy, adnexectomy, salpingotomy, salpingectomy, ectopic pregnancy, ovarian cystectomy) Small to moderate-size laparoscopic hysterectomy (LH, LASH) Myomectomy Tubal microsurgery and suturing
LH = laparoscopic hysterectomy; LASH = laparoscopicassisted subtotal hysterectomy.
TABLE 2. Gynecologic Laparoscopic Procedures Performed with the Lapman Procedure Adnexectomy Ovarian cystectomy Salpingostomy (ectopic pregnancy) Salpingectomy Myomectomy (subserosal) LASH Diagnostic laparoscopy
Number 18a 7 2 5 4 4 8
LASH = laparoscopic-assisted subtotal hysterectomy. aOne case of severe adhesions in a woman with a history of pelvic surgery required one assistant.
courses were uncomplicated. There is a learning curve of around five cases to become familiar with the position of the knobs on the palm pad. Software allows navigation in a three-dimensional pelvic environment using a palm-pad joystick connected to the serial port of the surgeon’s office computer, making training outside the operating room possible. Now that laparoscopic surgery has clearly been validated, future developments in this field will involve improvements in surgeon comfort by attempting, among other things, to grant operators full autonomy of movement and vision. In surgery, eyes and fingers work together; anything that alters this relationship must be examined and improved, a goal that dynamic laparoscope manipulators try to achieve. The second goal relates to the quality of assistance. In contrast to academic institutions where operating rooms are generally overstaffed and the assistants are well qualified, having good assistance in peripheral hospitals, if any at all, can be problematic. Moreover, it is hard to imagine that straightforward basic laparoscopy cases will always require two operators; staff shortages should not be an
FIGURE 4. Setup for gynecologic surgery. (A) = assistant, (S) = surgeon.
This observation raises an interesting point about such scope holders: they allow the surgeon to operate with few personnel for straightforward uncomplicated procedures (solo surgery) and therefore help in scheduling surgical assistance: no-assistance surgery could be possible for adnexal surgery of moderate size (5–6 cm) and subtotal hysterectomy of (sub)normal uterine size, whereas human assistance could be reserved for more complex cases (Table 1). Future developments in hand control and improved ergonomics combined with the learning process will probably enable surgeons to operate on more complex pathologies using this technology. Clinical experience is available from 48 cases in which Lapman was used successfully and uneventfully in gynecologic laparoscopic surgery (Table 2); all postoperative
77
Palm-Controlled Laparoscope Holder Polet and Donnez
obstacle to performing endoscopic surgery. In this respect, future developments in the field of artificial assistance and surgical ergonomics will be closely followed.
3. Niebuhr H, Born O: Image tracking system. A new technique for safe and cost-saving laparoscopic operation. Chirugerie 2000, 71:580–4.
References
4. Falcone T, Goldberg JM, Margossian H, et al: Robotic-assisted laparoscopic microsurgical tubal anastomosis. Fertil Steril 2000, 73:1040–2.
1. Mettler L, Ibrahim M, Jonat W: One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynaecological surgery. Hum Reprod 1998, 13:2748–50.
5. Omote K, Feussner H, Ungeheuer A, et al: Self-guided robotic camera control for laparoscopic surgery compared with human camera control. Am J Surg 1999, 177:321–4.
2. Yavuz Y, Ystgaard B, Skogvoll E, et al: A comparative experimental study evaluating the performance of surgical robots Aesop and Endosista. Surg Laparosc Endosc Percutan Tech 2000, 10:163–7.
78
The Journal of the American Association of Gynecologic Laparoscopists
Gynecologic Laparoscopic Surgery with a Palm-Controlled Laparoscope Holder Roland Polet, M.D., and Jacques Donnez, M.D., Ph.D.
Abstract
(J Am Assoc Gynecol Laparosc 2004, 11(1):73–78)
During laparoscopic surgery, the operator relies on the skills of an assistant, particularly during laparoscope manipulation. If possible, the surgeon would prefer to hold the scope while at the same time operating with both hands similar to open surgery conditions. A palm electronic interface (Lapman) was developed to allow remote control of a laparoscope manipulator and to make laparoscope displacement and instrument manipulation synchronous for the surgeon. It was tested in gynecologic surgery, where it restored vision and instrument manipulation and allowed laparoscopic surgery to be performed with fewer personnel.
In laparoscopic surgery, the surgeon often delegates endoscope manipulation, and thereby vision control, to the assistant; this is a source of some discomfort and ergonomic constraint. To some extent, however, assistance can be considered a versatile feature, as it is influenced by skill, interest, fatigue levels, and, sometimes, simply availability. That assistant-dependent laparoscopic surgery can be unpredictable and led us to think about how to improve surgeon autonomy in endoscopic surgery. We devised and developed a laparoscope holder, autoremote-controlled by the surgeon (Lapman), and tested it in simple gynecologic laparoscopic procedures.
