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Biomedical Engineering in Gastrointestinal Surgery
and launched to revolutionize the new surgical approach. First clinical
experiences were favorable
[25].
This well designed device was inserted into the abdomen via a slightly
larger than standard trocar. Triangulation could be achieved with true left
and true right instrumentation. It is a purely mechanic single operator platform with additional working channels for auxiliary instruments (
Fig. 7.73).
The SPIDER could be activated in a very intuitive manner since the
effectors worked like standard rigid instruments (
Fig. 7.74). One of the
only drawbacks was that it was available just in one size. In very small
patients, the arms were too long if the device was inserted through the
navel (
Fig. 7.75).
Figure 7.73 The SPIDER surgical system: (A) When the system is passed through the
trocar, the arms are folded together; (B) within the abdomen, the manipulators are
spread to allow cooperative manipulations. All from MITI.
Figure 7.74 Explosive drawing of the SPIDER. The system is mounted to the OR
table using a rigid arm. From the SPIDER user manual.
Operative (Surgical) Laparoscopy
Figure 7.75 (A) External view of the SPIDER in use; (B) the strictly coaxial view
reduces to some extent versatility. All from MITI.
323
The SPIDER system was certainly the first step ahead toward
clinically mature mono-port surgery.
Unfortunately, the system is no longer available on the market since
the company focuses on the development of a roboterized version of the
SPIDER called SurgiBot, which is now available as Senhance Surgical
Robot System.
7.4.2.2 Critical Comments and Outlook
Even though much progress has already been achieved in instrumentation, mono-port surgery has still many specific drawbacks. Continuous
R&D efforts are required to overcome the still existing problems.
Even if double-curved instruments are used, the kinematics of the
surgical manipulations are complex and difficult to learn. The operative
field exposure is reduced, since the scope is in a coaxial position to the
instruments. Since mono-port trocars have to have a larger diameter than
standard 10-mm laparoscopic trocars, a real incision of the abdominal wall
is necessary. Even if the incision is carefully occluded after the operation,
the risk of a cicatricial hernia is considerably higher than after the use
of a standard trocar, in particular in the navel. The practical feasibility of
mono-port surgery depends strongly upon the individual anatomical
situation. In large, very obese patients it may even be impossible. Even in
experienced hands, mono-port surgery has a prolonged OR time as compared to conventional laparoscopic procedures, and is more expensive.
The only clear advantage seems to be a better cosmesis although even this
is argued in a meta-analysis
pain reduction after mono-port surgery
Whether mono-por t is as safe or even safer is still unclear, but even if
only the incidence of incisional hernia would grow, the use of mono-port
would become difficult to justify
[26]. Careful studies failed to demonstrate
[27] (Fig. 7.76).
[28] (Table 7.7).
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Biomedical Engineering in Gastrointestinal Surgery
Figure 7.76 Comparison of postoperative pain scores after (A) normal laparoscopic
cholecystectomy, (B) minilaparoscopic, and (C) mono-port surgery. No statistical difference is obtained among the techniques
[27].
Conclusively, the impact of mono-port is significantly lower on the
quality of delivering surgical care as compared with the introduction of
multitrocar laparoscopic surgery (
Fig. 7.77).
Nonetheless, it should be considered that mono-port surgery is still in
its infancy. It is warranted to assume that it will gain more popularity as
soon as more advanced instruments are available. They should meet at
least the following criteria:
• insertion via a standard trocar,
• free selection of the FOV,
• intuitive command of the instruments,
• availability in more than one size.
Operative (Surgical) Laparoscopy
Table 7.7 Mono-port surgery as compared to standard laparoscopic procedures
Superior Equal Inferior
Cosmesis 3
Pain 3
OR time 3
Blood loss 3
Complications ?
Applicability 3
Costs 3
325
Figure 7.77 Relationship between trauma reduction and costs: a nonlinear function.
From MITI.
It is certainly not very easy to develop a system as described above and
to make it mature for clinical use at a reasonable prize, but the example
of the SPIDER system makes one optimistic that it is not impossible.
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J Gastrointest Surg 2015;19:135562.
CHAPTER 8
Interventional Flexible
Endoscopy
Until the early 1970s, flexible gastroenterologic endoscopy was confined
to diagnostic purposes. The examination was well accepted by the
patients. The esophagus, stomach, and duodenum could be thoroughly
investigated, as well as the colon, in an outpatient procedure. At that
time, it led to a worldwide explosion in the use of diagnostic endoscopy.
The window to therapeutic endoscopy was opened—independently of
each other—by Classen in Germany and Kawai in Japan in the year 1973.
