Laparoscopic Instruments Research Articles

A Feasible Technique for Transoral Endoscopic Thyroidectomy Through Vestibular Access Using a Single-port Technique: A Video Vignette in Cadaver Dissection

The aim of this study was to evaluate the safety and feasibility of a single-port system for transoral endoscopic thyroidectomy with vestibular access (TOETVA). Two embalmed human cadavers were used to test the single-port technique. After positioning, a median vestibular incision was made. Adipose tissue was dissected through the mentum with a Kelly clamp to reach the subplatysmal level. The Keyport Single Port System (Richard Wolf) was then inserted. After port placement, flexible endoscopic dissectors and a 5-mm endoscope were advanced. After removing the dissectors, we inserted the ArtiSential laparoscopic instruments. We also used a 3-port TOETVA on another human cadaver to compare the results with those of the single-port surgery. In the first cadaver, skin tension was observed during trocar insertion and dissection. Trocar insertion resulted in skin perforation in the submental area. In the second cadaver, the single-port trocar was successfully inserted despite the significant skin tension. However, the trocar did not allow the necessary surgical maneuvers to proceed with subsequent surgical steps and create a working space. Postprocedural anatomic dissection revealed that the distal branches of the mental nerve were related to the trocar passage. Our cadaver study demonstrated that single-port TOETVA is unsafe and not feasible with the current technology of the Keyport single-port system. This approach needs to be improved to perform this technique without injury to distal branches of the mental nerve, skin perforation, and other complications.

Ergonomic Design and Assessment of an Improved Handle for a Laparoscopic Dissector Based on 3D Anthropometry.

Laparoscopic surgery (LS) has been shown to provide great benefits to patients compared with open surgery. However, surgeons experience discomfort, low-efficiency, and even musculoskeletal disorders (MSDs) because of the poor ergonomic design of laparoscopic instruments. A methodology for the ergonomic design of laparoscopic dissector handles considering three-dimensional (3D) hand anthropometry and dynamic hand positions was addressed in this research. Two types of hand positions for grasping and stretching were scanned from 21 volunteers using a high-resolution 3D scanner. The 3D anthropometric data were extracted from these 3D hand pose models and used to design an improved handle (IH) that provides additional support for the thumb, a better fit to the purlicue, and a more flexible grasp for the index finger. Thirty subjects were invited to evaluate the IH in terms of muscular effort, goniometric study of motion, and efficiency and effectiveness during four trials of a laparoscopic training task. Questionnaires provided subjective parameters for ergonomic assessment. Positive results included less muscle load in the trapezius as well as significant but small angular differences in the upper limb. No significant reduction in the trial time and no increased percentage of the achievement were observed between the IH and the commercial handle (CH). Improved intuitiveness, comfort, precision, stability, and overall satisfaction were reported. IH provides significant ergonomic advantages in laparoscopic training tasks, demonstrating that the proposed methodology based on 3D anthropometry is a powerful tool for the handle design of laparoscopic dissectors and other surgical instruments.

EXVIVO AND IN VIVO PORCINE ANIMAL MODEL FOR VALIDATION OF UNIVEC TRANSANAL DEVICE

Abstract Introduction Colorectal cancer screening has led to a greater number of early lesions being diagnosed. At the rectal level, minimally invasive surgery has become more important since major surgery increases morbimortality. This experimental study evaluates the feasibility, safety, and effectiveness of the UNIVEC® device for both abdominal and transanal procedures and compares it to other devices prior to its commercialization and use in the clinical setting. Methods UNIVEC® is a transanal device with a pneumatically sealed channel that allows the introduction of the flexible endoscope and 2 accessory channels. Thirty-two porcine models were used in the 2-phase study. Results Phase I: 18 models and 2 procedures (hysterectomy and cystectomy) were used and UNIVEC® was compared with 2 devices (SILS®, GelPOINT®). Phase II: 14 models and 3 procedures (polypectomy, EMR, DSE). The final prototype design was satisfactory and met the established minimum performance requirements. Conclusions UNIVEC® is a transanal device that allows for hybridization of laparoscopic and endoscopic instrumentation. A model anatomically similar to that of the human was needed to assess intraoperative complications arising during surgery before its clinical application. The porcine model, due to its anatomical characteristics and experience, was the model of choice in our project. The ex vivo model facilitates learning the technique of the device prior to its use in vivo, which offers greater final cost-effectiveness.

