Standard Laparoscopic Instruments Research Articles

Hybrid robotic systems

Standard laparoscopic instruments have limited dexterity because of their few degrees of freedom, making some surgical tasks extremely challenging. Robotic surgery was developed to overcome these issues, but the da Vinci system is associated with high costs. During recent years, many companies developed new robotic systems to improve dexterity and ergonomics with less impact on cost-effectiveness. This work describes the main commercially available modular robotic platforms, focusing on the technology, architecture and features, and advantages and disadvantages of each system. One of the main advantages of modular systems is the possibility of performing the whole procedure robotically or performing part of the procedure laparoscopically and part robotically as a hybrid approach. Next-generation robotic systems mainly include a modular design, open or semiopen consoles, smaller instruments, decreased cost, and augmented reality. To date, there are still few data in the literature comparing the systems, as many of them are awaiting regulatory approval. Thus, future studies are necessary to answer these questions. Many other robotic platforms are currently under development and will be available on the market, with a potential to alter surgical practice.

Potential applications of single-incision laparoscopic totally preperitoneal hernioplasty.

The totally preperitoneal (TPP) approach is a new concept that was recently introduced. Although the TPP approach combined with single-incision laparoscopic hernia repair has its own advantages, there is little evidence reflecting the characteristics and feasibility of either approach. To analyze the potential applications of single-incision laparoscopic TPP (SIL-TPP) inguinal hernia hernioplasty for the treatment of inguinal hernias. A total of 152 SIL-TPP surgeries were performed at the First Affiliated Hospital of Ningbo University from February 2019 to November 2022. A single-port, named Iconport, and standard laparoscopic instruments were used during the operation. Demographic data, intraoperative parameters and short-term postoperative outcomes were collected and retrospectively analyzed. The demographic data of 152 patients underwent SIL-TPP were shown in Table 1. The average age was 49.5 years (range from 21 to 81 years). The average body mass index was 27.7 kg/m2 (range from 17.7 kg/m2 to 35.6 kg/m2). SIL-TPP were conducted successfully in 147 patients. Three patients were converted to the SIL-transabdominal preperitoneal laparoscopic herniorrhaphy at the initial stage of the study due to a lack of experience. In 2 patients with incisional hernias, an auxiliary operation hole was added during the SIL-TPP procedure, as required for surgery. The mean operative time was 64.5 minutes (range: 36.0-110.0 minutes) for unilateral direct and femoral hernias and 81.6 minutes for indirect hernias (range: 40.0-150.0 minutes). The mean postoperative hospital stay was 3.4 days. SIL-TPP is feasible and has advantages for inguinal hernia repair. SIL-TPP has potential benefits for patients with various abdominal wall hernias. Consequently, doctors should be encouraged to actively apply the TPP approach combined with a single incision in their daily work.

Can you feel the force just right? Tactile force feedback for training of minimally invasive surgery—evaluation of vibration feedback for adequate force application

BackgroundTissue handling is a crucial skill for surgeons and is challenging to learn. The aim of this study was to develop laparoscopic instruments with different integrated tactile vibration feedback by varying different tactile modalities and assess its effect on tissue handling skills.MethodsStandard laparoscopic instruments were equipped with a vibration effector, which was controlled by a microcomputer attached to a force sensor platform. One of three different vibration feedbacks (F1: double vibration > 2 N; F2: increasing vibration relative to force; F3: one vibration > 1.5 N and double vibration > 2 N) was applied to the instruments. In this multicenter crossover trial, surgical novices and expert surgeons performed two laparoscopic tasks (Peg transfer, laparoscopic suture, and knot) each with all the three vibration feedback modalities and once without any feedback, in a randomized order. The primary endpoint was force exertion.ResultsA total of 57 subjects (15 surgeons, 42 surgical novices) were included in the trial. In the Peg transfer task, there were no differences between the tactile feedback modalities in terms of force application. However, in subgroup analysis, the use of F2 resulted in a significantly lower mean-force application (p-value = 0.02) among the student group. In the laparoscopic suture and knot task, all participants exerted significantly lower mean and peak forces using F2 (p-value < 0.01). These findings remained significant after subgroup analysis for both, the student and surgeon groups individually. The condition without tactile feedback led to the highest mean and peak force exertion compared to the three other feedback modalities.ConclusionContinuous tactile vibration feedback decreases the mean and peak force applied during laparoscopic training tasks. This effect is more pronounced in demanding tasks such as laparoscopic suturing and knot tying and might be more beneficial for students. Laparoscopic tasks without feedback lead to increased force application.

