Instruments For Laparoscopic Surgery Research Articles

Quantification of electrosurgery-related critical events during laparoscopic cholecystectomy – a prospective experimental study among surgical novices

Uncontrolled movement of instruments in laparoscopic surgery can lead to inadvertent tissue damage, particularly when the dissecting or electrosurgical instrument is located outside the field of view of the laparoscopic camera. The incidence and relevance of such events are currently unknown. The present work aims to identify and quantify potentially dangerous situations using the example of laparoscopic cholecystectomy (LC). Twenty-four final year medical students were prompted to each perform four consecutive LC attempts on a well-established box trainer in a surgical training environment following a standardized protocol in a porcine model. The following situation was defined as a critical event (CE): the dissecting instrument was inadvertently located outside the laparoscopic camera’s field of view. Simultaneous activation of the electrosurgical unit was defined as a highly critical event (hCE). Primary endpoint was the incidence of CEs. While performing 96 LCs, 2895 CEs were observed. Of these, 1059 (36.6%) were hCEs. The median number of CEs per LC was 20.5 (range: 1–125; IQR: 33) and the median number of hCEs per LC was 8.0 (range: 0–54, IQR: 10). Mean total operation time was 34.7 min (range: 15.6–62.5 min, IQR: 14.3 min). Our study demonstrates the significance of CEs as a potential risk factor for collateral damage during LC. Further studies are needed to investigate the occurrence of CE in clinical practice, not just for laparoscopic cholecystectomy but also for other procedures. Systematic training of future surgeons as well as technical solutions address this safety issue.

A Fully 3D-Printed Steerable Instrument for Minimally Invasive Surgery.

In the field of medical instruments, additive manufacturing allows for a drastic reduction in the number of components while improving the functionalities of the final design. In addition, modifications for users’ needs or specific procedures become possible by enabling the production of single customized items. In this work, we present the design of a new fully 3D-printed handheld steerable instrument for laparoscopic surgery, which was mechanically actuated using cables. The pistol-grip handle is based on ergonomic principles and allows for single-hand control of both grasping and omnidirectional steering, while compliant joints and snap-fit connectors enable fast assembly and minimal part count. Additive manufacturing allows for personalization of the handle to each surgeon’s needs by adjusting specific dimensions in the CAD model, which increases the user’s comfort during surgery. Testing showed that the forces on the instrument handle required for steering and grasping were below 15 N, while the grasping force efficiency was calculated to be 10–30%. The instrument combines the advantages of additive manufacturing with regard to personalization and simplified assembly, illustrating a new approach to the design of advanced surgical instruments where the customization for a single procedure or user’s need is a central aspect.

Potential Value of Haptic Feedback in Minimally Invasive Surgery for Deep Endometriosis.

Introduction. Laparoscopic treatment of deep endometriosis (DE) is associated with intra- and post-operative morbidity. New technological developments, such as haptic feedback in laparoscopic instruments, could reduce the rate of complications. The aim of this study was to assess the room for improvement and potential cost-effectiveness of haptic feedback instruments in laparoscopic surgery. Methods. To assess the potential value of haptic feedback, a decision analytical model was constructed. Complications that could be related to the absence of haptic feedback were included in the model. Costs of complications were based on the additional length of hospital stay, operating time, outpatient visits, reinterventions, and/or conversions to laparotomy. The target population consists of women who are treated for DE in the Netherlands. A headroom analysis was performed to estimate the maximum value of haptic feedback in case it would be able to prevent all selected intra- and post-operative complications. Results. A total of 9.7 intraoperative and 47.0 post-operative complications are expected in the cohort of 636 patients annually treated for DE in the Netherlands. Together, these complications cause an additional length of hospital stay of 432.1 days, 10.2 additional outpatient visits, 73.9 reinterventions, and 4.2 conversions. Most consequences are related to post-operative complications. The total additional annual costs due to complications were €436 623, amounting to €687 additional costs per patient. Discussion. This study demonstrated that the potential value for improvement in DE laparoscopic surgery by using haptic feedback instruments is considerable, mostly caused by the potential prevention of major post-operative complications.

