HAND-EYE COORDINATION Dr. Ross test-drove the latest in laparoscopic technology.

The advantages of minimally invasive surgery depend on advances in access, visualization and instrumentation. The exhibit hall at the Society of American Gastrointestinal and Endoscopic Surgeons' annual conference, held in Baltimore this spring, offered practitioners the opportunity to check out the latest innovations in one place. To put it simply, I was a kid in a candy store. Here's some of the technology that caught my eye.

Articulating HD 3D Laparoscopic Surgical Video System from Olympus
Olympus is marketing its new laparoscope as an economical alternative to surgical robotics. Just because a facility can't budget the $1.5 million to $2.2 million (plus use and maintenance expenses) for a robot doesn't mean it has to forgo the benefits that depth perception brings to lap surgery. The 10mm scope incorporates twin visual channels to produce binocular vision, twin light sources to fully illuminate the site, and a "chip on the tip" to deliver a high-quality image. Polarized glasses let you see the 3D effect on a high-definition display. It also has a bendable tip. Dials at your fingertips enable angulation of up to 100 degrees in 4 directions, so you can look behind things while the scope remains stationary.

SEE AROUND CORNERS The articulating tip of Olympus's 3D HD scope lets users see beyond a stationary scope's view.

It's easy to overlook, but the single cable that carries both the power and light cords from the back of the hand controls, in line with the device (instead of the power cord coming out the back and the light cord perpendicular or at an angle), is inspired design. When you're performing single-incision lap surgery, an instrument with a cord sticking out the side can interfere with other instruments. A cord out the back end makes for a flatter instrument and a less crowded port. The articulating, 3D, HD scope hadn't been priced at the time of the conference, but Olympus reps estimated the costs of the entire video platform at $150,000, which included the 2 video towers necessary for 3D images and the camera control unit to combine their signals.

New Abilities for Intuitive Surgical's da Vinci Robot
If, on the other hand, your facility has invested in a da Vinci Surgical Robot, you'll surely be interested to learn that Intuitive Surgical has introduced attachments that expand its ability: a stapler, a vessel sealer and a contrast imaging component. Previously, surgeons could perform a range of robotically assisted laparoscopic techniques from the control console, but stapling wasn't one of them. The physician's assistant, standing by the OR table with a handheld endoscopic stapler, would be required to undertake the task. So the new stapler attachment puts more control into a remote surgeon's fingertips. Intuitive's reps said it would cost a few thousand dollars to add the ability to existing robots, plus the per-use cost of consumable, 50-fire, staple cartridges.

ABLE ACCESSORIES Intuitive Surgical has given da Vinci control over stapling, sealing and contrast imaging from the control console.

The company also introduced the EndoWrist One Vessel Sealer. This articulated attachment gives surgeons more reach when cutting, sealing and dissecting, which makes a lot of sense, because then you can bring the instrument to the tissue, not the other way around. And Firefly Fluorescence Imaging uses intravenously injected indocyanine green and a laser-emitting scope to let us visualize vasculature and perfusion while we're operating with robotic precision.

iDrive Ultra from Covidien
The iDrive Ultra looks like a cordless electric drill. What it offers is fully powered endoscopic stapling, and it's a welcome development. A manual endo-stapler tends to require a great deal of force to fire, which usually ends up monopolizing both of your hands. The iDrive makes the job much easier, and single-handed. There's no question that laparoscopic surgeons will benefit from this ergonomic advance, especially we women.

SINGLE-HANDED STAPLING Covidien's iDrive Ultra makes laparoscopic stapling light work.

When I'm working with thick tissue, I've had manual stapler handles crack on me, but this device is fail-safe. Indicator lights warn you when it senses that tissue is too thick, when the battery is spent or when you need to reload. If there's an issue hindering its operation when it's handed to you, it's not going to let you go ahead, and that's valuable feedback.

The iDrive features Covidien's Tri-Staple Technology, the ability to deploy 3 different heights of staples for varying tissue anatomy. It's fully autoclavable, except for the non-sterile, rechargeable, lithium-ion battery, which provides 8 to 10 hours of use. Covidien says the stapler costs $10,000 to $12,000, and a 50-staple reload $200 to $300.

OVS-1 Video System from Olive Medical
The typical support setup for video imaging includes a camera control unit, light source and display monitor stacked on a tower or cart. It makes a substantial footprint in the OR and it costs in the $40,000 range. Olive Medical is promoting its OVS-1 system as a "video tower in a box." It incorporates a 12.1-inch, HD, touchscreen display, camera unit and LED light source in a 7-pound device that's 14 inches by 10.5 inches by 4 inches. And it lists at less than $11,000.

TOWER IN A BOX Olive Medical's OVS-1 fits a monitor, camera control unit and light source in a 7-pound package.

As a small, all-in-one system, it's got a lot to recommend it to office-based surgical facilities or endo procedure rooms. The reps said EGD and ENT docs working in clinics really like the box. But surgeons working in highly equipped ORs should know that they can't just plug their favorite scope into the box. It only accommodates the Olive Medical camera, so you have to purchase the entire package to take advantage of its benefits.

