What's New for Minimally Invasive Surgery?


Advanced imaging, robotic assistance and other looks into laparoscopy's future at the SAGES exhibit hall.

Dr. Ross AFFORDABLE ROBOTICS Dr. Ross (seated) checks out the ALF-X surgical robotic system at the TransEnterix booth. The company says ALF-X provides robotic benefits at an affordable cost.

In minimally invasive surgery, smaller incisions and the ability to visualize minuscule details make a big difference. I'm always on the lookout for improvements and innovations, and I found many in the exhibit hall at the Society of American Gastrointestinal and Endoscopic Surgeons' conference in Boston in March that were worth a look. Here's my take on what I saw.

utoLap Image-Guided Laparoscope Positioning System

Medical Surgical Technologies
AutoLap Image-Guided Laparoscope Positioning System
This ultra-responsive robotic assistant points the camera wherever your instruments go. A lot of surgeons who do single-incision laparoscopy aren't used to holding the scope steady and don't like stopping the procedure to adjust it, but since we're control freaks it's difficult to rely on someone else to handle it for us. This robotic arm, which secures to the table and clamps the scope, gives us control while letting us focus on our technique. Through its image-analysis software, you tag an instrument for it to recognize, then it tracks and follows your instrument's movements in real time, without manual intervention. You can still move the scope by hand while it's in the robot's grip, if necessary, or wirelessly through a small joystick on a single-use remote control ring. It seems pretty intuitive to learn and, best of all, it's compatible with standard scopes, tools, imaging systems and OR tables, so you can use it with all your own equipment. It lists at $100,000 to $120,000, with a disposables kit (sterile drapes, attachment clips and the wireless controller) at $150 to $200.

Visera 4K Ultra High-Definition Imaging System

Visera 4K Ultra High-Definition Imaging System
A 4K imaging system like the one Olympus introduced provides minimally invasive surgery with impressively detailed and immersive visualization of the patient's anatomy. It could even be argued that 4K ultra-high definition brings more advantages to the table than 3D imaging does. At present, 3D cameras are only available on 10 mm laparoscopes, while Olympus's 4K platform offers 10 mm and 5 mm scopes, and the smaller diameter lets you minimize the size of the incision.

With 4 times the resolution of HD as well as additional light and intensified color, the Visera 4K system delivers eye-popping results to the 55-inch display. Looked at up close, the image isn't grainy at all, not even when you zoom in. The only question is: Where will you put the big screen in your OR? It's marvelous for teaching, but too much information above the patient can be overwhelming, impairing communication and ergonomics.

Olympus reps pointed out that Visera's 4K camera-to-monitor imaging chain was developed in collaboration with Sony, with the scope maker contributing its optical expertise and the electronics company handling the digital imaging technology. I'm wondering if the future of this joint venture could add deflectable-tip and 3D scopes to the platform. Pricing was not available at the show.

LMD-X550MT 55-inch 4K 3D Monitor

Sony Electronics
LMD-X550MT 55-inch 4K 3D Monitor
If your facility has already invested in 3D laparoscopy, or if your docs still do fine with HD scopes, Sony has big news on a big screen. Its new monitor, scheduled for availability later this year, can take their signals and scale them up to 4K resolution on a 55-inch screen.

I have to say, the resulting images look very good. It's a medical-grade monitor, so it's suitable for the sterile field, but it's a wall unit in size. Its ability to present 4 different quadrants eliminates the need to install several smaller screens. And its compatibility with any company's scope system future-proofs it against equipment upgrades. Also neat: Sony offers a polarized 3D-viewing surgical faceshield for those who'd rather not wear the standard sunglasses.

Sony also showcased its Content Management System, a companion technology to 4K and HD video-recording devices. The CMS, as they call it, lets you easily and intuitively archive, search, review, edit, attach patient information to and share digital video and still images. The centralized system is accessible through your IT network, and user access is securely controlled. My wish list still includes the ability to record in 3D for later review, but in the meantime this looks like a useful solution.

Intuitive Surgical
Integrated Table Motion
For some complex abdominal laparoscopic cases, repositioning the patient in mid-procedure to let gravity shift and hold the organs for you can be extremely helpful. If you're performing these procedures robotically, however, you've had to undock (then re-dock) the instrument arms whenever you want to move the table and the patient, which takes up a lot of OR time.

Until now. The creator of the da Vinci surgical robot and surgical table manufacturer Trumpf Medical have engineered an automated solution. As a surgeon repositions the TruSystem 7000dV table, it wirelessly communicates its position to the da Vinci Xi system (pictured right). This lets the robot orient and adjust its instrument arms, the boom and the scope to stay right where the surgeon left them, remaining in place in the patient's anatomy. The surgeon can even work while the table is moving. This economy of movement stands to save OR time, support surgical techniques and improve patient safety.