(up-down, backward-forward) beside the operating table during the setup phase. The overall dimension of the manipulator is 37 × 63 cm at the base, with a base height of 110 cm extending to 150 cm, depending on requirements. The laparoscope is held by the shaft connected by the surgeon to the arm so it can be moved three dimensionally in the pelvis. Based on anatomic landmarks that determine no maximum movements of a laparoscope required during surgery, the parts of the arm are designed with motors and brakes. The speed of the movements is nonlinear, slower at the beginning for safety, then increasing, which smooths displacement. A sound signal (beep) tells the user when the end of a movement is reached in one direction. The hand control (Figure 2) is a tiny electronic circuit embedded in silicone that is molded on the surgeon’s palm to raise the thenar eminence of the nondominant hand toward the last three fingers in their natural flexed position. Six knobs corresponding to the six directions are set out on a pad: three rows of two knobs, using the last three fingers. The unit attaches to the index finger under a sterile glove. Pressing a button activates a radiofrequency emission that is recognized by the receiver. The system will move only when a button is pressed; release of the button leads to an immediate stop of the system. Pressing several buttons at once according to a prescribed scheme enables such setup actions as switching on the laser pointer (for the setup phase), backward-forward, up-down movement of the rolling base, and placing the arm in the neutral position. This control is autoclavable, and batteries allow 100 minutes of uninterrupted activation. As there is a learning curve to become accustomed to the position of the buttons on the pad, software was developed to allow training in three-dimensional manipulation
Lapman Description The device was designed as a dynamic laparoscope holder to hold only the endoscope, not instruments, which are directly manipulated by the surgeon. The project was conducted together with a commercial company (MEDSYS, Gembloux, Belgium) to engineer the manipulator. The ideal laparoscope holder should cause the least possible hindrance to the surgeon and instruments in the operating area, be motorized to enable the laparoscope to move in three planes to cover the whole surgical field (in-out, left-right, up-down), be equipped with a discrete remote hand-control, and meet requirements of cost-effectiveness, taking into account health care constraints. The system consists of two parts: the manipulator that holds the laparoscope, and the hand control that remotely controls the laparoscope’s three-dimensional displacement. The manipulator is composed of a rolling base, supporting the arm, and a shaft (Figure 1). The rolling base is mounted on motorized wheels so that it can move in two planes
From the Department of Gynaecology, Cliniques Universitaires Saint-Luc, Louvain-en-Woluwe, Belgium (both authors). Corresponding author Roland Polet, M.D., Department of Gynaecology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate, 10, 1200 Louvain-enWoluwe, Belgium. Dr. Polet receives royalties from the manufacturer, MEDSYS, Belgium. Submitted January 23, 2003. Accepted for publication July 16, 2003. Reprinted from the JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS, February 2004, Vol. 11 No. 1 © 2004 The American Association of Gynecologic Laparoscopists. All rights reserved. This work may not be reproduced in any form or by any means without written permission from the AAGL. This includes but is not limited to, the posting of electronic files on the Internet, transferring electronic files to other persons, distributing printed output, and photocopying. To order multiple reprints of an individual article or request authorization to make photocopies, please contact the AAGL.
73
Palm-Controlled Laparoscope Holder Polet and Donnez
FIGURE 1. Lapman laparoscope holder.
outside the operating room using a hand-controlled joystick connected to the computer’s serial port.
As the manipulator acts as a linear translator for the laparoscope through the shaft connection, it is mandatory to calibrate it by approximating, as closely as possible, its geometric center (marked by a laser pointer) with the geometric center of the patient (umbilicus) during setup. The working volume can be defined as a trapezoidal cube with an x-y-z axis. First, the x axis of the laparoscope is paralleled to the x axis (inclination) of the assistant by visual approximation. Then, the surgeon determines the laparoscope position that is considered to be the central (z), highest (y), and most cranial points (x) of working volume (Figure 3). A helium-neon laser-pointing system mounted on the manipulator indicates the geometric position of the machine and must coincide with the patient’s umbilicus. The autoclavable sterile shaft is clipped onto the scope and
Surgical Technique The manipulator is placed on the right side of the patient, parallel to the table; it is set in the neutral position. The floor must be free of cables and obstacles that would impede movement of the rolling base. The patient is placed in dorsolithotomy position with the perfused right arm beside her. The Lapman is fully covered with a transparent sterile drape. The laparoscope is introduced with the patient in Trendelenburg position. Once the diagnostic phase of laparoscopy is complete, one proceeds to laser calibration of the manipulator.
