The expo hall at this year's Society of American Gastrointestinal and Endoscopic Surgeons conference featured innovations in hernia repair, a computer-guided surgical stapler, a ligasure designed for 5mm ports and, of course, free booze. How else can you explain the gaggle of conference attendees at the showroom doors 15 minutes before they opened? The happy hour crowd at the end of the first day was festive, but I bypassed the beer cart and traded in my scalpel for a pen to bring you the latest in minimally invasive surgery. Here's what I found.

Developments in laparoscopy
The Olympus staff ushered me over to the LTF-VP Video Laparoscope. It boasts a 5mm deflectable tip, which means the surgeon doesn't need to change scopes when working between 5mm and 10mm ports; he simply turns the tip sideways to fit into any size incision. That's a huge advantage. A computer chip at the video end of the scope offers a clearer image with less distortion which, combined with an auto-focus feature, makes this scope an attractive option for essentially any laparoscopic procedure.

Another compelling addition to the laparoscopic surgery market was the Laparocision Scope Controller by GMP Surgical Solutions. The system clamps onto existing surgical table rails, holds the scope in place and is manipulated via a foot-pedal control. With the operating physician in complete control of the scope, the surgeon and a scrub nurse are all that is required to perform surgery. I gave this system a test drive in the expo hall and really enjoyed its handling and performance. The foot control let me keep both hands in the surgical field, plus - and this is the best part - I could also easily take off the scope's arm with a quick clamp release to switch to hand-controlled surgery. That simple toggle between automatic and manual control sold me on this product.

Richard Wolf displayed a similar system, the LapMan Scope Holder. The system can be rolled up next to the bed, so it's easy to set up, and features an autoclavable arm to hold the scope in place. As opposed to a foot control, this setup works off a hand remote that fits under the surgeon's glove in the sterile field.

Ethicon, a Johnson & Johnson company, displayed a new line of trocars, the Endopath Xcel. The instrument is designed for multiple, one-handed instrument exchanges through a funnel-shaped housing unit. It boasts a small profile and durable seal that accommodates instrument sizes of 4.7mm to 12.9mm. A neat feature of this trocar: Its seal is also integrated, meaning it maintains insufflation throughout the entire procedure. That feature helps with instrument control and may even decrease surgical times, as your docs won't have to replace a seal in the middle of a case.

Cutting and coagulating
To reduce the need for ligatures, you might want to consider Ethicon's new entry into the minimally invasive market: the Harmonic Ace Scalpel. The instrument lets surgeons cut and coagulate without exchanging instruments. In addition to its versatility, the Harmonic Ace transects tissue without the use of a blade. So how, you ask, does this mystical instrument dissect human tissue? With an electric current? Nope. By cauterization? Good guess, but incorrect. A high rate of vibration (55,000 pulses per second, says the company) causes the cutting. Buying this scalpel for your ORs will mean no electricity to or through the patient, less thermal spread and tissue damage, minimal smoke in the surgical field and a new pair of shoes for the wife of your Ethicon rep.

Aesculap's Bi-polar Scissor (PL-700) is a safety solution when thermal spread and stray currents are a concern. The scissors also employ built-in ceramic blade technology to self-sharpen as you cut during surgery. That's a nice feature; the scissors will stay sharp throughout the entire procedure, even against the dulling nature of bi-polar energy. The scissors are fully disposable and have a universal design, meaning you can use them with any bi-polar generator.

The SpaceMaker Plus Dissector System by Auto Suture is an instrument that creates space for hernia repairs in a two-for-one fashion. In other words, I can dissect tissue and establish a sealed port access with this one piece of equipment. Currently, I insert a BDB balloon trocar to create space and remove the entire trocar before employing another balloon trocar to seal the entry. With the SpaceMaker Plus, I would make a 10mm to 12mm incision in the umbilicus, slide the instrument in, inflate the first balloon to create a space and then pull back on the handle, which employs the second balloon that seals the port. Think of this instrument as two-for-one deal, kind of like a television with a built-in DVD player.

