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Researchers conducted a prospective randomized controlled clinical trial at Bern University Hospital in Switzerland to compare a laparoscopic procedure with a mini-laparotomy for insertion of a peritoneal catheter during ventriculoperitoneal (VP) shunt surgery. The deciding factor was the rate of shunt malfunction. Although overall shunt failure rates did not differ substantially between patients in the two surgery groups, the authors identified a significant reduction in the rate of distal (abdominal) shunt failure in patients in whom laparoscopy was used. Detailed findings of the clinical trial are reported and discussed in "Laparoscopically assisted ventriculoperitoneal shunt placement: a prospective randomized controlled trial" by Philippe Schucht, MD, Vanessa Banz, MD, PhD, and colleagues, published today online, ahead of print, in the Journal of Neurosurgery Background: Hydrocephalus is a condition in which there is excessive accumulation of cerebrospinal fluid (CSF) in chambers of the brain known as ventricles. If left uncorrected, the excess CSF can exert pressure on critical brain structures, causing the patient to experience cognitive, visual, or motor deficits; seizures; or even death. Ventriculoperitoneal (VP) shunts are frequently placed to redirect excess CSF away from the brain and into the peritoneal cavity in the abdomen, where the body can absorb it. Most VP shunts consist of a catheter that is placed in one of the ventricles in the brain, a one-way valve that draws excess CSF away from the ventricles, and a second catheter placed under the skin that carries this excess fluid down to the peritoneal cavity. Placement of a VP shunt is a two-part operation. In addition to surgery to the head, where the ventricular catheter and pump are placed, an incision must be made in the abdomen for placement of the end of the peritoneal catheter. The focus of this study is on two abdominal procedures: mini-laparotomy, which involves open surgery, and a laparoscopic approach, a less invasive procedure in which a small puncture hole is made through which the end of the peritoneal shunt catheter is inserted into the peritoneal cavity and positioned with the aid of a tiny laparoscopic camera. Present Study: The authors state that 120 adult patients were randomized to undergo a laparoscopic procedure or mini-laparotomy for insertion of a peritoneal catheter during initial or revised VP shunt surgery for hydrocephalus. Data were collected around the time of surgery and 6 and 12 months later. The primary end point of this study was the overall rate of shunt malfunction (failure or complication related to any part of the shunt system) at 12 months postoperatively. Secondary end points included the overall rate of shunt malfunction at 6 weeks and 6 months postoperatively, the rate of distal shunt malfunction (failure or complication related to the peritoneal catheter) at all three time points, the lengths of the operation and hospital stay, and the rate of morbidity. Findings of previous retrospective studies had indicated the superiority of laparoscopic shunt placement over mini-laparotomy in the rate of distal shunt malfunction (and consequently the overall rate of shunt malfunction) as well as the durations of surgery and hospitalization. The authors conducted this prospective clinical trial to collect stronger evidence to corroborate or negate these earlier findings and to determine which shunt placement procedure might be superior. In the present study the overall shunt malfunction rate at 6 weeks postoperatively was significantly higher in patients who underwent mini-laparotomy. By the end of the follow-up period (12 months), however, the difference in overall shunt malfunction between the two surgery groups was no longer significant. Overall shunt malfunction occurred in 18.3% of patients who underwent mini-laparotomy and 15% of patients who underwent laparoscopic shunt placement (p = 0.404). There were no significant differences in the durations of surgery and hospitalization, or in the need for pain management between the two patient groups; however, the authors reported "a trend toward fewer infections and shorter operation times in the laparoscopic cohort." What was significant, however, was the difference in distal shunt malfunction. There was no case of distal shunt malfunction (0%) in the laparoscopic shunt placement group, whereas there were five such cases (8%) in the mini-laparotomy group (p = 0.029). Distal shunt malfunction results from malposition of the peritoneal catheter during surgery or later movement of the catheter away from its proper position. Neither occurred in the laparoscopic shunt placement group. When asked about the take-away message of the study, Dr. Schucht stated "Using laparoscopy for VP shunt placement can decrease the rate of distal shunt failures and is an elegant, feasible alternative to the standard mini-laparotomy approach."

Laparoscopy is a form of minimally invasive or keyhole surgery. In this type of surgery, a surgeon can examine the inside of the abdomen or pelvis using small incisions to insert tools and instruments. A laparoscope, which has a camera and light at the tip is passed through the incision and used to relay images of the internal structures to a TV monitor. This type of surgery is preferred over traditional open surgery, which requires a large incision in the abdomen to expose the internal organs. Laparoscopy is associated with less pain, bleeding and scarring, a faster recovery time and a shorter hospital stay. The tools used in laparoscopic surgery have been studied and refined over the decades. One example is the TransEnterix which was approved by the U.S. Food and Drug Administration in October 2009. It has a SPIDER surgical system that uses flexible instruments and requires only one incision to be made in the belly button area. This allows for rapid healing after the operation. The system was developed by Dr. Richard Stac from Duke University. Other electronic tools have been developed in recent years to help surgeons optimize the surgical process. Features of these developments include visual magnification to improve the quality of images on the viewing screen; simulators that surgeons can use to practice procedures and hone their surgical skills; stabilization to eliminate vibration caused by machinery or shaking hands; and the reduced number of incisions required to operate successfully. Only example of a sophisticated robotic platform is the daVinci Surgical System, which was approved by the U.S. Food and Drug Administration in 2000. The robot acts as an aid in complex minimally invasive surgery and is controlled by a surgeon via a console. The system is commonly used for prostatectomy and is also used for cardiac valve repair and gynecology procedures. According to the manufacturer Intuitive Surgical, the instrument is named after Leonardo daVinci because he is said to have designed the first robot. The use of robotics in surgery has been encouraged as a potential solution to helping underdeveloped countries, where one main hospital could act as the operating centre from which several robotic machines could be controlled in distant locations. The benefits to the military is also of interest in terms of providing mobile medical care without having to endanger doctors directly.

