Clinical experience with a multifunctional, flexible surgery system for endolumenal, single-port, and NOTES procedures

Single-port and incisionless surgical approaches hold the promise of fewer complications, reduced pain, faster recovery, and improved cosmesis compared with traditional open or laparoscopic approaches. The ability to select an access approach (i.e., endolumenal, single-port, transvaginal, or transgastric) with one platform may be important to optimization of individual patient results. The authors report their results using these four separate surgical approaches tailored to three different therapeutic procedures, all with the use of a single flexible platform, the Incisionless Operating Platform (IOP). After institutional review board approval, the IOP was used to perform nine cholecystectomies via transvaginal (TV) (n = 4), transgastric (TG) (n = 4), and single-port transumbilical (TU) (n = 1) access. Two appendectomies were performed via TG access. Endolumenal access was used for 18 gastric pouch and stoma reductions after Roux-en-Y gastric bypass. The TG and TV procedures involved the use of one to three trocars. The recorded data included safety, procedural success, operative time, patient pain assessment (on a 0–10 scale) at discharge, and length of hospital stay. Procedural success was achieved for 16 of 18 endolumenal procedures, 1 of 1 single-port procedure, and 10 of 10 NOTES procedures. For 5 of 10 NOTES procedures, only one small trocar was required. The mean operative times were 79 min for pouch with stoma reduction, 171 min for cholecystectomy, and 274 min for appendectomy. Of 29 patients, 27 were discharged in 24 h or less. The average pain scores were 0.44 for pouch with stoma reduction, 1.3 for cholecystectomy, and 2.5 for appendectomy. No significant complications occurred. The ergonomics of IOP allowed the surgeon to interface with the system using an endoscopic or laparoscopic orientation. Availability of a multifunctional, flexible surgery platform provides a choice of a single-port or incisionless surgical approach with the potential to reduce complications, pain, and recovery time while improving cosmesis

Feasibility of joystick guided colonoscopy

The flexible endoscope is increasingly used to perform minimal invasive interventions. A novel add-on platform allows single-person control of both endoscope and instrument at the site of intervention. The setup changes the current routine of handling the endoscope. This study aims to determine if the platform allows effective and efficient manipulation to position the endoscope at potential intervention sites throughout the bowel. Five experts in flexible endoscopy first performed three colonoscopies on a computer simulator using the conventional angulation wheels. Next they trained with the joystick interface to achieve their personal level of intubation time with low pain score. 14 PhD students (novices) without hands-on experience performed the same colonoscopy case using either the conventional angulation wheels or joystick interface. Both novice groups trained to gain the average expert level. The cecal intubation time, pain score and visualization performance (% of bowel wall) were recorded. All experts reached their personal intubation time in 6 ± 6 sessions. Three experts completed their learning curve with low pain score in 8 ± 6 sessions. The novices required 11 ± 6 sessions using conventional angulation wheels, and 12 ± 6 sessions using the joystick interface. There was no difference in the visualization performance between the novice and between the expert groups. This study shows that the add-on platform enables endoscope manipulation required to perform colonoscopy. Experts need only a relatively short training period. Novices are as effective and as efficient in endoscope manipulation when comparing the add-on platform with conventional endoscope contro

Natural orifice surgery: initial clinical experience

Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience. Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance. Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred. The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access

Intuitive user interfaces increase efficiency in endoscope tip control

Background Flexible endoscopes are increasingly used to perform advanced intraluminal and transluminal interventions. These complex interventions demand accurate and efficient control, however, current endoscopes lack intuitiveness and ergonomic control of the endoscope tip. Alternative handheld controllers can improve intuitiveness and ergonomics, though previous studies are inconclusive concerning their effect on the efficiency of endoscope manipulation. The aim of this study is to determine the efficiency of a robotic system with intuitive user interface in controlling the tip of the flexible endoscope. Methods We compared the efficiency of time and tip trajectory when steering the endoscope tip using the conventional steering wheels and a robotic platform with three different user interfaces: a touchpad in combination with a position control algorithm, a joystick combined with linear rate control, and a joystick combined with non-linear rate control. Fourteen participants, without a medical background, used all four interfaces. They performed both large navigational and fine targeting tasks in a simulated environment which allowed objective cross-subject comparison. Afterward, the participants were asked to select their preferred steering method. Results Participants were significantly faster in steering the endoscope tip when using robotic steering compared to using the conventional steering method. Between the robotic interfaces, using the touchpad was significantly faster compared to the joystick with linear rate control. Use of the joystick with non-linear rate control led to a shorter tip trajectory compared to the touchpad. The majority of participants preferred the joystick with non-linear rate control over the other steering methods. Conclusions This work shows that intuitive user interfaces can improve the efficiency of endoscope tip steerin