In keeping with the two-for-one theme, Valleylab's LigaSure V is one instrument that coagulates and cuts, and it can now be inserted in 5mm ports (and on tissues and vessels up to 7mm in diameter). Since the Ligasure V fits into a smaller port, surgeons can perform lap procedures through a smaller incision. I used to be limited by the size of ligatures. If I knew a ligature was needed during a case, I'd make a 10mm incision even though the surgery could be performed through a 5mm port. Valleylab has eliminated that dilemma. The LigaSure V features handswitch activation, eliminating the need for a footswitch.

For a different approach to sealing and cutting tissue, you can use Starion Instruments' TLS2 Thermal Ligating Shears through a 5mm trocar. The shears cut and seal simultaneously using focused thermal energy, as opposed to ultrasound, mono-polar or bi-polar currents. By using heat, no electrical transfer through the patient takes place, resulting in focused energy and minimal thermal spread. Surgical site visibility is also improved, as smoke and water vapor are reduced. The one feature I loved about this product was the fact that it comes with a disposable sterile cord. I've seen similar products that are disposable, but the cord needs to be sterilized each time. By including a disposable cord kit, the TLS2 is conducive to quick case turnarounds. The shears cut with a double-action jaw, which minimize the need for instrument passing. One concern I have: Thermal energy could mean cutting and sealing will take longer, but the $7,500 list price makes this an instrument worth looking into.

PlasmaJet by Plasma Surgical emits low flow plasma energy, using neutral plasma coagulation to seal tissue and stop surgical bleeding. Instead of an electrical current flow to the tissue, a .15mm argon plasma beam creates a thin layer of coagulated tissue, eliminating the need for using a ground plate during the procedure. The high energy emitted from this device means the PlasmaJet never comes in contact with tissue while creating a rapid hemostasis. PlasmaJet is available in disposable handpieces for open and laparoscopic procedures. Each hand piece costs $295.

With ERBE USA's modular VIO System, you build a customized electrosurgical unit from the generator up. The VIO System integrates an electrosurgical generator and argon coagulator into a space-saving workstation. In addition to a streamlined design, the system employs reposable bi-clamps; the company's rep says trials in Germany show you can use the clamps up to 30 times before replacing them. The base price of the unit is $40,000; ERBE is still determining the cost of the VIO System's handpieces.

Hernia repair
SepralMesh IP now offers a new version of its old hernia mesh. Dubbed Sepramesh IP, the product is coated with hydrogel to protect internal organs from the mesh for 14 days post-op. The gel - along with the mesh's bioresorbable fibers - combine to provide reinforcement to the repair site for 28 days after application, and also reduce the rate of mesh infection. In addition to its protective qualities, the mesh rolls up tight for placement, but then expands nicely to fill the problem area. I also noticed and was impressed by the fact that the mesh is translucent, allowing for easy viewing of the surgical site during the repair.

I found the Bioabsorbable Hernia Plug by Gore Medical Products to be very interesting. Unlike mesh, which acts as a foreign body response, this plug is 100 percent bioabsorbable and easily tailored to fit any defect. While mesh walls off a hernia and lets scar tissue form, that area could become infected. Gore Medical's plug promotes tissue in-growth by becoming absorbed by the tissue that surrounds the repaired hernia. The absorbed plug then disappears in six months, leaving a defect healed with native tissue.

To keep mesh in place, Sofradim offers I-clip, the first absorbable hernia fixation device. Surgeons currently use tacks or staples when placing mesh for hernia repair. This hardware holds mesh in place and allows the material to in-grow, but the tacks or staples remain in the body. The I-clip acts like a visceral suture once implanted, and is completely resorbable by body tissue after 12 months, the company says.

Clips and closing
Power Medical Interventions' Computer Powered Surgical Stapling (CPSS) lets you determine staple height in the midst of closing by providing real-time feedback to surgeons based on the thickness of tissue. Surgeons refer to an LCD screen on the unit's microprocessor or listen to voice commands, letting them know if the staple site requires green (large) staples or blue (small) staples. Once you select a staple size, the device delivers them via hand remote, which provides computer-powered closing for consistent force and staple placement. The device contains both green and blue staples and won't fire if you select an inappropriate size, ensuring that you'll use the correct size staple on the right size tissue. Instead of rigid plastic arms, the device's jaw is attached to a flexible shaft, which I believe would help access smaller incisions, such as those in the chest cavity and pelvic area. In addition, the remote contains a directional keypad that articulates the jaws 360 degrees for access in tight surgical sites.