The US Food and Drug Administration has recommended that the use of uterine smashers in laparoscopic uterine myomectomy and hysterectomy may cause unknown tumors to spread in the abdominal cavity, leading to an increased risk of disease. This proposal has caused tremendous repercussions and discussions. At one time, there were different opinions and no one. And our experts suggest that, just like the usual sterility awareness during surgery, everyone should also establish a sense of no tumor, this consciousness should be implemented in the whole process of preoperative diagnosis, intraoperative operation and postoperative care. The US Food and Drug Administration (FDA) recently recommended that the use of uterine pulverizers in laparoscopic myomectomy and hysterectomy may cause unknown tumors to spread in the abdominal cavity, leading to an increased risk of disease. instrument. The FDA has asked manufacturers to inspect the label of the relevant equipment (tissue pulverizer) and is considering adding a "black box" warning - this is the strongest warning the FDA can issue. This proposal has caused tremendous repercussions and discussions. At one time, there were different opinions and no one. So, what is the pulverizer used in laparoscopic surgery, and how much risk it has, should we stop laparoscopic surgery to avoid risk? the reason Smashing can cause tumor spread "Minimally invasive surgery is the general trend of surgical development and the pursuit of goals." Xiu Dianrong, director of the Third Hospital of Peking University, said in an interview with the reporter of the Chinese Journal of Science. Laparoscopic surgery is a newly developed minimally invasive treatment method. Compared with traditional surgery, it is very popular among patients, especially after surgery, which has small scars and meets aesthetic requirements. Young patients are more willing to accept. In layman's terms, laparoscopic surgery is a surgeon inserting a laparoscopic lens into the abdominal cavity of a patient, transmitting the intra-abdominal condition to the TV screen in real time, and performing an intra-abdominal operation through the abdominal puncture hole using an elongated instrument. "The comminution tools used in minimally invasive surgery may indeed spread the sarcoma that was not detected before surgery," said Li Xiaoguang, director of the Department of Gynecology, Cancer Hospital, Chinese Academy of Medical Sciences. "When uterine myomectomy is performed under laparoscopy, the fibroids to be removed are usually cut into small pieces with a pulverizer, and then the tissues are taken out through the operation holes." Li Xiaoguang said, "This operation mode, if Misuse of patients with uterine sarcoma may accelerate the progression of the patient's lesions." Li Xiaoguang told reporters that the pulverizer produced small tumor tissue fragments during the rotary cutting process, and the tumor cells shed in the abdominal pelvic cavity, which would cause the iatrogenic tumor to be transplanted in the abdominal cavity. When the pulverizer is rotated, it may cause sarcoma tissue and cells to be crushed, broken, and locally infiltrated and grow, resulting in local recurrence of the tumor. In fact, doctors have already sounded the alarm for the smashing technique. In 2011, Jeong-Yeol Park, a gynecologic oncologist at the Lushan Hospital in Seoul, Korea, compared the treatment of 56 patients with suspected leiomyosarcoma for hysterectomy. The results showed a 5-year survival rate of 73% in 31 patients who did not receive comminution, compared with 46% of the 25 patients who underwent comminution. "In the medical activities, the principle of oncology is the first. Compared with oncology, it is a icing on the cake. It cannot be inverted." Xiu Dianrong expressed his understanding of the FDA's proposal. debate It is not advisable to negate the minimally invasive "However, I just don't agree with the idea that smashers and laparoscopic surgery are no longer used because of the risk of surgery." China-Asia-Pacific Association of Minimally Invasive Gynecologic Oncology (CP-AMIGO) expert committee, Southern Medical University, Zhujiang Liu Muzhen, deputy director of the Obstetrics and Gynecology Department of the hospital, said in an interview with the reporter of the Chinese Journal of Science. Liu Muzhen introduced that the clinical uterine pulverizer is an important helper for gynecological minimally invasive surgery, so that a large number of patients with uterine fibroids removal and huge hysterectomy can enjoy the benefits of laparoscopic minimally invasive surgery. "Most of the uterine malignancies can be diagnosed preoperatively, and the incidence of uterine sarcoma accounts for less than 3% in patients with fibroids. The proportion of patients who are completely misdiagnosed as benign before surgery will be lower." Liu Muzhen said, "Current laparoscopy Technology is very mature and standardized in the diagnosis and treatment of most diseases, and it can basically replace or even surpass the traditional surgical methods." "The phenomenon that laparoscopic tumor dissemination is easier is not recognized by most people. Similarly, traditional surgical incision implantation, sinus metastasis exists." Xiu Dianrong also said that the surgical approach is not the cause of tumor spread, fatal The reason is tumor, not comminution. "In any case, the surgical approach of uterine fibroids should be based on the patient's age, fertility requirements, the number of fibroids and growth sites, whether or not combined with other diseases, and the patient's subjective willingness to weigh the pros and cons." Liu Muzhen believes that "blind stop pulverizer is Some are overkill, and some are overkill." solve Establishing cancer-free awareness is the key So, what can be done to reduce the risk of laparoscopic tumor spread? Li Xiaoguang mentioned in the interview that it is very important that the doctor needs to have a sense of cancer. "Like the usual sterility awareness during surgery, everyone should also establish a sense of no tumor, this consciousness should be carried out in the whole process of preoperative diagnosis, intraoperative operation and postoperative care." Li Xiaoguang suggested. "Before the operation, the patient's condition must be carefully evaluated. This is the most important measure to avoid the tumor-distributing tumor." Liu Muzhen believes that the patient's condition should be preliminarily collected through detailed medical history collection and necessary imaging examination. judgment. For laparoscopic subtotal hysterectomy, uterine and cervical malignant lesions should be strictly excluded before surgery, which is suitable for any benign disease patients who are scheduled for laparoscopic surgery. "You can give a segmental curettage and check the tumor markers before surgery." Li Xiaoguang suggested that once the malignancy is suspected, avoid using a pulverizer, and remove the tumor or uterus completely through the abdomen or transvaginal. "When the surgery is found to be beyond the pre-judgment, the operation under the microscope is more difficult, beyond the technical ability of the doctor, the surgeon can switch to the laparotomy according to the condition or choose other safer surgical methods." Li Xiaoguang said, "If the organization takes out It was found to be a malignant lesion. It is necessary to remove as much as possible the residual tumor fragments during the comminution. Repeated, large-scale abdominal irrigation is an effective method." When talking about reducing the risk of laparoscopic dissemination, Xiu Dianrong said: "Strictly follow the oncology principle to treat the entire surgical procedure of the tumor patient, including the specimen to be delivered in the specimen bag, not to squeeze the tumor during surgery, etc. There are many specific The operational considerations reduce these things. However, the most fundamental factor is actually the biological behavior of the tumor itself, which plays a very important role in the prognosis of cancer patients." Reflection New technology requires data support and regulatory supervision It is worth rethinking that medicine is still unknown in medicine. Sometimes, the pursuit of novelty and skill in surgery has caused new pain. Xiu Dianrong mentioned that China lacks large case data, and the introduction and use of many new technologies lacks supervision and even blindly expands the indications. This problem needs to cause us to think. Although the current large number of laparoscopic surgery in China has benefited many patients, it is undeniable that many hospitals, especially some hospitals at the grassroots level, have imperfect techniques in the use of laparoscopy, and the surgical indications are not tightly controlled. This is a big hidden danger. "In fact, the most important indication for laparoscopic surgery is the doctor's skill. Starting from taking the mirror, step by step training and accumulation, can you truly grasp the mystery." Xiu Rongrong said, "Otherwise, even if there are clear indications, technology If it is not in place, it will cause the patient to be hurt." Liu Muzhen believes that when the pulverizer and laparoscope should be used, when