Laparoscopic training instruments designed to provide real-time feedback for surgical trainees

Laparoscopic training instruments designed to provide real-time feedback for surgical trainees

Design and Evaluation of a Balanced Compliant Laparoscopic Grasper.

In laparoscopic surgery, quality of haptic feedback is reduced compared to conventional surgery, leading to unintentional tissue damage during grasping. From the perspective of haptics, poor mechanical design of laparoscopic instrument joints induces friction and a nonlinear actuation-tip force relation. In this study, a novel laparoscopic grasper using compliant joints and a magnetic balancer is presented, and the reduction in hysteresis and friction is evaluated. The hysteresis loop of the novel compliant grasper and two conventional laparoscopic graspers (high quality leading commercial brand and low quality unbranded grasper) were measured. In order to assess quality of haptic feedback, the lowest grasper tip load perceivable by instrument users was measured with the novel and the conventional laparoscopic graspers. The hysteresis loop measurement yielded a mechanical efficiency of 43% for the novel grasper, compared to- 25% and 23% for the Aesculap and the unbranded grasper, respectively. The forces perceivable by the user through the novel grasper were significantly lower (mean 1.37N, SD 0.44N) than those of conventional graspers (mean 2.15N, SD 0.71N and mean 2.65N, SD 1.20N, respectively). The balanced compliant grasper technology has the ability to improve the quality of haptic feedback compared to conventional laparoscopic graspers. Research is needed to relate these results to soft and delicate tissue grasping in a clinical setting, for which this instrument is intended.

The experience with Mini- or Less-open Sublay operation.

The MILOS concept binds the benefit of the sublay mesh augmentation in the way of functional and morphological reconstruction of the abdominal wall without the need to use penetrating fixation elements and with the benefits of minimal surgical access. The transhernial approach is carried out at low cost with standard laparoscopic instruments. The authors carried out retrospective analysis of the years 2018-2022. Included are all patients operated by the MILOS concept. The patients have suffered of the midline hernias type M according to European Hernia society, eventually combined with rectus diastasis. Authors present their own experience of this new treatment method. The evaluation of complications was performed. In the observed time we have operated 61 patients. In the years 2018 and 2019 together 35 patients were treated, none in the year of 2020. Because of the COVID plaque was the 2020 "Year of restrictions". In the year 2021 and first quarter of 2022 we have already cured 26 patients. In this time 2 major complications and 3 minor complications were observed. Since the 2nd quarter of 2022 we have already upgraded to eMILOS. Our experience with this new hernia repair shows that this treatment possibility is feasible for general use also in small district departments without the need to use of robotic technology. This skill will be necessary for future F.E.B.S AWS (Tab. 2, Fig. 3, Ref. 15). Text in PDF www.elis.sk Keywords: incisional hernia, epigastric hernia, MILOS, Mini- or Less-open sublay operation, rectus diastasis, sublay mesh, uniport, abdominal wall surgery.

ArtiSential<sup>TM</sup> Revolutionizes Traditional Laparoscopy in Urology by Introducing the Dexterity of a Robotic System to a Laparoscopic Instrument <br/>—First Experiences in Urology in Europe by the Ukrb in Neuruppin

We describe the first two conventional, laparoscopic renal operations with a new multi-degree of freedom articulated single-use laparoscopic instrument (ArtiSentialTM). The two patients underwent different laparoscopic interventions at Ukrb University (Neuruppin, Germany): nephrectomy and Anderson-Hynes-pyeloplasty. All procedures were completed, with no need for conversion or placement of additional ports. No intraoperative complications or technical failure of the instrument was recorded. The mean operative time was 180 min median length of stay was 11.5 d. The instrument could be opened out of the sterile packaging and used at once when it was needed, because it is a single-use instrument. There was real haptical feedback and the costs are minimal compared to robot surgery. The use was straightforward and rapid processes after an intensive training of 4 h in a dry lap. Awaiting future investigations in larger series, this study proves the safety and feasibility of renal surgery with ArtiSentialTM and provides relevant data that may help early adopters of this surgical instrument.

