Laparoendoscopic single-site surgery cholecystectomy using a novel retraction device
Anthony Yuen-Bun Teoh, Jeff Siu-Wang Wong, Philip Wai-Yan Chiu, Paul Bo-San Lai and Enders Kwok-Wai Ng

The Endograb™ grasping and maneuvering system was proved as a safe and effective method to improve gallbladder retraction during LESS cholecystectomy. By eliminating the need for an extra trocar for retractor, EndoGrab™ reduced instrumental crowding of the para-umbilical incision. EndoGrab™ also showed the potential to be used successfully in additional organ retraction.

Initial results of reduced port laparoscopic gastrectomy for gastric cancer
Atsushi Iida, Takanori Goi, Daisuke Fujimoto, Yasuo Hirono, Takuma Nishino, Shigehiro Yokoi, Takeshi Watanabe, Tamotsu Togawa, Toshihisa Kimura, Hidenori Fujii

The use of EndoGrab™ laparoscopic maneuvering system allowed the procedure of a single-incision laparoscopic right hemicolectomy procedure was enabled for colon malignancy, overcoming the technical problems related to SILC (such as instrument crowding, in-line viewing, insufficient countertraction). EndoGrab™ presented excellent short-term outcomes. The use of the EndoGrab™ was essential to maintain minimal invasiveness and oncological safety, especially in difficult situations such as an unfavorable visual angle when performing a lymph node dissection around the middle colic vessels.

Utility of an Internal Retractor (EndoGrab) for the Management of the Vesicouterine Ligamentb during Laparoscopic Radical Hysterectomy
Eiji Kobayashi Mamoru Kakuda Yusuke Tanaka Akiko Morimoto Tomomi Egawa-Takata Shinya Matsuzaki Yutaka Ueda Kiyoshi Yoshino Tadashi Kimura

Leveraging EndoGrab™ proprietary MicroAnchoring™ technology ,Surgeons were able to easily reproduce a suitable surgical view that simulated the one obtained by an abdominal route for radical hysterectomy. Radical hysterectomies in all 17 cases was completed with no ureteral injuries.

Advantages of Minimal Incision Laparoscopic Cholecystectomy
Nasser Sakran MD1,2, David Goitein MD1,3, Asnat Raziel MD1, Dan Hershko MD3 and Amir Szold MD1

Two novel stand-alone maneuvering devices: EndoGrab™ and EndoLift™ were introduced during laparoscopic procedure. The gallbladder is retracted supero-laterally by the EndoGrab™ device, facilitating dissection of the structures at the Calot triangle

Single-incision laparoscopic cholecystectomy: lessons learned for success
Noam Shussman • Avraham Schlager • Ram Elazary • Abed Khalaileh • Andrei Keidar • Mark Talamini • Santiago Horgan • Avraham I. Rivkind • Yoav Mintz

The EndoGrab™ single hand application system shows an improved surgeon’s ability to perform both a safe and efficient laparoscopic procedure. EndoGrab™ retraction capabilities are versatile, retracting angels can be changed during the procedure as needed.

Providing more through less: current methods of retraction
in SIMIS and NOTES cholecystectomy

Avraham Schlager • Abed Khalaileh • Noam Shussman • Ram Elazary •
Andrei Keidar • Alon J. Pikarsky • Avi Ben-Shushan • Oren Shibolet • Santiago Horgan •Mark Talamini • Gideon Zamir • Avraham I. Rivkind • Yoav Mint

The EndoGrab™ single hand application is an easy-to-use surgeons’ support system, demonstrating optimal retraction and exposure during laparoscopic procedures, with no complications

Introduction

Minimally Invasive Surgery (MIS) has revolutionized the field of surgery, offering patients faster recovery times, reduced pain, and minimized scarring compared to traditional open surgeries. Over the years, advancements in technology have further enhanced the capabilities of MIS, making it a preferred choice for various surgical procedures across different medical specialties.

Advancements in Minimally Invasive Surgery

Minimally Invasive Surgery (MIS) has witnessed remarkable advancements, revolutionizing the landscape of surgical procedures. With smaller incisions and specialized tools, MIS offers patients numerous benefits, including reduced pain, shorter hospital stays, faster recovery times, and lower risks of complications compared to traditional open surgeries. These advancements are made possible by cutting-edge technologies and innovative techniques that continue to evolve.