should not be used, how to reduce the risk of disseminating tumors, etc., it is necessary to analyze and study a large number of clinical cases to draw conclusions. [As a general use of uterine pulverizers in China, our corresponding academic groups should take active actions and organize experts to evaluate them instead of waiting for foreign data." Liu Muzhen suggested, [After all, the incidence of uterine sarcoma varies from country to country. The risk of tumor spread is naturally different." "All in all, the warnings put forward by the FDA, we need to pay attention to it, but we cannot completely negate the past experience because of the waste of food, thus damaging the interests of most patients." Liu Muzhen believes. Related Reading Laparoscopy Laparoscopy is a device with a miniature camera. Laparoscopic surgery is performed using a laparoscope and related instruments. After surgery, only 1 to 3 linear scars of 0.5 to 1 cm were left in the abdominal cavity. It can be said that the operation is small and the pain is small. Therefore, some people call it "keyhole" surgery. In 1901, Ott, a gynaecologist in Petersburg, Russia, made a small incision in the anterior wall of the abdomen, inserted a vaginal device into the abdominal cavity, and reflected the light into the abdominal cavity with a cephaloscope to examine the abdominal cavity. In the same year, German surgeon Kelling inserted a cystoscope into the abdominal cavity of the dog for examination and said that the examination was a laparoscopic endoscopy. In 1910, Jacobeaus of Stockholm, Sweden, first used the term laparoscopy, which used a trocar to make a pneumoperitoneum. In 1911, Bernhein, a surgeon at Johns Hopkins Hospital in the United States, inserted a rectaloscope into the abdominal cavity through an incision in the abdominal wall and used the emitted light as a light source. In 1924, Kansas, a physician in Kansas, USA, inserted a nasopharyngeal mirror into the abdominal cavity of a dog and recommended a rubber gasket to help close the puncture cannula to avoid air leaks during operation. In 1938, the Hungarian surgeon Veress introduced a gas injection needle that can be safely made into a pneumothorax. When doing pneumoperitoneum, it can prevent the needle tip from damaging the internal organs under the needle. The idea of making a pneumoperitoneum with a compromised safety puncture needle is generally accepted and is still in use today. The inventor of the true targeted abdominal examination was German gastroenterologist Kalk, who invented a 135° lens system with a straight forward strabismus. He is believed to be the founder of laparoscopic surgery for the diagnosis of liver and gallbladder disease in Germany. In 1929 he first advocated the use of double-sleeve puncture needle technology. In 1972, the American Gynecologic Laparoscopic Physician Association planned to complete nearly 500,000 cases of abdominal examination in the next few years. This type of examination has been widely accepted by gynecologists. Nearly one-third of gynecologic operations at the Cedars-Sniai Medical Center in Los Angeles use diagnostic or therapeutic laparoscopy. In 1986, Cuschieri began an animal experiment of laparoscopic cholecystectomy. At the first World Congress of Surgery Endoscopy in 1988, he reported that a laboratory animal was successfully treated with laparoscopy for cholecystectomy and was applied to the clinic in February 1989. Philipe Mouret, a French surgeon who succeeded in laparoscopic cholecystectomy for the first time in humans, succeeded in performing laparoscopic cholecystectomy in the same patient with laparoscopic 1987, but did not report it. In May 1988, Dubois of Paris applied it to the clinic on the basis of laparoscopic cholecystectomy experiments in pigs. The results were first published in France and presented at the annual meeting of the American Society of Digestive Endeurists in April 1989. The video of the operation made a sensation in the world. It first shocked the American surgical community, and the craze of laparoscopic cholecystectomy in the United States led to laparoscopic cholecystectomy from the animal experiment, clinical exploration stage to the clinical development stage. In February 1991, Zhai Zuwu completed the first laparoscopic cholecystectomy in China, the first laparoscopic surgery in China. Laparoscopy has become a new branch of modern surgery. As a revolution, modern laparoscopic surgery is developing rapidly. At present, laparoscopic surgery mainly involves three disciplines: general surgery, gynecology, and urology. It also involves partial surgery in pediatrics, vascular surgery, orthopedics, and abdominal surgery. (Chengjie finishing) Source: Chinese Journal of Science

Laparoscopic surgery can be widely used in the comprehensive treatment of tumors. Beijing Cancer Hospital General Surgery successfully performed laparoscopic radical resection for an 88-year-old man. This is by far the oldest patient to be treated with laparoscopic surgery in the hospital. It is noteworthy that Su Xiangqian, an associate professor of the Beijing Cancer Hospital General Surgery for this patient, took the lead in applying laparoscopic techniques to the comprehensive treatment of tumors in the oncology hospital. In the past two years, laparoscopic radical colorectal cancer has been successfully cured. Surgery, gastric stromal tumor resection, liver tumor resection, intraperitoneal hyperthermic perfusion chemotherapy, abdominal mass biopsy, middle and low rectal cancer radiotherapy before the transfer, cholecystectomy and castration surgery, etc., increased for cancer patients The opportunity to cure. He believes: "Laparoscopy will play an increasingly important role in the comprehensive treatment of tumors, especially in elderly patients." ■The scope of application of laparoscopic surgery is expanding According to Associate Professor Su Xiangqian, laparoscopic technique is a great technological revolution in the field of surgery in the 20th century. Since the first French doctors used laparoscopic techniques to complete cholecystectomy in 1987, laparoscopic techniques have rapidly spread throughout the world. After nearly 20 years of development, laparoscopic techniques have been widely used in general surgery, urology and gynecology, and become the representative of minimally invasive surgery. Laparoscopic surgery in China has a history of more than ten years. From the initial cholecystectomy to the present, it has been successfully applied to the diagnosis and treatment of abdominal diseases such as stomach, colorectal, hepatobiliary and pancreas. Laparoscopic surgery has the advantages that traditional open surgery can't compare, such as clear vision, accurate positioning; small surgical incision, less bleeding, less damage to the patient's body function, postoperative pain, no need for analgesia; postoperative patient's gastrointestinal tract Fast function recovery, short hospital stay, etc. Laparoscopic surgery has long been recognized for the treatment of benign diseases, but for the treatment of tumors, people often doubt whether laparoscopic techniques can achieve the effect of radical cure. In this regard, Associate Professor Su Xiang explained that according to international evidence-based medical evidence, laparoscopic surgery can achieve the same level of open surgery as the scope of tumor resection, the number of lymph node dissection and the long-term survival of patients. effect. Its safety and effectiveness in the treatment of malignant tumors have been recognized at home and abroad. -- Information from: China Medical News

Recently, the nation's first high-definition digital integrated laparoscopic operating room was officially launched at the Guangdong Provincial People's Hospital. The operating room is used by specialists. The operating room is equipped with a variety of gastrointestinal surgery-specific laparoscopic equipment and a set of remote consultation terminals. The well-equipped operation room makes gastrointestinal surgery more refined and humanized. According to Lin Feng, director of the Department of Gastrointestinal Surgery at the hospital, the biggest difference between the operating room and the traditional operating room is that all medical equipment can be organically linked with the physician through a centralized control system. As long as the doctor can complete the operation of surgical instruments, access to patient information, remote consultation and other tasks through the touch screen. The reporter saw five screens hanging in different positions in the operating room. Its video communication system is linked to more than 1,180 operations such as Japan, the United States, and the United Kingdom. During the operation, if the surgeon encounters a problem, he can call the Internet phone at any time to ask for [foreign aid" or [help the other operating room". In addition, domestic experts only need to open the terminal at the place covered by the cell phone signal, input the surgical machine number of the operating room, and insert a 3G network card to view the operation status of the surgical image and various machines in real time and perform the surgery. Real-time remote guidance.

