Minimally Invasive Surgery Procedures Research Articles

The integration of minimally invasive surgery in surgical practice in a Canadian setting: results from 2 consecutive province-wide practice surveys of general surgeons over a 5-year period.

Although minimally invasive surgery (MIS) has been quickly embraced, the introduction of advanced procedures appears more complex. We assessed the evolution of MIS in the province of Quebec over a 5-year period to identify areas for improvement in the modern surgical era. We developed, test-piloted and conducted a self-administered questionnaire among Quebec general surgeons in 2007 and 2012 to examine stated MIS practice, MIS training and barriers and facilitators to the use of MIS. Response rates were 51.3% (251 of 489) in 2007 and 31.3% (153 of 491) in 2012. A significant increase was observed for performance of most advanced MIS procedures, especially for colectomy for benign (66.0% v. 84.3%, p < 0,001) and malignant diseases (43.3% v. 77.8%, p < 0,001) and for rectal surgery for malignancy (21.0% v. 54.6%, p < 0.001). More surgeons practised 3 or more advanced MIS procedures in 2012 than in 2007 (82.3% v. 64.3%, p < 0,001). At multivariate analysis, the 2007 survey administration was associated with fewer surgeons practising advanced MIS (odds ratio 0.13, 95% confidence interval 0.06-0.29). In 2012, more respondents stated they gained their skills during residency (p = 0.028). From 2007 to 2012 there was a significant increase in advanced MIS procedures practised by general surgeons in Québec. This technique appears well established in current surgical practice. The growing place of MIS in residency training seems to be a paramount part of this development. Results from this study could be used as a baseline for studies focusing on ways to further improve the MIS practice.

Design and performance evaluation of a 3-axis force sensor for MIS palpation

Purpose – This paper aims to develop a novel miniature 3-axis force sensor which can detect the interaction forces during tissue palpation in MIS (minimally invasive surgery). MIS offers many significant merits compared with traditional open surgery, the wound to the patients and the postoperative pains are alleviated and reduced dramatically. However, the inherent drawback due to lack of force feedback still exists while conducting some operation procedures. For example, tissue palpation performed easily during open surgery could not be realized in an MIS manner. Design/methodology/approach – The force sensor is based on the resistive-based sensing method that utilizes strain gauges to measure the strain when the external loads are acting on the tip of the sensor. A novel flexible tripod structure with bending and compression deformations is designed to discriminate the magnitudes and directions of the three orthogonal force components. A linear characteristic matrix is derived to disclose the relationship between the sensitivity and the geometric parameters of the structure, and a straightforward geometric parameterized optimization method considering the sensitivity isotropy is proposed to provide the sensor structure with high sensitivity and adequate stiffness. Findings – The sensor prototype can perform force measurement with sensing ranges of ± 3.0 N in axial direction and ± 1.5 N in radial direction, and the resolutions are 5 per cent and 1 per cent, respectively. It is concluded that this force sensor is compatible with MIS instruments and the ex-vivo experiment shows that the sensor can be used to perform tissue palpation during MIS procedures. Originality/value – This paper is intended to address the significant role of force sensing and force feedback during MIS operations, and presents a new application of the resistive-based sensing method in MIS. A tripod structure is designed and a straightforward optimization method considering the sensitivity isotropy of the sensor is proposed to determine geometric parameters suited for the given external loads.

Factors affecting the selection of minimally invasive surgery for stage 0/I colorectal cancer

PurposeTo evaluate which factors affect selection of minimally invasive surgery (MIS) or open procedures for patients with stage 0/I colorectal cancer. The short-term and oncologic outcomes of MIS were also compared to those of open procedures. MethodsA total of 181 consecutive patients underwent either MIS (laparoscopy: n = 146, robot: n = 8) or open (n = 27) colorectal resection for stage 0/I disease. ResultsElderly patients (≥80) were more common in the open procedure group (22.2%) than the MIS (7.8%) group (p = .02). Surgeon A performed more MIS procedures than surgeon B (p = .003). There were no differences in the 30-day complication rate between open (37%) and MIS (21.4%) groups (p = .08). Time to tolerable diet (p = .002) and length of hospital stay (p = .02) were shorter in the MIS group. There were no differences in the cancer-specific survival (p = .71) and recurrence-free survival rates (p = .67) between open and MIS procedures. ConclusionsPatient factors (old age) and surgeon factors (surgeon B) were barriers to the choice of MIS. Old age and operating surgeons were not associated with adverse 30-day complications. The short-term and oncologic outcomes of MIS were comparable to those of open procedures. It is safe to expand the indication for MIS to elderly patients.