EndoGrab and EndoLift from Virtual Ports
I do all of my laparoscopic cases through a single incision, so anything that helps keep access and visibility simple and uncluttered is worth looking into. Virtual Ports' EndoGrab ($150) and EndoLift ($250) are hands-free internal retractor devices that don't require additional incisions, ports or instruments, the way manual graspers or retractors do.

CLIP IT The EndoGrab from Virtual Ports offers internal retraction without impeding instruments or adding an incision.

I like how these devices work. The EndoGrab has 2 articulated, atraumatic clips that anchor organs to the abdominal wall. The EndoLift has a telescoping stainless steel bar between the clips to lift and hold larger organs against the wall. These single-use items are deployed with an applier through a 5mm port. After the organ is anchored, you remove the applier and can use the port for other purposes. You remove the repositionable retractors at the case's completion.

INNOVATIONS
Also Seen at SAGES

NovaTract's retraction system.

NovaTract Surgical's internal retraction system was not yet approved for the U.S. market at the time of the conference, but what it proposes is improved tissue manipulation through adjustable tension and modifiable retraction angles. The 5mm laparoscopic entry device uses the single or multiple ports that have already been placed to gain access to the peritoneal space and anchor and reposition the gall bladder, for example, against the abdominal wall. The company says it can assist in visualization without adding ports, and without necessitating surgeons to change their technique.

Pinpoint by Novadaq.

Novadaq, the company that developed Firefly Fluorescence Imaging for the da Vinci robot, introduced a standalone laparoscopic technology, the Pinpoint Endoscopic Fluorescence Imaging System. The system combines the company's Spy fluorescence technology with high-definition resolution to offer multimodal laparoscopic imaging. A 10mm HD camera with white light shows the standard imaging mode. The injection of indocyanine green enables Spy's contrast imaging mode. Pinpoint mode combines the two to illuminate HD visualization with a real-time fluorescent view of blood flow and tissue perfusion for clearer anatomical images.

Genicon's Geni-Strong specimen retrieval bags.

Genicon's Geni-Strong laparoscopic specimen retrieval bags are made from tear-resistant nylon, not polyurethane, which means they're protected against bursting and won't propagate tears if they're nicked by instruments, says the company. The watertight bags are available in 3 sizes. The medium and medium/large sizes can fit through a 10mm port, while the large fits through a 12mm port.

GelPoint Mini from Applied Medical.

Applied Medical has adapted its GelPoint Advanced Access Platform, a multiple-access, single-incision port device, to the demands of even smaller incisions. The GelPoint Mini accommodates 1.5cm to 3cm incision sizes (down from 1.5cm to 7cm) and varying abdominal wall sizes while allowing the triangulation of 5mm to 10mm instruments. The device system is priced at $400 to $500.

— David Bernard

ON HAND Karl Storz's set of 3mm laparoscopic instruments let surgeons go even more minimally invasive.

3mm Instruments from Karl Storz Endoscopy
One key to the continuing development of minimally invasive surgery is reducing the size of the instruments while sustaining the strength and utility of their larger counterparts. I've handled other less-than-rigid mini tools that don't leave me confident they'll be able to do the job, but Karl Storz's 3mm laparoscopic instruments feel sturdy. Advances like this could play a big role in expanding single- or limited-incision laparoscopy. The instruments list at $950 to $1,100 per instrument, comparable to 5mm and 10mm versions. Reusable trocars to provide access for 3mm instruments, available in pediatric and bariatric lengths, are $600.

IN THE PINK Lexion Medical's InsuFlow Synergy port adds abdominal access to InsuFlow's gas pre-conditioning function.

InsuFlow Synergy by Lexion Medical
Lexion Medical is known for its InsuFlow laparoscopic gas-conditioning device, that pink cylinder on the insufflation line that warms and humidifies the CO2 going into the pneumoperitoneum. Now, that pre-conditioning is available from a 5mm instrument port, the InsuFlow Synergy. In addition to delivering 95 ?F, 95% relative humidity CO2 for less fog and less post-op pain, like the InsuFlow, the Synergy's multi-directional gas dispersion at the distal end provides pneumo stability. The list price is about $95 to $105. If you're performing conventional laparoscopy and working with multiple incisions and ports, this device might benefit the patient without getting in the surgeon's way.

GUIDE LINES The Weck EFx from Teleflex assists in suturing to ensure secure endo fascial closure every time.

Weck EFx Endo Fascial Closure System from Teleflex
Teleflex has acquired medical manufacturer Weck and along with it the Weck EFx Endo Fascial Closure System. It's an unassisted approach to closure suitable for port sites 10mm or larger. The company says it delivers uniformly reproducible results across varying patient anatomy and that it minimizes the risk of post-op port-site hernia. At the exhibit hall, Teleflex reps demonstrated it on a sponge: The device goes into the defect, a loaded suture passer slides through the guide channel and approximation wings, and removal of the device facilitates closure and suturing. List price is about $100.