Xinhua News Agency, Shenzhen, November 27th, the reporter learned from the 2017 World Medical Robot Conference held in Shenzhen that the domestically assisted abdominal surgery robot is expected to be mass-produced in three years. According to Sun Lining, deputy director of the State Key Laboratory of Robotics and Systems, medical robots, especially surgical robots, are the [rich and handsome" in the field of robotics. The technical thresholds and R&D and manufacturing costs are high. At present, there are already many research teams in China that are working on the development of surgical robots, and have developed a complementary laparoscopic surgical robot system with independent intellectual property rights. In addition to individual high-precision core components, the system's main hardware, software, materials and system design are independently developed by our research team. Sun Lining said that after the domestically-assisted laparoscopic surgery robot is on the market, the consumables can also be made domestically, and the surgery cost will be greatly reduced, so more patients can enjoy this high-end medical service. "Domestic scientists are still working on developing intelligent surgical robots that can sense the doctor's intentions." Sun Lining said that it is expected that the energy production of domestically assisted laparoscopic surgery robots will be on the market in about three years. (Reporter Bao Xiaojing Xiao Sisi)

On the morning of May 30, in the integrated operating room of the new comprehensive ward building of Ruijin Hospital, Professor Zheng Minhua, director of the Department of Gastrointestinal Surgery/Shanghai Minimally Invasive Surgery Clinical Medicine, successfully implemented a 3D laparoscopic right colon for an 82-year-old female patient. Radical radical surgery, and for the first time with virtual reality technology (VR) to achieve a panoramic view of surgery and laparoscopic VR live broadcast, the onlookers feel the immersive surgery through the phone and eye mask. This is the first live broadcast of virtual reality 3D laparoscopic surgery in China. On the morning of June 3 (Tomorrow), the official release of the panoramic +3D laparoscopic VR operation will be held at Ruijin Hospital. This may change the way minimally invasive surgery and surgical teaching. What is the difference between VR live broadcasts? VR live broadcast is one of the more widely used applications in virtual reality (VR) technology. It can be completely recorded on the first scene by 360 degrees through a special panoramic camera. Transfer to the cloud, and then through the special APP or WeChat web-side video player combined with the existing simple virtual reality device to achieve VR surgery live. In the past, minimally invasive surgery was observed and observed. Only the images under the endoscope could be seen. The low-grade doctors who could not visit the scene could hardly understand the mystery and skills in difficult surgery. The emergence of VR live broadcasts has solved these dilemmas. The viewers can see the live video of the panoramic video through the computer or mobile phone screen, and feel the first viewing angle. After wearing VR glasses, you can experience an unprecedented immersive experience, as if the viewers were performing surgery in the first perspective. The live debugging of VR operation is another new attempt and exploration of the concept of [Minimal Surgery PLUS". It is also the first live broadcast of 3D laparoscopic surgery successfully using VR technology in China. I am immersed in the surgery, using the perspective of the main knife Compared with traditional surgery, laparoscopic surgery requires a real-time broadcast of the laparoscopic image in addition to the panoramic view of the operating room. In the live debugging of the VR operation, under the initiative of Professor Zheng Minhua, the panoramic view of the operating room and the 3D laparoscopic image were simultaneously passed through VR. The glasses live, the surgeon can not only realize the implementation of the two screens through VR glasses, but also can switch between the two screens by the observer himself. Professor Zheng Minhua said, "The previous live broadcast of 3D laparoscopic surgery required 3D TV or 3D display, 3D glasses. Now only one mobile phone plus a pair of plug-in VR glasses can be realized. In the future, our operating room display classroom may no longer be Requires a variety of TV screens, relying on VR live broadcast technology, doctors' learning will also get rid of time and space restrictions, students can watch VR surgery pictures online and feel immersive surgery experience if they have network and mobile phone. Real-time reproduction of virtual reality scenes. Even the surgical methods of minimally invasive surgery will change due to the reduction of screens. This is a subversive change in online education and observation of medical education and surgery, and it is also an innovation that Minimally Invasive Surgery PLUS hopes to advance. idea".

According to foreign media reports, a former British soldier has become the first patient in the UK to undergo laparoscopic kidney transplantation. Brian Blanchard suffers from kidney failure and needs to be maintained by dialysis. Last month, the doctor performed a kidney transplant with laparoscopic surgery. There are two breakthroughs in this technology. One is that the transplanted organ comes from his sister Pam Marphett. The doctor takes out the donated kidney through her groin instead of the traditional abdomen, leaving almost no postoperative scars. Another breakthrough was that the removed kidney implanted in Brian's body had less than 2.5 inches of incision in the abdomen. Previously, the size of the incision for a kidney transplant was 10 inches. Surgeons say the new technology lays the foundation for safer transplants and allows patients to recover faster. Advances in technology have made laparoscopic kidney transplantation possible. Professor Pranjal Modi from Royal Liverpool Hospital in India initiated a minimally invasive surgery in 2010 to remove the kidneys from the navel without scar endoscopy. He successfully performed 172 minimally invasive procedures in Ahmedabad, northern India. But the operation has never been done elsewhere. Professor Modi is also proficient in organ harvesting from the groin. The purpose of both endoscopic techniques is to allow patients to recover as quickly as possible, reducing the risk of postoperative pain and infection and allowing patients to be discharged as soon as possible. The doctor not only avoided a major surgical incision for Brian, but also avoided new scars. The doctor performed a kidney transplant through his old appendicitis surgical scar.

