Abstract:

In recent years, laparoscopic surgery underwent a huge investment from both the clinical and research points of view to perform classic procedures through a single (S) incision or single port, resulting in the development of different instruments and ports. The main advantage of the S-access laparoscopy (SAL) is cosmesis. Future investigations will provide other potential advantages, such as improvement in postoperative pain and patient satisfaction. We report our initial experience on 115 patients utilizing a SAL (appendectomy, cholecystectomy, incisional hernia repair, Nissen fundoplication, upper gastrointestinal surgery, diagnostic laparoscopy, hepatic resection, splenectomy), along with the new curved reusable instruments (Karl Storz - Endoskope, Tuttlingen, Germany). The curves of the instruments enable the surgeon to work in an ergonomic position similar to classic laparoscopy, establishing a working triangulation inside the abdomen as well as outside. The cost of SAL is similar to classic laparoscopy as only reusable products are used.

Authors:

Giovanni Dapri, MD, Lorenzo Casali, MD, Jean Bruyns, MD, Jacques Himpens, MD, Guy-Bernard Cadiere, MD, PhD

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Abstract:

Surgical training is undergoing drastic changes, and new strategies should be adopted to keep quality standards. The authors review and advocate the use of surgical recordings as a useful complement to current training, assessment, and revalidation modalities. For trainees, such recordings would promote quality-based and competence-based surgical training and allow for self-evaluation. Video logbooks could be used to aid interaction between trainer and trainee, and facilitate formative assessment. Recordings of surgery could also be integrated into trainees' portfolios and regular assessments. Finally, such recordings could make surgeons' revalidation more sensible. The routine use of records of surgical procedures could become an integral component of the standard of care. This would have been an unattractive suggestion until recently, as analogue recording techniques are inconvenient, cumbersome, and time consuming. Today, however, with the advent of inexpensive digital technologies, such a concept is realistic and is likely to improve patient care.

Authors:

Pietro Gambadauro, MD, Adam Magos, MD

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Abstract:

There has been an emergence of reduced port techniques for laparoscopic surgery over the past three years. Although growing in presentations and papers, few scientific studies have yet to be published demonstrating benefits and risks of these techniques. In particular, very little is mentioned regarding the increased costs. This brings to the forefront the concept that the development of new surgical techniques should adhere to safe standards of surgery and undergo continued evaluation during development to ensure they maintain safety, and are able to be reproduced by our colleagues. Evaluation also needs to focus on costs, both economical and ecological. A review of our first three years experience of single port access surgery has been done. Costs in terms of both the potential economic and environmental impact have also been evaluated as compared with multiport procedures. In the first 36 months of this evolving technique, we were able to mimic multiport procedures with similar results. The costs of single port access are less than comparable multiport procedures, both in terms of dollars as well as medical waste. We are able to now offer "proof of concept" of a novel reduced port procedure from four important aspects in the development of new surgical techniques. We demonstrate comparable results in terms of outcomes and safety, improvement in financial and environmental costs, as well as showing initial success with training and application of the procedure by our colleagues.

Authors:

Erica R Podolsky, MD, Laura St. John-Dillon RN, MBA, Stephanie A. King, MD, FACOG, Paul G. Curcillo II, MD

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Abstract:

We describe our laparoscopic nephrectomy technique of placing trocars directly on the fascia once the skin and the subcutaneous layers are prepared. A series of 10 consecutive patients were operated on by single-incision laparoscopic nephrectomy (SILN). With a 5-cm mean skin incision, the fascia was prepared and 3/4 trocars inserted separately directly on the fascia. Surgical strategy followed the standard technique, except for the use of articulating instruments and 5-mm optic. Demographics, body mass index (BMI), operative time, blood loss, perioperative complications, transfusions, hemoglobin decrease, analgesic requirement, length of stay, and final pathology were recorded. Postoperative and prior-to-discharge visual analogue scale (VAS) pain evaluations were also collected, together with the limitations inherent in the instruments' placement and parallel driving during the procedure.

Authors:

Stefano Gidaro, MD, PhD, Luca Cindolo, MD, FEBU, Fabiola Raffaella Tamburro, MD, Nicola Longo, MD, PhD, Vincenzo Mirone,MD, Antonello Forgione, MD, PhD, MBA, Luigi Schips, MD

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Abstract:

With the introduction of natural orifice translumenal endoscopic surgery (NOTES), there has been interest in the general surgery community for developing safe, scarless surgery. NOTES itself brought additional risks to GI surgery, and as such it has not achieved mainstream acceptance. Single site is considered by many surgeons as a bridge between traditional laparoscopic surgery and NOTES without the inherent risks of NOTES. However, initial single-site procedures using standard instrumentation are technically challenging due to the absence of instruments that facilitate triangulation, avoid conflicts between the instruments and the camera, maintain pneumoperitoneum, and reduce operative stress. The TransEnterix SPIDER platform has been created to overcome these difficulties. The SPIDER is a sterile and disposable device that contains 4 working channels (2 flexible instrument delivery tubes positioned laterally and 2 rigid channels, superiorly and inferiorly to accommodate an endoscope or any of the shelf rigid surgical instruments). Procedures facilitated by this platform are considered to use a hybrid flexible laparoscopic technique. Initial experience in over 100 cases with the SPIDER, including colectomy, cholecystectomy and adjustible gastric banding, has shown this system to be effective. Technical pearls when using the SPIDER include pulling rather than pushing, and increased use of electrocautery. These learning curve lessons for flexible laparoscopy will be described in detail, including a discussion of advantages and disadvantages. The SPIDER platform facilitates safe and straightforward single-site laparoscopic surgery.

Authors:

Nestor Villamizar, MD, Aurora D. Pryor, MD

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