Use Of Minimal Access Surgery Research Articles

EP.WE.31A snapshot audit on the current practice of minimal access surgery in the UK during COVID-19 pandemic

AimsCOVID-19 is an ongoing global pandemic that poses potential increase in the risk of post-operative complications. Early guidelines placed an embargo on minimal access surgery, aiming to minimise risk to patients and the surgical team through aerolisation of the virus. We aimed to assess the practice of minimal access surgery during the peak of the pandemic and associated surgical outcomes.MethodsAn email link to an online questionnaire was distributed to a variety of surgical specialties via the Royal College of Surgeons COVID group and ALSGBI members. Data collection was carried out over a 4-month period. Data assessed included screening methods, case volume, surgical approach and patient outcomes.ResultsA total of 118 responses from a variety of surgical specialties were collected over 59 units, ranging in grade from Consultant to SHO/Core Trainee.The volume of minimal access procedures decreased during the pandemic from 94.9% of units to 39.0% (P < 0.001), with a greater percentage opting for an open approach (54.2% vs 39.0%, P < 0.001).Combining screening methods was a favoured approach, and it was frequently used alongside a designated ‘Clean’ theatre.A small proportion of patients suffered from post-operative COVID-19 complications (15.3%), but COVID-19 mortality was low.ConclusionsWhilst the risk of COVID-19 infection was not completely abolished perioperatively throughout the pandemic, it appears to be minimised by use of adequate screening with designated clean areas. It would therefore support guidelines advocating continued use of minimal access surgery during peaks of COVID-19 if prudent peri-operative measures are taken.

75 A Snapshot Audit on the Current Practice of Minimal Access Surgery in the UK During COVID-19 Pandemic

Abstract Aim COVID-19 is an ongoing global pandemic that poses potential increase in the risk of post-operative complications. Early guidelines placed an embargo on minimal access surgery, aiming to minimise risk to patients and the surgical team through aerolisation of the virus. We aimed to assess the practice of minimal access surgery during the peak of the pandemic and associated surgical outcomes. Method An email link to an online questionnaire was distributed to a variety of surgical specialties via the Royal College of Surgeons COVID group and ALSGBI members. Data collection was carried out over a 4-month period. Data assessed included screening methods, case volume, surgical approach and patient outcomes. Results A total of 118 responses from a variety of surgical specialties were collected over 59 units, ranging in grade from Consultant to SHO/Core Trainee. The volume of minimal access procedures decreased during the pandemic from 94.9% of units to 39.0% (P &amp;lt; 0.001), with a greater percentage opting for an open approach (54.2% vs 39.0%, P &amp;lt; 0.001). Combining screening methods was a favoured approach, and it was frequently used alongside a designated ‘Clean’ theatre. A small proportion of patients suffered from post-operative COVID-19 complications (15.3%), but COVID-19 mortality was low. Conclusions Whilst the risk of COVID-19 infection was not completely abolished perioperatively throughout the pandemic, it appears to be minimised by use of adequate screening with designated clean areas. It would therefore support guidelines advocating continued use of minimal access surgery during peaks of COVID-19 if prudent peri-operative measures are taken.

Assessment of the training program for Versius, a new innovative robotic system for use in minimal access surgery

ObjectivesThe Versius surgical system has been developed for use in robot-assisted minimal access surgery (MAS). This study aimed to evaluate the effectiveness of the Versius training program.DesignA 3.5-day program following...