Laparoscopic surgery depends on access. Trocars and ports serve as conduits for cameras; grasping, dissecting, cutting and sealing instruments; mesh positioners; staplers and a host of other devices reaching in to treat the otherwise untouchable surgical site in the abdominal cavity. The narrower instruments and smaller incision sizes that support minimally invasive surgery shrink the necessary diameter of these access ports and, consequently, their impact on surgical patients' tissue, a benefit which sparked the concept of single-incision laparoscopy, in which one port does the job. But as surgical techniques and surgical access have miniaturized, a single port now has to play many roles. Simply delivering access isn't enough: Ports must offer other functional advantages as well, as surgical innovators and medical device manufacturers have recently realized. For example, one access device manufacturer also offers a way to ensure predictable incision closing outcomes. When is a port not a port? When it's actually 3 or more ports. Or when it's also an insufflation device. Or when it's part of a multi-tasking laparoscopic management system. Among the recent developments to hit the access market: a reusable trocar, designed to be as easy to take apart and clean as it is easy on your supply budget; a multiple-port access device that's been reduced in size but doesn't reduce instrument articulation; trocars that can accommodate versatile combinations of instrument sizes; a port that warms insufflation gas to benefit the surgeon and patient; and a port that provides access, pressure, insufflation and filtration in one system.

Minimally invasive laparoscopic surgery into the 3D era Ruijin Hospital takes the lead in three-dimensional field of vision operation, superior visual effects bring greater safety In the busy and nervous operating room, the surgeons wore "3D sunglasses". The two doctors held the robotic arm and looked up the movement in the patient's abdominal cavity on the display. Different from the past, on this display labeled "3DHD", the abdominal organs and blood vessels are well-defined, just like watching a 3D movie. Yesterday morning, in the operating room of Shanghai Ruijin Hospital, doctors were giving an 84-year-old woman a bowel cancer radical surgery. This is the second patient who has undergone 3D high-definition laparoscopic surgery in China. It was here five days ago and completed the first 3D high-definition laparoscopic surgery in China. The application of 3D high-definition technology to the clinic is regarded by the international medical community as the future of minimally invasive surgery visualization. Its superior visual effect means faster and more accurate surgical operation, less complications and higher safety. New problems after not "opening" "Can you give me a pair of glasses to see the effect? Well, the vision is really different! If used for our pelvic lymphadenectomy, the effect must be very good, the traditional screen is two-dimensional, can not see clearly." 8 am yesterday , Ruijin Hospital Branch, Shanghai Mini-invasive Surgery Clinical Medical Center, a holistic operating room, just an empty obstetrician and gynecologist came to observe the "new weapon" - 3D minimally invasive laparoscopic surgery. Technological advances always make surgeons eager to try. Today, laparoscopic surgery is always closely related to the word "minimally invasive". Fill the patient's abdominal cavity with a certain amount of inert gas to make it slightly bulge, creating a spacious space for the operation; then, three small hole-sized holes are equally spaced around the patient's navel to insert the surgical arm. Start surgery... This is the classic preparation for laparoscopic surgery. Since the end of the last century, this kind of minimally invasive surgery has been introduced into the country. Because of its small incision, low amount of bleeding, short operation time, and low hospitalization days, it has gradually become the patient's first choice. Traditional open surgery has retreated to the second line. However, when the surgical laparotomy turned to the "keyhole" minimally invasive surgery - the incision was getting smaller and smaller, shrinking to 0.5-1.0 cm, or even 0.2 cm, the surgeons who observed the abdominal cavity through the display realized the new problem: in the second On the screen, the organs, tissues, and blood vessels that originally had the context are on the same plane. Doctors operating through the robotic arm are likely to "walk the wrong way" or "docked out." "The occurrence of dislocations means that it may increase the amount of bleeding, prolong the operation time, and even increase the complications, affecting the prognosis of surgery." Vice President of Ruijin Hospital, Professor Zheng Minhua, director of Shanghai Minimally Invasive Surgery Clinical Medicine Center said. He is the chief surgeon in the first and second cases of 3D high-definition laparoscopic surgery in China. Doctor wearing 3D glasses for surgery In the new 3D HD laparoscopic surgery, the change first appeared on the laparoscope. The original 1 cm diameter imaging lens was changed to the left and right lens, which is equal to two miniature cameras. They are matched with the polarizer worn by the doctor. The doctor saw the 3D visual effect on the display. In addition to the 3D effect, the display labeled "3DHD" has a video resolution of 1080P. Zheng Minhua said that 3D HD technology has especially improved the perception of depth by laparoscopic doctors, which is not possible with 2D visual effects. In medical school, medical students learn human anatomy, which is three-dimensional; but because of the clinical application of laparoscopic surgery over the past decade, they have witnessed the two-dimensional world on the screen. The process of re-recognizing the anatomy is very uncomfortable for beginners. "The human body is a three-dimensional world. Today's technology is to restore the three-dimensional world in the body based on the smallest wound." The international medical community has the opinion that the 3D high-definition effect allows surgeons to better observe the fine vascular structure, and these The blood vessels in the structure pulsate and help the doctor identify more quickly, thereby reducing the risk of accidental damage to the blood vessels to a greater extent. In addition, it provides hardware preparation for more complex procedures, including operations involving the liver, stomach, and pancreas. Technological progress, basic skills decline? Currently, 3D high-definition laparoscopic surgery is suitable for all patients who are eligible for laparoscopic surgery without increasing the financial burden. "The cost is the same as the cost of laparoscopic surgery." Zheng Minhua said. In the United States, Professor Timothy Locke of the Colorectal Department of the University of Surrey bluntly said: "If you can perform three-dimensional vision surgery, how can someone choose two-dimensional field surgery? You know how many surgeons are trying to complete some In the complicated operation, I have to close one eye? It is time to perform minimally invasive surgery in the three-dimensional field of view." As the leader of the Laparoscopic and Endoscopic Surgery Team of the Chinese Medical Association, Zheng Minhua became the whole minimally invasive surgery for 3D high-definition laparoscopic surgery. The direction of the discipline and the attitude are cautious. "It should be just an innovative component, not a direction." It is reported that at the recent German Electronics Show, there have been holographic camera technologies achieved by 700 cameras, which can present the anatomical position of 360, which is of great significance for complex and difficult operations involving liver, stomach and pancreas. In addition, at present, above 1080P, there is also a 4K Ultra HD resolution. [Minimally invasive technology has entered a new platform period, and the emergence of many new technologies is helping surgeons better achieve clinical goals, but it is hard to say where the future is going." In fact, there is controversy about 3D high-definition laparoscopic surgery. One view is that the original two-dimensional screen allows doctors to exercise a [feeling experience" in actual combat – even in areas that are invisible to the human body, they still have an anatomical structure and reach the target position by hand touch. A clear three-dimensional screen may leave the surgeon's basic skills a waste. However, just as "the computer ruined computing power and the computer ruined a good word", no one can deny the contribution that these technological advances bring to humanity.