Robotic-Assisted Surgery

One of the most significant advancements in MIS is robotic-assisted surgery, where robotic systems are used to perform intricate procedures with enhanced precision. Surgeons can control robotic arms with high dexterity, allowing for complex maneuvers in tight spaces. This technology has expanded the scope of MIS to include procedures in various specialties such as urology, gynecology, and gastrointestinal surgery.

Advanced Imaging Technologies

Advancements in imaging technologies such as laparoscopy, endoscopy, and ultrasound have greatly improved visualization during MIS. High-definition cameras provide detailed views of internal organs, aiding surgeons in performing procedures with greater accuracy. Real-time imaging also enables surgeons to navigate anatomical structures safely, reducing the risk of complications.

Miniaturized Surgical Instruments

The development of miniaturized surgical instruments has been pivotal in enhancing the efficacy of MIS. These instruments are designed to access hard-to-reach areas through small incisions, minimizing trauma to surrounding tissues. With improved ergonomics and functionality, surgeons can perform delicate maneuvers with ease, leading to better patient outcomes.

Innovative Surgical Techniques

In addition to technological advancements, innovative surgical techniques have emerged to further refine MIS procedures. Techniques such as single-port surgery, where multiple instruments are inserted through a single incision, reduce scarring and improve cosmetic outcomes for patients. Other techniques like natural orifice transluminal endoscopic surgery (NOTES) explore new pathways for minimally invasive access, pushing the boundaries of what is possible in surgery.

Challenges in MIS

Minimally Invasive Surgery offers significant benefits but also presents challenges:

1. Instrumentation and Ergonomics: Delicate instruments and ergonomic challenges can
   affect surgical precision and performance.
2. Cost and Resource Allocation: Implementing MIS is costly, requiring investments in
   equipment and ongoing maintenance.
3. Procedure-Specific Limitations: Some surgeries may not be suitable for MIS due to
   anatomical complexities.
4. Complications and Learning: Despite benefits, MIS can still lead to complications,
   requiring continuous learning and improvement.
5. Learning Curve: Surgeons need specialized training for MIS techniques, including robotic
   systems, which can impact outcomes during the learning phase.
6. Limited Haptic Feedback: MIS lacks tactile feedback, requiring surgeons to rely heavily
   on visual cues and imaging technologies.

Why Virtual Ports?

While MIS has made tremendous strides, challenges such as port crowding and limited maneuverability still exist. Virtual Ports addresses these challenges and plays a critical role in the success and future of MIS for several reasons:

1. Minimizing Crowdedness: Virtual Ports’ platform allows surgeons to minimize port crowding, creating a better surgical area and improving overall surgical efficiency. By reducing the number of physical ports needed, Virtual Ports streamlines the surgical process and enhances the surgeon’s ability to maneuver instruments effectively.
2. Parallel Maneuvering: Traditional MIS often requires multiple ports for retraction, dissection, and irrigation, leading to a crowded surgical field. Virtual Ports introduces parallel maneuvering capabilities, enabling portless surgery and allowing for multiple parallel manipulations simultaneously. This innovative approach not only reduces port usage but also enhances the surgeon’s control and precision during robotic surgery.
3. Portless Near-Unlimited Manipulations: With Virtual Ports’ platform, surgeons can
   perform nearly unlimited manipulations during robotic surgery without hogging any
   physical ports. This flexibility enables the performance of more complex surgeries with
   fewer limitations, ultimately improving patient outcomes and expanding the scope of
   MIS procedures.

In conclusion, Virtual Ports’ platform is a game-changer in the field of MIS, offering unparalleled benefits such as minimized crowding, parallel maneuvering, and portless nearunlimited manipulations. By addressing key challenges and enhancing surgical capabilities, Virtual Ports is critical to the success and future advancement of Minimally Invasive Surgery.

Want to learn more? info@virtual-ports.com

Introduction

Robotic surgery has ushered the medical field into a new era, transforming procedures with unmatched precision. A survey¹ revealed that 78% of U.S. surgeons are intrigued by surgical robotics. Robotic-assisted surgery brings direct benefits like shorter patient recovery and enhanced visualization for surgeons. It offers a greater range of motion, high-resolution imagery, and improved access. Patients benefit from fewer complications, shorter hospital stays, and faster recovery.