74
February 2004, Vol. 11, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
FIGURE 2. Lapman hand control under glove of surgeon’s left hand.
FIGURE 3. Working volume of Lapman manipulator.
75
Palm-Controlled Laparoscope Holder Polet and Donnez
controlled robot, and the Endosista (Armstrong, High Wycombe, UK)2 moves in accordance with the surgeon’s head, which it tracks using a headband pointer. Imagtrack (Olympus, Tokyo, Japan)3 is an immobile 13-mm cameralaparoscope, inside which a mobile chip is displaced in the x-y axis, under voice or fingertip control, through a unit attached to the handle of the left instrument. These dynamic laparoscope holders must be clearly distinguished from the fully integrated and most expensive robots4 (Zeus, Computer Motion, Santa Barbara, CA; Intuitive, Intuitive Surgical, Sunnyvale, CA), which manipulate not only the endoscope but also the instruments themselves, allowing telesurgery among other things. The surgeon’s and assistant’s positions around the manipulator are peculiar to each speciality. In gynecology, the assistant, if available, is best placed between the patient’s legs (Figure 4); a longer shaft allows interpositioning of the assistant to the right of the patient, in front of the operator. The importance of correct calibration of the system cannot be overemphasized; it is essential to obtain clean movements. The device was conceived to rotate and slide along a central axis called the zero point. Neglecting to approximate the umbilicus carefully with the zero point can cause the system to generate minor disturbances in movements due to a lever arm effect. This laparoscope manipulator has several advantages. Like any other, it provides the surgeon with a steady image, which is useful for suturing and helps in orientation. Latent response to the surgeon’s command is virtually nil. The device allows one to work with fewer personnel; in straightforward operations it is possible to operate alone in comfortable conditions, the only function assigned to the circulating nurse being manipulation of the uterus from below. Upper abdominal surgery can be performed by rotating the device cranially. Finally, this instrument is likely to be cost effective, as many insurance carriers do not pay for an assistant in some laparoscopic procedures. The present version of the Lapman does have some limitations. Fog formation could force the surgeon to put down the instruments, disconnect the laparoscope, retrieve it, wipe it, and reintroduce it, thus interfering with fluency of the operation. Practically, the simple use of antifog solution is enough to avoid this problem. Cleaning the lens in such conditions takes less than 15 seconds. Investigative literature5 on dynamic laparoscope positioning noted that the frequency of lens wiping due to fog formation is significantly reduced compared with human manipulation of the laparoscope. Obliquity is possible in the x-y axis but not in the y-z and x-z axes; in the latter axes, displacement is sequential and requires separate activation of the knobs. Generally, as movements obtained with most laparoscope holders are sequential, not oblique, these systems do not cope well with the need to move around a lot on the target. Extensive adhesiolysis, bulky targets (large uteri, large ovarian cysts), and two distant operative fields in the same operation (laparoscopic promontofixation) are not ideally served by this manipulator and should give preference to human assistance.
inserted into the arm of the manipulator through the sterile drape covering the scope holder. The complete setup takes less than 3 minutes. Surgery can then begin. Discussion The general organization and positioning of the surgical team around the operating table is a matter of surgeon’s preference. Formerly, the telescope was manipulated by the surgeon who was thus sacrificing one hand for visual control of surgery. Manipulation of laparoscopic instruments one by one was performed with the remaining hand, other instruments being delegated to an assistant. Alternatively, and most commonly, manipulation of the laparoscope can be assigned to an assistant, which affords the surgeon fluency and speed during surgery by restoring symbiotic control of both hands. However, management of the optical field is directly dependent on the qualities of the assistant, whose ability to anticipate may not always be optimal; indeed, not uncommonly, the assistant may be unaware of the next step of the operation. The ideal and most comfortable solution would be to restore the surgeon’s control of both hands and eyes without intermediaries. Development of an adequate user-friendly interface to pilot navigation of the scope is of crucial ergonomic importance to the surgeon. The task was to find which neuromuscular function could be used to achieve command of six degrees of freedom without interfering with other functions. We chose to regulate control of the laparoscope holder with the last fingers of the left hand, which is usually the nondominant hand whose function in dissection is limited to traction, retraction, and irrigation, relatively trivial tasks. A foot pedal such as the Aesop robot (Computer Motion, Santa Barbara, CA) requires eye control and can be uncomfortable to use over time1. Besides, the foot is often