Challenges to implement laparoscopic appendectomy as the first-line treatment for acute appendicitis: a fifteen-year experience in a tertiary hospital in Brazil.

the barriers to implement emergency laparoscopy in public teaching hospitals involve issues such as resident learning curves and resource costs and availability. This study was designed to describe the issues facing the implementation of laparoscopic approach for acute appendicitis over 15 years in a single academic center in Brazil. retrospective study of patients undergoing emergency appendectomy from 2004 to 2018. Clinical data were compared to four major actions implemented in the emergency surgical service: minimally invasive surgery training for residents (2007), laparoscopic stump closure using metal clips (2008), 24/7 availability of laparoscopic instruments for emergency surgeries (2010), and third-party contract for maintenance of the laparoscopic instruments and implementation of polymeric clips for stump closure (2013). We evaluated the increase in laparoscopic appendectomy after the implementation of those major changes. we identified 1168 appendectomies during the study period, of which 691 (59%), 465 (40%), and 12 (1%) were open, laparoscopic, and converted, respectively. The implementation of the major changes since 2004 resulted in an increase of laparoscopic appendectomies from 11% in 2007 to 80% in 2016. These actions were decisive in the widespread use of laparoscopy for acute appendicitis (p<0.001). The standardization of the hem-o-lok clip in the treatment of the appendiceal stump made the procedure more feasible, reducing the surgical time using laparoscopic access and increasing the team's adherence, so that this became the route of choice in about 85% of cases in the period from 2014 to 2018, 80% performed by 3rd year resident physicians. No intraoperative complications were noted related to laparoscopic access, even in more complicated appendicitis. There was no mortality reported, no reoperations or readmissions to hospital during a 30-day postoperative period. the development of a feasible, reproducible, and safe technical standardization, associated with continuous cost optimization, are the cornerstones for a consistent and viable change in the current practice for appendectomies in middle and lower-income countries.

Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gains.

Perioperative services comprise a large portion of hospital budgets; the procurement and processing of surgical inventories can be an area for optimization in operational inefficiency. Surgical instrument trays can be customized as procedure-specific or standardized as trays that can be used in numerous procedure types. We conducted an interventional study to determine the cost savings from standardizing laparoscopic surgery instrument trays. A single-period inventory optimization model was used to determine the configuration of a standardized laparoscopic (SL) tray and its minimal stock quantity (MSQ). Utilization of instruments on the general surgery, gynecology, and gynecological oncology trays was recorded, and daily demand for trays (mean, SD) was assessed using daily operating room (OR) case lists. Pre- and post-intervention costs were evaluated by reviewing procurement data and quantifying medical device reprocessing (MDR) and OR processes. The SL tray was trialled in the OR to test clinical safety and user satisfaction. Prior to standardization, the customized trays had a total inventory size of 391 instruments (mean instruments per tray: 17, range: 12-22). Daily demand was an MSQ of 23 trays. This corresponded to a procurement cost of $322,160 and reprocessing cost of $41,725. The SL tray (mean instruments per tray: 15, mean trays/day: 9.2 ± 3.2) had an MSQ of 17 trays/day. The total inventory decreased to 255 instruments, corresponding to a procurement cost of $266,900 with savings of $55,260 and reprocessing cost of $41,562 with savings of $163/year. After 33 trial surgeries, user satisfaction improved from 50% to 97% (p < .05). Standardization to a single SL tray using the inventory optimization model led to increased efficiency, satisfaction, and significant savings through aggregating specific service demands. The inventory optimization model could provide custom solutions for various institutions with the potential for large-scale financial savings. Thus, future work using this model at different centres will be necessary to validate these results.

Research on laparoscopic surgical instrument detection technology based on multi-attention-enhanced feature pyramid network

Laparoscopic surgery is a very active area of research in clinical medicine. Detection of tools in surgical videos can help physicians operate surgical instruments, reduce complications, and ensure patient safety. However, the size of laparoscopic surgical instruments is highly variable, leading to poor detection. Feature pyramid networks (FPNs) can effectively solve the problem of multi-scale target detection, but FPNs still have some problems that limit the full utilization of multi-scale features. By analyzing the FPN design problem, we propose the Multi-Attention Augmented Feature Pyramid Network (MAFPN), which can fully utilize the multi-scale features. First, we replace the convolutional block with feature selection module (FSM) that combines channel attention and global attention, which selectively maintains important information and enhances the expressiveness of features at each scale. Second, the global contextual information is captured by the self-attentive augmented fusion module (AAFM), which enriches the high-level feature information in the FPN and enhances the feature fusion effect. Finally, we use Dynamic Convolution Decomposition (DCD) to alleviate the impact of upsampling while enhancing the feature expression ability. The experimental results on the laparoscopic surgical instrument detection dataset m2cai16-tool-locations show that the average precision of MAFPN is 96.5 when the IOU is 0.5, which is 1.8% better than the baseline method RetinaNet, and the average precision is more than 1.6% better than the comparison network. Compared with the state-of-the-art method, the performance of laparoscopic surgical instrument detection is superior.

Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device

IntroductionComplex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. MethodsWe describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. Results16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0–10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices. ConclusionsThe study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Usefulness of the new articulating laparoscopic instrument in laparoscopic pancreaticoduodenectomy.

Minimally invasive pancreaticoduodenectomy has been developed in two tracts of robotic and laparoscopic surgeries. Laparoscopic approach remains a frequently performed surgical method that accounts for a significant portion of minimally invasive pancreaticoduodenectomy. However, biliary and pancreatic reconstruction stages are still demanding procedures because of the inherent limitations of conventional laparoscopic instruments. Therefore, recently developed articulating laparoscopic instruments have greater dexterity similar to robotic instruments seem to be able to compensate for the weak points of conventional laparoscopic instruments. In this article, we demonstrate the hepaticojejunostomy and duct-to-mucosa pancreaticojejunostomy technique using the new articulating laparoscopic instrument.

Face, content, and construct validity of the virtual immersive operating room simulator for training laparoscopic procedures.

The aim of this work is to present the face, content, and construct validation of the virtual immersive operating room simulator (VIORS) for procedural training of surgeons' laparoscopic psychomotor skills and evaluate the immersive training experience. The VIORS simulator consists of an HMD Oculus Rift 2016 with a visor on a 1080 × 1200 pixel OLED screen, two positioning sensors with two adapted controls to simulate laparoscopic instruments, and an acrylic base to simulate the conventional laparoscopic setup. The immersion consists of a 360° virtual operating room environment, based on the EndoSuite at Hospital Infantil de Mexico Federico Gomez, which reproduces a configuration of equipment, instruments, and common distractions in the operating room during a laparoscopic cholecystectomy procedure. Forty-five surgeons, residents, and medicine students participated in this study: 27 novices, 13 intermediates, and 5 experts. They completed a questionnaire on the realism and operating room immersion, as well as their capabilities for laparoscopic procedural training, scored in the 5-point Likert scale. The data of instrument movement were recorded and analyzed using 13 movement analysis parameters (MAPs). The experience during training with VIORS was evaluated through NASA-TLX. The participants were enthusiastic about the immersion and sensation levels of the VIORS simulator, with positive scores on the realism and its capabilities for procedural training using VIORS. The results proved that the VIORS simulator was able to differentiate between surgeons with different skill levels. Statistically significant differences were found in nine MAPs, demonstrating their construct validity for the objective assessment of the procedural laparoscopic performance. At cognitive level, the inversion experience proves a moderate mental workload when the laparoscopic procedure is carried out. The VIORS simulator has been successfully presented and validated. The VIORS simulator is a useful and effective device for the training of procedural laparoscopic psychomotor skills.

Ensayo clínico multicéntrico para la resección de pólipos rectales mediante un nuevo dispositivo de acceso transanal híbrido laparoendoscópico

IntroductionComplex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. MethodsWe describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. ResultsSixteen patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic mucosal resection (EMR) (6.3%), endoscopic submucosal dissection (ESD) (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days, respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0–10 (9.43, 9.71, 9.29 and 9.50, respectively). All the investigators have previous experience with transanal devices. ConclusionsThe study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

OGBN P04 Laparoscopic Cholecystectomy- can we make it both Greener and cheaper?