Laparoscopic Sleeve Gastrectomy Smart Trocar Site Modification in Patients with Extreme Obesity.

Laparoscopic sleeve gastrectomy (LSG) is one of the most common bariatric surgeries performed worldwide. Although it has established itself as a satisfactory procedure on its own, it can also function as the first part of a two-stage treatment strategy. This is especially true in situations of extreme obesity (obesity grade IV or higher). One rationale for choosing a two-stage treatment is the technical difficulty of doing other types of bariatric procedures involving anastomoses due to body physique and level of visceral adiposity. LSG in patients with such a high body mass index (BMI) is comparatively simpler technically, but it does also have a degree of complexity for similar reasons. Here, we present an innovative port configuration for LSG that can significantly reduce ergonomic challenges and enhance the safety of the procedure in patients with extreme obesity. This new trocar site arrangement is generally suitable for individuals with grade IV obesity or above. It is especially effective for people with obesity at or above grade V. Only standard laparoscopic instruments are used. This design preserves the ideal manipulation and elevation angles at 60° and allows surgeons to use standard laparoscopic instruments with lowered shoulders, reducing muscular strain and fatigue. Additionally, it improves patient safety. In patients with extreme obesity, this proposed port configuration for LSG can significantly reduce ergonomic difficulties and increase surgical safety.

Laparoendoscopic Single-Site Inguinal Herniorrhaphy: Experience of a Single Institute

Background: Minimally invasive techniques for inguinal herniorrhaphy have focused on developing the laparoendoscopic single-site (LESS) procedure to improve cosmesis. Outcomes of total extraperitoneal (TEP) herniorrhaphy vary considerably because of being performed by different surgeons. We aimed to evaluate the perioperative characteristics and outcomes of patients undergoing the LESS-TEP approach for inguinal herniorrhaphy and to determine its overall safety and effectiveness. Methods: Data of 233 patients who underwent 288 laparoendoscopic single-site total extraperitoneal approach (LESS-TEP) herniorrhaphies at Kaohsiung Chang Gung Memorial Hospital between January 2014 and July 2021 were reviewed retrospectively. We reviewed the experiences and results of LESS-TEP herniorrhaphy performed by a single surgeon (CHC) using homemade glove access and standard laparoscopic instruments with a 50 cm long 30° telescope. Results: Among 233 patients, 178 patients had unilateral hernias and 55 patients had bilateral hernias. About 32% (n = 57) of patients in the unilateral group and 29% (n = 16) of patients in the bilateral group were obese (body mass index ≥ 25). The mean operative time was 66 min for the unilateral group and 100 min for the bilateral group. Postoperative complications occurred in 27 (11%) cases, which were minor morbidities except for one mesh infection. Three (1.2%) cases were converted to open surgery. Comparison of the variables between obese and non-obese patients found no significant differences in operative times or postoperative complications. Conclusion: LESS-TEP herniorrhaphy is a safe and feasible operation with excellent cosmetic results and a low rate of complication, even in obese patients. Further large-scale prospective controlled studies and long-term analyses are needed to confirm these results.

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.