Ectopic Pregnancy: A Paradigm Shift

Background: Ectopic pregnancy is a catastrophic and life-threatening condition and one of the commonest acute abdominal emergencies in day to day practice. The objectives of this present study were to know the incidence of ectopic pregnancy at the tertiary care center, evaluate age group, parity, and risk factors of ectopic pregnancy, and analyse clinical presentation, outcome, management, and associated morbidity and mortality with ectopic pregnancy. Methods: It was a retrospective study done at GSL Medical College and General Hospital, Rajahmundry from 1stAugust 2019 to 31st July 2020. A total of 58 patients with ectopic pregnancy were analysed on clinical presentation, clinicalfindings, investigations, operative findings and outcome. Results: A majority of women were in the age group of 22-32 years and most of them were multigravida. Commonest risk factors were previous history of abortion, tubal ligation and pelvic inflammatory disease. Amenorrhea and pain abdomen were the most common presenting symptoms. Ampulla of the fallopian tube was the commonest site for ectopic pregnancy. There were no maternal deaths and majority were discharged within seven days without serious morbidity. Conclusion: Ectopic pregnancy still remains one of the major causes of maternal morbidity and mortality. With the use of better diagnostic modalities, ectopic pregnancies can be detected early, and referral in hemodynamically stable condition along with use of minimal access surgery or medical management not only reduces maternal morbidity but also preserves future fertility

Enigma Still Unconquered- Ectopic Pregnancy

Background: A ruptured ectopic pregnancy is a true emergency and remains the leading cause of pregnancy related deaths worldwide. The objective is to study the clinical profile of ectopic pregnancy in a tertiary care hospital. Methods:A retrospective study conducted at Coimbatore Medical College Hospital from Jan 2019 to Dec 2020. A total of 149 patients with ectopic pregnancy were analysed on patient characteristics, risk factors, intraoperative findings and treatment modality. Results: A majority of patients with ectopic pregnancy (64.5%) did not have any risk factors, while 33.5% had predisposing risk factors associated with ectopic pregnancy. Most common presentation was ruptured tubal ectopic and the commonest site was ampulla (85.9%). There was 1 maternal death out of 149 cases reported (0.67%). Conclusion: Ectopic pregnancy still remains one of the major causes of maternal morbidity and mortality. Early diagnosis and referral in hemodynamically stable state along with use of minimal access surgery or medical management can change the scenario of ectopic pregnancy in the developing world.

Machine Learning Aided Photonic Diagnostic System for Minimally Invasive Optically Guided Surgery in the Hepatoduodenal Area

Abdominal cancer is a widely prevalent group of tumours with a high level of mortality if diagnosed at a late stage. Although the cancer death rates have in general declined over the past few decades, the mortality from tumours in the hepatoduodenal area has significantly increased in recent years. The broader use of minimal access surgery (MAS) for diagnostics and treatment can significantly improve the survival rate and quality of life of patients after surgery. This work aims to develop and characterise an appropriate technical implementation for tissue endogenous fluorescence (TEF) and assess the efficiency of machine learning methods for the real-time diagnosis of tumours in the hepatoduodenal area. In this paper, we present the results of the machine learning approach applied to the optically guided MAS. We have elaborated tissue fluorescence approach with a fibre-optic probe to record the TEF and blood perfusion parameters during MAS in patients with cancers in the hepatoduodenal area. The measurements from the laser Doppler flowmetry (LDF) channel were used as a sensor of the tissue vitality to reduce variability in TEF data. Also, we evaluated how the blood perfusion oscillations are changed in the tumour tissue. The evaluated amplitudes of the cardiac (0.6–1.6 Hz) and respiratory (0.2–0.6 Hz) oscillations was significantly higher in intact tissues (p < 0.001) compared to the cancerous ones, while the myogenic (0.2–0.06 Hz) oscillation did not demonstrate any statistically significant difference. Our results demonstrate that a fibre-optic TEF probe accompanied with ML algorithms such as k-Nearest Neighbours or AdaBoost is highly promising for the real-time in situ differentiation between cancerous and healthy tissues by detecting the information about the tissue type that is encoded in the fluorescence spectrum. Also, we show that the detection can be supplemented and enhanced by parallel collection and classification of blood perfusion oscillations.