3D Coordinate Estimation of Surgical Instruments in Laparoscopic Surgery with Deep Neural Network

3D Coordinate Estimation of Surgical Instruments in Laparoscopic Surgery with Deep Neural Network

Skills of using harmonic scalpel in laparoscopic surgery for colorectal cancer

Harmonic scalpel is an important instrument for laparoscopic surgery, and it can be used for dissection and hemostasis. During the procedure of laparoscopic surgery for colorectal tumor, surgeons can use Harmonic scalpel to identify the surgical plane around the mesorectum and mesocolon. We summarized technical points based on our own 15-year experiences of harmonic scalpel use in laparoscopic surgery for colorectal surgery, and extracts them into five words, which are 'shave, poke, cut, peel and push'. These skills are described in combination of the illustrations and videos in this article.

A New Device to Prevent Irregular Adsorption of Fatty Tissue While Using an Irrigation-suction Instrument for Laparoscopic Surgery: Divided Silicone Drain Tip.

Background:While using an irrigation-suction instrument for laparoscopic surgery, irregular adsorption of fatty tissue may damage the tissue or obstruct continuous sucking. A new device made up of a divided silicone drain tip to prevent irregular adsorption was reported.Materials and Methods:A cigarette-type silicone drain was cut 4 cm in length. It was slipped over the instrument to cover the side holes, leaving 1.0 to 1.5 cm free from the end of the instrument. It was fixed by means of 1-0 silk above the side holes. Finally, the free tip was divided vertically into 4 even pieces like octopus arms.Results:This device could prevent the irregular adsorption of fatty tissue (greater and lesser omentum, or epiploic appendices) and could suck saline, fresh, and coagulated blood almost continuously.Conclusions:This simple and easy device facilitated the prevention of irregular adsorption of fatty tissue while using an irrigation-suction instrument for laparoscopic surgery.

Laparoscopic Tissue Retractor Based on Local Magnetic Actuation

Magnetic instruments for laparoscopic surgery have the potential to enhance triangulation and reduce invasiveness, as they can be rearranged inside the abdominal cavity and do not need a dedicated port during the procedure. Onboard actuators can be used to achieve a controlled and repeatable motion at the interface with the tissue. However, actuators that can fit through a single laparoscopic incision are very limited in power and do not allow performance of surgical tasks such as lifting an organ. In this study, we present a tissue retractor based on local magnetic actuation (LMA). This approach combines two pairs of magnets, one providing anchoring and the other transferring motion to an internal mechanism connected to a retracting lever. Design requirements were derived from clinical considerations, while finite element simulations and static modeling were used to select the permanent magnets, set the mechanism parameters, and predict the lifting and supporting capabilities of the tissue retractor. A three-tier validation was performed to assess the functionality of the device. First, the retracting performance was investigated via a benchtop experiment, by connecting an increasing load to the lever until failure occurred, and repeating this test for different intermagnetic distances. Then, the feasibility of liver resection was studied with an ex vivo experiment, using porcine hepatic tissue. Finally, the usability and the safety of the device were tested in vivo on an anesthetized porcine model. The developed retractor is 154 mm long, 12.5 mm in diameter, and weights 39.16 g. When abdominal wall thickness is 2 cm, the retractor is able to lift more than ten times its own weight. The model is able to predict the performance with a relative error of 9.06 ± 0.52%. Liver retraction trials demonstrate that the device can be inserted via laparoscopic access, does not require a dedicated port, and can perform organ retraction. The main limitation is the reduced mobility due to the length of the device. In designing robotic instrument for laparoscopic surgery, LMA can enable the transfer of a larger amount of mechanical power than what is possible to achieve by embedding actuators on board. This study shows the feasibility of implementing a tissue retractor based on this approach and provides an illustration of the main steps that should be followed in designing a LMA laparoscopic instrument.

Design Concept of Hybrid Instrument for Laparoscopic Surgery and Its Verification Using Scale Model Test

This paper proposes a new design concept of hybrid instrument for single-port laparoscopic surgery (SPLS) and a new method of verification using a scaled-up prototype based on the principle of elastic similarity. The proposed concept is a hand-held instrument that uses a tendon-gear mechanism for dexterous movement of its end-effector and servomotors with flexible tendon-sheath transmission to maintain the dexterity by compensating the loss of output angle from tendon elongation during the manual operation. The kinematic relationship of the tendon-gear mechanism was derived mathematically, and the ratio of external moment to resistive flexural stiffness of the articulating joint was matched between the real-sized model and the large-scale prototype. Our scale model tests have shown good agreement between their input–output relationships under the equivalent loading conditions, and thus verified the validity of similarity analysis. Also, the proof-of-concept experiments have demonstrated the functionality of output loss compensation of the hybrid instrument. Our methodology can be used to simplify and speed up the prototype development process for SPLS by avoiding miniaturization challenges such as high precision manufacturing, which is costly and time-consuming.

