Organ Retraction Research Articles

Elastic Intra-corporeal Retractor for Bariatric and Upper Gastrointestinal Surgery.

In minimally invasive upper gastrointestinal and bariatric surgery, proper organ retraction, especially liver retraction, is essential to achieve better per-operative precision and safety. Most currently used methods require specific material which might not be available in all hospitals. We introduce an easily reproducible low-cost trocar-less elastic intra-corporeal retractor (ICR). ICR was created then used in two institutions where around 500 upper gastrointestinal and bariatric procedures are jointly performed yearly. Its design and application require an elastic rubber band, three staples, and a needle holder. For liver retraction, ICR is anchored to the right diaphragmatic crus and the anterior abdominal wall, creating a triangular shaped retractor. ICR requires around 2-3min for application and can be easily repositioned for adequate exposure. Its trocar-less and intra-corporeal characteristics offer the advantage of decreasing the risk of bleeding, infection, and liver injury accompanying additional trocars, transcutaneous punctures and conventional retractors. ICR is a safe, effective, inexpensive, and easily reproducible intra-corporeal organ retractor which can be used in both laparoscopic and robotic bariatric surgery.

A newly developed surgeon‐controlled suction device in robotic‐assisted thoracoscopic surgery

AbstractIntroductionAssistant surgeons usually clean the surgical field with a suction cannula in robotic‐assisted surgery. This manipulation requires skill and experience to avoid interfering with the operation of the console surgeon. Recently, we created a new suction device that a console surgeon can manipulate with the robotic arms.Materials and Surgical TechniqueA small metal suction tip with as a lumen and small side pores for suction and can be connected to a silicone tube connected to wall suction. The tip of the silicone tube can be grasped with robotic forceps and used for organ retraction as well as suction. The suction device has been used in eight lung lobectomy cases and four lung segmentectomy cases to date. There were no major difficulties related to the new suction device except for metal tip disconnection and blood clots clogging.DiscussionOur newly developed surgeon‐controlled suction device is inexpensive, easy to handle, and useful for suction, blunt dissection, and organ retraction in robotic‐assisted thoracoscopic surgery, especially when performing lymph node dissection.

Minimizing invasiveness and simplifying the surgical procedure for upper and middle early gastric cancer with near-infrared light and organ traction

BackgroundSurgeons are often faced with optimal resection extent and reconstructive method problems in laparoscopic gastrectomy for gastric cancer in the upper and middle body of the stomach. Indocyanine green (ICG) marking and Billroth I (B-I) reconstruction were used to solve these problems with the organ retraction technique.Case presentationA 51-year-old man with upper gastrointestinal endoscopy revealed a 0-IIc lesion in the posterior wall of the upper and middle gastric body 4 cm from the esophagogastric junction. Clinical T1bN0M0 (clinical stage IA) was the preoperative diagnosis. Laparoscopic distal gastrectomy (LDG) and D1 + lymphadenectomy was decided to be performed considering postoperative gastric function preservation. The ICG fluorescence method was used to determine the accurate tumor location since the determination was expected to be difficult to the extent of optimal resection with intraoperative findings. By mobilizing and rotating the stomach, the tumor in the posterior wall was fixed in the lesser curvature, and as large a residual stomach as possible was secured in gastrectomy. Finally, delta anastomosis was performed after increasing gastric and duodenal mobility sufficiently. Operation time was 234 min and intraoperative blood loss was 5 ml. The patient was allowed to be discharged on postoperative day 6 without complications.ConclusionThe indication for LDG and B-I reconstruction can be expanded to cases where laparoscopic total gastrectomy or LDG and Roux-en-Y reconstruction has been selected for early-stage gastric cancer in the upper gastric body by combining preoperative ICG markings and gastric rotation method dissection.

Use of a T'LIFT transabdominal organ retraction device in two-portal laparoscopic ovariectomy in dogs.