According to foreign media reports, a former British soldier has become the first patient in the UK to undergo laparoscopic kidney transplantation. Brian Blanchard suffers from kidney failure and needs to be maintained by dialysis. Last month, the doctor performed a kidney transplant with laparoscopic surgery. There are two breakthroughs in this technology. One is that the transplanted organ comes from his sister Pam Marphett. The doctor takes out the donated kidney through her groin instead of the traditional abdomen, leaving almost no postoperative scars. Another breakthrough was that the removed kidney implanted in Brian's body had less than 2.5 inches of incision in the abdomen. Previously, the size of the incision for a kidney transplant was 10 inches. Surgeons say the new technology lays the foundation for safer transplants and allows patients to recover faster. Advances in technology have made laparoscopic kidney transplantation possible. Professor Pranjal Modi from Royal Liverpool Hospital in India initiated a minimally invasive surgery in 2010 to remove the kidneys from the navel without scar endoscopy. He successfully performed 172 minimally invasive procedures in Ahmedabad, northern India. But the operation has never been done elsewhere. Professor Modi is also proficient in organ harvesting from the groin. The purpose of both endoscopic techniques is to allow patients to recover as quickly as possible, reducing the risk of postoperative pain and infection and allowing patients to be discharged as soon as possible. The doctor not only avoided a major surgical incision for Brian, but also avoided new scars. The doctor performed a kidney transplant through his old appendicitis surgical scar.

Surgical site infections (SSIs), among the most common complications in health care, are responsible for delayed wound healing, hospital readmissions and other health ramifications. A study recently published in JAMA Network found that 0.5% to 3% of patients undergoing surgery will experience an infection at or adjacent to the surgical site. Proper, methodical wound care is your best defense against SSIs and other complications. Expedited healing Thanks to advanced wound care products such as dressings, topical agents and active wound care devices, surgical staff can now choose from a variety of options designed to speed up the healing process and minimize the risk of infection. [To get the best results in wound healing, you must first consider your patient," says Jay Calvert, MD, a board-certified plastic surgeon with offices in Beverly Hills and Newport Beach, Calif. [Look at their risk of wound breakdown, and consider factors such as whether they are physiologically stable and practice good nutrition." Dr. Calvert also recommends assessing each patient`s wound healing ability through a detailed history, physical exam and laboratory examination of their blood chemistry, such as albumin and pre-albumin levels. [Successful wound care involves a systemic attitude towards wound healing," Dr. Calvert says. [It`s not just a local wound environment that makes a difference. There is absolutely no substitute for excellent surgical technique." Alternative closure devices Surgeons have long used sutures, surgical staples and skin glues as a means of closing surgical wounds, but wound closure devices now offer an alternative. While some of the devices continue to use sutures and staples that assist in closing wounds, others offer a needle-free alternative to sutures, medical staples and glue. Dr. Calvert has found barbed sutures to be effective and efficient in closing wounds. Although barbed sutures were first introduced in 1964, Dr. Calvert notes they`ve evolved over the years and are now available as innovative wound closure devices that close wounds securely without the need to tie knots. Research has shown that two-layer wound closure with barbed sutures using a wound closure device was safer, faster and resulted in fewer postoperative complications than three-layer closure with conventional, non-barbed sutures. Although Dr. Calvert acknowledges that barbed sutures are more costly, he says they provide advantages such as more uniform wound closure, a lower incidence of postoperative bleeding, shorter closure times. They are available in both absorbable and non-absorbable monofilament materials. Patients typically undergo skin closure after surgery using conventional sutures or skin closure devices. Closure devices provide equal efficacy when compared with standard closure methods such as sutures. At Cedars-Sinai Medical Center in Los Angeles, Randolph Sherman, MD, FACS, a plastic surgeon and chief of plastic and reconstructive surgery, says many patients prefer subcuticular sutures, or intradermal sutures that are placed immediately below the epidermal layer. The increased availability of natural materials that can be absorbed by the body have made them a popular option. [They`re absorbent, and dissolve as the body heals," Dr. Sherman says. [They have less chance of reopening and patients experience less pain and discomfort." Levi Harrison, MD, APC, an orthopedic surgeon and owner of The Harrison Orthopedic Institute in Glendale, Calif., also uses plastic strips for wound closures that feature self-absorbing sutures. He notes high patient satisfaction. [Although patients have a post-op appointment, it eliminates the need to remove sutures in 10-14 days," he says. Negative pressure wound therapy Negative pressure wound therapy (NPWT), also known as vacuum-assisted closure (VAC), is a type of wound care treatment designed to speed up healing by applying sub-atmospheric pressure. While not every surgical wound requires a VAC, Dr. Calvert says they`re effective in treating plastic surgery conditions such as an infected abdominal wound or a thigh lift that broke down, rather than as a primary method for closing wounds. Compared to a normal saline dressing, VAC has been shown to decrease wound infection incidence and improve healing time. Dr. Sherman says surgeons depend on VAC devices as part of a comprehensive wound management plan. [A wound VAC provides a healthy way of dealing with an open wound," he says. [It decreases the frequency of dressing changes and also improves outcomes." NPWT has successfully been used in specialties including dermatology, podiatry, cardiology and orthopedics. [Wound vacuum systems are best used for large wounds, those that have extensive drainage, or to relieve pressure from the wound and to evacuate drainage and bacteria, while bringing the edges of the wound closer together," says Dr. Harrison. [One of the goals of the wound vac is to promote healthy, rich granulation tissue at the wound site." Studies have also shown that using incisional NPWT after groin incisions for arterial surgery reduces the incidence of SSIs compared with standard wound dressings. Venita Chandra, MD, a board-certified vascular surgeon with Stanford Medicine in Palo Alto, Calif., has found success treating patients at higher risk of incisional complications with an NPWT system designed specifically for the management of closed surgical incisions. [Both obesity and diabetes are growing healthcare issues and we know wound healing can be more challenging with this subset of patients," says Dr. Chandra. [Obesity has been associated with an increased risk of SSIs, so it`s important to be proactive about preventing skin and wound complications." Antibacterial dressings Both antibacterial and antimicrobial dressings work to accelerate wound healing and reduce the risk of infection. They can be paired with sponges, woven gauze and other dressing technologies and are available in different shapes, sizes and thicknesses. [Too much is not good, too little isn`t either, so finding the dressing that is just right is the key," Dr. Calvert says. [If you`re dealing with a wound breakdown, then you`ll need to be more aggressive about how to keep it clean and support the wound for closure." In his plastic surgery practice, Dr. Calvert prefers using antimicrobial or antibacterial skin closures, non-adherent dressing pads that deliver a sustained release of antimicrobial agents to the wound. He says they are easy to use and have a decreased risk of resistance. [For facelifts, I use Xeroform gauze, which is a bismuth impregnated gauze to prevent infection," Dr. Calvert says. [My patients also take oral antibiotics in addition to the wound care we provide." With high-risk patients, Dr. Chandra has found success using time-released absorbable antibiotic beads that deliver high doses of antibiotics directly to the surgical site. Like other wound care technologies, these antibiotic beads have evolved over the years, with newer versions offering reliable elution of antibiotics and effective protection against infections. Wound lavage is essential Irrigating the surgical site is a major part of wound care. It serves to remove debris and foreign material, while also reducing the risk of SSIs to patient. While some surgeons irrigate with antibiotic solution tailored to each patient, there also are readymade products available that go beyond traditional irrigation to also offer debridement and cleansing solutions that include antiseptics. Dr. Calvert swears by his irrigation process, something he practices religiously in all of his operations. [I do mostly facelifts, rhinoplasty and cosmetic breast surgery, and I use antibacterial irrigation for each of those operations every single time to reduce the chance of infection," he says.

