Diagnostics & Imaging Week Contributing Writer

CHICAGO – National and international laparoscopic surgeons convened here for the Society of Laparoendoscopic Surgeons (SLS; Miami) 17th annual meeting to share what they have researched in minimally invasive techniques spread across multi-specialties, such as urology, gynecology, and general surgery.

With an international membership of over 6,000 surgeons, the SLS offers the unique approach of bringing together all the subspecialties that use the techniques and tools of minimally invasive surgery. Just when one thought minimally invasive surgery couldn't get any less intrusive, new technologies are discovered that are one step less invasive than the most recent advance.

Such was the case at this meeting where single port surgery, articulated laparoscopic instruments, and other novel devices were launched that allow the surgeon and patient the benefits acquired with less traumatic techniques.

One way to convert more open surgeries into laparoscopic surgery is to allow more movement inside the abdomen, which in some surgeries cannot be done with rigid laparoscopic instruments. By adding articulation to the rigid laparoscopic instrument, the surgeon can enjoy better movement and manipulation of organs within the abdomen and perform tasks that cannot be done with rigid instruments.

Several companies have developed such instrumentation, which has enabled surgeons to do more procedures laparoscopically. In a presentation, "Comparison of Conventional and Second-Generation Articulating Laparoscopic Instruments," Chandru Sundaram, MD, of Indiana University Medical School, (Indianapolis), reported on the differences in conventional vs. articulating laparoscopic instruments when used to perform a series of standardized tasks performed by novices.

She found that except for one cutting task where the articulated instrument group was slower but more accurate, "there were no other statistically significant differences in speed, accuracy, or comfort between the two groups." Sundaram added, "The limitations of conventional laparoscopy have driven the development of articulating instruments. These instruments may help expand the indications for conventional laparoscopy especially in areas where robotic technology is not available or affordable."

Five companies are addressing this opportunity, each with its own strategy. Ethicon Endosurgery (Cincinnati) has licensed a line of Harmonic instruments that use ultrasound to simultaneously cut and coagulate to Intuitive Surgical (Sunnyvale, California), for use with the da Vinci robotic system. The robot employs a fully articulating arm called Endowrist, to which the harmonic instruments attach.

At this point, Ethicon Endosurgery is not selling a separate, independent line of articulating laparoscopic instruments.

Novare Surgical (Cupertino, California) and Starion Instruments (Sunnyvale, California) partnered in a distribution agreement that allows Starion's tissue welding technology to be integrated into Novare's articulated instruments, resulting in both a full freedom of movement hand-held laparoscopic instrument and cut-and-seal capability. Novare distributes instruments manufactured by Starion, incorporating the latters tissue welding technology.

CambridgeEndo (Framingham, Massachusetts) manufactures a line of hand-held fully articulating laparoscopic instruments that employ RF energy for coagulation, as does Covidien (Norwalk, Connecticut).

It is curious that none of these companies claim or even suggest that their instruments could be considered an alternative to the surgical robot, but is some ways, they truly are.

The articulated instruments are designed to allow for more surgeries to be performed laparoscopically, improving the surgeon's dexterity, to allow for better suturing, and all of the associated benefits for the patient: shorter hospital stay, less chance of blood loss, less chance of infection, quicker return to activities — much the same as is true for the robot.

Granted, the robot has additional advantages such as 3-D visualization, more finesse when suturing, and tremor removal, but one might beg the question of cost vs. benefit.

One thing the robot has not yet performed, but articulated handheld laparoscopic instruments have, is Single Port Access, coined SPA, surgery where three or four trocars are placed within a single opening in the abdomen, usually the umbilicus; instead of three to four small stab incisions placed in different spots on the abdomen.

Results of the first 100 cases were reported here by Paul Curcillo, MD, of Drexel University (Philadelphia), wherein he entered (primarily) the umbilicus with a 1.5 cm to 2 cm incision and placed three trocars within that incision to perform a variety of surgical procedures.

Curcillo found that "operative times, results and outcomes were similar for comparable standard multiport procedures." He cautioned the audience that "long-term follow-up is necessary to ensure that no added complications occur later compared with standard multiple-port techniques."

He also stated that initially he always used articulating instruments for SPA surgeries but found that for most procedures there is enough "independence of movement" with standard instruments. He now has an articulated instrument ready for each case, but doesn't open it unless is it needed, keeping the costs down for performing these new procedures.

Curcillos said, "All the SPA procedures are the same standard procedures, done in the same way. The only difference is the access. We don't change the game.

Currently, there are 25 surgeons trained to perform SPA surgery, with more signed up to learn from around the world.

Stephanie King, MD, also of Drexel, presented "Single Port Access Hysterectomy and Oophorectomy," which also demonstrated the feasibility of performing surgery through the umbilicus, leaving virtually no scar; unlike laparoscopic surgery where there are three or four stab scars from the various ports used for trocars and cameras.

She compared two patient groups: one that had SPA surgery and the other that underwent standard laparoscopic surgery, reporting: "Patient populations and surgical indications were similar in both groups. Operative times were comparable, as was blood loss and length of stay."

King concluded that "Early results comparing SPA procedures to standard multiport procedures demonstrate comparable results, but allow us to perform the procedures through a single incision concealed within the umbilicus."

Both Curcillos and King stressed the importance of maintaining the same standard dissection technique and doing the same procedure as always, just reducing the number of abdominal entry points to one. Both surgeons said they feel that "SPA surgery is a viable, cost-conscious alternative to multiport surgery."

SPA surgery allows the surgeon to perform the same procedure, with the same outcome, and at the same cost, but gives the patient only one hidden scar in the bellybutton.

Another advance in general laparoscopic surgery that was launched here and also received an innovation award was the Prosurgics (Cupertino, California) Free Hand robotic camera holder.

The camera is securely clamped onto the OR table, while the surgeon wears a controller attached to his surgical cap. The Free Hand device then moves the camera according to the surgeon's head movements, leaving the surgeon free to move the camera where he wants it without an assistant doing it for him.

The Free Hand laparoscopic camera holder was designed to bring affordable and cost-effective robotic support to the OR; acting as an extension of the operating surgeon and potentially eliminating the requirement of an assistant.