Evaluation of Perioperative and Quality of Life Outcomes Along with Cost Effectiveness in Laparoscopic Transabdominal Retrorectus Mesh Repair for Ventral Hernia: A Prospective Observational Study

Introduction: Laparoscopic ventral hernia repair has its advantages of reduced postoperative complication and early return to work. Owing to the need of a cost-effective technique with similar perioperative outcomes, transabdominal retro-rectus mesh repair (TARM) is a suitable and less expensive alternative compared with other methods of laparoscopic ventral hernia repair. Methods: Patients with primary (n = 7) or incisional (n = 17) hernia were selected to be operated on using TARM procedure. Quality of life was evaluated in terms of time to return to usual routine work, the sensation of mesh (using Carolinas Comfort Scale, CCS), tolerance to early oral feed, formation of seroma, suture site infection and hernia recurrence. Results: The average defect size was 2.8 cm with a mean BMI was 28.17 kg/m2. The average duration of surgery was 165 mins. Mean postoperative pain score after 1 day, 1 week, 1 month, 3 months and 6 months were 3.5, 2, 0.58, 0.5 and 0 respectively. Seroma formation occurred in 6 (25%) and hematoma in 1 (4%) patient. The mean time to resumption of daily activities was 6.25 days. Mean CCS after 1 month and 3 months are 30 and 16.2 respectively. No cases of recurrence or chronic pain were observed during 6 months follow-up. Conclusion: Laparoscopic TARM appears to be a feasible, safe and cost-effective method of ventral hernia repair due to standard laparoscopic instruments used, no contact with bowel and use of plain polypropylene mesh respectively.

Single incision laparoscopic totally preperitoneal hernioplasty (SIL-TPP): Lessons learned from 102 procedures and initial experience.

Background:The abdominal wall in groin area is conventionally considered that it was comprised by 9 layers. Single incision laparoscopy totally extraperitoneal hernioplasty (SIL-TEP) reported before were operated through the front of the posterior rectus sheath.Method:102 SIL-TPP were conducted from October 2018 to October 2020 at The Affiliated Hospital of Medical School of Ningbo University using a self-made single-port device and standard laparoscopic instruments. Clinical data, demographic and intraoperative findings, and short-term postoperative outcomes were analyzed.Results:Of the 102 hernias treated, 46 were right inguinal hernias, 33 were left inguinal hernias and 23 were double-side inguinal hernias. All patients received the SIL-TPP and no conversion happened. The mean left-side and right-side hernia operative time was almost same. The left-side and right-side operative time were 75.48 ± 26.95 and 76.24 ± 26.09 minutes, respectively. The mean operative time was 75.92 ± 26.45 (range, 29–170 minutes) in unilateral inguinal hernia. Mean operative time was 104.17 ± 28.58 minutes (range, 67–180 minutes) in double-side inguinal hernia. The intraoperative complications rate was 21.57 (22/102) and all the complications were Peritoneum or sac tearing. Postoperative complications occurred in 3 cases (1 case wound seroma, 1 case urinary retension and 1 case upper respiratory infection) and were successfully treated conservatively. The mean hospital stay was 2.8646 ± 1.38 days. The 24 hours Visual analogue scale score was 2.28 ± 0.77. During follow-up to June 2022, no recurrence case occurred.Conclusion:SIL-TPP is safe and feasible. SIL-TPP has its unique skills and advantages to treat inguinal hernia. Large-scale randomized controlled trials comparing SIL-TPP inguinal hernia repair with conventional single port and conventional three port laparoscopic totally extraperitoneal hernioplasty with short-term outcome and long-term recurrence rate are needed to confirm these results.

Introducing the New Surgical Robot HUGO™ RAS: System Description and Docking Settings for Gynecological Surgery.

