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What's New in Minimally Invasive Surgery
A review of new products displayed at the SAGES meeting.
David Renton
Publish Date: October 10, 2007   |  Tags:   General Surgery

Once exotic and complicated, laparoscopy is the here-to-stay present and future of surgery. I've had the opportunity to try some of the newer instruments at Ohio State University College of Medicine, so it was interesting to see some of the prototypes I worked with as finished products on display at the SAGES conference in Las Vegas in April, where there was no shortage of innovative products. Here are the ones I thought you'd find most interesting.

Coming soon to an OR tray
The days of inflexible laparoscopes are ending. Many newer instruments feature flexible options we wish we had. Case in point: the Laparo-Angle Maryland Dissector from Cambridge Endoscopes, which recently earned FDA approval and will soon be on the market. Traditionally, dissectors have been designed to remain straight from handle to tip, but with this the shaft can be bent until the tip is positioned at a right angle. All the physician has to do is rotate a knob to make it bend, then lock it in place with a button. This is the sort of innovation that makes cutting and extraction during laparoscopic procedures much easier.

The EndoEYE deflectable tip video laparoscope from Olympus America, which is soon going high-def, has a similar feature. The camera tip can bend to go above and beyond the full range of motion, allowing it to see around sharp angles to afford a better view of the surgical site. It is available with or without the deflectable tip and in 5mm and 10mm sizes. The company currently has a 10mm deflectable tip model with a camera that offers high-definition resolution on the market, which costs about $17,000, and it will soon be coming out with a 5mm deflectable tip HD scope.

Suturing is often called the most difficult part of laparoscopic training, but in the future this could be less of a challenge thanks to the Endo-Stitch from Autosuture. The surgeon closes the wound with this device by putting the handles together and flipping the toggle levers, which passes a pre-loaded sutured needle from one jaw to the other. This single-use device costs $100. The company also diplayed a prototype model of an Endo-Stitch that could be passed through an endoscope.

Another advance from Autosuture is the DST series EEA Bariatric Stapling System, which will soon be on the market. This device is inserted orally and has 21mm and 25mm tilt-top anvils to make the procedure easier and less invasive for the patients.

Do you believe in silver's antiseptic powers? I-Flow touted the On-Q SilverSoaker, the first antimicrobial catheter for post-op pain relief. Once placed in the patient, a low level of silver is slowly released, reducing the possibility of the catheter becoming microbially compromised. Besides the added layer of protection, this product is the same non-narcotic, post-op pain relief system that bathes the surgical sites with local anesthetic.

Ethicon unveiled the Dextrus hand access system, which is still awaiting 510(k) approval from the FDA. There are two different types of devices in this product line that could bring the surgeon's hands back into minimally invasive surgery: One is a wrist cuff lined with a gel seal designed to allow a physician to put his hand through a small hole and manipulate a patient's internal organs without the traditional larger incision; the other is made up of a variety of cuffs attached to very small devices, such as scissors or clips, that fit on the surgeon's fingertips.

It's not only hand-held surgical tools that are technologically advancing. The larger pieces of equipment that line the walls of ORs are also getting better, and these can either make the surgeon's job easier or change the way we treat certain conditions. One new product that could cut down on OR space usage is the Valleyab ForceTriad Energy Platform. This combines three different generators in one stack to provide enhanced monopolar and bipolar energy with LigaSure tissue fusion technology. The surgeon can fuse blood vessels with one connection with a single machine instead of having to buy three, and will have considerably more space in the OR. It has a barcode scanner to automatically detect what other instruments in the Valleylab product line are inserted, but was built with an open system so it can still incorporate other tools. The list price is about $20,000.

High-definition operating theater
Many of the newer endoscopes incorporate high-definition cameras, but the benefit is lost if you're still viewing the picture through an old monitor. So if you're going to buy new equipment, you may want to get a complete setup, from endoscopes to displays.

Karl Storz Endoscopy-America launched the Image 1 HD line. This setup offers a camera with a 16:9 CCD image display that projects depth-of-field to a widescreen monitor with 1080p resolution that provides a clear image of minute details. The monitor costs $18,000, the camera $21,000 and the CCU $14,000.

Those who want a full redesign with enhanced technology may want to look at the iSuite Operating Room from Stryker. I've worked in one of these and have seen how they integrate technology at all levels, from smaller high-definition scopes to ceiling-mounted monitors that can display X-rays and CT scans to recording devices that can simulcast your procedure to other facilities. Such a suite can cost $200,000 and up, with an orthopedic arrangement being much more expensive.

A few new meshes
When it comes to mesh, the choices in materials, shapes, sizes and coatings keep growing.

The Proceed Mesh from Ethicon, a coated mesh, is designed for laparoscopic ventral hernia repair. This monofilament polypropylene features a rough side and a slippery side coated with a bioabsorbable material to facilitate healing. It is easy to handle, has a blue stripe to distinguish the parietal side from the visceral side and costs $800 to $1,200.

In a similar way, the Parietex Composite Mesh from Autosuture has a coating on one side, but it works in a different way. This mesh, which can be used for either open or laparoscopic ventral procedures, has a reabsorbable film on one side and is made from hydrophilic polyester and a composite barrier to reduce the risk of tissue attachment. The manufacturer declined to disclose the price.

Laparoscopic meshes aren't the only ones evolving. The Ultrapro Hernia System from Ethicon, which is made for open inguinal repair, has an onlay patch and underlay patch connected by a mesh column to eliminate migration. It can cost $170 to $300, depending on the manufacturer's contract with the facility.

Training for tomorrow
While today's laparoscopy residents may struggle with adjusting to the way laparoscopes feel in their hands, new advances in all areas of technology may make the training much easier for tomorrow's students. New simulators could cut down on the procedure and instructor time, reduce the number of errors and practically eliminate equipment breakage costs.

An example is the Laparoscopy VR system from Immersion Medical. The controls are modeled on the handgrips for dissectors, but when in use the students feel everything the high-quality video display shows, including the sensation of bumping the shaft of another dissector and the softness of internal organs, in the handgrips. It's not quite a perfect physical simulation, but it's close enough to help students develop their tactile abilities. The system also includes a wide range of didactic instructional content to help first-year residents or surgeons who are not trained in laparoscopic procedures.

We're probably going to see more of these sorts of training aides in the near future. There was a separate room at the conference devoted to new educational technology. This will make the learning process easier for the next generation, just as the improvements on existing devices will make operating easier for those of us who are currently operating.

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