Video Processing to Locate the Tooltip Position in Surgical Eye–Hand Coordination Tasks

Trajectories of surgical instruments in laparoscopic surgery contain rich information about surgeons' performance. In a simulation environment, instrument trajectories can be taken by motion sensors attached to the instruments. This method is not accepted by surgeons working in the operating room due to safety concerns. In this study, a novel approach of acquiring instrument trajectories from surgical videos is reported. A total of 12 surgical videos were obtained for this study. The videos were captured during simulated laparoscopic procedures where subjects were required to pick up and transport an object over 3 different targets using a laparoscopic grasper. An algorithm was developed to allow the computer to identify the tip of the grasper on each frame of video, and then compute the trajectories of grasper movement. The newly developed algorithm successfully identified tool trajectories from all 12 surgical videos. To validate the accuracy of this algorithm, the location of the tooltip in these videos were also manually labeled. The rate of accurate matching between these 2 methods was 98.4% of all video frames. Identifying tool movement from surgical videos creates an effective way to track instrument trajectories. This builds up the foundation for assessing psychomotor performance of surgeons in the operating room without jeopardizing patient safety.

An articulated handle to improve the ergonomic performance of robotic dextrous instruments for laparoscopic surgery

Abstract. Hand-held robotic instruments with dextrous end-effectors offer increased accessibility and gesture precision in minimally invasive laparoscopic surgery. They combine advantages of both intuitive but large, complex, and expensive telesurgery systems, and much cheaper but less user-friendly steerable mechanical instruments. However, the ergonomics of such instruments still needs to be improved in order to decrease surgeon discomfort. Based on the results of former experimental studies, a handle connected to the instrument shaft through a lockable ball joint was designed. An experimental assessment of ergonomic and gesture performance was performed on a custom-made virtual reality simulator. Results show that this solution improves ergonomics, demanding less wrist flexion and deviation and elbow elevation, while providing gesture performance similar to a robotic dextrous instrument with standard pistol-like handle configuration.

Conceptual design of a novel multi‐DoF manual instrument for laparoscopic surgery

Laparoscopic surgery is becoming increasingly popular throughout the world. But the conventional instruments used in many surgeries are not flexible enough to be operated. Challenging tasks, such as suturing and knot-tying tasks are difficult to complete using conventional instruments with limited degrees of freedom (DoFs). In the paper, a novel cable-driven multi-DoF manual instrument is presented with a simple structure but strong functionality. The proposed instrument has been developed with a wristlike operation end (OE), a wristlike end effector (EE), and the transmission system. It can be operated intuitively. The orientation and the position of the EE are directly controlled by surgeons due to the one-to-one motion mapping structure. The clamp structure and tension device are reasonably designed. The pitch, yaw, and the open and close motion are actuated by cables. Based on the optimization index Global Condition Index (GCI), four cables are used to actuate the pitch and yaw motions, while other two are used for the open and close motion. The layout of the cables is also determined by the GCI. Experiments carried out with a prototype show that tasks such as suturing and knot-tying can be completed comfortably. Due to the intuitive control and multi-DoFs, surgeons can use the prototype to finish the tasks with ease. The instrument developed herein with intuitive control and dexterity can be used alone or together with a robotic system to accomplish some challenging tasks that are difficult for conventional instruments.

Easy Grasp: A novel hybrid-driven manual medical instrument for laparoscopic surgery

A novel compact manual instrument for laparoscopic surgery, Easy Grasp, is proposed and the prototype is developed. It is a hybridization of cable and link drives. The instrument conforms to the ergonomic engineering and it can realize roll, pitch, and yaw motions. Owing to the parallelograms and universal joints, the motions outside the abdomen can be mapped to the end-effector motions inside the abdomen exactly. The workspace of the wrist-like joint is a submanifold of special orthogonal group and is evaluated by the matrix exponential parameterization. The structure of the instrument is designed optimally on the basis of the kinematic analysis together with the global condition index. The instrument can not only satisfy the needs of basic tasks, but also be used to accomplish difficult tasks such as suturing and knot-tying. Experimental results show that the instrument works as well as commercial products. The ease of use will make the instrument effective in laparoscopic surgery. The structure of the instrument is a prototype for other manual instruments and provides a framework for instrument design.