This study provides a detailed description of the new HUGO™ RAS System and suggests docking settings for gynecological surgery. The system is composed of an “open” surgical console with an HD–3D passive display, a system tower, and four arm carts. Each arm has an extremely wide range of adaptability resulting from the numerous joints. The human cadaver labs were performed at the ORSI Academy between August and December 2021. All procedures were performed by two surgical teams, each composed of a high-volume surgeon experienced in robotic surgery, gynecologic oncology, and pelvic sidewall surgery, and one bedside assistant. Three main gynecological surgical scenarios were identified: standard pelvic surgery, pelvic sidewall surgery, and para-aortic/upper abdominal surgery. Concerning the port placement, the chosen options were called “straight” and “bridge”; instead, the so-called “compact” and “butterfly” configurations were identified for the arm cart positioning. Four cadavers were used to perform total hysterectomy, radical hysterectomy, pelvic exenteration, pelvic and para-aortic lymphadenectomy, and omentectomy. We performed several tests, identifying the best system configurations to draw the proper efficiency from the flexibility of the system in all gynecological surgical scenarios. The straight port placement seems to be adequate for standard pelvic surgery. The bridge trocar position is best to reach the deeper and lateral anatomical regions of the female pelvis. The compact and butterfly arm cart allocations are adequate for both straight and bridge port placement. When deep pelvic surgery was performed, the bedside assistant became more proficient by working with a standard laparoscopic instrument from an ancillary port placed in the left iliac fossa. The arm carts needed to be moved in an open manner, like for the proposed butterfly configuration. On the contrary, the compact disposition left enough space to assist from Palmer’s point port. Several basic and advanced gynecological surgical procedures were performed and completed successfully without encountering any technical or surgical issue, the results obtained were judged sufficient to proceed with the clinical experience in daily practice. The HUGO™ RAS system is flexible and highly performative in various surgical scenarios.

Flexible single port access in transoral endoscopic thyroidectomy vestibular approach

Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is regarded the only no-scar technique which combines minimized surgical trauma with all advantages of endoscopy such as enhanced view, fluorescent parathyroid imaging (FPI) and optimum cosmesis. Addressing TOETVA specific local risk profiles like mental nerve injury, the potential of skin lesions or difficult specimen retrieval we modified the three trocar based TOETVA towards a soft single port platform. Single port-TOETVA (SP-TOETVA) was established and retrospectively analysed in five patients using a soft handmade single port housing multiple trocar valves. Standard laparoscopic instruments, one articulating instrument and a vessel-sealing device were utilized. CO2 insufflation was maintained at 6-8 mmHg. In all patients SP-TOETVA was completed successfully. Hemigland and total thyroid volumes ranged from 5-40 and 55 mL, respectively. Neither additional trocars nor conversion to open was required. Operation time yielded 102-214 min. Neuromonitoring and FPI were applied. The soft wound protection foil served for convenient specimen harvest. No intra- or postoperative complication occurred. In particular, no functional impairment on mental nerve was seen. SP-TOETVA with the soft and flexible handmade single port system is feasible and ensures wound protection. It allows for easy instrument application and benefits of minimally invasive surgery without the specific risk of lateral vestibular incisions.

Early experience with the ARTISENTIAL\xae articulated instruments in laparoscopic low anterior resection with TME

BackgroundThe notion of articulation in surgery has been largely synonymous with robotics. The ARTISENTIAL® instruments aim at bringing advanced articulation to laparoscopy to overcome challenges in narrow anatomical spaces. In this paper, we present first single-center results of a series of low anterior resections, performed with ARTISENTIAL®.MethodsBetween September 2020 and August 2021, at the Department of Surgery, St. Marienkrankenhaus Siegen, Siegen, Germany, patients with cancer of the mid- and low rectum were prospectively enrolled in a pilot feasibility study to evaluate the ARTISENTIAL® articulated instruments in performing a laparoscopic low anterior resection. Perioperative and short-term postoperative data were analyzed.ResultsSeventeen patients (10 males/7 females) were enrolled in this study. The patients had a median age of 66 years (range 47–80 years) and a median body mass index of 28 kg/m2 (range 23–33 kg/m2). The median time to rectal transection was 155 min (range 118–280 min) and the median total operative time was 276 min (range 192–458 min). The median estimated blood loss was 30 ml (range 5–70 ml) and there were no conversions to laparotomy. The median number of harvested lymph nodes was 15 (range 12–28). Total mesorectal excision (TME) quality was ‘good’ in all patients with no cases of circumferential resection margin involvement (R0 = 100%). The median length of stay was 9 days (range 7–14 days). There were no anastomotic leaks and the overall complication rate was 17.6%. There was one unrelated readmission with no mortality.ConclusionsLow anterior resection with ARTISENTIAL® is feasible and safe. All patients had a successful TME procedure with a good oncological outcome. We will now seek to evaluate the benefits of ARTISENTIAL® in comparison with standard laparoscopic instruments through a larger study.