5 New Tools of the Gastro Trade

    Aesculap's Caima\n
  • Advanced bipolar technology coupled with the ability to articulate 40 degrees from center in any direction let Aesculap's Caiman devices cut and seal almost anywhere. The direction of articulation is set by a manually operated, 360-degree-rotating turret at the distal end. Named after an alligator-like reptile, the Caiman's jaws are available in 5 mm (list price $775) and 12 mm (list price $900) sizes for both open and bariatric lengths.
  • Insorb Shorty Absorbable Subcuticular Skin Stapl\er
  • When closing a case doesn't require Insorb's $50 30-staple unit, reach for the $30 single-use Insorb Shorty Absorbable Subcuticular Skin Stapler, which contains 8 polymeric staples. Incisive Surgical says you can close incisions of up to 6 cm without suture knots, cosmetic concerns or the need to remove metal staples.
  • Covidien Signia Power Stap\ler
  • The Covidien Signia Power Stapler from Medtronic can fire 100 staples in 8 seconds, then cut between them to resect the tissue. Before it does that, though, it tells the user when it's able to carry out the job successfully, preventing firing failures and broken handles. A microchip in each single-use reload cartridge communicates real-time feedback on device assembly and stapling force to a display screen at the distal end for better clinical decisions. Medtronic is anticipating the product's launch later this year.
  • WATS (Wide Area Trans-epithelial Sampling) 3D Biopsy\ kit
  • The random sampling of traditional forceps biopsies during upper GI endoscopy may miss many suspicious cells that signal Barrett's esophagus and dysplasia. The WATS (Wide Area Trans-epithelial Sampling) 3D Biopsy kit captures a more comprehensive view to increase detection. Picture drilling a few targeted holes here and there, versus collecting 100 thin slices and integrating them into a 3D image of the submucosal circumference. CDx Diagnostics not only analyzes the kits' samples, with the help of a network of computers and in-house pathologists, but also bills insurers for you.
  • Lapro-Shark Laparoscopic Port Closure D\evice
  • Offering itself as a safer, simpler, more precise method of suturing up a port incision, the Lapro-Shark Laparoscopic Port Closure Device from Brainchlid Surgical Devices keeps the needle protected inside a guide, to prevent the risk of injury to intra-abdominal tissue. The suture is also fed through a guide to make threading the needle automatic. The device's shape efficiently retracts skin and subcutaneous tissue, and its ergonomic handle makes suture manipulation easy. The Lapro-Shark lists at $765.

— David Bernard

Surgibot and\ ALF-X

Surgibot and ALF-X
In surgical robotics, da Vinci is still the only game in town, though we're starting to hear about other entries in the field. TransEnterix is awaiting the FDA's approval on 2 alternatives, for which it says costs would be comparable to the da Vinci.

The SurgiBot is a 2-armed, single-port, tableside system. You stand up at the controls, which are directly connected to the arms and their instruments. Its OR-to-OR mobility suggests that it's geared toward smaller facilities. Its pistol-grip controls might take some getting used to. Now that we've become accustomed to the ergonomically natural 3-fingers-and-wrist articulation of da Vinci's controls, using pistol-grips is like going back to the limitations of conventional laparoscopic tools.

3D sun\glasses

ALF-X is a multi-port system, for which you sit down at a remote console and wear 3D sunglasses, through which infrared tracking lets you direct the scope with your eye movements. You just look where you want to go, which is neat. The problem here, though, is space. The system includes 3 boom-mounted arms. With the da Vinci, you've got only 1 boom and you have to carefully orchestrate your table and equipment for a case, even in a large OR.

FIMX 314 Surgical \Platform

Fortimedix Surgical
FIMX 314 Surgical Platform
The things we love about surgical robotics can also be accomplished with single-incision laparoscopy, especially when we have articulating instruments. This low-profile single-port platform lets you emulate conventional laparoscopy through a 15 mm umbilical incision. The system, compatible with standard trocars, features mechanical arms that hold a pair of 5 mm articulated tools to allow triangulation and range of motion with laparoscopic hand movements. In addition to the 2 instruments, the multiple-use introducer also simultaneously accommodates a 5 mm scope and a 3 mm suction-irrigation device. It's easy to use, and the angle it works at doesn't obstruct your technique. But it only has 4 access lumens, which limits your flexibility to use all the tools you typically need during a case. If you rely on a 5 mm liver retractor, in addition to your scope, 2 instruments and the suction, you'll have to switch out one of the instruments. Otherwise, you'll have to set up another port, and then it's no longer single-incision surgery. Fortimedix submitted the device for FDA approval this spring.


1588 AIM (Advanced Imaging Modalities) Platform
In an exhibit hall that seemed to focus on bigger, more detailed images, Stryker's new video system offered the angle of showing you what the human eye can't see.

Its high-definition scopes deliver 5 visualization modes that use light source settings and digital image processing to step up minimally invasive views in real time, to improve your ability to identify critical anatomy, your surgical technique, your outcomes and your patients' safety. ENV (Endoscopic Near-Infrared Visualization) highlights vascular and biliary anatomy through contrast fluorescence imaging. IRIS (Infrared Illumination System) employs a lighted stent to increase the visibility of the ureters. Clarity helps you to see through surgical smoke, fog, moisture and debris. DRE (Dynamic Range Enhancement) brightens dark parts of an image. And Desaturation allows variable color adjustments to better distinguish tissue.

These are neat options. They'll help a lot in training and in cases where you have inflammation or other advanced illness. And since Stryker's platform is suitable for arthroscopy as well as laparoscopy, you've got a cross-specialty versatility benefit. But you'll have to replace your entire video tower and all your scopes to get these views. I love new technology, but not at the expense of having to buy a whole new system.

Pinpoint Endoscopic Fluorescence Imag\ing System

Novadaq Technologies
Pinpoint Endoscopic Fluorescence Imaging System
The 5 mm laparoscope in Novadaq's Pinpoint system is able to provide monochromatic, green-contrast, and color-segmented fluorescence imaging to visualize vascularity in esophagectomies, assess tissue perfusion for colon resections, avoid nicking the common bile duct during lap choles, and other outcome improvement and patient safety purposes in minimally invasive surgeries.

It does this simultaneously with its HD white-light imaging, so you never have to switch between settings or otherwise alter your technique or operating plans. You likely won't need these visualization options for every case — ?as experienced surgeons will tell you, standard moves have served us well long before image enhancement technologies were developed — but sometimes they're very valuable.

As with Stryker's 1588 AIM platform, adopting Pinpoint requires you to invest in a new tower and scope system. Novadaq's image enhancement has been integrated into da Vinci robots, and it's really useful there. I'd be eager to see them license the technology into other companies' products as well. OSM

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