Minimally invasive surgery for congenital cystic adenomatoid malformations - early experience

PurposeThe aim of this study is to present our experience with minimally invasive surgery (MIS) for congenital cystic adenomatoid malformations (CCAMs).MethodsThe medical records of infants under 2 years of age who underwent operation for a CCAM from 2009 to 2014 were retrospectively reviewed.ResultsMIS (9 of thoracoscopy and 1 of laparoscopy) was performed for 10 infants (male:female = 7:3) with CCAM. CCAM were discovered prenatally around gestational age of 24.7 weeks. The median gestational age was 38.6 weeks, and the median body weight was 2,817.5 g. None had respiratory distress after birth. The median age at the time of operation was 0.94 years (range: 8 days–1.66 years). Two underwent the operation during the neonatal period; one because of a coexisting large esophageal duplication cyst and the other due to diagnostic uncertainty. While awaiting operation, 5 of CCAM had grown without respiratory symptoms, and 2 infants had experienced pneumonia. The mean operative time was 98 minutes (range: 70–227 minutes), and there were no conversions or perioperative complications. The infants resumed enteral feeding within 2 days and were discharged within 7 days, except for 1 infant who underwent esophageal duplication cyst excision. During the follow-up period, there were no cases of either remnant lesions or respiratory symptoms.ConclusionMIS for CCAMs is safe and feasible, with excellent cosmesis and short hospital stays. Increasing experience with various MIS procedures will widen the indications for MIS in lung pathology.

Comparison of the costs of nonoperative care to minimally invasive surgery for sacroiliac joint disruption and degenerative sacroiliitis in a United States commercial payer population: potential economic implications of a new minimally invasive technology

IntroductionLow back pain is common and treatment costly with substantial lost productivity and lost wages in the working-age population. Chronic low back pain originating in the sacroiliac (SI) joint (15%–30% of cases) is commonly treated with nonoperative care, but new minimally invasive surgery (MIS) options are also effective in treating SI joint disruption. We assessed whether the higher initial MIS SI joint fusion procedure costs were offset by decreased nonoperative care costs from a US commercial payer perspective.MethodsAn economic model compared the costs of treating SI joint disruption with either MIS SI joint fusion or continued nonoperative care. Nonoperative care costs (diagnostic testing, treatment, follow-up, and retail pharmacy pain medication) were from a retrospective study of Truven Health MarketScan® data. MIS fusion costs were based on the Premier’s Perspective™ Comparative Database and professional fees on 2012 Medicare payment for Current Procedural Terminology code 27280.ResultsThe cumulative 3-year (base-case analysis) and 5-year (sensitivity analysis) differentials in commercial insurance payments (cost of nonoperative care minus cost of MIS) were $14,545 and $6,137 per patient, respectively (2012 US dollars). Cost neutrality was achieved at 6 years; MIS costs accrued largely in year 1 whereas nonoperative care costs accrued over time with 92% of up front MIS procedure costs offset by year 5. For patients with lumbar spinal fusion, cost neutrality was achieved in year 1.ConclusionCost offsets from new interventions for chronic conditions such as MIS SI joint fusion accrue over time. Higher initial procedure costs for MIS were largely offset by decreased nonoperative care costs over a 5-year time horizon. Optimizing effective resource use in both nonoperative and operative patients will facilitate cost-effective health care delivery. The impact of SI joint disruption on direct and indirect costs to commercial insurers, health plan beneficiaries, and employers warrants further consideration.

Advances in bio-tactile sensors for minimally invasive surgery using the fibre Bragg grating force sensor technique: a survey.

