Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1550_Библиотеки_им_академика_М_И_Перельмана
.pdf
343
27 Future Perspectives on Scarless Surgery
Single-Incision Laparoscopic Surgery (SILS)
On the fl ip side from NOTES, the drive for scarless surgery has pushed laparoscopic
surgeons to go from multiport to single-port surgery and sharpen their laparoscopic
skills. Single-incision laparoscopic surgery has become the rage, and industry and
patients are there to support it. New devices and instruments appear almost on a
weekly basis for surgeons and researchers to make new leaps in the frontier of
single-incision laparoscopy.
Laparoscopy began in the early 1900s without video and exploded once video
was installed in the 1980s. Since the 1980s, surgeons have become adept at per-
forming virtually any and all procedures that can be done open. On our voyage
toward scarless surgery, we have challenged ourselves by decreasing the number of
access ports needed to perform a procedure. Single-incision surgeries have blos-
somed throughout the country and world, from the early simple gallbladder and
appendix to sleeve gastrectomies and colon resections. Most of these procedures
can now be hidden by using the ideal historical natural ori fi ce, the umbilicus.
Transumbilical surgery has made general surgery a scarless domain. The umbilicus
can be opened 3–5 cm. Using one of many single-port devices on the market, three
to four instruments can be introduced and a dozen procedures performed. Once the
procedure is complete, the single port is removed, the umbilicus carefully closed to
avoid hernia formation, and a little skin glue applied to cover the umbilical incision.
No one can ever tell this person had surgery because the patient remains without a
visible scar, scar less .
Currently, transumbilical surgery is the most effective platform for performing a
multitude of procedures and leaving no visible scar. The domain is already saturated
with a multitude of single-access ports, newly developed instruments helping sur-
geons overcome the coaxial sword fi ghting by reproducing triangulation. This is
made possible by either bending the instruments or making them fl exible. The
development of new instruments for the fi eld of single-incision laparoscopic sur-
gery is expanding on a daily basis. New video camera devices are also being pro-
duced to once again provide more fl exibility when working from a single port to be
able to view the anatomy from multiple angles, thereby enlarging the working
space.
Needlescopic Surgery
Needlescopic surgery is a new form of laparoscopic surgery using instruments that
are 2–3 mm in diameter, including the camera. Clearly, this technology is better
suited for our pediatric surgery colleagues. However, newer instruments are con-
structed better and stronger for eventual use in adult patients. This approach allows
344
A.R. Aurora and J.L. Ponsky
the surgeon to use standard laparoscopic positioning while making smaller incisions
that may be virtually invisible once healed. On the down side, an incision will even-
tually have to be made to be able to extract the given specimen.
Devices and Instrumentation
Single-Port Devices
There have been a number of single-port access devices developed for entry into the
abdominal cavity through a single site, whether it is the umbilicus or through another
site of the abdominal wall (Fig. 27.1 ). The principle is the same: One incision is
made in the skin and fascia through which a rigid or spongy 3–5-cm device is
inserted. The device may have a fi xed number of trocar sites, or they can be placed
on an as-needed basis. The most common models currently used employ the use of
down-sized, streamlined, low-pro fi le trocars with smaller heads to reduce the clash-
ing of trocars and camera at the fulcrum of entry.
Camera Options
The conventional angled laparoscope is most commonly used for single-incision
laparoscopy. Typical adjustments for SILS compared to standard laparoscopy are to
use a 5-mm scope with a longer shaft. A 5-mm scope gives you more space at the
point of entry and makes the platform less rigid and easier to move other instru-
ments. With the use of a longer scope, the camera head is drawn away from the
patient, thereby decreasing external clashing with the operator. Clearly, these
bene fi ts are not without the sacri fi ce of inferior lighting and therefore an overall
decrease in image quality. A 5-mm coaxial 30° laparoscope does exist that provides
excellent imaging, and this does dismiss the need for a longer laparoscope.
