Andrew S Kastenmeier, MD, Konstantinos I Makris, MD, Christy M Dunst, MD, Lee L Swanstrom, MD. The Oregon Clinic
Objective: The quest to minimize pain and scarring from surgical access has led to the development of novel techniques and surgical platforms. Natural orifice transluminal endoscopic surgery (NOTES) emerged as a revolutionary method of eliminating external surgical incisions, but it has not achieved widespread acceptance due to inherent technical challenges.
Single incision laparoscopic surgery (SILS) has gained popularity by maintaining the laparoscopic approach, while limiting the incisions. Despite good results, such “scarless” surgery has yet to become widely integrated due to its steep learning curve. It is commonly stated that the cosmetic benefits are outweighed by a significantly more difficult dissection.
“Microsurgical” laparoscopic instruments, traditionally 3 mm or less in size, have been suggested as an alternative since incisions heal with an almost imperceptible scar. Initial evaluation of these instruments was unfavorable because of reduced rigidity as a result of the minimal diameter. This led to significant shaft flexion with even minimal force and occasional instrument fracture.
We present our early experience with a new generation of instruments that combine a small-diameter shaft with markedly improved strength.
Methods: The Transenterix (Durham,NC) Microlaparoscopic instrument line includes an array of 2.7-mm reusable tools with standard end effectors and Castro-Viejo handles. Ceramic and titanium construction along with reusable 2.8-mm trocars adds strength and rigidity to the instrument shaft. Instruments are offered in both 16-cm and 30-cm lengths (picture).
In a series of 5 foregut cases (4 Nissen fundoplications and a giant paraesophageal hernia reapair with biologic mesh implantation) we replaced two of the five standard ports with Transenterix Microlaparoscopic ports. The remaining three ports were standard size (5-10 mm) to accommodate suture needles, mesh insertion, a standard camera, an energy device, and a liver retractor.
Results: In all operations we found that the instruments were able to grasp tissue well and withstand acceptable torque forces for dissection, retraction, and suture placement. None of the procedures required the insertion of additional ports or the conversion of microlaparoscopic ports to standard sized. Microlaparoscopic needle drivers were used for intracorporeal suture approximation of the crura, mesh implantation, and fundoplication. In addition to successful completion of all procedures, intracorporeal knot tying appeared easier with the microlaparoscopic needle drivers due to the ergonomics of the handle and the small size of the needle driver tips. No complications occurred. Pain control was excellent only with non-narcotic analgesics after discharge. Cosmesis was excellent with nearly invisible scars at the micro trocar sites.
Conclusion: The Transenterix microlaparoscopic instruments allow reduced incision size and likely reduced post-operative pain without prohibitive loss of instrument strength and rigidity. More importantly, the benefits are achieved through a standard laparoscopic approach without the need to learn a new surgical technique or use a new surgical platform. Future developments in microlaparoscopic imaging and energy devices will allow further reduction in port size. Further studies are necessary to quantify the risks, benefits, and costs of microlaparoscopy.
Session: Emerging Technology Poster
Program Number: ETP081