The large interest in utilising fibre Bragg grating (FBG) strain sensors for minimally invasive surgery (MIS) applications to replace conventional electrical tactile sensors has grown in the past few years. FBG strain sensors offer the advantages of optical fibre sensors, such as high sensitivity, immunity to electromagnetic noise, electrical passivity and chemical inertness, but are not limited by phase discontinuity or intensity fluctuations. FBG sensors feature a wavelength-encoding sensing signal that enables distributed sensing that utilises fewer connections. In addition, their flexibility and lightness allow easy insertion into needles and catheters, thus enabling localised measurements inside tissues and blood. Two types of FBG tactile sensors have been emphasised in the literature: single-point and array FBG tactile sensors. This paper describes the current design, development and research of the optical fibre tactile techniques that are based on FBGs to enhance the performance of MIS procedures in general. Providing MIS or microsurgery surgeons with accurate and precise measurements and control of the contact forces during tissues manipulation will benefit both surgeons and patients.

3D Spherical Harmonics Deformation Visualization of Intraoperative Organ

This paper gives a literature review on the recent experiments on real time 3D visualization of intraoperative organ deformations. Restricted visualization is major challenge in minimal invasive surgery (MIS). For MIS procedures to be safe clear visualization of the surgical scene is required. This can be done based on limited field-of-view and a pre-operative image. This paper presents a review on various visualization techniques emerged recently. The survey is represented in tabular form for quick reference. Index Terms—Deformations, minimal invasive surgery (MIS), surface reconstruction.

Probabilistic Tracking of Affine-Invariant Anisotropic Regions

Despite a wide range of feature detectors developed in the computer vision community over the years, direct application of these techniques to surgical navigation has shown significant difficulties due to the paucity of reliable salient features coupled with free--form tissue deformation and changing visual appearance of surgical scenes. The aim of this paper is to propose a novel probabilistic framework to track affine-invariant anisotropic regions under contrastingly different visual appearances during Minimally Invasive Surgery (MIS). The theoretical background of the affine-invariant anisotropic feature detector is presented and a real-time implementation exploiting the computational power of the GPU is proposed. An Extended Kalman Filter (EKF) parameterization scheme is used to adaptively adjust the optimal templates of the detected regions, enabling accurate identification and matching of the tracked features. For effective tracking verification, spatial context and region similarity have also been incorporated. They are used to boost the prediction of the EKF and recover potential tracking failure due to drift or false positives. The proposed framework is compared to the existing methods and their respective performance is evaluated with in vivo video sequences recorded from robotic-assisted MIS procedures, as well as real-world scenes.

Environmental Impact of Minimally Invasive Surgery in the United States: An Estimate of the Carbon Dioxide Footprint

To attempt to quantitate the carbon footprint of minimally invasive surgery (MIS) through approximated scope 1 to 3 CO(2) emissions to identify its potential role in global warming. To estimate national usage, we determined the number of inpatient and outpatient MIS procedures using International Classification of Diseases, ninth revision-clinical modification codes for all MIS procedures in a 2009 sample collected in national databases. Need for surgery was considered essential, and therefore traditional open surgery was used as the comparator. Scope 1 (direct) CO(2) emissions resulting from CO(2) gas used for insufflation were based on both escaping procedural CO(2) and metabolic CO(2) eliminated via respiration. Scopes 2 and 3 (indirect) emissions related to capture, compression, and transportation of CO(2) to hospitals and the disposal of single-use equipment not used in open surgery were calculated. The total CO(2) emissions were calculated to be 355,924 tonnes/year. For perspective, if MIS in the United States was considered a country, it would rank 189 th on the United Nations 2008 list of countries' carbon emissions per year. Limitations include the inability to account for uncertainty using the various models and tools for approximating CO(2) emissions. CO(2) emission of MIS in the United States may have a significant environmental impact. This is the first attempt to quantify CO(2) emissions related to MIS in the United States. Strategies for reduction, while maintaining high quality medical care, should be considered.

A study of psychomotor skills in minimally invasive surgery: what differentiates expert and nonexpert performance