Abstract Background Laparoscopic cholecystectomy is one of the most common operations in the UK, with around 60,000 performed in the UK each year. Large numbers of single use instruments are used in laparoscopic surgery, despite the availability of reusable and hybrid alternatives. A hybrid instrument is one where most of the instrument is reusable but it also has a single use replaceable component Operating theatres are a major carbon hotspot within healthcare. The NHS alone is estimated to be responsible for about 4% of England's carbon emissions, thought to be similar in Scotland and operating theatres account for up to 33% of solid waste produced in hospitals. The NHS has a target of reaching net zero emissions by 2040. There is a wide variability in surgical instruments use for laparoscopic cholecystectomy between operators and hospitals - our aim was to examine what was currently being used within 7 different hospital within a single health board, and to suggest the ‘greenest ’ possible instrument tray. It has already been shown that for a single procedure, the cost of using a hybrid laparoscopic clip appliers, scissors, and ports was 47% of that of single-use equivalents, and the carbon footprint 76% lower (Rizan 2021) Methods Visits to the 7 hospital sites currently performing laparoscopic cholecystectomy within a single health board was carried out by 3rd Year medical Student, as part of a Sustainability in Surgery SSC, during a 4 week period in May 2022. This was a snap shot audit and only one surgeon per site was visited. The items used during laparoscopic cholecystectomy were recorded with focus on the use of reusable, hybrid and single use tools. Costs and supplier information were gathered from theatre staff and company representatives. The relevant elements of the surgical tray setups were collated into a table and costs were compared. CO2 footprint was also collated when available. Results There was a wide variation in surgical set ups between hospitals within the same health board. 3 hospitals no longer had any reusable laparoscopic instruments and used all single use, the rest used a combination of single use, hybrid and disposable. All hospitals except one used single use laparoscopic ports- the other used hybrid ports. Most hospitals used single use clip appliers- one surgeon used ties instead. 2 hospitals used skin staples for skin closure. No single hospital utilised the most sustainable option in every item analysed. Costs were analysed below. Single use items were cheaper than reusables for nearly all key items but more expensive in the long term. Hybrid items had lower or similar costs to single use and much lower carbon emissions. Waste and decontamination costs were not taken into account in this analysis. Conclusions Taking the most sustainable practises from the hospitals we visited, an ‘ideal setup’ from an environmental viewpoint was devised using items already available within the health-board. We suggest that this be adopted to reduce both carbon emissions as well as costs. Where the upfront costs of purchasing new reusable instruments are prohibitive, hybrid instruments are recommended. Addressing simple things such as swapping low cost single use plastic item for their reusable counterparts is important and often overlooked. Using reusable instruments to the end of their lifespan, efficient decontamination and regular maintenance also play a role in reducing impact and costs. Further work is required by the healthcare sector and manufacturers to carry out environmental analyses for commonly used items and provide data upon which purchasing decisions could be made to improve sustainability and allow the NHS to meet its net zero target.

Hybrid Laparo-Endoscopic Resection of Submucosal Cardial Tumors Assisted by Flexible Articulated Instruments

We report a new surgical method in 10 patients who underwent hybrid laparo-endoscopic resection (HLER) of submucosal tumors with the combination of flexible articulated laparoscopic instruments (FALI). We have assessed technical reproducibility, safety, and morbidity. Resection was completed in all cases. Mean surgical time was 60 min (30–85). Median tumor size was 16 mm (12–30). The more frequent location was the gastroesophageal junction. No complications were observed during the procedure. Length of stay was 1 day in all cases. We have found HLER to be a safe procedure allowing margin resection and organ preservation. The addition of FALI added ease of performance in hard-to-reach tumor locations.

Use of an intragastric trocar to perform a novel stapling procedure for reflux disease.

Background and study aims A percutaneous intragastric trocar (PIT) enables intraluminal use of laparoscopic tools and helps overcome traditional limitations of endoscopy. The aim of this study was to determine the efficacy of using a PIT to perform an anti-reflux stapling procedure. Materials and methods Trocars were placed in four animals and an articulating stapler was used to perform fundoplication under endoscopic guidance. Animals were monitored for 14 days post-procedure. Functional lumen imaging of the esophagogastric junction (EGJ) was performed at baseline, immediately post-intervention, and at 14 days. Results The procedure was successful in all animals who survived to day 14 without distress or significant adverse events. Baseline EGJ distensibility was 5.0 ± 1.2 mm 2 /mmHg, 2.7 ± 0.7 mm 2 /mmHg post-procedurally, and 3.0 ± 0.8mm 2 /mmHg on day 14. Average change in distensibility pre- and post-procedure was -2.3 ± 1.8 mm 2 /mmHg (95 % confidence interval [CI] -0.5 to 5.1, P = 0.08) while change in pre- and day 14 distensibility was -2.0 ± 1.4 mm 2 /mmHg (95 % CI -0.1 to 4.2, P = 0.06). Conclusions An intragastric trocar allows for use of large-diameter laparoscopic instruments to safely and effectively perform endoluminal fundoplication with anti-reflux properties that persist for at least 14 days.

