Mikael H. Sodergren

An articulated universal joint based flexible access robot for minimally invasive surgery

This paper introduces an articulated robotic device based on universal joints with embedded micro motors for minimally invasive surgery. The device features an articulated distal tip with seven independently controllable degrees-of-freedom (DoF), arranged as two universal joints (intersecting pitch and yaw) and three single DoF joints (yaw only); two Ø3mm internal channels, one for an on-board camera for visualization and the other for passing interventional instruments. The design allows the robot to explore the entire peritoneal cavity from a chosen single incision point. A trans-vaginal procedure using the device to locate the uterine horn, as a model of a human fallopian tube, and apply an endoscopic clip was carried out during a live porcine trial to demonstrate the potential for performing a Natural Orifice Translumenal Endoscopic Surgery (NOTES) tubal ligation procedure.

Single-incision Laparoscopic Surgery (SILS) in general surgery: a review of current practice.

Single-incision laparoscopic surgery (SILS) aims to eliminate multiple port incisions. Although general operative principles of SILS are similar to conventional laparoscopic surgery, operative techniques are not standardized. This review aims to evaluate the current use of SILS published in the literature by examining the types of operations performed, techniques employed, and relevant complications and morbidity. This review considered a total of 94 studies reporting 1889 patients evaluating 17 different general surgical operations. There were 8 different access techniques reported using conventional laparoscopic instruments and specifically designed SILS ports. There is extensive heterogeneity associated with operating methods and in particular ways of overcoming problems with retraction and instrumentation. Published complications, morbidity, and hospital length of stay are comparable to conventional laparoscopy. Although SILS provides excellent cosmetic results and morbidity seems similar to conventional laparoscopy, larger randomized controlled trials are needed to assess the safety and efficacy of this novel technique.

Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice

BackgroundNatural orifice translumenal endoscopic surgery (NOTES), with its focus on eliminating incision-related complications, promises to revolutionize the way surgery is performed. This study aimed to summarize the clinical applications of NOTES for humans, outline the techniques used, and discuss the complications and limitations of current techniques.MethodsA literature search was performed using PubMed and Medline search tools to review the extent and outcomes of human procedures undertaken using the NOTES technique in its pure form or as a hybrid procedure reported until July 2008. The end points were the types of operation performed, the approach and technique used for each operation, and the procedure-related complications and technical limitations.ResultsThis review considered 16 publications reporting on 49 human subjects. All the studies except three used hybrid NOTES procedures, with varying amounts of transabdominal assistance. Three transvaginal cholecystectomies, one transvaginal appendectomy, and eight transgastric appendectomies have been performed using a pure NOTES technique. To date, 15 NOTES transvaginal cholecystectomies and 10 NOTES appendectomies (8 transgastric and 2 transvaginal) are reported. Other procedures including peritoneoscopy and sigmoid colectomy are described. Three cases of minor morbidity are reported and no mortality.ConclusionsAlthough initial human results seem encouraging, it is important that this research be conducted in a way that minimizes bad publicity and describes both favorable and adverse outcomes. Robust trials must be conducted at established centers with appropriate experience and institutional board ethical review to allow safe introduction of this novel technique, with adequate and expedient reporting of serious adverse events. The limitations of the current tools and methods are discussed, and suggestions are made for further improvements in the technology to facilitate NOTES operations.

The role of robotic assisted laparoscopy for oesophagogastric oncological resection; an appraisal of the literature.