Robotic surgery successfully treats various conditions in colorectal, general, gynecologic, heart, endometriosis, head and neck, thoracic, and urologic surgeries. This white paper delves into the multifaceted challenges faced by robotic surgery and explores groundbreaking innovations.

Challenges in Robotics

Crowdedness of Arms and Collision Risks:

Robotic surgery grapples with a significant challenge posed by the crowdedness of robotic arms, both internally and externally. This overcrowding elevates the risk of collisions, which can disrupt the seamless execution of surgical procedures. Particularly in robot-assisted minimally invasive surgeries (MIS), collision risks emerge from interactions with surgeon-controlled instruments and nontarget tissues during surgical tasks. Addressing this challenge requires the development of advanced controllers to prevent collisions, safeguard the robotic system, and enhance the safety and efficacy of robot-assisted MIS. These collisions, if unchecked, have the potential to inflict damage on the robotic system or harm normal body tissues, underscoring the need for controllers to prevent collisions, especially when the in vivo scene is not visible to surgeons.

Restriction on Surgeons and Healthcare Systems:

Optimizing the efficiency of surgeons is a pivotal imperative in the realm of robotic surgery. The primary goal is to refine and streamline the movements of surgeons within the robotic system, aiming to enhance precision while mitigating procedural complexities. A notable challenge in this pursuit is the limited haptic feedback experienced by surgeons during robotic procedures². Unlike traditional surgery, where surgeons can directly feel tissues and resistance, robotic systems provide restricted tactile sensations. This reduction in haptic feedback necessitates an adaptation in the surgeon’s approach to ensure accurate maneuvering and procedural success. Additionally, there is a significant dependence on technology inherent in robotic surgery. Surgeons need specialized training to operate robotic systems effectively, creating a scenario where only a subset of surgeons can perform procedures using this technology, potentially limiting its widespread adoption. The learning curve associated with mastering robotic surgical systems further highlights the complexity of integrating this technology into medical practice, requiring surgeons to invest time and practice to attain proficiency in operating the robotic console and translating their skills from traditional surgery to the nuances of a robotic platform.

Cost and Availability:

Cost and availability pose additional challenges to the adoption of robotic surgery. The substantial financial investment required for acquiring and maintaining robotic systems³ may create barriers, limiting access to this technology in certain healthcare settings. Not all hospitals or surgical centers may have the financial resources to invest in these advanced robotic platforms.

Limitations of Robotic Surgery

Effective communication and coordination within the surgical team are crucial elements during robotic procedures. The intricate nature of these surgeries emphasizes the need for seamless teamwork to achieve successful outcomes and minimize the risk of errors. Synchronization among team members, along with adequate training in working with the robotic system, becomes paramount.

In addition, procedure-specific constraints may pose challenges. Certain robotic systems have limitations in the types of procedures they can perform. Surgeons may encounter restrictions tied to the specific capabilities of the robotic platform, influencing the range of surgeries that can be conducted robotically. A nuanced understanding of the robotic system’s capabilities is essential, guiding surgeons in the selection of procedures that align with optimal outcomes.

Furthermore, traditional robotic surgery introduces port-related challenges. The use of multiple ports, each featuring larger diameters (e.g., 11mm), deviates from the established minimally invasive approach characterized by 5mm ports in laparoscopy.

The performance of intricate and specialized procedures, particularly in oncological surgeries, is a significant challenge, constituting only of cases due to their delicate nature. Addressing these challenges highlights the importance of ongoing advancements in robotic technology, aiming to overcome port limitations and broaden the scope of specialized procedures that can be performed robotically.

In the past two decades, minimally invasive techniques for treating solid organ tumors have evolved, initially through laparoscopic approaches and later through robotic surgery. The introduction of robotic platforms around the turn of the century has played a crucial role in overcoming limitations associated with laparoscopic surgery. These advancements include high-definition three-dimensional visualization, wristed instruments, tremor stabilization, reduced operator fatigue, and improved ergonomics. Despite the acknowledged benefits of minimally invasive surgery, there is limited long-term evidence supporting its superiority over traditional approaches in cancer surgery.

