Can cross-handed approach improve maneuver in transumbilical laparoscopic surgery?

Abstract

Transumbilical laparoscopic or laparoendoscopic singlesite surgery (LESS) is an emerging concept that has developed rapidly during the past 5 years. Almost all traditional laparoscopic surgeries can be performed transumbilically, including surgeries for morbid obesity, liver, splenic, or gastrointestinal diseases. It is estimated that 50–80 % of traditional laparoscopic surgery could be performed transumbilically in the next 5 years according to the LESSCAR consensus [1]. However, the procedure is more difficult than traditional laparoscopic surgeries due to associated technical challenges, including laparoscope and instruments crowding around the umbilicus, loss of triangulation between the two instruments in the operative field, and the required ambidexterity of the surgeons to adopt relatively difficult maneuvers. The enlarged end of the trocars is the main reason for external interference. Another factor is the instruments handles, which are usually very close to the ports. The crowding around the umbilicus can be effectively overcome by using our improved ports, because their maximum diameters are much smaller than those of commercially available trocars. The distance from the handles to the ports becomes longer when using the lengthened instruments, which results in longer distance between the instruments handles and can partly avoid external interference [2]. To overcome the problem of loss of ‘‘triangulation’’ caused by in-line viewing in transumbilical laparoscopic surgery, the articulated instruments have been developed. The problem is that when the tips of the instruments are bent in toward the target tissue, the surgeon’s hands tend to collide and the handles externally move toward one another. To avoid crossing the hands with this technique, the possible solution could be using the cross-handed approach, whereby the operator’s left hand operates the instrument on the right, and vice versa. Theoretically, cross-handed manipulation can overcome the problem of loss of triangulation under the circumstance of the in-line viewing system. Some people believe that it is an ideal solution to the most difficult problem in transumbilical laparoscopic surgery. Others consider that it can be uncomfortable and create additional difficulty in safe dissection of the target tissues. In addition, with the crossing of two instruments internally, they may compete for the same space in a vertical plane, which may limit their motion in the abdomen [3]. Do articulated instruments and cross-handed approach really benefit transumbilical laparoscopic surgery? To answer this question, it needs to be further evaluated objectively. Botden et al. [4] compared maneuver of curved instruments and cross-handed approach on standardized box trainer tasks and showed the results that the dissection task was performed faster and with less errors by using curved instruments than the crossed SPA setting. Their study also showed that the double-curved instruments were more potential for safe use than the cross-handed maneuver in conventional instruments in single-port laparoscopic surgery. However, other research concluded that crossed maneuver system gave a task performance equivalent to that of obtained with uncrossed system [5]. We recently set up a mechanical evaluation platform for single-port laparoscopic surgery on which a port (SILS Port, Covidien, Mansfield, MA) with two sensors around it was introduced. The instruments motion in the port can J. Zhu (&) A. A. Xu Department of General Surgery, East Hospital, Tongji University School of Medicine, 150 Jimo Road, Pudong, 200120 Shanghai, China e-mail: zhujiangfan@hotmail.com