Surgeon's Wrist Research Articles

Does radiation exposure during pediatric supracondylar humeral fracture surgery change according to the C-arm position? A comparison of two different techniques

IntroductionIn the surgical treatment of supracondylar humeral fractures (SHF), the surgeon has to stand right next to the fluoroscopy device, so it is very important to know how to use it in the most appropriate way to reduce radiation exposure. The aim of this study was to investigate the effect of using C-arm in uniplanar (inverted) and biplanar (standard-horizontal) configurations on (1) the radiation exposure to the surgeon, and (2) surgical time and fluoroscopy exposure time. Material and methodsThis prospective randomised study was conducted on 20 patients who underwent fluoroscopy during closed reduction and percutaneous pinning for a SHF. In the first configuration, the C-arm was inverted and the image intensifier was used as a surgical table. In the second configuration, the C-arm was used biplanar. The operations were performed by 5 surgeons, with each surgeon using each method only twice. During the operation, to find a value closed to direct radiation exposure measurement was made by attaching a dosimeter to the wrist and scatter radiation exposure was measured by attaching a dosimeter to the neck and waist of the surgeons. The operation time and fluoroscopy exposure time were determined. ResultsThe duration of operations performed with the biplanar C-arm position and the fluoroscopy exposure time in operations performed with the uniplanar method were found to be statistically significantly longer (p = 0.001). The measurements on the dosimeter worn on the neck of surgeons were found to be statistically significantly higher while using the uniplanar C-arm configuration (p = 0.001). There was no statistically significant difference between the dosimeter measurements on the wrists and waists of the surgeons and the C-arm configurations (p = 0.820; p = 0.185). ConclusionsAlthough the use of biplanar C-arm has no effect on radiation exposure to the surgeon's wrist, the most important advantages are that the neck area is exposed to less radiation and it shortens the fluoroscopy time so the use of a biplanar C-arm can be recommended. Level of evidenceLevel II

8387 Instructional Video on Tandem Vaginal Cuff Closure

<h3>Study Objective</h3> To demonstrate the steps of tandem vaginal cuff closure, outline specific movements of the surgeon and assistant, and provide suggestions for efficient closure. <h3>Design</h3> Instructional Video. <h3>Setting</h3> Operating room of large academic hospital. <h3>Patients or Participants</h3> Single patient undergoing a laparoscopic vaginal cuff closure at the time of hysterectomy. <h3>Interventions</h3> In this technique, two surgeons close the vaginal cuff at the time of hysterectomy through an umbilical port for the 5mm camera and two 5mm lateral ports for instrumentation. This eliminates the need for fascial closure and improves cosmesis. The surgeon stands at the patient's left and holds the needle driver in the right hand. The surgeon positions the needle correctly to facilitate an efficient and effective cuff closure starting from the patient's right and proceeding toward the left. The direction of closure is from posterior to anterior. At least 5mm of vaginal mucosa is incorporated into each bite, and uterosacral and cardinal ligaments are incorporated bilaterally to provide support. A key component is to push the needle through the tissue, with over supination of the surgeon's wrist while lifting the needle cephalad. This over-supination allows better visualization and provides the correct angle for needle reloading. The assistant, standing on the patient's right, provides visualization, places the loop of the barbed suture over the needle, and manipulates the anterior or posterior cuff over the needle. <h3>Measurements and Main Results</h3> Complete and efficient vaginal cuff closure with incorporation of uterosacral and cardinal ligaments for support. <h3>Conclusion</h3> With the use of two skilled surgeons, we demonstrate the efficient movements required to carry out a tandem vaginal cuff closure.