A high level of psychomotor skills is required to perform minimally invasive surgery (MIS) safely. To assure high quality of skills, it is important to be able to measure and assess these skills. For that, it is necessary to determine aspects that indicate the difference between performances at various levels of proficiency. Measurement and assessment of skills in MIS are best done in an automatic and objective way. The goal of this study was to investigate a set of nine motion-related metrics for their relevance to assess psychomotor skills in MIS during the performance of a labyrinth task. Thirty-two surgeons and medical students were divided into three groups according to their level of experience in MIS; experts (>500 MIS procedures), intermediates (31-500 MIS), and novices (no experience in MIS). The participants performed the labyrinth task in the D-box Basic simulator (D-Box Medical, Lier, Norway). The task required bimanual maneuvering and threading a needle through a labyrinth of 10 holes. Nine motion-related metrics were used to assess the MIS skills of each participant. Experts (n = 7) and intermediates (n = 14) performed significantly better than the novices (n = 11) in terms of time and parameters measuring the amount of instrument movement. The experts had significantly better bimanual dexterity, which indicated that they made more simultaneous movements of the two instruments compared to the intermediates and novices. The experts also performed the task with a shorter instrument path length with the nondominant hand than the intermediates. The surgeon's performance in MIS can be distinguished from a novice by metrics such as time and path length. An experienced surgeon in MIS can be differentiated from a less experienced one by the higher ability to control the instrument in the nondominant hand and the higher degree of simultaneous (coordinated) movements of the two instruments.

Miniature 3-Axis Distal Force Sensor for Minimally Invasive Surgical Palpation

Minimally invasive surgery (MIS) is a surgical technique that offers distinct advantages in reducing pain and patients' recovery time. However, the drawback due to the lack of force and tactile feedback presents a great deal of limitations in MIS procedures. Tissue palpation, which is easily conducted during traditional open surgery to examine tissue properties and abnormalities, is not possible when performing surgery in a minimally invasive manner. This paper proposes a specially designed miniature 3-axis distal force sensor that can be used to perform tissue palpation, measuring tissue interaction forces at the tip of a surgical instrument. Relying on an optical sensing scheme, the sensor can measure forces within measurement ranges of ±3 N in axial direction and ±1.5 N in radial direction. The resolution is 0.02 N. It is compatible with laparoscopic operations and can be used to localize tissue lesions or relatively hard nodules buried under an organ's surface, which are not detectable by visual means.

Trends in Urology Resident Exposure to Minimally Invasive Surgery for Index Procedures: A Tale of Two Countries

To interrogate case-log data for American and Canadian urology residents to define trends in minimally invasive surgery (MIS) and open surgery and compare operative experiences between these 2 groups. Case-log data from 2004 to 2009 for American urology residents was compared with Canadian residents for 8 index cases, which are routinely performed in both an MIS and open approach. These included nephrectomy (donor, radical, simple, partial), prostatectomy (radical), adrenalectomy, pyeloplasty, and nephroureterectomy. Linear regression analysis demonstrated a significant increase in the percentage of MIS radical prostatectomies performed by American residents (11.2%-52%), compared with Canadian residents (0.74%-11.2%). There was also a significant increase in the percentage of MIS donor nephrectomies by Canadian residents (5.6%-68.7%), compared with American residents (70.1%-89.1%). For Canadian residents, exposure to the following 3 MIS procedures increased significantly over open approaches: adrenalectomy, radical prostatectomy, and donor nephrectomy. For American residents, all index procedures with the exception of adrenalectomy underwent a significant increasing trend (all p < 0.05). Trends for 8 index procedures confirm a continuing shift towards MIS for the majority of procedures in both countries. Differences may be only temporal and relate to dissimilar health care delivery models with a resultant lag in the adoption of laparoscopy and robotics in Canada. The impact of these trends upon ultimate surgical competence of graduates remains to be seen.

Real Time 3D Visualization of Intraoperative Organ Deformations Using Structured Dictionary

Restricted visualization of the surgical field is one of the most critical challenges for minimally invasive surgery (MIS). Current intraoperative visualization systems are promising. However, they can hardly meet the requirements of high resolution and real time 3D visualization of the surgical scene to support the recognition of anatomic structures for safe MIS procedures. In this paper, we present a new approach for real time 3D visualization of organ deformations based on optical imaging patches with limited field-of-view and a single preoperative scan of magnetic resonance imaging (MRI) or computed tomography (CT). The idea for reconstruction is motivated by our empirical observation that the spherical harmonic coefficients corresponding to distorted surfaces of a given organ lie in lower dimensional subspaces in a structured dictionary that can be learned from a set of representative training surfaces. We provide both theoretical and practical designs for achieving these goals. Specifically, we discuss details about the selection of limited optical views and the registration of partial optical images with a single preoperative MRI/CT scan. The design proposed in this paper is evaluated with both finite element modeling data and ex vivo experiments. The ex vivo test is conducted on fresh porcine kidneys using 3D MRI scans with 1.2 mm resolution and a portable laser scanner with an accuracy of 0.13 mm. Results show that the proposed method achieves a sub-3 mm spatial resolution in terms of Hausdorff distance when using only one preoperative MRI scan and the optical patch from the single-sided view of the kidney. The reconstruction frame rate is between 10 frames/s and 39 frames/s depending on the complexity of the test model.