Limited Carpal Fusion with Headless Compression Screws

Though their etiology and pathology are distinct, the treatment of symptomatic diaphragm eventration and paralysis is the same – diaphragm plication. Though there is little data to objectively compare plication techniques, all offer significant improvement in symptoms, pulmonary function, and respiratory quality-of-life scores. Nonetheless, potential advantages of a robot assisted laparoscopic approach to plication include lower morbidity than thoracotomy and laparotomy techniques; avoidance of single lung ventilation, less intercostal nerve pain, and greater working domain compared with thoracotomy and thoracoscopic approaches; and enhanced dexterity as compared with standard laparoscopic instrumentation.

Robot-Assisted Laparoscopic Diaphragm Plication

Though their etiology and pathology are distinct, the treatment of symptomatic diaphragm eventration and paralysis is the same – diaphragm plication. Though there is little data to objectively compare plication techniques, all offer significant improvement in symptoms, pulmonary function, and respiratory quality-of-life scores. Nonetheless, potential advantages of a robot assisted laparoscopic approach to plication include lower morbidity than thoracotomy and laparotomy techniques; avoidance of single lung ventilation, less intercostal nerve pain, and greater working domain compared with thoracotomy and thoracoscopic approaches; and enhanced dexterity as compared with standard laparoscopic instrumentation.

Robotic Gynecologic Surgery: A Beginner's Guide to Becoming an Effective Bedside Assistant

<h3>Study Objective</h3> Learning to become an effective bedside assistant during robotic gynecologic surgery is a difficult task with many real-world nuances. The authors aim to create a video to be a guide for those individuals beginning to fill the role of the bedside assistant in robotic gynecologic surgery, such as residents, physician assistants, and operating room staff. <h3>Design</h3> Instructional video footage was filmed to demonstrate appropriate handling of the robotic system at the bedside. Additional footage was selected that illustrates concepts of best practices in robotic gynecologic surgery. <h3>Setting</h3> This video takes place within a Minimally Invasive Gynecology operating room using a standard robotic system. <h3>Patients or Participants</h3> This video is intended for those beginning to fill the role of bedside assistant in robotic gynecologic surgery (i.e., residents, physician assistants, and surgical scrub technicians/nurses). <h3>Interventions</h3> This video reviews components of the patient cart, cannulas, and instruments in a common robotic system. The video also distills the key points of docking the patient cart, mounting cannulas, and handling of robotic instruments. It highlights safe techniques with use of standard laparoscopic instruments through the assistant port. Additionally, it helps identify ways to be a helpful bedside assistant, including multiple ways to improve the surgeon's visualization of the operative field and anticipate the needs of the primary surgeon. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> The skills of being able to efficiently handle robotic equipment, optimize the surgeon's visualization, and be prepared for next steps in the surgery are illusive to the novice bedside assistant. Review of high yield concepts can help prepare those beginning to fill the role of the bedside assist in robotic gynecologic surgery. This video illustrates many of these concepts and techniques with the intention of guiding those who are new to this role.

Chirurgie endoscopique de l’acétabulum : vision ou illusion ?

Displaced acetabular fractures usually require open surgical approaches. Aim of this cadaver study was to evaluate a laparoscopic approach to prepare the anterior acetabular column and the quadrilateral plate in analogy to the laparoscopic pelvic lymphadenectomy. The laparoscopic preparation and anatomy is presented and illustrated step by step in a human cadaver followed by a modular plate osteosynthesis of the anterior column involving the quadrilateral plate is performed via a minimally invasive approach using standard laparoscopic instruments. In conclusion we could demonstrate that the laparoscopic preperitoneal preparation of the acetabulum according to the laparoscopic pelvic lymphadenectomy provides more free range for the surgical instruments compared to a previously described total extraperitoneal approach. The development of specific reduction tools and implants is under investigation. Until then, at least the laparoscopic preparation could be introduced in the clinical setting in the near future. Type of studyTechnical Note–Cadaver Study.