V-040 LAPAROSCOPIC TRANS-ABDOMINAL PREPERITONEAL PROCEDURE (TAPP) FOR RIGHT INGUINAL HERNIA WITH HANDXTM HOOK AND NEEDLE HOLDER

Abstract AIM HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip. This report is to show the feasibility and safety of this technology applied in inguinal hernia repair. MATERIALS AND METHODS We report the case of the laparoscopic repair of a right inguinal hernia using HandXTM instruments. RESULTS The index case was a 55-year-old, otherwise healthy male, with an inguinal right hernia. Three trocars were used: one 10 mm umbilical and two of 5 mm, approximately 4 cm laterally from the umbilicus and 1 cm under the level of the horizontal umbilical line. The dissection started with peritoneal cut, from the antero-superior iliac spine to the medial umbilical ligament, into the preperitoneal avascular plane. The anatomical landmarks (epigastric vessels, Cooper and Gimbernat ligaments, the corona mortis and external iliac vessels) were identified and well exposed. A polypropylene mesh was inserted from the optical trocar, placed in the appropriate position and fixed with three separated stiches handled with the articulating needle holder. The peritoneal flap was closed with a readsorbable running suture handled with the HandX instrumentation. No blood loss nor intraoperative or post-operative complications were recorded CONCLUSIONS The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic TAPP.

V-055 LAPAROSCOPIC FUNDOPLICATION WITH HANDXTM HOOK AND NEEDLE HOLDER

Abstract Aim HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip.This report is to show the feasibility and safety of this technology implemented with a monopolar dissecting hook in a complex abdominal procedure. Materials and Methods We report the case of the laparoscopic repair of a large hiatal hernia using HandXTM instruments. Results The index case was a 69-year-old female with symptomatic large paraesophageal hiatal hernia. Three 5 mm trocars were used: 1 in the left midclavicular line, 1 in on the right of the midline close to the costal arch and 1 assistant on the right midclavicular line, one 11 mm umbilical. The sac was dissected with the HandXTM monopolar hook and the stomach was fully reduced into the abdomen with the hernia sac. The hiatus was closed with three separated stiches handled with the articulating needle holder. A Nissen funduplication was performed. Three separated stiches were used to secure the wrap, using the HandX needle holder. At the end of the operation a mesh was used to reinforce the hiatus. The operative time was 80 minutes, no blood loss nor intraoperative or post-operative complications were recorded Conclusions The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic Nissen fundoplication.

An intuitive surgical handle design for robotic neurosurgery

PurposeThe expanded endoscopic endonasal approach, a representative example of keyhole brain surgery, allows access to the pituitary gland and surrounding areas through the nasal and sphenoid cavities. Manipulating rigid instruments through these constrained spaces makes this approach technically challenging, and thus, a handheld robotic instrument could expand the surgeon’s capabilities. In this study, we present an intuitive handle prototype for such a robotic instrument.MethodsWe have designed and fabricated a surgical instrument handle prototype that maps the surgeon’s wrist directly to the robot joints. To alleviate the surgeon’s wrist of any excessive strain and fatigue, the tool is mounted on the surgeon’s forearm, making it parallel with the instrument’s shaft. To evaluate the handle’s performance and limitations, we constructed a surgical task simulator and compared our novel handle with a standard neurosurgical tool, with the tasks being performed by a consultant neurosurgeon.ResultsWhile using the proposed handle, the surgeon’s average success rate was 80%, compared to 41% when using a conventional tool. Additionally, the surgeon’s body posture while using the suggested prototype was deemed acceptable by the Rapid Upper Limb Assessment ergonomic survey, while early results indicate the absence of a learning curve.ConclusionsBased on these preliminary results, the proposed handle prototype could offer an improvement over current neurosurgical tools and procedural ergonomics. By redirecting forces applied during the procedure to the forearm of the surgeon, and allowing for intuitive surgeon wrist to robot-joints movement mapping without compromising the robotic end effector’s expanded workspace, we believe that this handle could prove a substantial step toward improved neurosurgical instrumentation.

Laparoscopic choledochal cyst resection using a novel articulating instrument in pediatric patients

Abstract Background Historically, choledochal cyst excision has been performed as an open procedure. Controversy remains regarding managing this technically challenging entity in a minimally invasive fashion. Methods A novel mechanically-designed intuitive, articulating instrument is used to facilitate intracorporeal suturing when there is limited working space. The mechanical design of the three-axis Gimbal cuff facilitates intracorporeal suturing by providing intuitive wristed function to the surgeon by translating the surgeon's wrist movement to the end effector. Results We describe the adoption of a novel articulating instrument to facilitate a primary hepaticoduodenostomy within the limited space of a pediatric porta and a redo hepaticojejunostomy. Conclusions These cases demonstrate the use of a novel articulating needle driver to sew an intracorporeal bilio-enteric anastomosis which obviates the need for robotic technology while expanding a laparoscopic surgeon's armamentarium.