To describe the use of the T'LIFT transabdominal organ retraction device to suspend ovaries during canine laparoscopic ovariectomy (LapOVE) and compare its use to a transabdominal suspension suture (TSS). Randomized clinical trial. Client-owned intact bitches (n=30). Dogs were randomly assigned either to group T, in which LapOVE was performed with the T'LIFT, or to group S, in which a TSS was used. Laparoscopic ovariectomy was performed by using a standard two-portal protocol. Signalment (age, weight, body condition score [BCS], fat score of the ovarian pedicle [FSOP]), overall operative time, ovarian resection time, and perioperative complications were compared between groups. No significant differences were found between groups regarding age, weight, BCS, or FSOP. Surgical times were not significantly different between groups. No significant differences in major or minor complications were recorded. Overall operative time was significantly shorter for the last half of the cases compared with the first half, for the overall population, and within each group. Ovarian resection time for the last cases was significantly shorter compared with that for the first ones only in group T. The T'LIFT was used to suspend ovaries for two-portal LapOVE, with no major complications noted. There was no significant difference in surgical times or complications compared with transabdominal suturing. The T'LIFT can be considered as an alternative to transabdominal suture for ovarian suspension in dogs undergoing LapOVE.

A Compliant Robotic Instrument With Coupled Tendon Driven Articulated Wrist Control for Organ Retraction

Organ retraction is a common and important task in minimally invasive surgery. It is a surgical technique to push aside or manipulate tissues/organs to improve the access and visualization of the surgical sites. Typical manual retractors are rigid and without any articulation. Physicians often struggle with minimizing the force applying onto the tissue while positioning the retractor to maintain optimal exposure. In this letter, we propose a novel compliant robotic organ retractor with coupled tendon driven articulated wrist control to address the aforementioned clinical risks. The compliant retractor exploits the buckling principle of a continuum bending beam mechanism, allowing it to interact with organ safely and smoothly. We also present a new tendon-driven, high torsional strength articulated joint and corresponding kinematics model to address the lack of dexterity issue. For the instrument control, a general algorithm framework is proposed to design the controller gain systematically, while eliminating the “disturbance” leaking caused by the coupled multitendon driven mechanism. Initial prototypes were built and integrated with the state-of-the-art surgical robotic platform, da Vinci Research Kit for basic functional evaluation. Preliminary simulation and experimental results demonstrate the capability of the proposed device for organ retraction. It is our hope that this novel instrument will become a new benchmark for organ retraction in terms of safety, precision, and dexterity.

In Vivo Measurement of Surface Pressures and Retraction Distances Applied on Abdominal Organs During Surgery.

This study undertook the in vivo measurement of surface pressures applied by the fingers of the surgeon during typical representative retraction movements of key human abdominal organs during both open and hand-assisted laparoscopic surgery. Surface pressures were measured using a flexible thin-film pressure sensor for 35 typical liver retractions to access the gall bladder, 36 bowel retractions, 9 kidney retractions, 8 stomach retractions, and 5 spleen retractions across 12 patients undergoing open and laparoscopic abdominal surgery. The maximum and root mean square surface pressures were calculated for each organ retraction. The maximum surface pressures applied to these key abdominal organs are in the range 1 to 41 kPa, and the average maximum surface pressure for all organs and procedures was 14 ± 3 kPa. Surface pressure relaxation during the retraction hold period was observed. Generally, the surface pressures are higher, and the rate of surface pressure relaxation is lower, in the more confined hand-assisted laparoscopic procedures than in open surgery. Combined video footage and pressure sensor data for retraction of the liver in open surgery enabled correlation of organ retraction distance with surface pressure application. The data provide a platform to design strategies for the prevention of retraction injuries. They also form a basis for the design of next-generation organ retraction and space creation surgical devices with embedded sensors that can further quantify intraoperative retraction forces to reduce injury or trauma to organs and surrounding tissues.

DEVELOPMENT OF BALLOON-BASED ORGAN RETRACTOR FOR LAPAROSCOPIC SURGERY

Effective organ retraction is essential to ensure safe and efficient surgery, in the case of laparoscopic surgery, organ retraction is particularly difficult to achieve. Currently such as cherry dissectors are used for retraction, however the small size results in excessive stress on the organ being retracted. Therefore, we are developing a balloon-based retractor that provides similar functionality as the cherry dissector, particularly being able to pass through a small port, yet being expandable to provide a much greater contact area as well as improved traction, thus providing increased operating efficiency and improved safety in organ retraction. In this paper, the relative merits and demerits of a number of currently available retractors are compared. Parameters under consideration include shape, size, effective traction (coefficient of friction), type of actuation and ease of use. While parameters such as pressure distribution and effective traction have been objectively measured, other attributes unique to the individual mechanisms are discussed, and finally feedback is provided from surgeons regarding the respective retractor’s ease of use and perceived efficacy.