used to accomplish intermittent actions such as coagulation. Voice interface is an attractive idea but limited by two drawbacks: latent response to the order, slowing down the operation when the surgeon has to move about frequently, and the impossibility of moving obliquely. The idea of scope holders is not new; static laparoscope holders have existed for a long time. Although they give the most stable image on the video screen, they are unable to follow dynamically, in real time, changes in the operative field required by the surgeon, unless the surgeon puts down one instrument in order to move the scope holder, interrupting concentration and impeding the general fluency of the operation. Besides providing steadiness and a substitute for human assistance, dynamic versions of these devices were developed to offer simultaneous visual control and instrument manipulation. In an open surgical field, the surgeon’s eyes and hands work in simultaneous interrelation. These machines differ in technology (influencing the price) and the interface used for command. Ideal characteristics should take into account cost, robustness, awkwardness, setup time, user-friendliness of the control unit, and response time to command. For example, the Aesop 30001 is a voice-
76
February 2004, Vol. 11, No. 1
The Journal of the American Association of Gynecologic Laparoscopists
TABLE 1. Indications for the Lapman in Laparoscopic Surgery Lapman Function Single or first assistant
Second assistant (laparoscope stability)
Indication Adnexal surgery (ovariectomy, adnexectomy, salpingotomy, salpingectomy, ectopic pregnancy, ovarian cystectomy) Small to moderate-size laparoscopic hysterectomy (LH, LASH) Myomectomy Tubal microsurgery and suturing
LH = laparoscopic hysterectomy; LASH = laparoscopicassisted subtotal hysterectomy.
TABLE 2. Gynecologic Laparoscopic Procedures Performed with the Lapman Procedure Adnexectomy Ovarian cystectomy Salpingostomy (ectopic pregnancy) Salpingectomy Myomectomy (subserosal) LASH Diagnostic laparoscopy
Number 18a 7 2 5 4 4 8
LASH = laparoscopic-assisted subtotal hysterectomy. aOne case of severe adhesions in a woman with a history of pelvic surgery required one assistant.
courses were uncomplicated. There is a learning curve of around five cases to become familiar with the position of the knobs on the palm pad. Software allows navigation in a three-dimensional pelvic environment using a palm-pad joystick connected to the serial port of the surgeon’s office computer, making training outside the operating room possible. Now that laparoscopic surgery has clearly been validated, future developments in this field will involve improvements in surgeon comfort by attempting, among other things, to grant operators full autonomy of movement and vision. In surgery, eyes and fingers work together; anything that alters this relationship must be examined and improved, a goal that dynamic laparoscope manipulators try to achieve. The second goal relates to the quality of assistance. In contrast to academic institutions where operating rooms are generally overstaffed and the assistants are well qualified, having good assistance in peripheral hospitals, if any at all, can be problematic. Moreover, it is hard to imagine that straightforward basic laparoscopy cases will always require two operators; staff shortages should not be an
FIGURE 4. Setup for gynecologic surgery. (A) = assistant, (S) = surgeon.
This observation raises an interesting point about such scope holders: they allow the surgeon to operate with few personnel for straightforward uncomplicated procedures (solo surgery) and therefore help in scheduling surgical assistance: no-assistance surgery could be possible for adnexal surgery of moderate size (5–6 cm) and subtotal hysterectomy of (sub)normal uterine size, whereas human assistance could be reserved for more complex cases (Table 1). Future developments in hand control and improved ergonomics combined with the learning process will probably enable surgeons to operate on more complex pathologies using this technology. Clinical experience is available from 48 cases in which Lapman was used successfully and uneventfully in gynecologic laparoscopic surgery (Table 2); all postoperative
77
Palm-Controlled Laparoscope Holder Polet and Donnez
obstacle to performing endoscopic surgery. In this respect, future developments in the field of artificial assistance and surgical ergonomics will be closely followed.
3. Niebuhr H, Born O: Image tracking system. A new technique for safe and cost-saving laparoscopic operation. Chirugerie 2000, 71:580–4.
References
4. Falcone T, Goldberg JM, Margossian H, et al: Robotic-assisted laparoscopic microsurgical tubal anastomosis. Fertil Steril 2000, 73:1040–2.
1. Mettler L, Ibrahim M, Jonat W: One year of experience working with the aid of a robotic assistant (the voice-controlled optic holder AESOP) in gynaecological surgery. Hum Reprod 1998, 13:2748–50.
5. Omote K, Feussner H, Ungeheuer A, et al: Self-guided robotic camera control for laparoscopic surgery compared with human camera control. Am J Surg 1999, 177:321–4.
2. Yavuz Y, Ystgaard B, Skogvoll E, et al: A comparative experimental study evaluating the performance of surgical robots Aesop and Endosista. Surg Laparosc Endosc Percutan Tech 2000, 10:163–7.
78