7758 The New Generation Articulated Laparoscopy in Gynecologic Surgery

<h3>Study Objective</h3> To discuss the advantages and disadvantages of a novel articulated laparoscopic device compared to conventional laparoscopy and to demonstrate its benefits using a simulator model. <h3>Design</h3> Educational video. <h3>Setting</h3> Laparoscopic simulator box at a simulation center. <h3>Patients or Participants</h3> We present a novel articulated laparoscopic instrument and our experience with the implementation of this device using a simulator box. <h3>Interventions</h3> The standardized Fundamental laparoscopic skill (FLS) peg transfer, tip positioning and laparoscopic suturing. <h3>Measurements and Main Results</h3> Conventional laparoscopy requires high skills mainly due to challenging ergonomics and a two-dimensional vision. Robotic surgery flourished as it improves precision with wristed instruments making surgical movements more intuitive and easier to master. However, limitations of robotic surgery include the absence of haptic or tactile feedback and a higher cost. Additionally, availability may be a problem in certain settings. We present a novel hand-held articulated laparoscopic device that provides haptic feedback, short set up time, and lower cost while improving precision and dexterity with wristed instruments. <h3>Conclusion</h3> This novel articulated laparoscopic instrument may be an option to offer minimal invasive surgery with increased dexterity at a lower cost compared with robotic surgery. This option potentially combines the benefits of conventional laparoscopy and robotic surgery. Future research is needed to determine the learning curve and operative advantages of this device.

Novel Technique for Performing a Minimally Invasive Myomectomy: Robotic vNOTES Myomectomy

<h3>Study Objective</h3> This video demonstrates robotic vaginal natural orifice transluminal endoscopic surgery (vNOTES) for myomectomy. <h3>Design</h3> There are various routes for myomectomy. The vaginal route is preferred for hysterectomy as it eliminates abdominal incisions and is associated with shorter hospital stays, operative time and recovery¹ and this can be assumed with myomectomy. However, visualization may be difficult with limited space. Robotic surgery offers enhanced visualization and precision. vNOTES myomectomy is previously described² however traditional laparoscopic instruments offer limited motion which makes suturing difficult. Robotic vNOTES is used for hysterectomy, sacrocolpopexy and endometriosis resection.^3,4,5,6 One study showed that for hysterectomy, there was no difference in operative time, admission length or postoperative pain between robotic and traditional vNOTES. This study proposed that robotic vNOTES was beneficial due to use of wristed instruments.³ Given advantages of vaginal and robotic surgery, the robotic vNOTES myomectomy technique was developed. <h3>Setting</h3> Academic hospital. Positioning was dorsal lithotomy, steep Trendelenburg. <h3>Patients or Participants</h3> A 28-year-old presented with pain and heavy periods. She had no significant history and had 3 prior vaginal deliveries. Imaging showed an 8cm posterior uterine fibroid and she desired fertility sparing, surgical management. <h3>Interventions</h3> A 3cm posterior colpotomy was made and an Alexis retractor with gel port was placed through the colpotomy. The Da Vinci robot was docked vaginally and myomectomy of an 8cm fibroid was performed. After the fibroid was detached, the myometrium was closed in layers. The robot was undocked and contained morcellation of the fibroid was performed using the ExCITE technique.⁷ The posterior colpotomy was closed. <h3>Measurements and Main Results</h3> The patient was discharged home same day with 100cc blood loss. <h3>Conclusion</h3> This video shows that robotic vNOTES is a feasible technique for myomectomy. It offers the benefits of minimally invasive vaginal surgery and the detail and precision of robotic surgery while maintaining quick post operative recovery and minimal blood loss.

8535 Troubleshooting Less Is More: Three Simple Tricks Every Gynecologist Should Know

<h3>Study Objective</h3> To describe three simple techniques every Gynecologist should know for troubleshooting in the operating room. <h3>Design</h3> This is an educational video. <h3>Setting</h3> Intra-operative video recordings from various patient encounters. <h3>Patients or Participants</h3> Patients were undergoing minimally invasive gynecologic surgery at a tertiary care center. <h3>Interventions</h3> Three interventions are demonstrated: 1) simplified steps to culdotomy without a uterine manipulator 2) use of a Bovie to activate a laparoscopic instrument 3) steps to backfilling the bladder and performing a bladder survey with a 30-degree laparoscope. <h3>Measurements and Main Results</h3> Safe and efficient care of patients. <h3>Conclusion</h3> These simple techniques are helpful when encountering an unexpected situation, they allow the surgeon to move forward safely and efficiently.