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Does Mini-Lap Make a Major Difference?
When it comes to surgical incisions, yes, size does matter.
Dan O'Connor
Publish Date: February 21, 2014
surgical technique IMPROVED COSMESIS Aesthetics can play a key role in the choice of surgical technique, says gynecologic surgeon Ceana Nezhat, MD, of Northside Hospital in Atlanta, Ga.

How much smaller can laparoscopic instruments get? Conventional laparoscopic instruments measure only about a half-inch in diameter, no wider than a dime, but are XXL compared to today's new breed of mini-laparoscopy tools. With narrow-lumen telescopes, coagulation instruments, bipolar grasping forceps and scissors measuring only about 1???8-inch in diameter — that's 2 lines on a ruler — as well as trocars that don't leave scars, mini-laparoscopy lets your surgeons perform minimally invasive surgery through smaller incisions than ever before. It also improves their access to the abdominal cavity for faster and safer surgeries. In most cases you don't have to cover the 3mm ports with bandages after surgery. A dab of adhesive wound-sealing glue renders scars nearly invisible.

Besides creating better cosmetic results for the patient and a marketing buzz for your facility, the mini-laparoscopic technique offers clinical advantages, too. By minimizing trauma and strain on the patient, it promotes less pain and a faster recovery. "It is a proven fact that the smaller the incision, the less pain, the fewer complications and the faster recovery patients will have," says Ceana Nezhat, MD, internationally renowned gynecologic surgeon and program director of minimally invasive surgery at Northside Hospital in Atlanta, Ga. "For my patient populations, it's been a blessing, a true advancement." If you're considering adding miniaturized instruments to your inventory, here are answers to 4 questions you might have.

1. Does mini-lap offer the same functionality as conventional laparoscopy? Yes. With mini-lap, the techniques and indications remain the same as a conventional 3-portal technique. It's just the fine nature of the miniaturized instruments that's different. "All you've done is remove 2 5mm trocars as well as post-op sutures," says an industry rep. The beauty of mini-lap is that surgeons don't need to learn new techniques. They perform laparoscopy as they're accustomed to doing, but with 2.5mm and 3mm instruments inserted through like-sized trocars, says surgical oncologist Paul Curcillo II, MD, FACS, of Fox Chase Cancer Center in Philadelphia, Pa.

The benefits of operating through smaller holes instead of 5mm ports? Access and safety, says Dr. Curcillo. Let's say your surgeons struggle to manipulate organs while maneuvering instruments through standard trocars. By inserting a mini-lap instrument through a small incision, they're able to retract organs or tissue and hold it in place without adding another port. Mini-lap also can be a much safer technique than suture retraction because surgeons aren't inserting sharp instruments into the abdominal cavity to secure anatomy, a real concern in patients with a history of adhesions. "We automatically offer small scopes to patients with severe adhesions," says Vangie Dennis, RN, BSN, CNOR, CMLSO, administrator of the Spivey Station Surgery Center in Jonesboro, Ga. "The last thing you want to do with a patient with adhesions is go in with a 10mm instrument."

2. Which procedures are best suited for mini-laparoscopy? When does it make most sense to reduce the number and the size of the operating ports and instruments? We put that question to a panel of 21 readers, and all but 1 mentioned laparoscopic cholecystectomies and appendectomies. Mini-lap is also especially beneficial for such procedures as ovarian cyst removal, tubal ligation, and biopsies of the pancreas and liver, our panelists say.

Perhaps mini-lap's greatest benefit is letting you perform purely diagnostic procedures via a single puncture site, says Ms. Dennis. Take the patient with non-specific abdominal pain, she says. "With mini-lap, you can get a safe view of what's going on. You can always switch to conventional instruments if you have to do operative work."

Dr. Nezhat has been able to perform procedures on patients for which previous conventional laparoscopy and open surgery attempts have been unsuccessful. With the mini-laparoscopy instruments, he has successfully treated severe endometriosis, including invasion to the bladder and ureter. He's performed hysterectomies and bowel procedures. He's also removed adhesions, large tumors and mesh embedded in organs.

thinner instrumentation

3. What about high-acuity procedures? Mini-lap instruments don't have the type of dexterity for gastric bypass, says the industry rep. "The intended use is for simple tissue manipulation," he says. The bigger the organ, the harder it is to hold with thin instrumentation. Ms. Dennis says mini-lap's smaller working jaws don't "take as big a bite," which not only limits procedures you can do, but could also prolong cases and force surgeons to alter their preferred techniques. Then there's the question of whether the tools are sturdy enough. "When going through a tiny port, they're not as stable as large instruments. They're fragile and can break," says Ms. Dennis. The thinner instruments aren't as strong as standard 5mm tools, and the graspers and dissectors on the ends of very fine tools aren't ideally suited for moving thick tissue or anatomy, says Dr. Curcillo. "You can pull most anything with a mini-lap instrument," he says, "but you can't always push tissue of significant weight."

Instrument manufacturers are reacting to the growing popularity of mini-lap with promising designs, including 3mm instruments that snap into standard laparoscopic handles. Also look for instrument sets that offer a complete array of miniaturized tools that match what's available in larger sizes. Needlescopic instruments are disposable self-contained systems — the tips of the sheaths house needles, letting surgeons pop them through the abdominal wall and employ graspers without the use of an additional port.

A study that compared laparoscopic cholecystectomy performed with either conventional or miniaturized instruments found that the use of mini-laparoscopic techniques resulted in decreased early post-operative incisional pain, avoided late incisional discomfort and produced superior cosmetic results. Researchers concluded that "although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective [lap chole]."

Dr. Nezhat suggests your surgeons start off with mini-lap instruments on simpler cases, such as bowel adhesions and appendectomies with non-infected appendices.

4. How challenging are they to clean? One facility manager told us that cleaning mini-lap instruments is a challenge. Not only are they difficult to flush, she says, but it's hard to find brushes that are small enough to fit into their tiny channels.