Some authors have described the use of the fl exible endoscope to perform single-
incision laparoscopic procedures. This technique provides a relatively unstable
operating platform and makes triangulation dif fi cult. The advantages of using a
fl exible endoscope are increased ergonomics, decreasing sword fi ghting and instru-
ment con fl ict inside the abdomen, and hassle-free vision with instantaneous camera
Fig. 27.1 Trocars and single-port devices. ( a ) SILS™ port (Copyright © 2012 Covidien. All
rights reserved. Used with the permission of Covidien). ( b ) SILS™ port, obturator, cannulas, and
obturator/cannula (Copyright © 2012 Covidien. All rights reserved. Used with the permission of
Covidien). ( c ) GelPOINT™ (Courtesy of Applied Medical Resources Corporation, Rancho Santa
Margarita, CA; all rights reserved)
345
27 Future Perspectives on Scarless Surgery
a
b
346
A.R. Aurora and J.L. Ponsky
irrigation. However, one must consider the availability of an extra set of trained
hands to maneuver the endoscope.
One company has developed an excellent compromise between a rigid laparo-
scope and a fl exible endoscope, known as the EndoEYE™ (Olympus Surgical,
Center Valley, PA) (Fig. 27.2 ). The EndoEYE is a rigid 5-mm high-de fi nition video
laparoscope with a fl exible tip that provides excellent images. It can be more easily
maneuvered than an endoscope and locked in place. This device is more amenable
to laparoscopy than an endoscope and its function grasped quickly.
Future endeavors may employ the use of a battery-powered wireless light-
emitting diode (LED) camera, which can be placed in the abdomen through a 2-cm
incision and then fi xed in placed with magnets. This device has been used and pro-
vides a view from above, is able to visualize all parts of the abdomen, but often does
not provide enough light. Research efforts will certainly overcome this dif fi culty in
the near future. The eventual development of wireless high-de fi nition CCD would
be a signi fi cant advance in the world of laparoscopy.
Lastly, one can imagine a microcamera fi xed in place on the abdominal wall that
now has auto tracking technology. The device recognizes the marker on the tip of
the instruments and can follow the procedure robotically without external guidance.
Currently, this technology is only being used in the security industry but could eas-
ily be adapted for use in surgery.
c
Fig. 27.1 (continued)
347
27 Future Perspectives on Scarless Surgery
Fig. 27.2 De fl ectable-tip
camera EndoEye™ (Courtesy
of Olympus Surgical, Center
Valley, PA)
Instruments
The most prevalent dif fi culties encountered during single-incision laparoscopic sur-
gery are the coaxial movement of instruments, lack of triangulation, and sword
fi ghting. These are worse when using an access device that has predetermined trocar
sites and trocar sites that are closer together. The single-port access devices that
allow for the operator to decide the trocar position and allow for greater space
between trocars are advantageous.
Standard, straight, rigid instruments are commonly used but newer prebent or
fl exible instruments are available and new ones are in development. Currently, sev-
eral companies have graspers, electrocautery, scissors, and suturing devices with
fl exible tips (Fig. 27.3a–d ). These instruments provide a degree of freedom with
some return to the concept of triangulation that is so important in laparoscopy.
However, these instruments are more expensive, nonreusable, and not as robust as
standard disposables.
Prebent instruments are more robust and reusable; however, they must be used
through a speci fi c access port. These instruments have been found to provide a
closer replication of standard laparoscopic movement and technique.
There has been interest in the development of “smart tools” with multifunctional
tips. The concept of a robotic device changing the tip of your instrument without
having to pull it out and replace it is another possible advance in instrument design
on the horizon. Early studies have suggested that this may signi fi cantly decrease OR
time and may reduce the risk of iatrogenic injury during surgery.
348
A.R. Aurora and J.L. Ponsky
a
b
c
d
Fig. 27.3 Flexible instruments (SILS™ hand instruments): ( a ) clinch; ( b ) dissector; ( c ) hook; ( d )
shears (All images copyright © 2012 Covidien. All rights reserved. Used with the permission of
Covidien)
349
27 Future Perspectives on Scarless Surgery
Advanced instruments for hemostasis and energy delivery are currently only
available in straight and rigid forms, i.e., harmonic and ligasure devices. These
devices will need to be developed in a fl exible form. There is currently only a fl exible
hook-cautery device available.
A newcomer to the single-incision laparoscopy scene is the Single Port Instrument
Delivery Extended Research (SPIDER
®
; TransEnterix, Durham, NC), which is
essentially a delivery system from a rigid platform of three 5-mm instruments that
are curved on the inside of the abdomen (Fig. 27.4 ). The SPIDER provides a good
rigid platform and does have easy maneuverability, triangulation, and a 360° range
of motion. It is currently undergoing clinical testing in humans.
Robotics
The current surgical robotic system in use provides an excellent platform for a lim-
ited number of minimally invasive laparoscopic procedures. Some are starting to
employ the robot for single-incision laparoscopic surgery although the bulkiness of
the current robot makes this challenging. There is development of motion-sensitive
gloves that can be worn by the surgeon, who can then control the movement of
robotic end effectors by simply moving his or her hands. One could also imagine a
robotic device that can hold and control an endoscope after its introduction by the
surgeon to the appropriate location. This would leave the surgeon’s hands free for
use of the instrumentation that could be passed via the endoscope.
The Face of Surgery 2025
True scarless surgery will not happen until technology catches up with our imagina-
tion. The development of wireless electricity by Marin Soljacic and Eric Giler
(WiTricity™; WiTricity Corp., Watertown, MA) that is now available for simple
Fig. 27.4 Single-Port
Instrument Delivery
Extended Research
(SPIDER
®
) device used for
single-incision surgery
(Courtesy of TransEnterix,
Durham, NC)
350
A.R. Aurora and J.L. Ponsky
household items is the launch pad for the future of surgical devices (Google
WiTricity). If one can deliver wireless energy precisely, to a focal point across a
distance, it will be the dawn of a new surgical era once again. One can imagine a
patient laying on the OR table with an active real-time 3D MRI virtual image device
providing instantaneous imaging of the inside of the patient (without a camera). A
robotic device would be placed beside the patient with access to a simple pencil-like
instrument that delivers wireless energy across the body wall to a desired focal point
inside the patient without touching the body. The surgeon would sit at a console
with 3D imaging provided by the MRI device in real time and be able to see and
direct the focal point of the energy device (i.e., red spot) inside the patient. Initially,
simple cases such as cholecystectomies and appendectomies could be done where
the organ in question could just be vaporized and the lumen sealed. Eventually,
other devices would need to be developed for more complex interventions. The key
is that the imaging technology and the wireless electricity already exist, and it is
therefore a relatively short leap to what is described here.
Conclusions
Regardless of the current fi nancial climate in medicine and surgery, one can be sure
that surgeons will not stop pushing the boundaries of what is possible and going
beyond it. It is almost innate in the human spirit to search for the undiscovered and
forge ahead into the unknown. We hope this chapter has provided some information
as to what is available out there and stimulated some interest in pushing the limits
of surgery further than currently known.
Reference
1. Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel
approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest
Endosc. 2004;60(1):114–7.
351
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6, © Springer-Verlag London 2013
Index
A
Abdominal morcellation , 152
Adrenal surgery . See Laparoendoscopic
single-site (LESS)
adrenal surgery
AirSeal
™
, 40–41
Alexis
™
, 162
AnchorPort
™
, 38
Appendectomy . See Natural ori fi ce
translumenal endoscopic
surgery (NOTES)
appendectomy
Articulating grasper , 207
Autonomy Laparo-Angle
™
, 43
Azimuth angle , 26
B
Bard EndoCinch T-tags , 222
Bariatric ports , 236
C
Charge-coupled device (CCD) , 341
Cholecystectomy . See Natural ori fi ce
translumenal endoscopic surgery
(NOTES) cholecystectomy
Chopsticks effect , 27
Clip closure devices , 75
Compression anastomoses
fl exible endoscopy , 220
limitations , 221
magnets , 220–221
NOTES , 225
Conventional laparoscopy (CL) , 14
D
Direct drive endoscopic system (DDES) ,
32–33
Direct suture closure , 73–74
E
Eagle claw endoscopic suturing device
(ECESD) , 109
EndoClips
™
, 105, 108
EndoEye
™
, 237, 346–347
Endo GIA
™
, 237
EndoGrab
™
, 54–55, 209–210
Endolift
™
, 65
EndoSAMURAI , 33
Endoscopic graspers , 206
Endoscopic suturing devices , 74
Endoscopic ultrasound (EUS) , 123–124
Ethicon Endo-Surgery SSL Access
System , 41
Extirpative renal surgery
development , 267–268
instruments and optics , 268
LESS nephrectomy
complications , 278
LDN , 276–277
literature , 269–272
nephroureterectomy , 275–276
pediatric , 278
PN , 273–274
retroperitoneal , 272–273
R-LESS partial nephrectomy , 274–275
robotic , 272
multichannel and handmade ports , 268
robotic LESS urologic surgery , 268–269
352
Index
F
Female sexual function index (FSFI) , 240
Fish-eye effect , 26
Flexible robotics
MASTER , 336
NeoGuide
®
, 336
Sensei
®
, 334–335
Viacath
®
, 336
G
Gastrojejunostomy . See Natural ori fi ce
translumenal endoscopic surgery
(NOTES) gastrojejunostomy
Gastrotomy techniques . See Transgastric
access
GelPOINT
™
, 160
GelPort
™
, 160, 236
GelPort
™
/GelPOINT
™
/Alexis
™
, 40
Gooseneck telescope , 29–30
g-Prox
®
, 44
H
Homemade single-port device , 41
Hybrid NOTES , 139, 178–179
I
Incisionless operating platform (IOP) ,
213–215
Innovative, safe, and sterile sigmoid access
(ISSA) , 118
InScope
®
MultiClip , 120–121
In vivo robots
categories , 336
miniature robotic platform , 337–338
mobile imaging , 336
multiarm, dexterous miniature robot , 337
pan-and-tilt imaging , 336
task-speci fi c , 337
L
Laparoendoscopic single-site (LESS) adrenal
surgery
advancements , 287–288
development , 282
indications , 284–285
instrumentation , 282–283
limitations , 286–287
literature , 285–286
minimally invasive adrenal surgery ,
281–282
special techniques , 285
surgical approaches , 284
Laparoendoscopic single-site (LESS)
nephrectomy
complications , 278
LDN , 276–277
literature , 269–272
nephroureterectomy , 275–276
pediatric , 278
PN , 273–274
retroperitoneal , 272–273
R-LESS partial nephrectomy , 274–275
robotic , 272
Laparoendoscopic single-site (LESS) pelvic
reconstructive urological surgery
advances , 298
complication , 299
demographics , 294–295
development , 293–294
fundamental rationale , 294
instruments used , 294, 296
intraoperative and follow-up , 296, 297
materials and methods , 294
randomized studies , 298–299
technical challenges , 298
Laparoendoscopic single-site (LESS)
pyeloplasty
abdominal cavity access , 259
outcomes , 264
patient positioning , 258
postoperative management , 261
preoperative planning and evaluation , 258
procedure , 259–261
reasons , 257–258
robotic
crossing technique , 263
da Vinci
®
Surgical System , 261
port placement , 262
Laparoendoscopic single-site (LESS) radical
prostatectomy
development , 301–302
patient selection , 302
R-LESS
acceptance , 302
access , 303
bladder mobilization , 304
bladder neck and seminal vesicle
dissection , 304–305
dorsal venous complex ligation , 304
endopelvic fascia incision , 304
LESS vs. 310
limitations , 308–309
outcomes , 306–308
pelvic lymph node dissection , 306
Соседние файлы в папке Библиотека им академика М.И. Перельмана