Adaptive Mean-Shift Kalman Tracking of Laparoscopic Instruments

Laparoscopic surgery becomes increasingly popular due to high benefits to both surgeon and patients. In this paper, we propose the adaptive mean-shift Kalman tracking algorithm based on the mean-shift algorithm and the Kalman filter for tracking a laparoscopic instrument in laparoscopic surgery. An iterative update of the target candidate in the mean-shift process can improve the tracking performance over a typical mean-shift algorithm. In addition, the Kalman filter is employed to enhance the chance of tracking accuracy, especially when the object disappears from the scene. In this study, we tested the tracking performance of our proposed algorithm by using the different situations from simulated videos. Our experimental results show that the proposed algorithm can locate the target object correctly even when the size and the shape of the target have been changed. In the difficult situation when the target is hiding behind an obstacle, this algorithm can still track the target object correctly after it becomes apparent. Therefore, this proposed algorithm can be used for locating the tip of the laparoscopic instrument in real laparoscopic surgery. the color tracking algorithm to control a robotic laparoscope instead of using human; however, this method cannot track many types of instruments. Casals et al. (3) introduced feature tracking algorithm based on shape information of a surgical instrument; however, it works only with a specific surgical instrument. Lee et al. (4) proposed a color and shape tracking algorithm by using the contour of the surgical instrument. This algorithm worked well in the normal situation, but not when the instrument is blocked by some obstacles. Wei et al. (5) presented a simple algorithm for tracking target features. However, this algorithm is based on the artificial color marks attached to a surgical instrument, but there are many disadvantages, such as sterilization of the mark on the surgical instrument and its convenience in the real practice. Because of some limitations in previous methods, in this paper, we propose a new object tracking algorithm to track the laparoscopic instrument called the adaptive mean-shift Kalman algorithm (6), which is based on the mean-shift algorithm (7) and the Kalman filter (8).In this algorithm, the size of the target candidate can be adjusted during tracking processes to increase the chance of tracking. We simulated videos with different scenarios to test the performance of our proposed algorithm. Furthermore, the proposed algorithm is intended to use for controlling our new laparoscopic-holder assistant robot (9-10) and tracking the tip of its instruments in laparoscopic surgery.

Imaging in Gynecologic Surgery

The technical development of instruments for endoscopic surgery started in the field of gynecology. In the early 1970s, with the improvement of optics and instruments for laparoscopic surgery, gyne-endoscopic surgery developed and set milestones for all other surgical fields. However, the general surgeons propagated the advantages of 2D or 3D imaging surgery much better than the conservative gynecologists. Surgery on a 2D screen without direct vision is regarded as more advantageous than open surgery and has achieved wide acceptance. Several schools of gynecologic endoscopy in Europe (in Kiel, Giessen, Clermont Ferrand and Strasbourg) have set guidelines for gyne-endoscopic surgery. Our catalog of indications in the areas of gyne-endoscopic surgery, published in 2002, reveals the broad application of these techniques today. 3D vision, robotic instruments and systems, such as the da Vinci(®) Surgical System from Intuitive Surgical, Inc. (CA, USA), round up the picture of endoscopic surgery. The advantages of endoscopic surgery over open surgery (more precision, less trauma, less postoperative pain, shorter hospital stays and a faster recovery period) are becoming more accepted. The present healthcare systems and hospital administrations understand the challenges of imaging in surgery, particularly in endoscopic surgery.

Single-Port Laparoscopic Cholecystectomy With the X-Cone: A Feasibility Study in 9 Pigs

Virtually any port system for single-port laparoscopic surgery is for single usage only. The aim of this study was to trial the novel and completely reusable port X-Cone in order to perform a cholecystectomy by one infraumbilical incision. Single access cholecystectomies were performed in 9 anesthetized domestic pigs in nonsurvival studies. Only one infraumbilical incision was performed for placing the reusable, multichannel steel port system. A newly developed angulated forceps was used besides regularly used instruments in laparoscopic surgery. The gallbladder was successfully removed in 9 pigs. At postmortem examination, the clips placed on the cystic duct and the cystic artery. No bile leakage was found at the operative field. Single-port cholecystectomy with the reusable X-Cone single-port system is safe and feasible. No additional incisions were needed. The system is ergonomically designed, easy to handle, and the learning curve for cholecystectomy is steep.