The day before I spoke with Peter Kim, MD, an orthopedic hand surgery specialist in the Boston area, he performed a unilateral endoscopic carpal tunnel release on a friend and colleague, another orthopedic surgeon. The surgery took place on Monday. Dr. Kim`s coworker was seeing patients by that Wednesday and operating again on Thursday - a mere three days after undergoing the minimally invasive surgical procedure. Not long before he operated on that orthopedic surgeon, Dr. Kim performed a bilateral case on a plastic surgeon. [Surgery was performed on a Thursday, she spoke at the podium on Friday and then operated on Monday," he says of the case. These recoveries are impressive by any standard, but as Dr. Kim points out, impressive is the norm when you`re performing endoscopic carpal tunnel release surgery the right way. [One true advantage of that procedure is an early return to work, particularly if you have bilateral carpal tunnel syndrome," he says, adding that the effectiveness and safety of the endoscopic procedure is noteworthy compared to the gold standard: open carpal tunnel release surgery. Mischaracterizations and misnomers Although the endoscopic approach is very popular among both surgeons and patients, it could be even more widespread if there weren`t still lingering misconceptions about its safety, according to Dr. Kim. He says one reason why the uptake of this procedure is a bit lower is that the most-quoted literature is woefully outdated. [The early literature on this that is most quoted is from the 1990s," he says. [There was no question there was a higher nerve injury rate with the endoscopic versus open release, but we understand the surgery way better than we did 20 years ago. Our ability to maneuver around the nerve and be safe is way, way better, and our ability to use the equipment is better as well." Explanations, expectations and execution Dr. Kim`s outcomes, rapid recovery times and relentless pursuit of maximum efficiency play a huge role in his ability to maintain a steady flow of patients - many of whom are surgeons themselves - without even marketing his practice. But he credits a large part of his success to the effectiveness of the approach as well as the dedication of his team to every part of the perioperative process, from setting expectations preoperatively to hammering home the importance of postoperative rehabilitation. • Selection. Dr. Kim says a crucial point takes place early in the process, when patients must decide how the operation will be done. [The first decision point is trying to pick open versus endoscopic, and I`ll walk patients through the mechanics of the surgery," he says. While Dr. Kim does perform open cases, the majority (around 60%) involve endoscopic carpal tunnel release -approximately 20 surgeries per week compared to around 10 open. The benefits of the endoscopic approach are especially apparent in bilateral cases. [If you have bilateral syndrome, normally I would steer you toward getting it done endoscopically because I do endoscopic bilateral carpal tunnel release with just skin glue - no bandages - so patients can get their hands wet in the shower starting day zero," says Dr. Kim. [This effectively cuts two recovery periods down to one recovery period." • Education. Once his patients pick a path, it`s all about setting expectations. Dr. Kim provides all the specifics on the dressing, what to expect in terms of pain, the rehab protocol and, of course, when they can go back to work - if they stick to the plan. [What I expect from them is, if you do X as far as the therapy goes, then you can expect Y. If you don`t do X, then you`re going to have a prolonged recovery," he says. [Have those conversations on the front end. I`m forthright so I tell patients, `Surgery is the easy part - the rehab is the most important part. If you stick with the program, I promise you we can get you to where you want to be.`" • Pain control. Another component of the speedy recoveries Dr. Kim provides is his approach to pain control. For the past five years, he`s maintained a narcotic-free policy for carpal tunnel release cases. [Once in a blue moon someone will call, and the most they`ll need is a Tylenol with codeine," says Dr. Kim. The key to his pain control strategy is to get out in front of the pain by frontloading patients with analgesics and anti-inflammatories. Patients receive monitored anesthesia care (MAC), everybody gets a Toradol IV and, postoperatively, most patients simply receive NSAIDs. Ultimately, the strategy sends patients to rehab right after surgery with little discomfort. [If you preemptively treat patients with anti-inflammatories intraoperatively and immediately post-op, I find their need for narcotics diminishes dramatically," he says. • Efficiency. Dr. Kim`s endoscopic carpal tunnel cases take, on average, anywhere from six to 11 minutes, skin-to-skin, getting the equipment turned over, up and running and plugged in. An elite, high-volume endoscopic carpal tunnel program comes down to an OR team that has internalized rapid turnover and understands the importance of having everything ready to go. [There`s nothing different about carpal tunnel efficiency from hernia efficiency or cataract efficiency," says Dr. Kim. [A lot of people say, `I don`t like to do an endoscope procedure because it takes too long,` but if you have staff that knows how to do it, the procedure takes no longer than an open release." `Highest badge of honor` Elite surgeons like Dr. Kim rely on the results of endoscopic carpal tunnel release procedures to speak for them. As a result, he`s become the type of surgeon who surgeons go to when they need their most vital tools - their hands - repaired. That trust is something he values unequivocally.