U-Clip from Medtronic is not a new product, but the company developed a new application for general surgery. Medtronic's device aims at taking the difficulty out of closing by eliminating knot tying and suture management. Surgeons pass U-Clip through body tissue before pinching a black area below the hook, engaging the U-Clip to snap shut, thus creating a knot. This device would work well in bowel and GI procedures. The cost is based on the diameter size of the U-Clip, at $15 for the smallest and $35 for the largest.

There are several ways to stop GI tract bleeding: through injection, cautery and band ligation. Boston Scientific has upgraded on one more. Its Resolution Clip Device is indicated for mechanical hemostasis by employing a 11mm-wide jaw on the bleeding site. Once you've stopped the bleeding, you fire off the clip, leaving it behind to act like a surgical staple. But here's what separates this product from others: If the bleeding continues after the jaw is closed on the problem area, I can open and reposition the clip up to five times instead of employing numerous clips. The Resolution also has a user-friendly handle that provides tactile feedback when the jaws close. The company's rep said this might not be the best way to stop bleeding, but it provides another option.

The look of Synovis Surgical Innovations' latest contribution to staple line reinforcement isn't new, but the material is. Peri-Strips Dry with Veritas are biocompatible; instead of a permanent implant, the reinforcement remodels to the body in 40 days, promoting tissue in-growth and becoming part of the tissue instead of a foreign object in the body. The company says the product is now available for Roux-en-Y, vertical-banded gastroplasty and biliopancreatic diversion procedures. In addition, each unit comes with vacuum-dried bovine pericardium strips in a mounting unit for easy application to a stapler-loading unit. The strips allow for overlapping of staple firings and are configured to fit open and endoscopic staplers.

Imaging systems
As high-resolution video screens, voice-activated equipment and integrated ORs become the norm rather than the exception, having the ability to digitally exchange patient records, live pictures and other information will soon be commonplace. Stryker hopes to stay ahead of the technology curve with its DICOM 3.0 system. The unit stores digital medical records - things like X-rays, MRIs and ultrasound images - to bring patient information into the OR. The unit also has online technical support. Instead of shipping out the console in the event of an equipment glitch, Stryker's technical support team takes control of the computer from offsite to fix the problem, or walk your staff through the solution.

Viking Systems offered 3-D technology for the OR before, but they've improved upon their previous products. The company's EndoSite 3Di Digital Vision System offers true optical imaging. Unlike other 3-D systems that trick the brain into seeing depth through the use of rapidly switching images, the EndoSite 3Di presents the surgical site in true 3-D, letting physicians see exact distances and depth of the surgical site. The system's scope has an enlarged exit portal that sends left and right images to the camera, which has a corresponding left and right imaging center. The information is then digitized and transmitted to three-paneled LCD screens built onto a lightweight helmet, enhancing visualization of anatomic structures and therefore improving performance during minimally invasive surgery.

Aloka's Alpha 5 digital ultrasound system transmits and receives noise-free signals, providing diagnostic information in a pure sound field, creating exceptional resolution. The system has many applications due to Aloka's wide variety of surgical transducers, including vascular, surgical oncology, neurosurgery and even urology. Alpha 5 features new intraoperative transducers that are comfortable to hold and more intuitive to use. Aloka is also developing a new micro-transducer specifically designed to scan the pituitary gland transsphenoidally.

Product potpourri
One of the more impressive innovations I encountered during my Outpatient Surgery Magazine tour of duty is the new line of Bert Endoscopic Retrieval Bags from Par' Medical. The bags have an impervious inner coating, are stitched and welded out of hot air balloon material and come in three sizes: Nubert (size = 120ml; volume = 17.5cm by 9.5cm; 10 bags per box), Albert (size = 900ml; volume = 30cm by 12.5cm; five bags per box) and Hubert (size = 3,000ml; volume = 35cm by 20cm; five bags per box).