Using a papillotome, Classen in Erlangen split the papilla of Vateri and
removed a bile duct stone on June 6, 1973 (
Papillotomy was the ignition spark of therapeutic endoscopy.
Endoscopic hemostasis with sclerosant agents in case of variceal bleeding
was the next step, followed by tissue removal, stenting, and increasingly
more advanced therapeutic procedures
Fig. 8.1).
[1].
8.1 “OPERATIVE” ENDOSCOPES
8.1.1 Upper Gastrointestinal Scopes, Colonoscopes
“Normal” flexible endoscopes, which were originally designed for diagnostic purposes, were the standard equipment in the early days of therapeutic endoscopy. Today, more dedicated endoscopes are available
(
Fig. 8.2). The working channel is larger (3.84.2 mm) which facilitates
washing and suction, in particular in the case of bleeding. Interventional
endoscopes may even have a second working channel.
Necessarily, they usually have a larger caliber and a higher stiffness
than pure diagnostic endoscopes. All of them are forward looking.
8.1.2 Side-Viewing Duodenoscopes
The so-called “endoscopic retrograde cholangiopancreatography”
(ERCP) is an endoscopic technique which allows the visualization of the
bile duct and pancreatic duct system by direct cannulation under
Biomedical Engineering in Gastrointestinal Surgery. © 2017 Elsevier Inc.
All rights reserved.
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Biomedical Engineering in Gastrointestinal Surgery
Figure 8.1 Poster commemorating the first endoscopic papillotomy with the original
images and documents of 1973. Courtesy: Prof. M. Classen.
Figure 8.2 Interventional flexible endoscope. From MITI.
radiographic control. Primarily, it has been a diagnostic tool, but today it is
almost exclusively used for therapy (this is why it is mentioned here and not
in Chapter 5.7: Endoscopy). The procedure is described in detail below (see
Section 8.4.4: Endoscopic Interventions on the Bile Duct (ERCP)).
Since the papilla is located at the left-lateral circumference of the duo-
denum, it is easily overlooked with a standard forward looking endoscope.
Interventional Flexible Endoscopy
Figure 8.3 (A) The handling of a duodenoscope with the Albarran lever; (B) tip of
the instrument with the lever for angulation. All from MITI.
331
The scopes for ERCP are, therefore, side-viewing ones. In addition, they
also provide a mechanism to deflect the cannula when it leaves the working channel to intubate the papilla (
Fig. 8.3).
The principle was originally developed for urology by J. M. Albar ran
and adopted to flexible endoscopy.
8.2 INSTRUMENTS
In addition to the biopsy forceps which were originally designed for diagnostic endoscopy, an increasing variety of flexible instruments and devices
was developed later, which greatly stimulated the introduction of new
endoscopic procedures into clinical care. Many new designs were actively
created by the endoscopists and found their way into industrial
production.
8.2.1 Knives
A knife is required if an incision into the tissue has to be made or if a lesion
has to be cut out. Most commonly, the so-called “needle knife” is used. In
its basic design, a cutting wire is advanced out of the tip of the instrument.
Meanwhile, even more advanced designs are available (
The insulated tip knife carries an insulating bead at the front end.
This enables the endoscopist to perform lateral cutting. The triangle
knife allows for cutting and targeted coagulation. Which instrument is
selected depends upon the specific application and the preference of the
endoscopist
[2].
The papillotome is a special type of laterally acting knife. A stainless
steel wire loop is sheathed on one side by an insulating plastic hose. The
contralateral side of the loop lies open (
Fig. 8.5A). If traction is exerted
Fig. 8.4).
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Biomedical Engineering in Gastrointestinal Surgery
Figure 8.4 (A) Plain needle knife; (B) insulated tip knife. All from MITI.
Figure 8.5 (A, B) The principle of a papillotome: If traction is exerted on the bare
steel wire, it shapes a tendon which can be used to cut if electrical current is sent
through the tendon. All from MITI.
to the outer part of the wire, a bow is shaped (Fig. 8.5B). If diathermy is
applied, adjacent tissue will be cut.
8.2.2 Hooks
The hook knife has an L-shaped tip. Using the hook, the tissue to be dissected can be brought under tension. Thus, a very precise cut is achieved
(
Fig. 8.6).
8.2.3 Snares
Snares are lasso-like wires which are positioned around the tissue which
has to be removed. Subsequently, the loop is closed while electrocautery
is applied, thus cutting the tissue out and sealing bleeding. They are available in a wide variety of shapes and sizes (
Fig. 8.7).