Interim safety analysis of the first-in-human clinical trial of the Versius surgical system, a new robot-assisted device for use in minimal access surgery

ObjectiveThe aim of this study was to provide an interim safety analysis of the first 30 surgical procedures performed using the Versius Surgical System.BackgroundRobot-assisted laparoscopy has been developed to overcome some of the important limitations of conventional laparoscopy. The new system is currently undergoing a first-in-human prospective clinical trial to confirm the safety and effectiveness of the device when performing minimal access surgery (MAS).MethodsProcedures were performed using Versius by a lead surgeon supported by an operating room (OR) team. Male or female patients aged between 18 and 65 years old and requiring elective minor or intermediate gynaecological or general surgical procedures were enrolled. The primary endpoint was the rate of unplanned conversion of procedures to other MAS or open surgery.ResultsThe procedures included nine cholecystectomies, six robot-assisted total laparoscopic hysterectomies, four appendectomies, five diagnostic laparoscopy cases, two oophorectomies, two fallopian tube recanalisation procedures, an ovarian cystectomy and a salpingo-oophorectomy procedure. All procedures were completed successfully without the need for conversion to MAS or open surgery. No patient returned to the OR within 24 h of surgery and readmittance rate at 30 and 90 days post-surgery was 1/30 (3.3%) and 2/30 (6.7%), respectively.ConclusionsThis first-in-human interim safety analysis demonstrates that the Versius Surgical System is safe and can be used to successfully perform minor or intermediate gynaecological and general surgery procedures. The cases presented here provide evidence that the Versius clinical trial can continue to extend recruitment and begin to include major procedures, in alignment with the IDEAL-D Framework Stage 2b: Exploration.

Usability assessment of Versius, a new robot-assisted surgical device for use in minimal access surgery

ObjectivesVersius is a teleoperated surgical robotic system intended for use in minimal access surgery. This study aimed to validate the safety and effectiveness of the Versius user interface in the...

Using end-user feedback to optimize the design of the Versius Surgical System, a new robot-assisted device for use in minimal access surgery

BackgroundRobot-assisted minimal access surgery (MAS) reduces blood loss, recovery time, intraoperative and postoperative complications and pain. However, uptake of robotic MAS remains low, suggesting there are barriers to its use....

The case of a forgotten stent: use of minimal access surgery to good effect

A 58-year-old gentleman presented with right side ureteric colic for six months duration. He had undergone an extended pyelolithotomy for a pelviureteric junction calculus 10 years back and he had defaulted follow up. His X-ray KUB revealed a large renal calculus with a calcified feeding tube, along with a large bladder calculus with encrustation of the tube in the bladder. Cystolitholapaxy was performed for the bladder calculus, and percutaneous nephrolithotomy was performed and the renal calculus along with the calcified feeding tube was removed. At the end of the procedure, the patient was left with only a single incision of 2cm length.

Challenges in the Widespread Use of Minimal Access Surgery for the Management of Abdominal Trauma: A Primer

Challenges in the Widespread Use of Minimal Access Surgery for the Management of Abdominal Trauma: A Primer

Challenges in the Widespread Use of Minimal Access Surgery for the Management of Abdominal Trauma: A Primer

Challenges in the Widespread Use of Minimal Access Surgery for the Management of Abdominal Trauma: A Primer

Gastric malignancy

To highlight the recent changes and development in the surgical management of gastric adenocarcinoma. There is significant development in the field. However, issues like extent of resection, lymphadenectomy, and minimal access approach are still to be refined for clinical and oncological effectiveness and safety. The outcomes of surgical treatment of gastric adenocarcinoma are improving due to several factors, including specialist unit settings, refinement of the surgical techniques, improved adequacy of lymphadenectomy and some other minor factors such as multidisciplinary team approach and the use of perioperative chemotherapy or radiotherapy. The most hot issue in the past year's literatures is the use of minimal access surgery for resection and lymphadenectomy. The trend of studies is supporting minimal access approach for limited, subtotal and even total gastrectomy. The outcomes of surgical treatment of gastric adenocarcinoma are improving. Minimal access approach to treat gastric adenocarcinoma is evolving and continuing to have a substantial role in current surgical practice. The potential role of minimal access surgery, surgical resectional techniques, extent of lymphadenectomy and setting of specialized units and multidisciplinary team approach have stimulated an active research.

