While many of the newly introduced devices for minimally invasive surgery are impressive simply from a technical standpoint, they become more interesting when you think about the problems that they can solve. We now have instruments that are easier to hold and ports that can make procedures safer and less painful for our patients, and if properly combined we may have more surgical options in the outpatient setting. Here are some of the new devices I saw at the 2008 SAGES conference in Philadelphia that can change how we operate.

Doing it all through one port
Despite all the talk about natural orifice surgery, as a surgeon I find the prospect of single-port surgery more interesting. Going through an opening close to the intended surgical site would be much easier than maneuvering through a patient's orifice and creating incisions in the patient's organs. To make this happen, though, we need instruments that can fit through such a small opening and still be maneuverable.

The Novare RealHand High Dexterity Maryland Dissector offers an interesting solution to the space problem. This instrument features a tip that can easily turn 90 degrees and a handle that moves easily to the left or right while the shaft remains straight. In effect, a surgeon could use two of these in a port and then turn the handles away from each other, which would give him the freedom to make all the necessary movements. A drawback of this instrument is its inability to lock in place when articulated, and at $435 it's expensive for a tool that's designed for a single use. These dissectors may work better in the hands of experts as opposed to novice surgeons because of the steep learning curve associated with mastering them.

Two of these dissectors can easily fit through the hole made by the Surgiquest Airseal Access System. The port for this device creates an invisible barrier inside the center of the trocar, without using gaskets or seals, by creating an airseal with the inflowing CO2. It recycles this air as it leaks out, so there is minimal loss of insufflation during the procedure.

According to Surgiquest's literature, you can fit up to three instruments through the 12mm port. This port recently earned FDA approval. The manufacturer says it will be on the market by fall, available in 12mm and 15mm sizes.

The reversible equivalent of a Roux-en-Y
Imagine if a Roux-en-Y gastric bypass could be performed in an outpatient setting, and if it were completely reversible with no anastomosis required. The combination of an old idea with a new one may make this possible.

We've had the Lap-Band AP System from Allergan and Covidien for some time; Ethicon is now entering the market with its Realize Adjustable Gastric Band. This system has a low-pressure balloon design to reduce tissue trauma and a 23mm band to get maximum secure placement while reducing the risk of slippage. The manufacturer is quick to point out that it also offers a Web site, www.realizeband.com, to help patients get additional information about how to manage and maintain their weight loss after the procedure. The price for this system varies depending on the patient's insurance plan.

Once a band is in place, the surgeon can endoscopically insert an EndoBarrier Gastrointestinal Liner (not yet FDA approved) from GI Dynamics. This long translucent sleeve goes into the duodenal bulb and can extend for two feet through the proximal jejunum. The patient can't digest food in these areas when the sleeve is in place, and if there are any complications the sleeve can be easily extricated.

Since this endoscopically deployed device would create the malabsorptive component of the Roux-en-Y bypass, it can effectively mimic the anatomic outcomes of this procedure when combined with a band. You can apply these in an outpatient setting, and both devices are completely removable at any time.

Fixing hernia repair problems
Some of the new meshes and hernia repair devices solve problems we used to have when treating these patients. The lightweight polypropylene C-QUR Mesh from Atrium Medical Corporation, for example, is coated with omega-3 fatty acids. The benefit here is that the body recognizes this bioabsorbable substance and reacts well with it, which means the patient will have less chance of adhesion or inflammation from it. I've seen videos where patients are re-operated on after having this mesh in place for nine months, and there was little visible adhesion and no mesh shrinkage. The manufacturer did not disclose a price for this mesh.

W.L. Gore & Associates unveiled its new synthetic bioabsorbable mesh at the conference, the Gore Bio-A Tissue Reinforcement. This is made from the same bioabsorbable material as Gore's Seamguard product, but is much thicker than that mesh. In effect, it has the same benefits as biologic hernia repair systems, but at $5 per square centimeter it's much more cost-effective than the $30 per square centimeter for systems derived from biological tissue.

It isn't just the meshes that can disappear into a patient's body. The AbsorbaTack 5mm Fixation Device from Covidien shoots tacks made from material that is partially absorbed at six months and essentially gone within a year. This may help reduce pain associated with permanent fixation devices that we've seen in the past. Surgeons will probably appreciate some of the features that make it easy to use, such as the "black dot" on the end of a tack to make it easy to see and the ratcheted handle that provides tactile feedback after firing. The price of this device is $30 per tack (with 20 tacks per device).

Easier on the hands, wrists and eyes
The products mentioned thus far may change the end result of our procedures. What about those that can make cases easier for surgeons and staff?

The Force TriVerse Electrosurgical Device from Covidien is a Bovie pen with added features that surgeons will greatly appreciate. The pen's design lets surgeons change the power setting using the slide bar on the pen itself.

There is also an added button called "Valleylab mode," which resembles the coagulation setting but with less thermal spread, to gives the surgeon more control and minimal collateral tissue destruction when dissecting.

Covidien also recently released the Endoclip III 5mm Clip Applier. At first glimpse you can see this has large clips, a slip-resistant grip and a long shaft to make it versatile. And unlike any other applier on the market, it features a digital display above the handle that counts how many clips you have left, eliminating the need to keep a mental count. Covidien declined to disclose the prices for either of these devices.

I've seen many residents fumbling with the controls on Ethicon's old Harmonic Ace Scalpels, so I was glad to see the more ergonomic redesign. Instead of using thumb buttons on the side, this new version's controls are like triggers on the grip, which should make them more intuitive. The manufacturer declined to disclose the price.

From an imaging standpoint, I never liked the fact that we were working in a 3-D environment but even with the best monitors we only got a 2-D view. A new video system from Matsushita Electronic Industrial Corp. has a novel solution to this dilemma. By wearing polarized glasses and looking at the display screen, you can get a full depth of field with much less uneasiness than many people feel when looking though other binocular or goggle systems. Another advantage here is that wearing the polarized goggles will give you OSHA-level eye protection. This product is licensed through Panasonic and is being used in Japan, but is not yet available in U.S. markets.