Moreover, a robotic approach is often linked to extended operative times and higher costs compared to laparoscopic methods. Critics argue that the use of robotic surgery should be justified by demonstrating superior functional and oncologic outcomes. While current literature supports the feasibility, safety, and short-term outcomes of robotic surgery in surgical oncology, there is a lack of understanding regarding its impact on long-term oncologic outcomes.

The future landscape of robotic surgery is marked by exciting possibilities driven by advancements in artificial intelligence (AI), expanding applications, and the continuous effort to overcome existing challenges.

Artificial Intelligence Integration:

AI plays a pivotal role in the current trajectory of robotic surgery, providing crucial guidance, information, and enhancing preoperative and intraoperative planning processes. The future envisions autonomous decision-making by surgical robots, heralding a new era of improved patient outcomes and procedural efficiency. Recent successes in AI integration include Intuitive Surgical’s digital tool for surgeons to analyze techniques, machine learning automating surgical procedures, and the application of AI to enhance decision-making and augment surgical processes. The integration of AI into robotic surgery holds the potential to revolutionize the field, extending the application of minimally invasive procedures.

Expanding Applications:

Robotic surgery has already established its presence in various medical specialties, from neurosurgery and urology to gynecology, gastrointestinal surgery, general surgery, and cardiac procedures. With technological advancements, the scope of robotic surgery is anticipated to broaden further, encompassing an even wider range of surgical procedures and specialties. This expansion into new areas promises enhanced precision, control, and accuracy in procedures that were once confined to traditional surgical techniques, heralding increased benefits for both patients and healthcare providers.

Single Port Advancements:

Single-port robotic surgery, rooted in single incision laparoscopic surgery (SILS), has evolved since its introduction in 2008 with the Da Vinci SP surgical system. Utilizing a small incision for intra-body procedures, this approach has expanded to cover various surgeries, including cholecystectomy, appendectomy, colectomy, nephrectomy, hysterectomy, myomectomy, gastric bypass, sleeve gastrectomy, and transoral robotic surgery. Advantages include enhanced instrument control, triangulation for 3D visualization, and ergonomic benefits for surgeons. Patients benefit from faster access to anatomy, reduced trauma, improved cosmetic outcomes, and shorter recovery times. Despite these advantages, challenges such as the cost of implementation, training time, and proving distinct patient benefits persist. As technology evolves, addressing these challenges becomes crucial to realizing the full potential of single-port robotic surgery.

Conclusion

Robotic surgery has evolved significantly, addressing challenges and introducing innovative solutions. The integration of single-port technologies and ongoing enhancements reflects a commitment to efficiency, minimally invasive procedures, and accessibility. Collaboration, research, and technological strides will shape the dynamic future of robotic surgery.

About Virtual Ports

Virtual Ports Ltd pioneers advanced Minimally Invasive Surgery (MIS) through its innovative MicroAnchoring™ technology, ensuring safer, cost-effective outcomes with the ‘Freedom to Operate’ initiative. This marks a significant leap forward in procedure simplicity and effectiveness, empowering surgeons and contributing to the transformative evolution of surgery. For instance, our technology allows surgeons to minimize port crowding, enhancing the surgical area. With Virtual Ports’ maneuvering system, surgeons gain control of the surgical space without relying on an assistant, enabling less experienced staffers to perform complex techniques with reduced risk to operational performance or patients.

Laparoscopic surgery, once a revolutionary approach, has evolved significantly over the years, leading to improved patient outcomes and a paradigm shift in surgical practices. This white paper delves into the latest advancements in laparoscopic techniques, instrumentation, and technologies, this paper aims to contribute to the understanding of how these innovations are reshaping the landscape of minimally

Introduction

Laparoscopic surgery, often hailed as a revolutionary milestone in medical history, has significantly transformed patient care since its inception. The technique, which involves performing operations through small incisions with the aid of a camera, has drastically reduced the invasiveness of traditional surgical procedures. Emerged in the late 20th century, laparoscopy marked a paradigm shift by minimizing scarring, shortening recovery times, and lowering the risk of complications for patients. This approach has become the gold standard for various surgeries, including gallbladder removals and appendectomies. The historical trajectory of laparoscopic surgery underscores its enduring impact on enhancing surgical precision, improving patient outcomes, and shaping contemporary healthcare practices.