They're very durable and nearly impossible to tear. Here's how they work. You grip the bag with forceps on an insertion pouch located at the bottom corner of the bag before you insert it through the surgical port. Once the tissue is loaded, a blue tag provides the surgeon with a clear landmark to ID the top of the bag; the surgeon then uses standard forceps to grasp that tag before pulling back through the port. The Berts self-close upon extraction because of an angled design, a feature I found most useful. All too often retrieval bags tear or are hard to maneuver in the tight confines of a lap-surgery site. This is a great product, and one that I hope to use in future cases.

Some products cut, others cauterize and some count. The Safety Sponge System by Surgicount Medical is an example of the latter. It can track OR towels and sponges, allowing for a faster and more accurate counting of surgical dressings used during the procedure. The system creates data matrix labels that are placed on sponges and towels; the labels are then scanned as they enter and leave the patient. A single nurse using a bedside scanner can do the scanning, a practice the company claims will shave 10 minutes to 14 minutes off procedure times. It's a system that works with all commercial manufacturers of sponges and towels, and will add $6 to $10 on procedure costs, says the company.

BariMD offers www.BariMD.com, an online resource for bariatric professionals, with content provided by the U.S. Bariatric Management Institution. There are varying levels of membership, with the cost dependent on how many areas of the site you'd like to access. The site is packed with information and helpful tools: patient- and program-data tracking, access to current news and bariatric surgery research, a store for finding surgical equipment, discussion forums by industry experts and an online newsletter. The newsletter is offered as a generic shell with the option to add specific information from your surgical program before e-mailing the document to patients, making it appear as if the newsletter originated from your facility.

The site also offers CEU credits. Staff can watch streaming video modules of actual classes as PowerPoint slides cycle on the screen during the talk. At the end of the presentation, an online test is offered, and the results are sent to the test-taker and the staff administrator.

Nothing spells excitement like preparing a patient's bowel for surgery, and I found an improvement on an already effective product: HalfLytely's Bowel Prep Kit. The company cut the required amount of patient liquid intake by half, from four liters to two liters. Patients down four bisacodyl tablets, add water to a container of HalfLytely and wait for a bowel movement. Patients then drink eight ounces of the HalfLytely solution every 10 minutes until the container is emptied.

The product's marketing director said HalfLytely lowers side effects while offering the same reliability as the company's original offering: NuLytely. The company also claims patients like this process much better because it's not as intimidating as drinking four liters; they're therefore more apt to follow and complete the prepping directives. I tend to agree and will try this kit out in my practice.

Hill-Rom's booth was a fun place to stop, if for no other reason than to talk to the two attendants who proudly wore the calf-sleeved version of the ActiveCare DVT. Both women looked like soccer midfielders instead of product reps, but it was apparent they were having a great time hawking the first portable intermittent pneumatic compression used to prevent deep vein thrombosis. It weighs only 1.5 pounds, is powered by a rechargeable battery with a four-hour lifecycle, can be used on both legs at once and operates any combination of sleeves - foot, calf- or thigh-length.

This product would be especially useful in addressing the post-op needs of obesity surgery patients, who could use the ActiveCare DVT instead of walking the halls to prevent blood clotting in the legs. The system works by applying intermittent, sequential pressure to the patient's leg, increasing the speed of venous blood flow and reducing the risk of clot formation.

Barrx Medical Halo360 System entered the show room fray with a product to combat Barrett's esophagus, a condition in which the lining of the esophagus is replaced by a type of tissue similar to that normally found in the intestine. The treatment of the condition traditionally involved two catheters; one used to size the esophagus and another employing bi-polar radiofrequency. The Halo360 System employs one scope (the energy controller and catheter work together) to ablate a large epithelial surface area while limiting depth of injury; circumferential RF energy delivery to 3cm of esophageal tissue is completed in less than one second. The procedure can be performed on an outpatient basis, under conscious sedation.

There is no treatment available to cure Barrett's esophagus. Patients need to have reflux surgery if the problem persists and may even develop cancer, resulting in the removal of the esophagus. The company's rep told me a study employing the Halo360 showed a 50 percent reduction of Barrett's esophagus after one use and a 75 percent reduction after three months. Those are incredible numbers that make this a compelling piece of equipment if the results hold up in clinical performance.