Minimally invasive gets even less traumatic

Just when one thought that minimally invasive surgery couldn't get any less intrusive, new technologies are discovered that are one step less invasive than the most recent advance.

Such was the case at the recent annual meeting of the Society of Laparoendoscopic Surgeons (SLS) where single-port surgery, articulated laparoscopic instruments, and other novel devices were launched that allow the surgeon and patient the benefits acquired with less traumatic techniques.

One way to convert more open surgeries into laparoscopic surgery is to allow more movement inside the abdomen, which in some surgeries cannot be done with rigid laparoscopic instruments. By adding articulation to the rigid laparoscopic instrument, the surgeon can enjoy better movement and manipulation of organs within the abdomen and perform tasks that cannot be done with rigid instruments.

Several companies have developed such instrumentation, which has enabled surgeons to do more procedures laparoscopically. In a presentation, "Comparison of conventional and second-generation articulating laparoscopic instruments," Chandru Sundaram, MD, of Indiana University Medical School in Indianapolis, reported on the differences in conventional vs. articulating laparoscopic instruments when used to perform a series of standardized tasks performed by novices.

She found that except for one cutting task where the articulated instrument group was slower but more accurate, "there were no other statistically significant differences in speed, accuracy, or comfort between the two groups." Sundaram added, "The limitations of conventional laparoscopy have driven the development of articulating instruments. These instruments may help expand the indications for conventional laparoscopy especially in areas where robotic technology is not available or affordable."

Five companies are addressing this opportunity, each with its own strategy. Ethicon Endosurgery in Cincinnati has licensed a line of Harmonic instruments that use ultrasound to simultaneously cut and coagulate. Those instruments have been licensed to Intuitive Surgical in Sunnyvale, CA, for use with the da Vinci robotic system. The robot employs a fully articulating arm called Endowrist, to which the harmonic instruments attach. At this point, Ethicon Endosurgery is not selling a separate, independent line of articulating laparoscopic instruments.

Novare Surgical of Cupertino, CA, and Starion Instruments of Sunnyvale, CA, partnered in a distribution agreement that allows Starion's tissue welding technology to be integrated into Novare's articulated instruments, resulting in a full freedom of movement hand-held laparoscopic instrument and cut-and-seal capability. Novare distributes instruments manufactured by Starion, incorporating the latter's tissue welding technology.

CambridgeEndo of Framingham, MA, manufactures a line of handheld fully articulating laparoscopic instruments that employ RF energy for coagulation, as does Covidien of Norwalk, CT.

The articulated instruments are designed to allow for more surgeries to be performed laparoscopically, to improve the surgeon's dexterity, to allow for better suturing, and all of the associated benefits for the patient: shorter hospital stay, less chance of blood loss, less chance of infection, quicker return to activities — much the same as is true for the robot. The robot has additional advantages such as 3-D visualization, more finesse when suturing, and tremor removal.