The introduction of surgical robotics to the field of surgical oncology brings with it an expectation not only of improved vision, instrumentation, and precision but also as a result, a potential for improved oncological outcomes. The current interest in the field of oesophagogastric oncology is explored in this review together with the benefits, real and potential, that robotic assistance offers surgical cancer resection as well as some of the limiting factors which may be hampering its uptake into current surgical practice. A systematic review of all the published literature up until April 2010 was examined across the field of esophageal and gastric cancer resection. A quantitative assessment of the oncological, operative, and functional outcomes was determined from each procedure. The level of evidence behind the results was determined using the Oxford Centre for Evidence-based Medicine Levels of Evidence; Therapy and Prevention. Three hundred and five cases from 19 independent studies were included for review. Nine studies explored the outcomes from robotic-assisted esophagectomy and eight, the robotic-assisted gastrectomy. Two articles included small case series of both procedures. The level of evidence was predominantly based on case series or expert opinion (Level 4 or 5) with only three unmatched or poorly matched comparative trials (Level 4) with no randomized trials evident. Improved operative outcomes and hospital stays were demonstrated with a reduction of 2 days when the robotic-assisted gastrectomy technique was employed compared with the open. No improvement in oncological outcomes could be identified with the use of the robot for either oesophageal or gastric cancer resection; however, in terms of short-term oncological outcomes, these were at least equivalent to the open approach for oesophageal cancer and early stage gastric cancer. Robotic-assisted laparoscopic surgery is a feasible technique to use to perform a safe and oncologically sound resection for oesophageal and early gastric cancer. Operative benefits appear to be encouragingly similar to the laparoscopic approach with some demonstration of improvement over the open technique despite a prolonged operative time. However, the level of evidence is suboptimal and more randomized controlled trials and long-term survival studies within a framework of measured and comparable outcomes is required.

Clinical outcome following Doppler‐guided haemorrhoidal artery ligation: a systematic review

Doppler‐guided haemorrhoidal artery ligation (DGHL) has experienced wider uptake and has recently received National Institute for Health and Clinical Excellence (NICE) approval in the UK. A systematic review of the literature was conducted to assess its safety and efficacy.

Navigation systems and platforms in natural orifice translumenal endoscopic surgery (NOTES)

INTRODUCTION The latest evolution in minimally invasive surgery is to avoid skin incisions by using natural orifices, called natural orifice translumenal endoscopic surgery (NOTES). However, to safely and efficiently perform NOTES, the requirements of the operating platform used need to be modified from the conventional endoscope. The aim of this paper is to systematically review specialised operating platforms used or in development for NOTES procedures. METHODS A review of the literature was conducted using Ovid EMBASE, Ovid MEDLINE, ISI Current Contents Connect and PubMed, a search tool of the National Library of Medicine and the national institute of Health, until the 1st of December 2008. Data was extracted to specifically characterise the available platforms, their availability, advantageous characteristics and potential disadvantages. RESULTS There were 9 studies included in this review describing 6 different navigation platforms and 3 robotic systems for NOTES. Based on this analysis, it is our opinion that although the described surgical systems and navigation platforms possess some attractive characteristics, such as maneuverability, stability, enhanced optics, and the ability to provide triangulation and insufflation with proper suction/irrigation maintenance, there does not appear to be one platform which is clearly superior to others. CONCLUSION Current instruments are not suited for effective surgery in a NOTES environment. There are several important requirements for NOTES platform: 1) to provide safe access to the peritoneal cavity; 2) to provide a stable channel for instrumentation passageway and safe navigation, 3) to provide good visualization and illumination, thereby decreasing disorientation, 4) to maintain proper insufflation and suction/irrigation, and 5) to provide maneuverability and triangulation of the instruments. Effective collaborations between clinicians, engineering departments and industry are essential to maximise and expedite the innovative process in producing an optimal NOTES platform.

Eye tracking for skills assessment and training: a systematic review

BACKGROUND The development of quantitative objective tools is critical to the assessment of surgeon skill. Eye tracking is a novel tool, which has been proposed may provide suitable metrics for this task. The aim of this study was to review current evidence for the use of eye tracking in training and assessment. METHODS A systematic literature review was conducted in line with PRISMA guidelines. A search of EMBASE, OVID MEDLINE, Maternity and Infant Care, PsycINFO, and Transport databases was conducted, till March 2013. Studies describing the use of eye tracking in the execution, training or assessment of a task, or for skill acquisition were included in the review. RESULTS Initial search results returned 12,051 results. Twenty-four studies were included in the final qualitative synthesis. Sixteen studies were based on eye tracking in assessment and eight studies were on eye tacking in training. These demonstrated feasibility and validity in the use of eye tracking metrics and gaze tracking to differentiate between subjects of varying skill levels. Several training methods using gaze training and pattern recognition were also described. CONCLUSIONS Current literature demonstrates the ability of eye tracking to provide reliable quantitative data as an objective assessment tool, with potential applications to surgical training to improve performance. Eye tracking remains a promising area of research with the possibility of future implementation into surgical skill assessment.