Endometrial cancer

Endometrial cancers are the most common gynaecological malignancies in the UK with approximately 4500 new cases occur each year and the incidence is rising. Increasingly there is evidence-based management and centralized specialist care of women with endometrial cancer. Women with high grade disease, deep myometrial invasion or lymphadenopathy should be managed by specialist gynaecological oncologists as part of a multi-disciplinary team (MDT). Results from important clinical trials now guide the application of surgical and non-surgical treatments. Surgery remains the cornerstone of management with a trend towards increased use of minimal access surgery. Radiotherapy-related morbidity can now be reduced by the more selective use of external beam radiotherapy. There remain several unresolved issues however and it is important that relevant clinical trials are offered to eligible women. Women must have multi-disciplinary input before treatment, so that up-to-date and evidence-based treatments and inclusion in clinical trials can be considered.

Open Versus Minimally Invasive Esophagectomy

To assess the trends in uptake of minimal invasive esophagectomy in England over the last 12 years (1996/1997-2007/2008) and to compare their clinical outcomes with those after open esophagectomy. Around 7400 people are affected each year in the United Kingdom. Prognosis following esophageal resection is, however, poor. Even after "curative" surgery, 5-year survival rates do not exceed 25%. The minimally invasive approach to esophagectomy has attracted attention as a potentially less invasive alternative to conventional surgery. Data on patients undergoing esophagectomy for esophageal cancer were extracted from a national administrative database. The outcomes of interest were in-hospital mortality, 30-day in-hospital mortality, 30-day total (ie, in and out of hospital) mortality, 365-day total mortality, 28-day emergency readmission rates, and length of hospital stay. Hierarchical logistic regression was used to identify the effect of minimal invasive esophagectomy (MIE) on the outcomes after adjustment for age, gender, socioeconomic deprivation, and comorbidity. A total of 18,673 esophagectomies were performed over the 12-year study period. The use of minimal access surgery increased exponentially over time (from 0.6% in 1996/1997 to 16.0% in 2007/2008). There was a suggestion that patients undergoing MIE had better 1-year survival rates than patients receiving open esophagectomy (OR = 0.68, 95% CI = 0.46-1.01, P = 0.058). The uptake of MIE in England is increasing exponentially. With the possible exception of 1-year survival, patients selected for MIE demonstrated similar mortality and length of stay outcomes when compared with those undergoing conventional surgery. These results need to be confirmed in large-scale randomized controlled trials.

Conservative Surgery for Carcinoma of the Cervix

Cancer of the cervix is the second most common female cancer, with more than half a million cases worldwide occurring annually. Although screening programmes have significantly reduced the incidence and death rates in the western world, social pressures have led to the delay in childbearing, increasing numbers of cervix cancer present early in reproductive life and at an early stage. These women are often anxious to retain their fertility potential, if at all possible. Standard treatment is either radical hysterectomy or radiotherapy to the pelvis, both of which will inevitably compromise fertility, rendering future childbearing impossible. This has led to a questioning of the rationale for extensive surgery in all cases of early stage cervical cancer. The experience of reducing the radicality of surgery while not compromising its efficacy has been learnt from the current management of breast cancer. Such that this may be applied to cervical cancer. Accurate staging and measurement using magnetic resonance imaging can indicate the site and location of the tumour, allowing a radical wide local excision of early stage tumours to be carried out. This allows conservation of the corpus uteri with a potential for fertility preservation. An isthmic vaginal anastomosis maintains continuity of the vaginal canal after insertion of an isthmic cerclage. Laparoscopic pelvic lymphadenectomy completes the procedure. This technique combines aspects of the traditional radical vaginal hysterectomy plus the use of minimal access surgery to carry out the pelvic node dissection. A more invasive abdominal approach has also been described. Over 900 cases have been carried out and published, with 790 carried out vaginally (radical vaginal trachelectomy) and 116 abdominally. There have been over 300 pregnancies with 195 live births. Premature rupture of the membranes is a risk, with 10% of babies being significantly premature. Delivery is by classical caesarean section. Fertility rates are good with a low recurrence rate of 4%. Overall, radical vaginal trachelectomy seems to be a safe procedure in well-selected cases when carried out in centres with appropriate experience of radical vaginal surgery, and laparoscopic techniques. Obstetric management in high-risk feto-maternal units is necessary in view of the high risk of prematurity. This new approach preserves fertility in previously impossible situations and questions traditional management and teaching.