Risk factors in patient safety: minimally invasive surgery versus conventional surgery

BackgroundThis study aimed to identify the frequency of events in the different patient safety risk domains during minimally invasive surgery (MIS) and conventional surgery (CS).MethodsA convenience sample of gynecologic MIS and CS was observed. Events were observed and categorized into one of the predefined patient safety risk domains.ResultsA total of 53 procedures were observed: 26 CS and 27 MIS procedures. The general characteristics were comparable between the two groups. A large number of environmental events were observed, averaging one every 2.5 min. Technical events and events of an organizational nature occurred more often in MIS (P < 0.01) than in CS (P < 0.01). The relative risk for the occurrence of one or more technical events in MIS compared with CS was 1.7, and the risk for two or more technical events was 4.1. A time out according to protocol showed no relationship to the occurrence of the different types of patient safety-related events.ConclusionThe technological complexity inherent in MIS makes this type of surgery more prone to technology-related problems than CS, even in a specially designed minimally invasive surgical suite. A regular time-out procedure developed for CS lacks the attention necessary for the complex technology used in MIS and therefore is insufficient for MIS procedures briefing. Incorporating a specially designed technology checklist in a regular briefing protocol could be a solution to decrease the number of events in MIS.

Diseño de una herramienta interactiva que facilite la enseñanza-aprendizaje de la cirugía mínima mente invasiva en colecistectomía

En los últimos años la práctica de la cirugía general se ha transformado debido a la introducción y el explosivo de- sarrollo de la cirugía videoendoscópica, lo que ha traído consigo avances en los instrumentos y equipos utilizados con el objetivo de facilitar el desarrollo de la técnica quirúrgica y minimizar los riesgos al paciente. El uso de las Tecnologías de la Información y la Comunicación (TIC) ha generado un cambio en los procesos curriculares. Este arículo presenta el desarrollo de un CD Interactivo para Colecistectomía Laparoscópica que facilita el entrena- miento en los procedimientos de Cirugía Mínimamente Invasiva (CMI) para optimizar el aprendizaje de los estu- diantes universitarios. Se utiliza una metodología de simulación virtual en un escenario de la cirugía endoscópica en el cual el estudiante puede desarrollar las habilidades y destrezas en esta modalidad quirúrgica.

Task-Specific Multiple-Arm Minimally Invasive Surgical Device Design Using Cooperative Kinematic Isotropy Indices

The transition from multiple-port to single-port robotic systems in minimally invasive surgery (MIS) procedures has made flexible, dexterous manipulation an essential capability. The requirement that single-port MIS devices span an enclosed surgical workspace through only one access point while avoiding collateral damage to surrounding tissues necessitates the employment of mechanically sophisticated, kinematically redundant device architectures. These redundant architectures, while capable of achieving clinically-acceptable performance levels on complicated MIS procedures, are difficult to design and can easily result in economically prohibitive or technically impractical solutions. The problem of balancing clinical functionality and design economy in single-port MIS devices becomes even more challenging when the dexterous use

Dionis: A Novel Remote-Center-of-Motion Parallel Manipulator for Minimally Invasive Surgery

The large volume and reduced dexterity of current surgical robotic systems are factors that restrict their effective performance. To improve the usefulness of surgical robots in minimally invasive surgery (MIS), a compact and accurate positioning mechanism, namedDionis, is proposed in this paper. This spatial hybrid mechanism based on a novel parallel kinematics is able to provide three rotations and one translation for single port procedures. The corresponding axes intersect at a remote center of rotation (RCM) that is the MIS entry port. Another important feature of the proposed positioning manipulator is that it can be placed below the operating table plane, allowing a quick and direct access to the patient, without removing the robotic system. This, besides saving precious space in the operating room, may improve safety over existing solutions. The conceptual design of Dionis is presented in this paper. Solutions for the inverse and direct kinematics are developed, as well as the analytical workspace and singularity analysis. Due to its unique design and kinematics, the proposed mechanism is highly compact, stiff and its dexterity fullfils the workspace specifications for MIS procedures.