Wrist at risk? – Considerations derived from a novel experimental setup to assess torques during hip reaming with potential implications on the orthopedic surgeons’ health

Orthopedic surgeons endure high physical stresses when performing surgery, as large forces and torques are applied commonly. Occupational risks are consequently higher when compared to other surgical disciplines. One example is the reaming of the acetabula during total hip arthroplasty, using customized instruments. This surgery may predispose the surgeon to overuse-related wrist pathology. In this study, torques acting along the reaming tool were measured, and the resulting forces applied to the orthopedic surgeons' wrists were estimated based on the measured torque data from hip reaming. Different reamer sizes and tool velocities were analyzed to determine how both parameters may influence the torques applied at the surgeon's wrist. Using a highly standardized setup, torques were measured while the reamer was pushed into the acetabula to remove cartilage. Maximum torques and stoppage torques at blocking of the reamer were compared between feed rates and reamer sizes. Peak values of the maximum torques along the reamer axis averaged 1.5–1.8 Nm. No significant difference between maximum torques and reamer sizes was found. A significant difference in maximum torques was noted between feed rates with a large effect (p = 0.010; η2 = 0.214) and a large interaction effect (p = 0.017; η2 = 0.186). Based on this experimental setup, it can be hypothesized that the impulsive behavior of the torque when the milling tool reaches the subchondral lamella could potentially contribute to wrist pathology. These preliminary data warrant further study. Consequently, torque limiters should be implemented in reamers to minimize the risk of occupation-related pathology to the wrist.

Is the Human Brain Capable of Controlling Seven Degrees of Freedom?

BackgroundConventional rigid laparoscopic instruments offer five degrees of freedom (DOF). Robotic instruments add two independent DOFs allowing unconstrained directional steering. Several nonrobotic instruments have been developed with the additional DOFs, but with these devices, surgeon's wrist movements are not intuitively transmitted into tip movements. In this study, a new articulated instrument has been evaluated. The aim of the study was to compare learning curves and performances of conventional laparoscopic instruments, the da Vinci system and Steerable devices in a crossover study. Materials and methodsA total of 16 medical students without any laparoscopic experience were trained for 27 h to operate all of a rigid, a robotic, and a new Steerable instrument in a random order. Learning curves and ultimate experience scores were determined for each instrument. Strain in wrist and shoulders was assessed with a visual analog score. ResultsPerforming the suturing task with rigid and robot instruments required 4 h of training, compared with 6 h to master the Steerable instrument. After 9 h of training with each instrument, completing the complex suturing pattern required 662 ± 308 s with rigid instruments, 279 ± 90 s with the da Vinci system, and 279 ± 53 s with the Steerable instrument. Pain scores were significantly higher after using the rigid instruments compared with the Steerable instruments. ConclusionsTransmission of torque and the presence of additional two DOFs in combination with reduced crosstalk significantly improved the instrument dexterity where the Steerable platform is concerned. Although the learning curve is longer, once mastered, it provides enhanced surgical freedom.

Needle-Assisted Laparoendoscopic Single-Site Radical Prostatectomy Using a New Series of Steerable Instruments: Feasible Option to Overcome Current Limits?

Abstract Introduction: Laparoendoscopic single-site surgery (LESS) made its introduction in the urologic community in 2007 and has significantly evolved since then.1–3 However, such a procedure remains a technical challenge.4 In this study, we have evaluated the feasibility of a needle-assisted LESS-radical prostatectomy (RP) procedure using a recently developed series of steerable laparoscopic instruments (Steerable Instruments, Ghent, Belgium) each having seven degrees of freedom.5 In contrast with existing articulated instruments, the steerable instruments permit torque transmission, in which rotation of the surgeon's wrist results in a rotation of the tip, even in bent position. Materials and Methods: The study was carried out in a nonsurvival porcine model, approved by the Ghent University ethical committee (EC2016/83). The procedure was designed and trained before on a series (more than six) of cadavers. A 12-mm Airseal® trocar enabling access for the steerable instruments and a 10-mm trocar for a 3...

