.svg?sfvrsn=be606e78_3)
Expect your general surgeons to be talking about new technology for one-hole surgery and hernia repair following last month's American College of Surgeons meeting in Washington, D.C. Clearly the hottest topic was one-hole surgery, more commonly known by such names as single-incision laparoscopic surgery (SILS) and single-port access (SPA), although many of the exhibitors expressed skepticism about whether it's here to stay or is a passing fad, as it's driven purely by cosmesis rather than outcomes (see "Is Ultra Minimally Invasive Surgery Here to Stay?" on page 34). Here's a look at 19 new products for minimally invasive surgery.
Sturdy and Sleek for Scarless Surgery
Laparoscopic instruments narrower than 5mm typically force surgeons to choose between strength and slenderness, giving up one or the other. Aesculap's Sovereign mini 3.5mm platform offers lightweight, reusable laparoscopic instruments that combine the 2 qualities and trocars that allow access through smaller incisions for minimal scarring. The modular design of the scissors, graspers, dissectors and needle holders easily disassemble for thorough cleaning.
Sovereign mini 3.5mm Laparoscopic Instruments and Trocars " Aesculap " www.aesculap.com
Tools That Fit the Hand
Applied Medical's Epix instruments replace the traditional pistol-grip handle with an ergonomically designed handle for increased comfort, tactile control and range of motion. The dissector features low-profile, curved jaws for precise handling, the scissors' dual-edge blade stays sharp through long procedures and the grasper offers atraumatic handling of tissue. The 5mm disposable instruments are available in 38cm and 45cm lengths.
Epix Laparoscopic Instrumentation " Applied Medical " www.appliedmedical.com
A Mesh That Matches Anatomy
The thin polymer filament, large (3mm square) pore construction and multidirectional stretch of Ethicon's Physiomesh ventral hernia patch combine to create a lightweight, flexible, partially absorbable composite mesh that conforms to the abdominal wall and promotes parietal tissue integration. A transparent film coating serves as a tissue separation barrier to minimize visceral attachment.
Physiomesh " Ethicon " www.herniasolutions.com
Anchors With Advantages
An alternative to conventional mesh fixation devices, Ethicon's SecureStraps resemble staples rather than screws. The 5mm, synthetic, absorbable strap fixation devices, dyed purple for visibility, are wide enough to secure even large-pore mesh with a low-profile design that minimizes contact with internal organs, even when they're inserted at an angle. The straps are deployed with a spring-loaded, single-use gun pre-loaded with 25 straps.
SecureStrap " Ethicon " www.herniasolutions.com
Better Than Biological Mesh?
According to Gore Medical, the company's synthetic BIO-A Tissue Reinforcement brings uniformity and consistent thickness to hernia repair, muscle flap reinforcement and general soft tissue scaffolding at a fraction of the cost of biological meshes. Plus, it has a 3-year shelf life and, not being derived from animal or human tissue, it holds no risk of disease transfer. The absorbable open pore structure facilitates rapid cell infiltration and vascularization.
BIO-A Tissue Reinforcement " W.L. Gore & Associates " www.goremedical.com
A Rigid Telescope With Retroflexion
The Karl Storz EndoCAMeleon is a 10mm rigid telescope with an articulating lens in the stationary tip that enables you to change the direction of view up to 120 ? at any time, even intraoperatively, without an inconvenient, time-consuming equipment change. A directional wheel at the base of the telescope, available in 32mm and 42mm lengths, opens up the surgical site to easy inspection, while a standard eyepiece allows you to connect any 3-chip or HD camera head.
EndoCAMeleon " Karl Storz Endoscopy-America " www.karlstorz.com
When LESS Does More
The equipment of Olympus's Laparo-Endoscopic Single-Site (LESS) system is engineered to make single-incision surgery practical. The TriPort and QuadPort allow simultaneous use of multiple instruments through a single incision. Tools are curved at both ends to prevent "sword fighting" interference. The 5mm EndoEYE laparoscope features a deflectable tip with 100 ? of angulation and an 80 ? field of view, and is supported by the Evis Exera II video system, which is compatible with any of Olympus's flexible or rigid scopes.
Laparo-Endoscopic Single-Site (LESS) Surgery Instrumentation Olympus America " www.olympusamerica.com/less
Saving Time in Mesh Placement
PolyTouch Medical's PatchAssist simplifies the process of mesh placement during laparoscopic ventral hernia repairs. After rolling up any commercially available mesh with the PatchAssist Furling Sleeve, users insert the PatchAssist through the trocar to introduce the mesh into the abdominal cavity (protecting the mesh's coating and reducing the risk of damage) and to hold the mesh against the peritoneum for tacking.
PatchAssist " PolyTouch Medical " www.polytouch-med.com
Patient Safety, Hinging on Improvement
The pinless hinges of the jaw closure mechanism in Richard Wolf's Eragon Monopolar Forceps mean internal tissue is at less risk of being wedged, snagged or unintentionally burned by the protruding hinge of conventional forceps. Single-finger access ratchet switches are placed on either side of the ergonomically designed handle for ambidextrous use. The single-piece device features a flush port for efficient cleaning and quick reprocessing with no disassembly and assembly. A variety of 5mm grasper and dissector tips are available.