The String Puppet Technique: A Useful Tool for Transumbilical Surgery

Introduction: Transumbilical single-port surgery (TSPS) has emerged to outdare minimally invasive surgery by trying to obtain better aesthetic results, further reduction of morbidity, and further enhanced postoperative recovery. Nonetheless, TSPS entails many challenges. One of them is the limited triangulation of the surgical instruments, which does not contribute to proper organ retraction during surgery. This makes dissection uncomfortable and difficult for the surgeon, and tissue retraction has to be accomplished by using fixation or sling sutures instead of another trocar. The learning curve of TSPS is harsh, because experience is needed to learn to manage the external crowding and collision of instruments, select the most adequate surgical instrument set to be used, and also wisely choose the best patient candidates for this type of procedure.1 The string puppet technique described in this article and displayed in the video (run time 1 minute, 51 seconds) is a useful TSPS maneuver that helps achieve optimal organ retraction. An internal grasper is used to hold organs or tissues inside the abdominal cavity but can be moved, directed, and controlled externally through leashes, just like a puppeteer manipulates a puppet. Materials and Methods: A straight needle with a 2.0 nylon suture is introduced through the skin in the epigastric region. The needle is then externalized through a 12-mm umbilical trocar using a 10-mm scope with a 6-mm working channel. The needle is removed from the suture and the loose end of the suture is held or fixed externally to avoid sliding inside the abdominal cavity. The procedure is repeated on the right flank. Once the two loose ends of the sutures are outside of the abdomen, they are both tied up to a stainless steel alligator clamp. The grasper is placed at the tip of the laparoscope with its jaws open and descends into the abdominal cavity through the operating channel. Once inside, the grasper can be directed and secured to the target area with the aid of a Thomas forceps. The alligator clamp allows for strong organ retraction but also easy repositioning. In this video, the infundibulum is held by the grasper and external traction is provided by means of both sutures. Movement and position of the organ or tissue can be adjusted and corrected during the surgery to accommodate to the surgeon's needs. Once no longer necessary, the grasper can be withdrawn along with both sutures through the umbilical port. Results and Conclusions: One of the major difficulties of TSPS is to achieve proper organ retraction. The string puppet technique is a useful maneuver to overcome this problem and can be used in any area of the abdomen. It is easy to perform, unexpensive, and does not require any sophisticated instruments. No competing financial interests exist. Runtime of video: 1 mins 51 secs

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.

Reduced-Port Distal Gastrectomy for Gastric Cancer Using Two Needle Devices, a GelPOINTTMDevice, and an Umbilical Zigzag Incision

