Little Giants: Smaller and Smarter Approaches Are Taking Minimally Invasive Surgery to the Next Level

William F Buitrago, MD, PhD, Thomas T Wang, MD, Philip L Leggett, MD. University of Texas, Houston, Department of Surgery; Houston Northwest Medical Center, Houston, TX.

The technology of minimally invasive surgery (MIS) continues to evolve at a rapid pace.  Smaller laparoscopic incisions lead to decreased post-operative pain, rates of ileus, wound infections, ventral herniation, adhesive bowel obstruction, and shorter hospital stays.  These benefits have continued to drive the miniaturization of new instrumentation. One such approach is mini-laparoscopy surgery (MLS), also known as micro-laparoscopy or needlescopic surgery, which uses 3mm or smaller ports and instruments instead of the traditional 5- and 10-12mm ones.  Multiple studies and small prospective randomized trials have shown that approaches using less and smaller incisions further reduce postoperative pain, improves cosmesis, and allow patients return to normal activities sooner as compared to conventional laparoscopic surgery.  However, widespread adoption of these have been slow due to instrument limitations with material flexibility, lack of electrical insulation, and durability. Therefore further studies are needed to weigh the benefits of these less invasive technologies over their limitations.

We present our experience with two different percutaneous MLS systems (MiniLap and Percuvance, Teleflex, Morrisville, NC) and a hands-free intracorporeal organ retractor system (Trio, FreeHold Surgical, New Hope, PA) used in a variety of surgical procedures including appendectomy, cholecystectomy, inguinal hernia repair (IHR), hiatal hernia repair (HHR), Nissen fundoplication (NF) and vertical sleeve gastrectomy (VSG). The purpose of this study is to evaluate the complication rate and cosmetic outcomes after MLS.  The MiniLap instruments have a 2.3mm shaft percutaneously inserted using an integrated needle tip. The grasper jaws or probe are deployed intracorporally to manipulate or coagulate tissue. We use this system during appendectomy, 3-port cholecystectomy and IHR. The Percuvance system has 2.9mm shafts percutaneously inserted using a Veress needle tip that is brought through a traditional 5mm-trochar for extracorporal exchange to 5mm interchangeable tool tips.  We use this system during IHR, HHR, NF, and VSG. The FreeHold Trio is a suture and hook, fully and continuously adjustable intracorporeal retractor system we employ for liver retraction during HHR, NF and VSG obviating the need of an additional incision for a Nathanson liver retractor.

In our study, greater than 20 appendectomies, 50 cholecystectomies, 20 IHR, 20 HHR/NF and 30 VSG were performed and analyzed. No intraoperative or major postoperative complications occurred. The average incisional pain score on postoperative day 1 and 7 was significantly less in the MLS port-sites. No significant differences occurred in the mean scores for pain 4 weeks after surgery. Cosmetic results were superior in the MLS port-sites at 1 and 3 months. No port-site infections or herniations were seen in either the MLS or 5mm port-sites. There was a single herniation adjacent to a 10mm port-site at the umbilicus in a VSG patient likely resulting from an existent hernia we failed to see at time of surgery. These preliminary results demonstrate that the smaller incisions of MLS offer advantages over larger ones. These are the basis of a prospective study to demonstrate the advantages of MLS over conventional laparoscopy and, further, will allow determining the true risks/benefits of MLS for multiple general surgery and bariatric procedures.