Eragon Monopolar Forceps " Richard Wolf Medical Instruments " http://www.richardwolfusa.com
|
Is Ultra Minimally Invasive Surgery Here to Stay? |
|
The tools and techniques that make one-hole surgery possible are generating significant interest among general surgeons. In all that talk, though, there's still a debate over whether ultra minimally invasive methods are here to stay, or just a passing fad driven by cosmetic outcomes. We asked a panel of experts in the field. In terms of surgical technique and technology, "we've had a bunch of swings and misses recently," says Daniel Herron, MD, FACS, chief of laparoscopic and bariatric surgery at the Mount Sinai School of Medicine in New York, N.Y. "Things that were touted as the next big thing and then went nowhere." Example: natural orifice translumenal endoscopic surgery (NOTES). While it's still breaking new ground, a practical clinical application — that is, a procedure that is more effective, more efficient and more economical than the alternative — has not yet materialized. Similarly, he explains, "most of the excitement for SILS seems to be coming from the industry side. Patient demand hasn't really been there, and the clinical benefits have not really been demonstrated. It's a work in progress. We'd like to see real clinical breakthroughs." David Renton, MD, MPH, assistant professor of surgery at Ohio State University in Columbus, admits that the training, time and expense required for NOTES practically ensure that it won't be exported from academic surgical settings any time soon. But it and other out-of-reach advances create more practical applications of the concept, of which one-hole surgery is a direct result. "The reason SILS got off the ground so quickly is because we were pushing hard with NOTES," he says. "It wasn't just that we were able to do the surgery, but it was also pushing the technology forward — curved instruments, articulated instruments, through laparoscopes, even needlescopic instruments that don't need ports — into something we can do right now, with no increase in the cost of operations." The end result? Perhaps a synergy of NOTES and SILS in more ORs. Or even human surgeons building their skills on the abilities of machines. According to Ramon Berguer, MD, associate professor of surgery at the University of California Davis School of Medicine in Sacramento, recent advances in the articulation of laparoscopic instruments may be influenced by the spectacle — and exorbitant cost — of surgical robotics. "A robot is prohibitively expensive for most surgical facilities," he says. "Graspers and dissectors that are fully articulated, not just flexible instruments, offer more degrees of freedom and enhance dexterity in a number of laparoscopic procedures, but not at the expense of a robot." — David Bernard |
Staples Save OR Time
Your OR time can cost hundreds of dollars a minute. SafeStitch says its Amid Stapler can attach mesh in open inguinal hernia repairs 5 to 10 minutes faster than suturing can, with less exposure for the patient. A low-profile stapler head can fit through an incision opened with a hemostat rather than a retractor, and the staples, which emerge at a 45 ? angle, can be used to close the skin as well.
Amid Stapler ($200) " SafeStitch Medical " www.safestitch.com
3-D in the OR
While Sony still classifies it as a work-in-progress, the company's freestanding, medical-grade, 3-D LCD Monitor could bring hassle-free depth perception to intraoperative imaging. Unlike 3-D technologies whose head-mounted displays or battery-powered goggles interfere with normal vision and workflow, Sony's micro-polarizing technology is viewed through lightweight, lightly tinted sunglass-style eyewear that doesn't need to be removed to operate. The 24-inch-diagonal screen features a 1,920 by 1,200 pixel resolution and a 16:10 aspect ratio and is compatible with 2-D as well as 3-D camera systems.
LMD-2451MT LCD Monitor " Sony Medical " http://www.sony.com/medical
Ultra Minimally Invasive Surgery
Stryker Endoscopy's MiniLap line provides access and instrumentation in 1 laparoscopic device. The 2.4mm disposable graspers and electrosurgical probes, each available in 4 tip styles, feature built-in insertion needles for percutaneous entry into the abdominal cavity without trocars. These tools don't compromise surgical technique or time and provide a seal to maintain insufflation pressure, while the minimized incisions require no closure and reduce scarring.
MiniLap Laparoscopic Instruments " Stryker Endoscopy " www.stryker.com/endoscopy
A Trocar With a View
SurgiQuest's AirSeal looks radically different than conventional trocars. An absence of seals, valves or gaskets inside the ports allow the insertion of any instrument up to 10mm, unimpeded specimen removal, and easy delivery of mesh and suture. An air curtain maintains positive insufflation pressure, continuously evacuates surgical smoke and prevents contaminant entry. Plus, scope lenses won't become smudged by passing through dirty seals.
AirSeal " SurgiQuest " www.surgiquest.com
The Port Stays Put
A cannula that pulls out when instruments are removed compromises insufflation pressure and visibility. SurgiQuest's 5mm AnchorPort Trocars automatically snug down when the obturator is removed, stabilizing the hub and remaining in place. The lower profile housing allows longer instrument reach and maneuverability while eliminating "sword fighting." The elastomeric cannula self-adjusts to the thickness of a patient's abdominal wall to prevent the cannula from blocking instruments' ability to reach tissue.
AnchorPort Trocars " SurgiQuest " www.surgiquest.com
Along Came a Spider
A laparoscopic platform with multi-specialty potential, TransEnterix's Spider Surgical System enables multiple flexible instruments to reach multiple sites through a single incision. The device, which enters through a 17mm port, unfolds inside the abdominal cavity into a system of articulating instrument delivery tubes and working channels, allowing a greater range of laparoscopic access with true-right and true-left instrumentation.
Spider Surgical System ($875) " TransEnterix " www.spidersurgery.com
.svg?sfvrsn=56b2f850_5)