Introduction: Single-incision laparoscopic surgery (SILS) and reduced-port surgery (RPS) have been introduced to provide better cosmetic effects and decrease postoperative pain and incision-related complications. In recent years, SILS and RPS procedures have been increasingly applied for a variety of abdominal surgeries, including cholecystectomy, appendectomy, and colectomy. However, it can be difficult to maintain triangulation and proper organ retraction because of the inadequate distance between instruments and the small number of access ports, respectively. In terms of gastrectomy for gastric cancer, which is associated with technical difficulties even with the conventional laparoscopic approach, SILS and RPS have not been applied widely. To resolve these problems, we devised a novel procedure of reduced-port gastrectomy for gastric cancer using two needle devices and the GelPOINT™ with an umbilical zigzag incision.1,2 In this video, we demonstrate reduced-port laparoscopic distal gastrectomy. Materials and Methods: A 64-year-old woman with early gastric cancer in the lower body of the stomach underwent laparoscopic distal gastrectomy with D1+ lymphadenectomy. After placing an umbilical zigzag skin incision measuring 3.5 cm, a GelPOINT was placed through the incision. The laparoscope and two conventional instruments were inserted through the GelPOINT. Two additional needle devices (Endo-Relief; Hope Electronics)3 were inserted in the right and left upper abdomen, with shaft diameter of 2.4 mm and tips of the same shape and size as those of the 5-mm-diameter instruments. The chief surgeon was positioned on the patient's right side, and he used the needle device in the right abdomen with his left hand and the instrument inserted through the GelPOINT with his right hand. The first assistant on the patient's left side used the left needle device with his right hand and another instrument through the GelPOINT with his left hand. Results and Conclusions: Distal gastrectomy with lymphadenectomy was performed using the same technique as that used for conventional five-port laparoscopic distal gastrectomy. After removal of the resected specimen through the umbilical incision, reconstruction was performed with the Roux-en-Y method. The umbilical incision was closed with absorbable sutures, and no sutures were required for the other two needle incisions. The total operative time was 329 minutes, and blood loss was minimal. There were no intraoperative or postoperative complications, and the patient was discharged 10 days after the surgery. Our reduced-port gastrectomy procedure has three key features. First, the 3.5-cm umbilical zigzag skin incision provides a sufficiently wide opening to prevent the instruments from clashing. The scar is well hidden and inconspicuous in the umbilicus. Second, by using Endo-Relief needle devices, which can be used as conventional laparoscopic instruments, postoperative pain is minimized and the two wounds outside the umbilicus are almost invisible several months after the surgery. Third, each surgeon has sufficient distance between instruments to maintain good triangulations. Taken together, this novel procedure permits safe and feasible reduced-port gastrectomy, similar to conventional laparoscopic gastrectomy, and provides excellent cosmetic results and decreased postoperative pain, resulting in almost SILS. No competing financial interests exist. Runtime of video: 6 mins 32 secs

The evolving application of single‐port robotic surgery in general surgery

Advances in the field of minimally invasive surgery have grown since the original advent of conventional multiport laparoscopic surgery. The recent development of single incision laparoscopic surgery remains a relatively novel technique, and has had mixed reviews as to whether it has been associated with lower pain scores, shorter hospital stays, and higher satisfaction levels among patients undergoing procedures through cosmetically-appeasing single incisions. However, due to technical difficulties that arise from the clustering of laparoscopic instruments through a confined working space, such as loss of instrument triangulation, poor surgical exposure, and instrument clashing, uptake by surgeons without a specific interest and expertise in cutting-edge minimally invasive approaches has been limited. The parallel use of robotic surgery with single-port platforms, however, appears to counteract technical issues associated with single incision laparoscopic surgery through significant ergonomic improvements, including enhanced instrument triangulation, organ retraction, and camera localization within the surgical field. By combining the use of the robot with the single incision platform, the recognized challenges of single incision laparoscopic surgery are simplified, while maintaining potential advantages of the single-incision minimally invasive approach. This review provides a comprehensive report of the evolving application single-port robotic surgery in the field of general surgery today.

Multiple Organ Retraction During Urological Laparoscopic Surgery

During laparoscopic surgery, as in open surgery, exposure is critical. We describe our surgical technique that provides intra-abdominal multiple organ retraction in order to obtain a stable surgical field and adequate exposure. The Flex Arm™ surgical holder (Mediflex Surgical Products, Islandia, NY) is an adjustable, spring-loaded articulating instrument holder. The device offers the flexibility of the attachment of multiple arms (up to three) on the same rod, which can rotate 360° to aid in positioning. This device permits multiple laparoscopic instruments to be held simultaneously. We used this device for multiple organ retraction during urological laparoscopic surgery (retroperitoneoscopic radical prostatectomy, n=5; laparoscopic radical nephrectomy, n=3; laparoscopic partial nephrectomy, n=2; laparoscopic pyeloplasty, n=2). We achieved significant improvements in the efficiency of retraction of the liver, kidney, colon, and prostate during urological laparoscopic surgery. Our method maintains a constant surgical field through the proper retractor position and the proper amount of isometric force for optimal exposure. With this device, instrument migration due to muscle fatigue and organ injury as a result of excessive force are all substantially reduced. We believe that this technique may be helpful not only in urological laparoscopic surgery, but also in laparoscopic approaches in other departments.