ТРАНСОРАЛЬНАЯ ТИРЕОИД- И ПАРАТИРЕОИДЭКТОМИЯ: СЕРИЯ НАБЛЮДЕНИЙ

Objective. To present the results of the author’s own series of transoral operations in patients with pathology of the thyroid and parathyroid glands. Methods. Transoral surgery was performed in women (n=20) and (n=1) man. All patients were operated on for the primary disease and met the selection criteria based on ultrasound and cytological examinations, hormonal levels, and somatic status. Indications for surgery were: nodular goiter in 17 cases, diffuse toxic goiter - in 2 cases, parathyroid adenoma - in 2 cases. The surgical technique included a three-port approach in the lower fornix of the vestibule of the mouth and a gas technique for maintaining the working cavity. Standard laparoscopic instruments and an energy based ultrasonic device were used for the operation. In the postoperative period, patients underwent a test for subjective assessment of the aesthetic result of the operation using the survey of thedermatology life quality index. Results. Thyroidectomy was performed in 4 patients, hemithyroidectomy - in 15 patients and parathyroidectomy - in 2 patients. In one patient, transoralparathyroidectomy was performed as a part of a simultaneous operation for multiple endocrine neoplasia type 1 syndrome. Papillary cancer T1N0M0 was verified in two patients after surgery. The mean operation time was 196.1 min (range 110 - 300 min). Average blood loss - 3 9.5 ml (range 10 - 300 ml). The nineth operation required the conversion due to severebleeding. In one case, the temporary recurrent laryngeal nerve(RLN)injury was reported, in one case - hematoma. After surgery, the median and average values of thedermatology life quality index were 1 (IQR 0-4) and 2.05, respectively, which indicates an insignificant effect on the quality of life. Conclusion. Transoral endoscopic surgery on the thyroid and parathyroid glands would be thepromising optimal choice in patients to avoid scarring on the neck.

Laparoscopic Acetabular Surgery (LASY) – vision or illusion?

Displaced acetabular fractures usually require open surgical approaches. Aim of this cadaver study was to evaluate a laparoscopic approach to prepare the anterior acetabular column and the quadrilateral plate in analogy to the laparoscopic pelvic lymphadenectomy. The laparoscopic preparation and anatomy is presented and illustrated step by step in a human cadaver followed by a modular plate osteosynthesis of the anterior column involving the quadrilateral plate is performed via a minimally invasive approach using standard laparoscopic instruments. In conclusion we could demonstrate that the laparoscopic preperitoneal preparation of the acetabulum according to the laparoscopic pelvic lymphadenectomy provides more free range for the surgical instruments compared to a previously described total extraperitoneal approach. The development of specific reduction tools and implants is under investigation. Until then, at least the laparoscopic preparation could be introduced in the clinical setting in the near future. Type of studyTechnical note – Cadaver study.

Robotic Transanal Surgery: A Novel Approach for Full-Thickness Rectal Excision.

Transanal excision of rectal lesions is a full thickness excision that is indicated in selected cases of early stage rectal cancer and in cases that have shown a major or complete clinical response after neoadjuvant chemoradiation. Complete clinical response includes also flat scar or teleangiectasia along with non palpable mass at digital exam and non visible lymphnodes at MRI.1 Full thickness excision is considered primarily as a radical excisionaI biopsy and it has the advantage (vs watch and wait approach) to provide a hystologic confirmation of the complete response. The excision of the tumor/scar and the suture of the rectal defect are technically demanding if performed with standard laparoscopic instruments because of the narrow working space. In order to overcome these difficulties we propose to use the daVinci® robotic platform. The robotic instruments are fully articulated at their tip and they allow the surgeon to easily operate within the lumen of the rectum and perform wrist like movements despite the narrow surgical space. The one limitation is represented by the cost of these procedures, so they should be reserved to selected, challenging cases (i.e. lesions of the mid-upper rectum and lesions that require extensive suture). The patients are either in lithotomy or prone position, depending on the site of the lesion. A gelpoint® system is inserted transanally in order to place the robotic trocars and the daVinci® system is then connected. The purpose of this video is to show the many advantages of the robotic platform in performing full thickness excisions and how the wrist like movements allow to perform transversal sutures thus minimizing the risk of stenosis of the rectum. See Video at http://links.lww.com/DCR/B515 .