Establishing the Maintenance Management System of Surgical Instruments for Laparoscopic Surgery -Improvements After Three Damages of Forceps During LAM -

At Yotsuya Medical Cube, during LAM, we have experienced three damages of forceps during surgery. All broken parts were successfully corrected immediately and no obvious invasion was observed during and after the surgery. However, such an interruption as damage of surgical instruments in a confined abdominal area always accompany risks like an extension of surgery and a possible shift to laparotomy. Moreover, interruptions during laparoscopic surgery give doctors a tremendous stress during procedure. In order to prevent such damage of surgical instruments, close attention of operating forceps as well as appropriate check and maintenance of all instruments for laparoscopic surgery are indispensable. At our hospital, we worked on establishing the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers. As a result, safer laparoscopic surgery has become possible, as no interruptions by damage of instruments has occurred and stress during procedures has been reduced. I think any medical facility requires to maintain quality control and establish its own management system of medical instruments. In this paper three cases of damage of forceps during LAM that we experienced will be reported and the maintenance management system of surgical instruments for laparoscopic surgery through cooperation with our clinical engineers will be introduced.

A remote palpation instrument for laparoscopic surgery: Design and performance

This paper describes the design and performance of a prototype remote palpation instrument with tactile feedback for laparoscopic surgery. Psychophysical experiments aiming at comparing palpation with and without tactile feedback are also described. The remote palpation instrument is designed to provide the surgeon with information about size and contact force distribution. The instrument consists of a tactile sensor and a tactile display, both of which are small enough to fit onto a conventional laparoscopic grasper. Static tests showed that hardness, size and shape were successfully rendered by the tactile display. Dynamic testing showed that the bandwidth is suboptimal, but at low frequencies the output from the remote palpation instrument is useful. For the psychophysical testing, nine subjects were asked to discriminate hardness and size of objects with and without tactile feedback. The results indicated that the instrument with tactile feedback can be helpful for hardness discrimination, although the difference between the two instruments was not statistically significant for neither hardness nor size. Comparisons with earlier, similar experiments showed that the quality of the grasper and size of the forceps affected the results, indicating that there is a great potential for improving laparoscopic graspers in general.

腹腔内組立式３指５自由度ハンド

In laparoscopic surgery, surgeons perform surgery in the abdominal cavity by using only rod-shaped instruments that can be inserted through the small halls of trocars. Thus, they cannot use large and complicated shaped traditional instruments for abdominal surgery, nor their hands directly. When it is difficult to perform surgery by using only instruments for laparoscopic surgery, surgeons often make a 7-8 [cm] incision through which large instruments or their hands can be inserted. This paper propose an assemblable mechanical hand like a human hand that can be inserted through trocars. There are two directions in this study. One is to develop a few degree of freedom hand specialized for a single task and the other to develop a large degree of freedom hand with multiple functions like a human hands. We developed an assemblable three fingerd five-DOF hand in the latter direction. This hand consists of body and finger units, and an installation tool. The finger unit is fixed to the body unit with only one screw by using the installation tool. To drive the fingers, power is transmitted with wires, gears and shafts. Experimental results verify that the hand can grasp and pushing aside various objects.

1P1-I12 腹腔内組立式3指5自由度ハンド(手術支援ロボティクス・メカトロニクス)

In laparoscopic surgery, surgeons cannot use large and complicated shaped traditional instruments for abdominal surgery and their hands directly. When it is difficult to perform surgery by using only instruments for laparoscopic surgery, surgeons often make a 7-8 cm incision through which large instruments or their hand can be inserted. This paper propose an assemblable mechanical hand like a human hand that can be inserted through trocars. We developed an assemblable three fingerd five-DOF hand. To drive its fingers, power is transmitted with wires, gears and shafts. Experimental results verify that the hand can grasp and pushing aside various objects.

Kritische Analyse der Leberresektionsmethoden

BACKGROUND: No doubt, liver surgery has become safer over the past two decades. Many people jump to the conclusion that this increase in safety is due primarily to new methods of dissecting through the liver. METHODS: We did a literature search over the period 1992–2004 and then considered the data within the articles on the basis of device design and our own personal experiences. RESULTS: For resection of malignancies, we rank the Cavitron ultrasonic surgical aspirator (CUSA) number one because of its utility in staying within tissue planes during resections while preserving vessels for ligature. We find the water jet the most useful instrument for living-donor resections because of the minimal necrotic margin. The floating ball has a particular utility in removing tumors from cirrhotic livers. The harmonic scalpel tops the instruments for laparoscopic surgery, primarily because the instrument is designed specifically for laparoscopic surgery and most tumors being removed via the laparoscope are small, benign ones. CONCLUSIONS: Technological innovations have definitely made their mark on liver surgery. However, the skill and experience of the surgeon but not the instruments determine the outcomes of patients after liver resections.