A Novel Procedure for Introducing a Large Gauze into the Corporeal Cavity by Using a Slim Trocar (the Tornado Gauze Procedure)

When a large gauze is needed during a single-incision surgery or reduced port surgery using slim (5-mm) trocars, the operation needs to be interrupted to introduce the gauze via an incision or to change to a large trocar. We describe here a novel procedure for introducing a large gauze into the corporeal cavity by using a slim trocar, called the "Tornado gauze procedure" (TGP). Commercially packed Trox(®) (Osaki Medical, Nagoya, Japan) gauze (30×150 mm, 4-ply) and a specially ordered precision stainless steel tube (Smart introducer; Kinugawa Factory, Kyoto, Japan) are used for the TGP. The gauze is screwed into the Smart introducer. When the surgeon needs a gauze, a Smart introducer with a gauze is set into the 5-mm trocar; then, the 5-mm grasper is used to push the gauze into the corporeal cavity with small screwing-in movements. The gauze is also gently removed from the corporeal cavity through a 5-mm trocar. This procedure efficiently and safely introduced the gauze for hemostasis, blunt dissection, suction filtering, and organ retraction without interrupting the pneumoperitoneum to introduce the gauze in single-incision laparoscopic cholecystectomy, transabdominal preperitoneal hernia repairs, and appendectomy, with good visualization and adequate working space. The rhythm of surgery remains undisturbed with the use of the TGP, even in a high-risk and high-stress situation. The port's valves were not disabled during surgery, and no procedure-related complications were reported. TGP is expected to be helpful to surgeons and enhance the safety of laparoscopic surgeries involving the use of slim trocars.

Utility of an Organ Retraction Sponge (Endoractor®) in Gynecological Laparoscopic Surgery

We evaluated the utility and safety of the Endoractor®, an organ retraction sponge that can be inserted through a 12-mm trocar to secure a surgical field in laparoscopic surgery. Retrospective study (Canadian Task force classification III) University-affiliated hospital Twenty-four women The Endoractor®, a 100% cellulose sponge fabricated by compression, can be inserted through a 12-mm port. Absorption of about 80 mL of physiological saline causes the swelling sponge to displace organs away from the surgical field. Measurements and Main result: we used the Endoractor® in 24 patients, placed in a horizontal position. In all patient, the intestine did not fall into the pelvis, and surgery was easily performed. Using the Endoractor®, even in a horizontal position without use of the Trendelenburg position, allowed a good surgical field to be secured.

Utility of an Organ Retraction Sponge (Endoractor) in Gynecologic Laparoscopic Surgery

Because it is minimally invasive, laparoscopic surgery is preferred over open surgery. However, it is often difficult to maintain an adequate surgical field during the procedure. As in open laparotomy, securing an adequate surgical field is important for adequate visualization. We evaluated the effectiveness and safety of the Endoractor, an organ retraction sponge that can be inserted through a 12-mm trocar to secure a surgical field in gynecologic laparoscopic surgery. The Endoractor, a 100% cellulose compressed sponge, can be expanded using physiologic saline solution, with the result that the swollen sponge displaces organs away from the surgical field. Between October 2009 and April 2010, we used the Endoractor in 24 patients, placed in a Trendelenberg position, during laparoscopic surgery. In no patients, even with return to a horizontal position, did the intestines fall into the pelvis, and surgery was easily performed. Mean (SD; 95% CI) operative time was 92.7 (44.5; 74.0–111.6) minutes, and blood loss was 54.1 (73.1; 22.9–82.1) mL. All patients were discharged on postoperative day 3. Even with the patient in a horizontal position without use of the Trendelenberg position, the Endoractor enables a good surgical field to be secured. It remains to be seen whether this device works as well in obese patients.

Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Chłosta P, Drewa T, Obarzanowski M, Antoniewicz A, Borówka A. Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question. Videosurgery and Other Miniinvasive Techniques. 2011;6(1):1-4. doi:10.5114/wiitm.2011.20985. APA Chłosta, P., Drewa, T., Obarzanowski, M., Antoniewicz, A., & Borówka, A. (2011). Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question. Videosurgery and Other Miniinvasive Techniques, 6(1), 1-4. https://doi.org/10.5114/wiitm.2011.20985 Chicago Chłosta, Piotr, Tomasz Drewa, Mateusz Obarzanowski, Artur Antoniewicz, and Andrzej Borówka. 2011. "Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question". Videosurgery and Other Miniinvasive Techniques 6 (1): 1-4. doi:10.5114/wiitm.2011.20985. Harvard Chłosta, P., Drewa, T., Obarzanowski, M., Antoniewicz, A., and Borówka, A. (2011). Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question. Videosurgery and Other Miniinvasive Techniques, 6(1), pp.1-4. https://doi.org/10.5114/wiitm.2011.20985 MLA Chłosta, Piotr et al. "Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question." Videosurgery and Other Miniinvasive Techniques, vol. 6, no. 1, 2011, pp. 1-4. doi:10.5114/wiitm.2011.20985. Vancouver Chłosta P, Drewa T, Obarzanowski M, Antoniewicz A, Borówka A. Do we need a cosmetic effect for radical nephrectomy? Laparoendoscopic single-site surgery would help to answer this question. Videosurgery and Other Miniinvasive Techniques. 2011;6(1):1-4. doi:10.5114/wiitm.2011.20985.

Triangulation: the holy grail of endoscopic surgery?

Interventional endoscopy has recently breached the boundaries of the gastrointestinal lumen, entering into the peritoneal cavity to perform natural orifice translumenal endoscopic surgery (NOTES) [1–3]. NOTES is defined as a surgical procedure in which visualization, dissection, and organ retraction is performed with flexible endoscopic instruments through the natural orifices of the body. NOTES is theoretically scarless, and therefore, incisional hernias and associated wound infections are avoided. Other potential benefits include reduced surgical trauma resulting in less postoperative pain and adhesion formation compared with laparoscopic surgery [3]. Currently, no randomized, controlled trial has demonstrated a true advantage of NOTES compared with laparoscopic surgery and the proposed benefits remain speculative. Thus far, and largely in animal laboratories, gastroenterologist and surgeon have opened and closed the gastrointestinal wall, peered into the peritoneal cavity, and demonstrated feasibility of organ resection [4, 5]. Why is it that despite being eager to perform endoscopic intraperitoneal surgery, gastroenterologists and surgeons have only scratched the surface of this novel surgical approach, which is still nowhere near primetime? When experts try to predict how NOTES could function, they normally look at the principles of laparoscopic surgery. Laparoscopic surgery is performed with careful placement of trocars to optimize exposure and to permit triangulation. It is assumed that triangulation is necessary to create traction and countertraction and that this physical principle is what permits appropriate retraction, dissection, or suturing. Accordingly, many experts have suggested that flexible endoscopic surgery will need to emulate the same principles of triangulation to be an effective surgical approach [6, 7]. Several articles have proposed a triangulating endoscope as a key element for the success of NOTES [3, 8–11]. Consequently, NOTES research in recent years has been dominated by major efforts to develop devices and platforms that simulate triangulation and surgical tasks based on how they are performed in the laparoscopic environment. The first patent describing the concept of an endoscope with angulating end-effectors was filed by Mitsui for Olympus as early as 1974 (United States patent number 3,915,157). This patent was subsequently further refined and advanced to a prototype triangulating endoscopic platform filed for patent in 1999 (Matsui et al., United States Patent number 6,352,503). Despite these enduring efforts to build a triangulating endoscopic platform, no such device has become available for clinical use, and those among us who had the opportunity to work with triangulating prototypes have realized that triangulating end-effectors at the tip of a flexible endoscope may have inherited more problems than solutions. Using the flexible translumenal instead of a laparoscopic approach for intraperitoneal surgery does not nullify surgical principles and certain tasks, such as robust organ retraction and classic suturing, will likely require triangulation. There D. von Renteln (&) T. Rosch Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Martinistrase. 52, 20246 Hamburg, Germany e-mail: renteln@gmx.net

