Are articulating laparoscopic instruments the answer for overcoming the technical challenges of performing intracorporeal maneuvers? Can new instruments copy the movements of a surgeon’s hand in a sensitive and exact fashion through a single access port?
Using new articulating laparoscopic instruments that mimic the surgeon’s hand move in a certain direction with the tip of the instrument, the world’s first-ever SPA bilateral ovary removal was recently performed.
Instead of rigid laparoscopic instruments, hand-held instruments that allow a full range of motion may be needed for advancing the new single port surgery techniques. In traditional laparoscopic surgery, surgeons rely on a visual path, coaxial alignment of the instruments, and the triangulation of the camera and the operating ports. The laparoscopic instruments and ports are positioned in such a way that the camera is midway between two instrument ports, resembling the setup of open surgery with the surgeons’ eyes and the two hands. The traditional laparoscopic instruments have four degrees of freedom: up/down, left/right, rotation, and in/out actuation. Unlike the traditional laparoscopic instruments, the new articulating devices add two degree of movements and allow moving the wrist left/right and up/down.
However, in a single port access (SPA) procedure the angle of motion is limited which may result in compromised wrist movements and difficulties reaching behind or around anatomical structures with rigid laparoscopic instruments. In three out of four hysterectomies, the ovaries are removed. In a laparoscopic-assisted vaginal hysterectomy (LAVH), the uterus is either removed vaginally or by cutting it into small pieces that are pulled out through the access port in the abdomen (often close to the naval). Traditionally this type of hysterectomy requires a minimum of three small incisions. New articulating instruments may make it easier to perform such advanced minimally invasive surgical (MIS) procedures if the various designs of laparoscopic suturing instruments can be provided in the new design.
The handles of such devices may have either a pistol grip or an in-line, coaxial handle, with or without a ring. The assisting grasping forceps is usually used by the nondominant hand of the surgeon and might be crucial in handling the tissue. New grasping devices might need to duplicate the curved and pointed tip design. A needle holder is generally used by the dominant hand of the surgeon and may benefit greatly from the added degree of freedom for handling the needle and suture material with a curved and blunt tip.
Six degrees of freedom instruments such as graspers, dissectors, needle drivers and scissors, may be useful in hybrid NOTES procedures with a single access port to enable minimally invasive approaches in gastric bypass, cardiac bypass, pulmonary lobectomy, GYN/OB and other general and urologic procedure.