An ergonomics study on wrist posture when using laparoscopic tools in four techniques in minimally invasive surgery

Purpose. With reference to four minimally invasive surgery (MIS) cholecystectomies, the aims were (a) to recognize the factors influencing dominant wrist postures manifested by the surgeon; (b) to detect risk factors involved in maintaining deviated wrist postures; (c) to compare the wrist postures of surgeons while using laparoscopic tools. Methods. Video films were recorded during live surgeries. The films were synchronized with wrist joint angles obtained from wireless electrogoniometers placed on the surgeon's hand. The analysis was conducted for five laparoscopic tools used during all surgical techniques. Results. The most common wrist posture was extension. In the case of one laparoscopic tool, the mean values defining extended wrist posture were distinct in all four surgical techniques. For one type of surgical technique, considered the most beneficial for patients, more extreme postures were noticed regarding all laparoscopic tools. We recognized a new factor, apart from the tool's handle design, that influences extreme and deviated wrist postures. It involves three areas of task specification including the type of action, type of motion patterns and motion dynamism. Conclusions. The outcomes proved that the surgical technique which is best for the patient imposes the greatest strain on the surgeon's wrist.

A Master–Slave Integrated Surgical Robot With Active Motion Transformation Using Wrist Axis

In this paper, a master–slave integrated surgical robot system for the laparoscopic surgery is proposed. Instead of commanding the manipulator from the remote master console, the proposed system integrates the master controller into the proximal end of the slave manipulator. The slave has a flexible wrist joint, whose bending angle is operated by a joystick on the master. Focusing on suturing of a curved needle, which is a common task in laparoscopic surgery, we developed an active motion transformation method that allows the surgeon to insert the needle easily. When inserting the needle, the proposed system transforms the surgeon's wrist rotation into the rotation about the bent forceps gripper. Positioning performance of the proposed system is evaluated by an experiment. Furthermore, we compared the suturing task performance between the proposed system and conventional forceps. The experimental results show that the proposed system reduces the contact force against an organ model.

Transperitoneal Deviceless Hand-Assisted Laparoscopic Living Donor Nephrectomy: An Alternative Technique for Kidney Recovery

Deviceless hand-assisted laparoscopic living donor nephrectomy is an alternative surgical technique that relies on the classic laparoscopic approach, supported by insertion of the surgeon's hand during kidney recovery without the need to use any device because of the sealing effect of the particular wall incision. From 2006 to 2008, deviceless hand-assisted laparoscopic living donor nephrectomy was performed in 25 patients (M/F = 7/18; mean age = 53 years; range = 30-68). One right nephrectomy was performed. We made a lateral paramedian incision. No sealing device is required in our technique because the pneumoperitoneum is maintained by the sealing effect of two complexes: the peritoneum/deep rectus abdominis muscle fascia and muscle itself/lateral edge of the double fascial incision. These structures clench around the surgeon's wrist, preventing leakage of CO₂. After dissection, the kidney is removed through the hand port without an endobag. Mean surgical time was 105 minutes (range = 60-150), estimated blood loss was 50 to 200 mL, and mean warm ischemia time was 3.5 minutes (range = 2-11). Mean hospital stay was 4 days (range = 3-6). One uncontrollable hemorrhage due to a renal vein lesion required conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.8 to 2.6 mg/dL. The ability to better control bleeding by manual compression, as well as the advantages related to decreased donor morbidity, shorter hospital stay, cost saving, and excellent graft function, make this deviceless technique a good option for kidney recovery.

The effect of supporting a surgeon's wrist on their hand tremor

Operative tremor can greatly influence the outcome of certain, precise, microsurgical operations. Reducing a surgeons tremor may not only improve the operative results but decrease the operative time. Previous studies have only measured uni or bi directional tremor and therefore have been unable to calculate both the overall tremor amplitude and the tremor reduction by resting the wrists. We measured the tremor of 21 neurologically normal volunteers while performing a micromanipulation task, with and without wrist support. Measurements were acquired in three dimensions using three accelerometers attached to the hand, allowing an overall tremor amplitude to be calculated. Resting the wrist on a gelled surface decreases an individuals tremor by a factor of 2.67 (P = 0). Supporting the wrists significantly decreases the amplitude of the tremor. Surgeons should consider using wrist supports when performing parts of operations which necessitate a high degree of accuracy.