The anterior approach to retroperitoneoscopic adrenalectomy in children: Technique

PurposeVery limited literature exists on minimally invasive adrenalectomy in children. Retroperitoneoscopic adrenalectomy (RPA) has the advantage of avoiding intra-abdominal organ retraction, but concerns have been expressed regarding RPA on the right side. Herein, we describe the second reported experience with the anterior approach to RPA in children, which appears to overcome the limitations previously ascribed to right RPA. Materials and methodsTwo children, aged 8 and 14-years, presented with incidental right adrenal masses. Both patients were placed in the lateral decubitus position with lumbar hyper-extension. A 5-mm, 3-port approach was used, as demonstrated in the video. ResultsPathology revealed a 7-cm ganglioneuroma and a 5-cm pheochromocytoma with intact surgical margins. Operative time with these large masses and first experience with this technique was 5 h in the first case and 3.5 h in the second. No intraoperative or postoperative complications were noted, with minimal blood loss and a hospital stay of 36 h in both cases. ConclusionThe anterior approach to RPA is feasible even in children with a smaller retroperitoneal space and a large adrenal mass. It provides excellent exposure of the adrenal gland and vein, even on the right side.

The Anterior Approach to Right Retroperitoneoscopic Adrenalectomy (RPA) in Children. A Point of Technique and Initial Experience

Purpose Very limited data exists about minimally invasive techniques for adrenalectomy in children. RPA has the advantage of avoiding intra-abdominal organ retraction. Concerns were expressed with the right side lateral RPA. Herein, we describe our initial experience with the anterior approach to right RPA in children. Material and Methods Two children, (8 and 14) years with incidentally discovered right suprarenal masses of 4x5x7 and 4x4x5 cm underwent the same technique. Both were placed in Lateral decubitus position with lumbar hyperextension. A 5mm, 3-port approach was used. Extra-gerotal retroperitoneal space was developed under direct vision. The first plane of dissection was anterior to the renal upper pole creating the anterior working space. The second was the plane separating the adrenal from the upper pole of the kidney. Then Medial to the adrenal mass the 3rd plane is easily entered between the inferior vena cava and the mass where adrenal vein is easily identified and controlled. Adrenal superior attachments were the last to divide as it suspend it throughout the procedure, hence no gland manipulation was required. Results Pathology was ganglioneuroma and pheochromocytoma. Operative time was 5 and 3.5hours (trainee involved), with hospital stay of 36 hours. No complications were recorded. Conclusions The anterior approach to right RPA is feasible even in children with a smaller retro-peritoneal space and a large adrenal mass. It provides superior exposure of the adrenal gland and vein compared to the lateral RP approach.

Single‐port laparoscopic surgery, the new evolution of endoscopic surgery

AbstractIntroduction: Laparoscopic surgery through a single port is gaining great interest throughout the world. Our group has pioneered and been a leader on these novel techniques. Here we describe our experience based on a model of single‐port laparoscopic cholecystectomy.Materials and Methods: From January 2008 until August 2009, over 200 patients have undergone single‐port laparoscopic surgery at our institution. Here, we analyze a cohort of the initial 100 cholecystectomies in order to evaluate a proposed technique, common challenges, the learning curve and potential solutions.Results: Single‐port laparoscopic surgery was feasible in all patients from this cohort. Patients were strictly selected. Operating times similar to those of conventional laparoscopy were only achieved after completing 50 cases. Common technical challenges included clashing instruments, deflection of laparoscope due to conflict with light source, and organ retraction. Acceptance by surgeons and lack of patience and time may become significant obstacles that prevent the procedure's widespread adoption. The excellent aesthetic results are superior to laparoscopy. Other benefits of laparoscopy are preserved and may prove to be superior on clinical trials.Discussion: Single‐port laparoscopic surgery is becoming popular worldwide. Safe and successful adoption requires learning the basic concepts of this method, identifying challenges, and implementing solutions. Once these essentials are mastered, the learning curve may be shortened, especially for experienced laparoscopic surgeons, and this technique may then be used to replicate many abdominal operations. Transparency with patients and team building are essential requirements for a successful adoption. Clinical trials are ideal before universal adoption.