Solid-state semiconductors are better alternatives to arc-lamps for efficient and uniform illumination in minimal access surgery

Current arc-lamp illumination systems have a number of technical and ergonomic limitations. White light-emitting diodes (LEDs) are energy-efficient solid-state lighting devices which are small, durable and inexpensive. Their use as an alternative to arc-lamp light sources in minimal access surgery has not been explored. This study aims to develop an LED-based endo-illuminator and to determine its lighting characteristics for use in minimal access surgery. We developed an LED endo-illuminator using a white LED mounted at the tip of a steel rod. Offline image analysis was carried out to compare the illuminated field using the LED endo-illuminator or an arc-lamp based endoscope in terms of uniformity, shadow sharpness and overall image intensity. Direct radiometric power measurements in light intensity and stability were obtained. Visual perception of fine details at the peripheral endoscopic field was assessed by 13 subjects using the different illumination systems. Illumination from the LED endo-illuminator was more uniform compared to illumination from an arc-lamp source, especially at the closer distance of 4 cm (0.0006 versus 0.0028 arbitrary units--lower value indicates more uniform illumination). The shadows were also sharper (edge widths of 16 versus 44 pixels for the first edge and 15 versus 61 pixels for the second edge). The overall mean image intensity was higher (127 versus 100 arbitrary units) when using the autoshutter mode despite the lower direct radiometric power, about one tenth of the arc-lamp endoscopic system. The illumination was also more stable with less flickering (0.02% versus 5% of total power in non-DC components). Higher median scores on visual perception was also obtained (237 versus 157, p < 0.001). The LED endo-illuminator provides more uniform illumination with sharper shadows, less flickering and better illumination for visual perception than the arc-lamp-based system currently used.

Development of force measurement system for clinical use in minimal access surgery

Analysis of force in minimal access surgery (MAS) is important for instrument design, surgical simulators, and in the understanding of tissue trauma incurred during surgery. The aim of this study is to develop a force measuring system for use with different instruments in clinical practice. Strain gauges were connected to both arms of a standard -5 mm interchangeable forceps handle. A rotational sensor was used to indicate the relative position of the handle arms, and consequently the jaws' position. A generic force-direction assembly was manufactured to determine the force direction at the port site. Interface electronics included signal conditioning and patient isolation circuits. Dedicated software was used for data acquisition, display, and analysis. To test their performance after sterilization, repeated force measures were obtained with the instruments after 10 cycles of autoclaving. Graduated weights were used to calibrate the strain gauges and a spring balance was employed to calibrate the force applied at the instrument tip. Calibration tests were also carried out to determine the effect of mounting the force direction assembly onto the access port. Gripping, dissecting, pushing, and pulling forces, along with the vector sum of forces acting at the port site, were synchronously displayed with the operative video record. Repeated autoclaving caused no deterioration in force sensing or signal transmission. The accuracy of the strain gauge readings was +/-0.05 V for the jaw force and +/-0.1 V for the force at the access port. The additional force created by the force direction assembly force was 7% of the port force alone. Force measurement system has been developed for clinical use. The system measures the gripping, dissecting, pulling and pushing forces as well as the force vector at port site. It also determines the position of instrument's jaws.

Minimal Access Surgery (MAS) in Children

Minimal Access Surgery (MAS) in children is relatively a new area. This technique of surgery has been validated in children for common operation than appendicectomy, nephrectomy, cholecystectomy etc. These are being regularly done at Apollo Hospitals and our experience is being presented. The use of MAS for reconstructive procedure is at a developmental stage and not yet widely evaluated over long term.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …