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
37
A. Rane et al. (eds.), Scar-Less Surgery,
DOI 10.1007/978-1-84800-360-6_4, © Springer-Verlag London 2013
Keywords Laparoendoscopic single-site • Single port • Port • Robotic • Natural
ori fi ce • NOTES • LESS • Laparoscopic
Introduction
A new era in medicine, minimally invasive surgery, has been initiated since the
implementation of laparoscopy. As this fi eld evolves, so does the push to further
reduce the invasiveness of laparoscopic surgery. To achieve this goal, surgeons have
begun limiting the number of abdominal incisions with laparoendoscopic single-
site surgery (LESS) or eliminating them completely through natural ori fi ce translu-
menal endoscopic surgery (NOTES) [ 1 ] . The latter has been demonstrated primarily
in preclinical animal models with limited clinical experience [ 2– 6 ] , while LESS has
undergone laboratory and clinical work and has proven to be feasible and applicable
for human intervention [ 7– 12 ] .
LESS has been documented in the literature since 1997 for various specialties,
including general surgery and gynecology [ 13, 14 ] . Limitations in technology at the
time of its introduction severely limited its permeation throughout clinical practice.
M. A. White , DO, FACOS
205 Corolwood Dr , San Antonio , TX 78213 , USA
Center for Robotic and Image-Guided Surgery ,
Glickman Urological and Kidney Institute, Cleveland Clinic ,
Q10, 9500 Euclid Avenue , Cleveland , OH 44195 , USA
e-mail: mikeawhite@sbcglobal.net
R. J. Stein , M.D. (
*)
Center for Robotic and Image-Guided Surgery ,
Glickman Urological and Kidney Institute, Cleveland Clinic ,
Q10, 9500 Euclid Avenue , Cleveland , OH 44195 , USA
e-mail: steinr@ccf.org
Chapter 4
LESS: Ports and Instrumentation
Michael A. White and Robert J. Stein
38
M.A. White and R.J. Stein
Current innovations such as articulating instrumentation and novel multilumen ports
have fostered a renaissance for LESS, with several recent clinical series reporting
successful completion of a range of procedures [ 8– 12 ] . The proposed bene fi ts of
LESS include improved cosmesis and reduced postoperative pain.
Ports
LESS is essentially laparoscopic surgery performed through a small incision at a sin-
gle site. These procedures are commonly performed via a commercially made single
port or through a single incision with multiple trocars. Additionally, standard trocars
can be added adjacent to the commercially available single ports (Table 4.1 ) through
the same skin incision but into a separate fascial stab. This is particularly helpful dur-
ing robotic laparoendoscopic single-site surgery (R-LESS). There are several single-
port devices available, each with its own advantages and disadvantages.
Multiple-Trocar Con fi guration
Piskun et al. were the fi rst to report utilizing multiple trocars through a single tran-
sumbilical incision to perform a cholecystectomy [ 13 ] . Two separate 5-mm trocars
were placed through an intraumbilical incision via two separate fascial stab inci-
sions. The procedure was performed and the specimen extracted after the fascioto-
mies were joined, leaving a virtually scar-free appearance. Utilizing a similar
approach, Raman et al. was able to complete two of three nephrectomies without
adding additional trocars and found “the single trocar to be more cumbersome with
fewer degrees of freedom than 3 adjacent trocars” [ 7 ] . While the above examples
were performed with traditional 5-mm trocars, purpose-built low-pro fi le kits are
now available; see the discussion that follows.
AnchorPort
TM
AnchorPort™ (Surgiquest, Orange, CT) consists of a small and low-pro fi le housing
that allows three 5-mm cannulae to be placed close together. The ports contain an
internal anchor that prevents the port from dislodging, and optical entry can be used
not just on the fi rst entry, but on all entries.
Multichannel Laparoscopic Ports
In an attempt to reduce abdominal wall trauma, multichannel laparoscopic ports
were designed. These ports are placed through a single skin and fascial incision via
an open (Hasson) technique primarily through the umbilicus.
39
4 LESS: Ports and Instrumentation
Table 4.1 Available single-port devices
Access device Features Advantages Disadvantages
TriPort™ advanced
surgical concepts
Flexible multichannel valve; up to three
instruments (1 × 12 mm; 2 × 5 mm);
covered with an elastomer
Adapts to incision and abdominal wall
thickness
Fragile when using 12-mm instruments;
lubrication required; constrictive
outer ring; gas leaking
QuadPort™ advanced
surgical concepts
Flexible multichannel valve; up to four
usable instruments (1 × 15 mm,
1 × 10 mm, 2 × 5 mm); covered with an
elastomer
Adapts to incision and abdominal wall
thickness
Fragile when using 12-mm instruments;
lubrication required; constrictive
outer ring; gas leaking
SILS™ Port Covidien Flexible platform; up to three individual
ports and instruments
Easy exchange of different size ports Dif fi cult to use with large abdominal
wall
GelPOINT™ applied
medical
Three components: GelSeal™ providing
PseudoAbdomen™ platform; Alexis™
wound retractor; self-retaining trocars
Larger outer working pro fi le for
enhanced triangulation; adapts to
incision and abdominal wall
thickness
Fragile; gas leakage during prolonged
procedures
AirSeal™ Surgiquest Oval valve-less cannula with invisible
pressure seal
Stable CO
2
pressure; multiple instru-
ment insertion
Rigid; less freedom of movement; noisy
AnchorPort™ Surgiquest Low-pro fi le ports of various lengths
placed in close proximity
Anchoring system; optical entry Rigid; less freedom of movement
Homemade Alexis™ wound retractor, latex glove,
variable ports
Inexpensive, larger outer working
pro fi le for enhanced triangulation;
adapts to incision and abdominal
wall thickness
Must be built for each case
OctoPort
TM
DalimSurg Wound retractor, three fl exible caps, three
cannulas, two channels for insuf fl ation
and smoke evacuation
Adapts to incision and abdominal wall
thickness; multiple caps allow
tailoring of procedure
Fragile when using 12-mm instruments;
lubrication required; constrictive
outer ring; gas leaking
SSL access system Wound retractor, 360° rotation of the seal
cap, three entry points, insuf fl ation
channel
Quick reorientation of instruments
during procedures, reduced need for
instrument exchanges
Rigid; less freedom of movement
X-Cone™ Storz Two-piece design, fl exible cap, three
cannulas
Reusable; easy to place Gas leakage from cap; the two pieces
disengage
40
M.A. White and R.J. Stein
R-Port
®
/TriPort™/QuadPort™
The TriPort and QuadPort (Advanced Surgical Concepts, Wicklow, Ireland) represent
an evolution of the R-Port and have been reported in LESS [
8, 10, 12, 15– 24 ] . The
device consists of a wound protector and a valve. The valve component incorporates
three or four inlets for the introduction of instruments. The three-inlet valve (TriPort)
has one portal for a 12-mm instrument and two for 5-mm instruments. The larger ver-
sion (QuadPort) has two inlets for 12-mm and two inlets for 5-mm instruments.
Advantages include ease of placement even through very small incisions and easy
introduction of instruments through the port. Disadvantages include possible tearing
and insuf fl ant leakage through the gel material covering the individual channels.
SILS™ Port
The SILS™ Port (Covidien, Cupertino, CA) is a fl exible laparoscopic multichannel
port that is made of soft foam designed to conform to the contours of the incision. It
contains a built-in insuf fl ation valve and three port sites that can accommodate two
5-mm cannulae and a single 12-mm cannula. Advantages include easy placement of
ancillary trocars next to the port through a separate fascial stab [
25, 26 ] . Disadvantages
include dif fi cult placement of the port through a very small (2-cm or less) incision
[ 25, 26 ] .
GelPort™/GelPOINT™/Alexis™
The GelPort™ (Applied Medical, Rancho Santa Margarita, CA) laparoscopic sys-
tem combines a GelSeal™ cap with the Alexis™ wound retractor. Designed for
hand-assisted laparoscopic procedures, the GelPort™ has been used during LESS
and R-LESS procedures [ 27– 29 ] . The GelPOINT™ (Applied Medical) represents
the evolution of the GelPort™ and is designed speci fi cally for LESS. It has a smaller
gel cap and four premade self-retaining 5-mm trocars, though various-sized trocars
can be placed similarly to the GelPort. Additionally, there is an insuf fl ation port
built into the side of the device, and the Alexis wound retractor is fi tted with a tether
for easier removal. Advantages include fl exibility of port size and positioning
through the GelCap as well as full utilization of larger incisions. Disadvantages
include dif fi culty introducing instruments and tearing of the wound protector, which
has largely been temporized with the development of a new instrument shield on the
advanced access platform.
AirSeal™
AirSeal™ (Surgiquest, Orange, CT) is a technology that recirculates and fi lters peri-
toneal gas. There are no valves or gaskets required, so multiple instruments and a
41
4 LESS: Ports and Instrumentation
camera can be inserted without a reduction in pneumoperitoneum. At the time of
this writing, only prototypes speci fi cally designed for LESS use have been
developed.
OCTO-Port™
The OCTO-Port™ (dalimSurgNET Corp., Seoul, South Korea) consists of an
abdominal wall retractor that varies in size from 1 to 5 cm. Two con fi gurations are
available for single-site surgery, including a cap with two 10/12-mm cannulas and a
single 5-mm cannula and a cap with one 10/12-mm cannula and two 5-mm cannu-
las. The cannulas are different heights to prevent external clashing, and the cap is
fl exible to allow for an improved range of motion.
Ethicon Endo-Surgery SSL Access System
The SSL Access System (Ethicon Endosurgery, Inc., Johnson and Johnson,
Cincinnati, OH) is a single-port access device that consists of a wound retractor and
a cap that has two 5-mm seals and a larger 15-mm seal in a low-pro fi le design.
Insuf fl ation is achieved through an additional channel on the cap. The internal
pro fi le of the device is minimal because trocars are not required. The device is able
to rotate 360° at the seal cap, enabling quick reorientation of instruments during
procedures and reducing the need for instrument exchange.
X-Cone™
The X-Cone (Karl Storz Endoscopy America, El Segundo, CA) is a reusable access
device for transumbilical laparoscopy that consists of a plastic, but fl exible, cap
with three channels that attach to a two-piece metal device. The device contains
three working channels that permit the introduction of instruments up to 12.5 mm
in size. Introduction is via a Hasson technique in two pieces that then easily
assemble.
Homemade Single-Port Device
Commercially produced multichannel laparoscopic ports are not available world-
wide and have pushed surgeons to create their own access devices [
30– 33 ] . The
most widely reported of these devices consist of the Alexis™ wound retractor, a
sterile surgical glove, and standard laparoscopic ports. The size seven surgical glove
is attached to the wound retractor and three or four of the fi ngertips are removed so
the cannulas can be inserted and tied in place. Insuf fl ation is performed through the
previously placed ports.
42
M.A. White and R.J. Stein
Multichannel Hybrid Laparoscopic Ports
The multichannel hybrid laparoscopic port has been conceived as much from natu-
ral ori fi ce translumenal endoscopic surgery (NOTES) as it has from LESS. It is a
complete system that behaves more as a surgical platform than a port alone. The
multichannel hybrid laparoscopic ports require specialized instruments ( fl exible
gastroscope, etc.) and are placed through a single skin and fascial incision using the
Hasson technique.
SPIDER™
The SPIDER™ (Trans Enterix, Inc., Durham, NC) is designed to allow multiple
surgical instruments to be advanced and manipulated through a single port. It con-
sists of an insertion trocar and retractable sheath that guides the distal end into the
abdominal cavity. There are four working channels (two rigid and two fl exible).
The two fl exible channels, known as IDTs (instrument delivery tubes), facilitate
motion to allow for a multidirectional and triangulated approach within the surgi-
cal fi eld. Crossing of instruments is not necessary, and therefore the left hand con-
trols the left instrument and vice versa with the right hand. Two rigid channels
positioned vertically to the operative fi eld accommodate the use of a scope and any
other rigid surgical instrument. Three pneumoperitoneum ports exist to maintain
pneumoperitoneum and facilitate insuf fl ation and/or smoke evacuation. The
SPIDER fl exible instruments include wavy or fenestrated graspers, Maryland dis-
sector, Hem-o-lock clip applier, shears, monopolar hook, and suction irrigator.
There is a docking ball that attaches the device to the stabilizer and subsequently
to the operating table.
TransPort™
The TransPort™ (USGI Medical, San Clemente, CA) provides stable access to the
operating site via one of the body’s natural ori fi ces or an incision in the umbilicus.
The TransPort has four large working channels, one for an endoscope and three oth-
ers for large-diameter instruments. This device creates a multitasking platform and
utilizes a fl exible endoscope along with multiple fl exible endoscopic instruments.
Laparoscopic Instrumentation
During LESS the laparoscopic instruments and the camera lens are in close proxim-
ity, resulting in intracorporeal instrument collision, hindering the surgeon from
operating ergonomically. To minimize clashing, speci fi cally designed instruments
have been created, including instruments that are prebent and ones that articulate.
43
4 LESS: Ports and Instrumentation
Prebent Instruments
In an attempt to improve ergonomics and reduce external crowding of instrumenta-
tion around the access site, prebent instruments (Olympus, Hamburg, Germany;
Karl Storz, Tuttlingen, Germany) have been designed and are available. These
instruments allow for triangulation and reduce internal and external clashing. When
compared to fl exible instrumentation in the laboratory setting, prebent instruments
were less time-consuming and were found to have better maneuverability [
34, 35 ] .
Flexible Instruments
Autonomy Laparo-Angle™
The Autonomy series (Cambridge Endo, Framingham, MA) allows for seven
degrees of freedom, full articulation, and a handle that locks at any angle and rotates.
Additionally, the instrument tip can rotate 360° around its axis, thereby allowing
simultaneous actions such as articulating downward while rotating. There are vari-
ous instruments available, including Metzenbaum scissors, a Maryland dissector,
monopolar hook cautery, and needle holders.
Real Hand™
Real Hand (Novare Surgical Systems, Cupertino, CA) instruments were designed
with an EndoLink
®
mechanism, which affords seven degrees of freedom of move-
ment. The full line of instruments includes a bipolar coagulator, various graspers,
dissectors, and needle drivers. All have a locking mechanism that allows for use as
a straight or up to 90° angulated instrument.
Roticulator™ Articulating Instruments
The Roticulator line of instruments (Covidien, Cupertino, CA) includes a grasper,
shears, and dissector. The Roticulator offers 0–80° of articulation, 360° rotation at
all articulation angles, spin-lock rotation position lock, ability to perform as a fully
rigid straight instrument, and a diameter of 5 mm.
Standard Laparoscopic Instruments
Conventional laparoscopic instruments can effectively be used with a LESS
approach. After surpassing a learning curve largely involved with minimizing clash-
ing, many surgeons have noted that the use of standard instrumentation is feasible
44
M.A. White and R.J. Stein
and not prohibitive. Advantages include signi fi cant cost savings, as articulating
instruments tend to be single-use.
NOTES Instrumentation
Despite the fact that the concept of NOTES predates LESS, clinical experience in
NOTES has lagged signi fi cantly. Reasons for this deliberate progress include con-
siderations of safety as well as greater reliance on more complex instrumentation
and technology. A large body of literature as well as industry support is dedicated to
the development and description of concept and prototype equipment. Herein we
aim to describe instrumentation that has been used clinically.
Flexible Instrumentation
Several clinical reports of hybrid and pure NOTES procedures have appeared in the
literature and will be detailed further in other chapters of this book. The majority of
initial work centered around the use of fl exible instrumentation introduced through
endoscopes, primarily gastroscopes. As these scopes were primarily designed for
basic intraluminal work, only a single working channel was included, largely for
instrumentation necessary for performance of biopsies. Due to the simultaneous
need for working instrumentation along with an instrument for retraction during
NOTES procedures, a dual-channel endoscope (Olympus GIF-2T 160) has prefer-
entially been used.
Access differs based on the natural ori fi ce chosen. Transvaginal access can be
gained with direct incision of the vaginal fornix after exposure using a weighted
speculum. The majority of reports discuss the use of a transumbilical port and lap-
aroscope to ensure that the peritoneum is suitable in addition to providing guidance
for access. A 2–3-mm needlescope can be used for this purpose [ 36 ] .
Transgastric access requires the use of endoscopic techniques for scope entry.
Use of a needle-knife for a full-thickness incision of the gastric wall is followed by
balloon dilation over wire guide and, fi nally, scope entry. An overtube can then be
advanced to maintain access. At the time of access, a closure system such as g-Prox
®
sutures (USGI, San Clemente, CA) can be preplaced for use in closure at the com-
pletion of the procedure [
37 ] . The g-Prox instrument has a dual function as a fl exible
grasper for retraction along with suturing capabilities for delivery of tissue anchors
through the g-Cath mechanism.
In terms of closure of the access site, standard open instrumentation and sutures
are used for closure under direct vision of transvaginal defects. Transgastric sites, as
noted above, can be closed using tissue anchors introduced with the G-prox mecha-
nism or may be sutured using a system such as the OverStitch™ (Apollo Endosurgery,
Austin, TX). The OverStitch is a single-use mechanism that is mounted to a dual-
45
4 LESS: Ports and Instrumentation
channel endoscope and can deliver full-thickness running or interrupted sutures.
Despite the availability of these commercial products, thus far sole reliance on these
closure mechanisms has not been practiced clinically. The use of standard laparo-
scopic sutured or stapled closure of the gastric entry site instead has been described
due to the need for a reliable gastric closure.