“Deviceless” Hand-Assisted Laparoscopic Donor Nephrectomy

Hand-assisted laparoscopic nephrectomy (HLN) in living donors is a minimally invasive surgical modality that uses classic laparoscopic techniques combined with the surgeon's hand as a support tool during renal dissection. We describe our experience with 14 donors undergoing HLN with a novel “deviceless” technique (DL-HLN). We used a midline or a paramedian incision. The first 10-mm trocar (camera) was inserted near the umbilicus and another 10-mm trocar placed under laparoscopic vision at the level of the anterior axillary line above the iliac crest. DL-HLN was performed in 14 patients (11 women and 3 men) of overall mean age of 40 years (range = 33–60). Left nephrectomy was performed in all cases. Mean surgical time was 105 minutes (range = 60–150). Estimated blood loss was 50 to 800 mL (mean = 200 mL). Mean warm ischemia time was 3.5 minutes (range = 2–11). Mean hospital stay was 4 days (range = 3–6). In one case, uncontrollable hemorrhage developed due to a renal vein lesion at the level of the adrenal vein outlet, requiring conversion to open surgery. As to graft function, recipient serum creatinine on day 7 ranged from 0.9 to 2.6 mg/dL (mean = 1.6). We used no device in our technique. The pneumoperitoneum was maintained by the sealing effect of the muscular fascia around the surgeon's wrist. Moreover, the kidney was removed through the hand port without an Endobag. Our modified HLN technique avoids the use of costly disposables and offers the advantages of a smaller incision.

Hand-assisted laparoscopic nephrectomy as a minimally invasive option in the treatment of large renal specimens

We describe our experience with hand-assisted laparoscopy (HAL) as an option for the treatment of large renal specimens. Between March 2000 and August 2004, 13 patients candidate to nephrectomies due to benign renal conditions with kidneys larger than 20 cm were included in a prospective protocol. Unilateral nephrectomy was performed in cases of hydronephrosis (6 patients) or giant pyonephrosis (4 patients). Bilateral nephrectomy was performed in 3 patients with adult polycystic kidney disease (APKD) with low back pain refractory to clinical treatment previous to kidney transplant. The technique included the introduction of 2 to 3 10 mm ports, manual incision to allow enough space for the surgeon's wrist without a commercial device to keep the pneumoperitoneum. The kidney was empty, preferably extracorporeally, enough to be removed through manual incision. We have assessed operative times, transfusions, complications, conversions, hospital stay and convalescence. The patients mean age (9 women and 4 men) was 58 years. Mean operating time was 120 +/- 10 min (hydronephrosis), 160 +/- 28 min (pyonephrosis) and 190 +/- 13 min (bilateral surgery for APKD). There was a need for a conversion in 1 case and another patient needed a transfusion due to a lesion in the renal vein; 2 patients had minor complications. HAL surgery is a minimally invasive alternative in the treatment of large renal specimens, with or without significant inflammation.

Minimally Invasive Radical Prostatectomy

Minimally Invasive Radical Prostatectomy

Mechanical manipulator for intuitive control of endoscopic instruments with seven degrees of freedom

Performing complex tasks such as vascular anastomosis in minimally invasive surgery (MIS) is demanding due to a disturbed hand-eye co-ordination, the application of non-ergonomic instruments with limited number of degrees of freedom (DOFs) and a lack of three-dimensional perception. Robotic tele-manipulatory systems enhance surgical dexterity by providing up to seven DOFs. They allow the surgeon to operate in an ergonomically favourable position with more intuitive manipulation of the instruments. Robotic systems, however, are very bulky, expensive and do not provide any force feedback from the tissue. The aim of our study is to develop a simple mechanical manipulator for MIS. The Minimally Invasive Manipulator (MIM) is a purely mechanical device. When manipulating the handle of the MIM, the surgeon's wrist and grasping movements, which are essential for suturing, are directly transmitted to the deflectable instrument tip in seven DOFs. It gives the surgeon direct control of the instrument tip. First phantom experience indicates that the system functions properly. The MIM provides force feedback to improve safety. A set of MIMs seems to be an economical and compact alternative to robotic systems and will offer more surgeons the capability to perform complex MIS and to shorten their learning curve.