Are Minimally Invasive Procedures Harder to Acquire than Conventional Surgical Procedures?

Background: It is frequently suggested that minimally invasive surgery (MIS) is harder to acquire than conventional surgery. To test this hypothesis, residents’ learning curves of both surgical skills are compared. Methods: Residents had to be assessed using a general global rating scale of the OSATS (Objective Structured Assessment of Technical Skills) for every procedure they performed as primary surgeon during a 3-month clinical rotation in gynecological surgery. Results: Nine postgraduate-year-4 residents collected a total of 319 OSATS during the 2 years and 3 months investigation period. These assessments concerned 129 MIS (laparoscopic and hysteroscopic) and 190 conventional (open abdominal and vaginal) procedures. Learning curves (in this study defined as OSATS score plotted against procedure-specific caseload) for MIS and conventional surgery were compared using a linear mixed model. The MIS curve revealed to be steeper than the conventional curve (1.77 vs. 0.75 OSATS points per assessed procedure; 95% CI 1.19–2.35 vs. 0.15–1.35, p < 0.01). Conclusions: Basic MIS procedures do not seem harder to acquire during residency than conventional surgical procedures. This may have resulted from the incorporation of structured MIS training programs in residency. Hopefully, this will lead to a more successful implementation of the advanced MIS procedures.

Minimally invasive surgery in neonates and infants

Minimally invasive surgery (MIS) has significantly improved the field of surgery, with benefits including shorter operating time, improved recovery time, minimizing stress and pain due to smaller incisions, and even improving mortality. MIS procedures, including their indications, impact, limitations, and possible future evolution in neonates and infants, are discussed in this article.

Neonatal minimally invasive surgery for congenital diaphragmatic hernias: a multicenter study using thoracoscopy or laparoscopy

Minimally invasive surgery (MIS) for late-presenting congenital diaphragmatic hernia (CDH) has been described previously, but few neonatal cases of CDH have been reported. This study aimed to report the multicenter experience of these rare cases and to compare the laparoscopic and thoracoscopic approaches. Using MIS procedures, 30 patients (16 boys and 14 girls) from nine centers underwent surgery for CDH within the first month of life, 26 before day 5. Only one patient had associated malformations. There were 10 preterm patients (32-36 weeks of gestational age). Their weight at birth ranged from 1,800 to 3,800 g, with three patients weighing less than 2,600 g. Of the 30 patients, 18 were intubated at birth. The MIS procedures were performed in 18 cases by a thoracoscopic approach and in 12 cases by a laparoscopic approach. No severe complication was observed. For 20 patients, reduction of the intrathoracic contents was achieved easily with 15 thoracoscopies and 5 laparoscopies. In six cases, the reduction was difficult, proving to be impossible for the four remaining patients: one treated with thoracoscopy and three with laparoscopy. The reasons for the inability to reduce the thoracic contents were difficulty of liver mobilization (1 left CDH and 2 right CDH) and the presence of a dilated stomach in the thorax. Reductions were easier for cases of wide diaphragmatic defects using thoracoscopy. There were 10 conversions (5 laparoscopies and 5 thoracoscopies). The reported reasons for conversion were inability to reduce (n = 4), need for a patch (n = 5), lack of adequate vision (n = 4), narrow working space (n = 1), associated bowel malrotation (n = 1), and an anesthetic problem (n = 1). Five defects were too large for direct closure and had to be closed with a patch. Four required conversion, with one performed through video-assisted thoracic surgery. The recurrences were detected after two primer thoracoscopic closures, one of which was managed by successful reoperation using thoracoscopy. In the neonatal period, CDH can be safely closed using MIS procedures. The overall success rate in this study was 67%. The indication for MIS is not related to weeks of gestational age, to weight at birth (if >2,600 g), or to the extent of the immediate neonatal care. Patients with no associated anomaly who are hemodynamically stabilized can benefit from MIS procedures. Reduction of the herniated organs is easier using thoracoscopy. Right CDH, liver lobe herniation, and the need for a patch closure are the most frequent reasons for conversion.