Advancements in Laparoscopic Techniques

Instrumentation innovations in laparoscopic surgery have ushered in a new era of precision and efficiency in minimally invasive procedures. One groundbreaking advancement lies in the development of articulating instruments designed to replicate the dexterity of a surgeon’s hand. These instruments offer unparalleled precision and maneuverability, especially crucial within the restricted confines of the body during laparoscopic surgeries. The introduction of energy devices, including ultrasonic shears and advanced electrosurgical instruments, has significantly improved the efficiency of cutting and coagulation processes during procedures.

The integration of robotic-assisted surgical systems stands out as a transformative innovation in laparoscopy. These robotic systems not only provide surgeons with enhanced control but also offer three- dimensional visualization, allowing for a more detailed and accurate representation of the operative field.
This proves particularly beneficial in intricate surgeries where precision is paramount.

Moreover, the continuous evolution of imaging technologies has contributed to the refinement of laparoscopic procedures. High-definition cameras and advanced three- dimensional visualization systems empower surgeons with a clearer view, enhancing their ability to navigate and execute intricate tasks with unprecedented clarity.
Collectively, these instrumentation innovations represent a comprehensive leap forward in the realm of laparoscopic surgery, promising improved surgical outcomes and a higher standard of patient care.

Innovations in training for laparoscopic surgery have been instrumental in ensuring surgeons acquire the skills necessary for successful and precise minimally invasive procedures. Traditional training methods often involved
a transition from open surgery to laparoscopy, but contemporary approaches focus on dedicated laparoscopic training programs. Virtual reality (VR) and augmented reality (AR) simulations have emerged as groundbreaking tools, providing a realistic and risk-free environment
for surgeons to practice and refine their techniques.
These simulations enable surgeons to navigate complex anatomies, enhance hand-eye coordination, and familiarize themselves with laparoscopic equipment.

Additionally, telementoring and teleproctoring have become essential innovations, allowing experienced surgeons to remotely guide and mentor trainees during laparoscopic procedures. This not only facilitates continuous learning but also expands access to expert guidance irrespective of geographical constraints. Moreover, the integration of haptic feedback systems in training simulators adds a tactile
dimension, allowing surgeons to feel realistic resistance and forces encountered during laparoscopic procedure.

While laparoscopy is generally considered a safe and minimally invasive approach, like any surgical procedure, it is not without potential complications. Complications may include injury to surrounding structures, bleeding, infection, and complications related to anesthesia. Rigorous attention to patient safety is paramount, necessitating thorough preoperative assessments, adherence to proper surgical techniques, and meticulous postoperative care.

Continuous improvement in surgical techniques plays a pivotal role in mitigating risks and enhancing patient safety. Surgeons must stay abreast of evolving technologies, incorporate best practices, and participate in ongoing training and education.
Implementing standardized protocols, utilizing advanced imaging technologies for better visualization, and fostering a culture of open communication within surgical teams are essential components of risk reduction.

Looking into 2024

The future of laparoscopic surgery holds exciting innovations and trends that are poised to transform the landscape of minimally invasive procedures. One notable trend is the continued integration of robotic-assisted surgical systems, offering enhanced precision and three-dimensional visualization.
As these robotic systems evolve, we can anticipate even greater dexterity and control in intricate surgeries. Additionally, advancements in augmented reality (AR) and virtual reality (VR) technologies are likely to revolutionize surgical training, providing more immersive and realistic experiences for surgeons. The development of smart instruments with sensors and artificial intelligence (AI) capabilities is another promising avenue, potentially offering real-time feedback and decision support during surgeries. Furthermore, personalized and patient-specific approaches, such as tailored surgical plans based on individual anatomy, may become more prevalent. As we embrace these innovations, laparoscopic surgery is poised for a future where efficiency, precision, and patient outcomes reach unprecedented levels.

About Virtual Ports

Virtual Ports Ltd pioneers advanced Minimally Invasive Surgery using its innovative MicroAnchoring™ technology. This groundbreaking devices’ platform empowers surgeons, marking a significant leap forward in procedure simplicity and effectiveness. Virtual Ports’ ‘Freedom to Operate’ initiative ensures safer, cost-effective outcomes and boosts healthcare system revenue.