A signi fi cant challenge when performing fl exible NOTES is the lack of a stable
platform. The orientation can often be dif fi cult, and fi ne control of the endoscope
during delicate dissection is ideal. Use of the TransPort™ steerable platform (USGI,
San Clemente, CA) allows for fi ne manipulation of the scope at its distal end while
the remainder of the shaft is maintained in a stable position [
37 ] . This platform also
includes three additional working channels for introduction of ancillary fl exible
instrumentation.
Once access is established and the endoscope is introduced into the peritoneum,
a variety of fl exible equipment can be used through the endoscopic channels, includ-
ing needle-knife, scissors, a variety of graspers, snares, electrocautery hook, etc.
Furthermore, through a transvaginal access, standard laparoscopic instruments or
articulating instruments with a rigid shaft can be introduced alongside the endo-
scope. This may be especially useful to create some additional triangulation as well
as more robust retraction.
Horgan et al. described use of an extra-long 75-cm articulating grasper (Novare
Surgical Systems, Cupertino, CA), which was introduced transvaginally alongside
the operating endoscope [ 37 ] . Alternatively, Davila et al. used the simple concept of
percutaneously introduced marionette sutures in order to successfully complete a
pure NOTES transvaginal cholecystectomy. These sutures are strategically placed
percutaneously and then through the organ of interest and fi nally suspended using a
clamp extracorporeally for effective retraction [ 38 ] .
Rigid Instrumentation
Due to signi fi cant challenges in performing NOTES procedures with a classical
fl exible endoscopic approach, Aron and colleagues introduced the concept of using
standard laparoscopic as well as rigid articulating instruments through a single-
access device placed transvaginally [ 39 ] . Using this approach, the authors were able
to perform nephrectomy in three cadavers. Thereafter, using a similar approach,
Sotelo and colleagues and Kaouk and colleagues both performed hybrid NOTES
nephrectomy [
40, 41 ] . Kaouk et al. then reported the fi rst pure NOTES nephrectomy
in humans [ 42 ] . The group used the TriPort (Advanced Surgical Concepts, Wicklow,
Ireland) as well as the GelPort (Applied Medical, Rancho Santa Margarita, CA)
transvaginally. Articulating instruments (Novare Surgical Systems, Cupertino, CA),
surgical staplers, as well as an extra-long electrosurgical hook were used for renal
dissection. Bene fi ts of the approach with rigid instrumentation include more robust
retraction and working instrumentation, which is vital for bulkier organs such as the
kidney (see Fig. 4.1 ).
46
M.A. White and R.J. Stein
Conclusion
LESS is developing at a rapid pace, and as more surgeons adopt this laparoscopic
approach, further re fi nement in technology will be identi fi ed. Signi fi cant improve-
ments in the toolbox will likely allow LESS techniques to be disseminated more
widely and include more complex procedures. NOTES is progressing at a more
deliberate pace due to the considerable demands of access, closure, vantage point,
and distance from target organ. Therefore, more substantial technological advance-
ment is necessary in order to make these procedures more reproducible. Computer
interface or robotic surgical instruments will likely greatly improve ergonomics and
precision.
References
1. Raman JD, Cadeddu JA, Rao P, Rane A. Single-incision laparoscopic surgery: initial urological
experience and comparison with natural-ori fi ce transluminal endoscopic surgery. BJU Int.
2008;101:1493–6.
2. Swain P. Nephrectomy and natural ori fi ce translumenal endoscopy (NOTES): transvaginal,
transgastric, transrectal, and transvesical approaches. J Endourol. 2008;22:811–8.
3. Gettman MT, Caddedu JA. Natural ori fi ce translumenal endoscopic surgery (NOTES) in urol-
ogy: initial experience. J Endourol. 2008;22:783–8.
4. Lima E, Rolanda C, Pêgo JM, et al. Third generation nephrectomy by natural ori fi ce translumi-
nal endoscopic surgery. J Urol. 2007;178:648–54.
5. Gettman MT, Lotan Y, Napper CA, Cadeddu JA. Transvaginal laparoscopic nephrectomy:
development and feasibility in the porcine model. Urology. 2002;59:446–50.
Fig. 4.1 Illustration of rigid
laparoscopic instrumentation
introduced through a
single-access device in order
to perform NOTES
nephrectomy (Reprinted
with permission, Cleveland
Clinic Center for Medical
Art & Photography © 2011.
All rights reserved)
Соседние файлы в папке Библиотека им академика М.И. Перельмана