Robotic surgery, telerobotic surgery, telepresence, and telementoring. Review of early clinical results.

Although laparoscopic cholecystectomy rapidly became the standard of care for the surgical treatment of cholelithiasis, very few other abdominal or cardiac operations are currently performed using minimally invasive surgical techniques. The inherent limitations of traditional laparoscopic surgery make it difficult to perform these operations. We, and others, have attempted to use robotic technology to (a) provide a stable camera platform, (b) replace two-dimensional with three-dimensional (3-D) imaging, (c) simulate the fluid motions of a surgeon's wrist to overcome the motion limitations of straight laparoscopic instruments, and (d) offer the surgeon a comfortable, ergonomically optimal operating position. In this article, we review the early published clinical experience with surgical robotic and telerobotic systems and assess their current limitations. The voice-controlled AESOP robot replaces the cameraperson and facilitates the performance of solo-surgeon laparoscopic operations. AESOP provides a stable camera platform and avoids motion sickness in the operative team. The telerobotic Zeus and da Vinci surgical systems permit solo surgery by a surgeon from a remote sight. These telerobots hold the camera, replace the surgeon's two hands with robotic instruments, and serve in a master-slave relationship for the surgeon. Their robotic instruments simulate the motions of the surgeon's wrist, facilitating dissection. Both telerobots use 3-D imaging to immerse the surgeon in a three-dimensional video operating field. These robots also provide operating positions for the surgeon console that are ergonomically superior to those required by traditional laparoscopy. The technological advances of these telerobots now permit telepresence surgery from remote locations, even locations thousands of miles away. In addition, telepresence permits the telementoring of novice surgeons who are performing new procedures by expert surgeons in remote locations. The studies reviewed here indicate that robotics and telerobotics offer potential solutions to the inherent problems of traditional laparoscopic surgery, as well as new possibilities for telesurgery and telementoring. Nonetheless, these technologies are still in an early stage of development, and each device entails its own set of challenges and limitations for actual use in clinical settings.

TECHNIQUE OF HANDOSCOPIC COLECTOMY

Introduction and aim: Ever since the introduction of laparoscopic surgery, the disadvantage of lack of tactile sensation has not been overcome. Over the past months, we had performed 16 handoscopic colectomies, we hereby demonstrate this method which can overcome the above problem by the following video.Method and material: We performed handoscopic right hemicolectomy for a patient suffered from carcinoma of right colon. After being anaesthesized, the patient was put in a modified lithotomy position. Pneumoperitoneum was created by the open method followed by a diagnostic laparoscopy. The air tight hand port system (Smith &amp; Nephew, MA USA) was then inserted in the infraumbilical region with skin incision length equivalent to the width of the surgeon's wrist (6.5 cm in our case). A 12 mm working port was then introduced in the supraumbilical region for the harmonic scalpel. Dissection proceeded in the usual order with the hand retracting, bluntly dissecting and the harmonic scalpel cutting. The bowel was then exteriorized for resection and anastomosis.Results: The surgery completed in 145 minutes with 10 mL blood loss. The patient resumed normal diet on day 4 and was then discharged on day 5. After 12 weeks of follow up, she encountered no adverse outcome.Discussion: The handoscopic technique provides tactile sensation and allows blunt dissection that are not possible for the purely laparoscopic technique. Any bleeding can be effectively controlled by fingers rapidly before definitive haemostatic measures. The enlarged view provides by the laparoscope enhances meticulous dissection for apical lymphadenectomy. Furthermore, the hand port itself is an effective protector of the wound minimizing wound contamination.Conclusion: Handoscopic colectomy is a feasible and promising procedure that enjoys the benefits of both the laparoscopic and open techniques.

Richard Selzer: The Rounds of Revelation

Richard Selzer: The Rounds of Revelation