Single incision laparoscopic totally extraperitoneal hernioplasty: lessons learned from 1,231 procedures.

PurposeAlthough there are many articles about single incision laparoscopic (SIL) hernioplasty, a large-scale study or article about its long-term outcome has not been reported yet. The aim of this study is to assess short- and long-term outcomes of SIL totally extraperitoneal (TEP) hernia repair with large number of cases.MethodsA prospectively collected database containing details of 1,231 procedures in 1,129 consecutive patients who underwent SIL-TEP hernia repair between June 2010 and December 2017 at a single institution was retrospectively analyzed. SIL-TEP hernia repair was performed using a glove single port device and standard laparoscopic instruments. Recurrence rate of SIL-TEP hernia repair was analyzed by a telephone questionnaire.ResultsAmong 1,129 patients, 1,027 (91.0%) had unilateral hernia and 102 (9.0%) had bilateral hernia. There were 12 (1.1%) conversions to single or 3 ports laparoscopic transabdominal preperitoneal hernioplasty or Lichtenstein repair. Mean operative time was 40.3 minutes for unilateral hernia and 61.6 minutes for bilateral hernia. Intraoperative complication rate was 21.8%. Most intraoperative complications were peritoneum or sac tearing (20.1%). Postoperative complications occurred in 97 (8.6%) cases, most of which were minor morbidity except for 1 mesh infection. Five-year recurrence rate was 4%.ConclusionSIL-TEP hernia repair is safe and technically feasible with acceptable short- and long-term outcomes. Large-scale randomized controlled trials comparing SIL-TEP hernia repair with conventional laparoscopic TEP are needed to confirm these results.

Learning curve of surgical novices using the single-port platform SymphonX: minimizing OR trauma to only one 15-mm incision

BackgroundMinimally invasive single-port surgery is always associated with large incisions up to 2–3 cm, complicated handling due to the lack of triangulation, and instrument crossing. The aim of this prospective study was to report how medical students without any laparoscopic experience perform several laparoscopic tasks (rope pass, paper cut, peg transfer, recapping, and needle threading) with the new SymphonX single-port platform and to examine the learning curves in comparison to the laparoscopic multi-port technique.MethodsA set of 5 laparoscopic skill tests (Rope Pass, Paper cut, Peg Transfer, Recapping, Needle Thread) were performed with 3 repetitions. Medical students performed all tests with both standard laparoscopic instruments and the new platform. Time and errors were recorded.ResultsA total of 114 medical students (61 females) with a median age of 23 years completed the study. All subjects were able to perform the skill tests with both standard laparoscopic multi-port and the single-port laparoscopic system and were able to significantly improve their performance over the three trials for all five tasks—rope pass (p < 0.001), paper cut (p < 0.001), peg transfer (p < 0.001), needle threading (p < 0.001), and recapping (p < 0.001). In 3 out of 5 tasks, medical students performed the tasks faster using the standard multi-port system—rope pass (p < 0.001), paper cut (p < 0.001), and peg transfer (p < 0.001). In the task recapping, medical students performed the task faster using the new single-port system (p = 0.003). In the task needle threading, there was no significant difference between the standard multi-port system and the new single-port system (p > 0.05).ConclusionThis is the first study analyzing learning curves of the commercially available SymphonX platform for abdominal laparoscopic surgery when used by novices. The learning curve and the error rate are promising.