The Natural Orifice Simulated Surgical Environment (NOSsE™): Exploring the Challenges of NOTES Without the Animal Model

In this paper, we introduce an inexpensive, realistic, and robust simulator model for training and requirement assessment of natural orifice transluminal endoscopic surgery (NOTES). A laparoscopic box trainer is converted into an effective NOTES environment, in which many of the challenges facing this new approach can be explored first hand in a laboratory setting. Using this simulator, experiments researching this new surgical field can be refined before moving into in vivo trials, such that the number of animals required for acquiring basic skills and validating new surgical protocols can be reduced. Additionally, the simulator has the potential to be utilized as an effective platform for education and training in NOTES, although formal validation is required before this can truly be appreciated.

Natural orifice translumenal endoscopic surgery applications in clinical practice

To review natural orifice translumenal endoscopic surgery (NOTES) applications in clinical practice and assess the evidence base for each application as reported in the literature. An electronic literature search was performed. Inclusion criteria were publications relating to NOTES applications in humans. For each type of operation the highest level of evidence available for clinical NOTES publications was evaluated. Morbidity and short-term operative outcomes were compared with gold standard published evidence where available. Finally, registered trials recruiting patients for NOTES applications were identified. Human NOTES publications with the highest level of evidence in each application are identified. There were no RCTs in the literature to date. The strongest evidence came in the form of large, multi-centre trials with 300-500 patients. The results are encouraging, comparable with gold standard techniques on morbidity and mortality. While short-term operative outcomes were also similar when compared to the gold standard techniques, other than improved cosmesis little else can definitely be concluded as a clear benefit of a NOTES procedure. The most common procedures are cholecystectomy, appendicectomy and peritoneoscopy mainly performed via transvaginal access. It is evident that morbidity appears to be higher when the transgastric route is used. The safety profile of hybrid NOTES transvaginal procedures is beginning to be confirmed as is evident from the large number of procedures presented in this review. A number of authors have presented work on pure NOTES procedures but the results are inconsistent and thus the vast majority of NOTES procedures worldwide are performed in a hybrid fashion with a variable amount of laparoscopy. This review of the clinical applications of NOTES summarises the growing evidence behind this surgical discipline and highlights NOTES procedures with an acceptable safety profile.

Presenting features of Enterobius vermicularis in the vermiform appendix

Objective. Enterobius vermicularis (pinworm) infestation can present with symptoms resembling acute appendicitis, although current evidence suggests that it does not necessarily cause acute appendicitis. The purpose of this study was to characterize the clinical presentation of patients with pinworms in the vermiform appendix and to establish features suggestive of this condition. Material and methods. A retrospective analysis of all patients undergoing appendicectomy with appendicular pinworms between 1998 and 2003 was undertaken. Patients were compared against 54 controls with confirmed acute suppurative appendicitis from the same time period. Presenting features, vital signs and modified Alvarado scores were obtained from the patients’ records. Results. Eighteen out of 1150 patients (1.5%) undergoing appendicectomy were proven to have pinworms (age range 8–37 years, 12 F, 6 M). Two of 18 appendices containing pinworms showed evidence of inflammation. Patients with pinworms had significantly lower white cell counts (WCCs) than the control group (median 8.9 versus 14.7, p=0.045), lower total Alvarado scores (median 5.5 versus 7, p=0.01) and were more likely to have had recurrent episodes of right iliac fossa (RIF) pain and previous hospital admissions (p<0.001). Conclusions. E. vermicularis infestation of the appendix should be considered in the differential diagnosis of patients who present with recurrent RIF pain but do not have a significantly raised WCCs, or high Alvarado scores. These patients should be investigated with early fecal sampling and night-time application of cellophane tape, and they may benefit from empirical antiparasitic treatment.