Success in the rapidly growing endoscopic spine surgery (ESS) space often comes down to striking a delicate balance between two sometimes disparate factors: Your surgeons` preferences and your vendor relationships. [You need to find the right surgeons who are willing to work with you to use the lowest-cost option with the highest quality of service," says Prashanth Bala, MS, MHA, vice president for ASC operations at Shields Health with direct oversight of strategy and operations for New England Surgical Suites (NESS) in Natick, Mass., a collaboration among Shields Health, Reliant Medical Group and several private practice physicians. [Without this balance, you`re going to either have quality issues because the surgeons aren`t going to be comfortable with the products you give them, or you`re going to lose money on every case you do because you bought something that`s too expensive and your surgery center is going to lose money. Threading that needle and finding the right surgeons and the right vendor partner is key." Mr. Bala should know - he says his NESS center began performing ESS cases in April of this year and is currently the only surgery center in the state of Massachusetts doing so. That exclusivity is likely to end in the near future with a surge in endoscopic spine cases expected and a growth rate of outpatient spine as high as 30% by 2026 according to some estimates. Minimal incision, reduced tissue damage ESS is an extra-minimally invasive approach to treating patients with chronic back and leg pain that uses a high-definition camera attached to an endoscope and inserted through a tiny incision - or dual incisions - in the patient. The key benefits of this approach are the minimal nature of the procedure and the return to full function due to a decrease in collateral tissue damage, according to Alex Vaccaro, MD, PhD, MBA, president of Rothman Orthopaedic Institute in Philadelphia. [The main difference between endoscopic spine surgery and other techniques is ESS significantly minimizes the tissue disruption necessary to make contact with the targeted tissues of interest like compressive soft tissue or bony lesions," he says, adding that ESS also can eliminate the need to place implants in spinal structures. John O`Toole, MD, MS, professor for the department of neurosurgery at RUSH University Medical Center in Chicago, says that limiting tissue disruption has a domino effect on the patient`s recovery process. [Minimal tissue disruption results in reduced postoperative pain, and therefore, a reduced need for postoperative pain medications - all of which produces earlier mobilization, a return to normal levels of activity and fewer opioid-related complications," he says. Evolving visualization Although ESS has been traditionally relegated to hospitals, many ASCs are all-in on the opportunity to bring this procedure to their centers - and technological advances are certainly expediting that migration. [A significant advancement in the field of endoscopic spine surgery is the evolution of the high-definition camera," says Dr. Vaccaro. [This is extremely important to allow optimal visualization of all the neurovascular structures, surrounding soft tissues and bone." The incision size, says Dr. Vaccaro, is basically the size of the endoscopic camera, working portals or instruments being used. For comparison purposes, consider the following: [A traditional open procedure for single-level lumbar decompressive surgery may be two inches or 50mm - an MIS tubular portal may be as wide as 22mm," says Dr. Vaccaro. [Endoscopic working portals may be on average between 10-13mm in size." From an equipment standpoint, Dr. Vaccaro says ESS does often require more technology and tools than other traditional approaches to spine surgery. [This includes different camera scope angles, monitors, a fluid bag irrigation system, different tools for burring, undercutting bone and angled curettes and pituitaries," he says, adding that specialized instruments have been developed for suture placement and knot tying as well as incisional closing. The equipment needed - particularly to start a practice - can be off-putting to facility leaders already wondering if they can succeed in this space. Mr. Bala urges patience and lots of research on the available vendor pool. For instance, when he first looked into ESS, he thought any surgeons he used would only do the procedure a certain way, which wasn`t an option. [When we got further and further into that conversation, the economics just weren`t going to work out to buy $450,000 worth of capital equipment," he says. [The price at the pump was still too high - it would have eaten up all our reimbursement." Instead, Mr. Bala and his team kept doing their research and eventually landed on a vendor that fit, a company that is leading the market in dual-port ESS. [It`s still endoscopic spine, but two small incisions provide you the same level of visualization," he says. The key was patience and finding a way to reconcile the surgeons` needs with the right company for the facility. [It`s finding the right vendor partner that is willing to work with you on pricing, support and a technique that your surgeons are willing to use," says Mr. Bala. [It`s also about finding the right surgeons who are willing to work with you to use the lowest-cost option but also provide the highest quality of service." The heart of ESS First and foremost, your facility must have the right surgeons driving your endoscopic program. That often means extensive training on this technique. [If you want to succeed in ESS, you should preferentially perform a fellowship with surgeons familiar with the technique," says Dr. Vaccaro. [Mastering this technique often a takes a focused apprenticeship." And if the fellowship didn`t include endoscopic exposure? [Then I would attend as many courses as possible and then visit surgeons who are facile in this approach to really learn the technique," he says. This expertise plays a vital role in patient selection, another area of ESS in which all successful service lines excel. As Dr. Vaccaro points out, not all candidates are suitable for this approach. [The best candidates are those who have symptomatic foraminal or exit nerve root stenosis," he says. [It is also very useful for removal of free fragment disk herniations once clear visualization is obtained." Dr. O`Toole agrees that careful selection is paramount and believes that young, healthy patients with [simple" spinal disorders - such as disc herniations at a single spinal level - are the ideal candidates, but points to the low-trauma approach of ESS as a reason for facilities to consider other patients, especially those who aren`t a good fit for traditional procedures. [The minimally invasive nature of ESS makes it an appealing option in patients whose age or comorbidities might preclude typical open spine surgery - as long as the pathology treated is appropriate," he says. The importance of finding the right surgeon is echoed emphatically by the non-surgeon Mr. Bala. [The first model we used was asking, do we have the surgeons that are capable?" he says. [We needed to ensure they were trained and fully capable of taking care of all the patient needs." To make sure everyone was not only capable but also well-prepared for ESS cases at the surgery center, Mr. Bala brought his vendor in and had a handful of spine surgeons and other staff come to do a cadaver lab at the facility. [They trained that evening, they did the cadaver lab at our facility, they tested it and then they did their first case not long after that and found that the technique was excellent," he says. Forging ahead Mr. Bala knows his ESS program is filling a need - one that is rapidly growing - and he`s happy the surgery center is positioned accordingly. [This is our attempt at saying, patients that require spine surgery have benefitted from excellent quality of care in hospitals, but now we want to drive that same high quality of care in our outpatient setting," he says. [We`re fortunate enough to be the ones who are leading that right now."

If you give a patient the choice between a one-and-a-half-centimeter incision on the crease in their wrist with a speedy recovery prognosis or a four-to-five centimeter opening on the palm of their hand that takes a little longer to heal, they`ll naturally gravitate toward that smaller incision and quicker recovery. At least that`s been the experience of Philip C. Marin, MD, a double board-certified plastic, reconstructive and hand surgeon in Pueblo, Colo., who has done more than 5,000 carpal tunnel procedures over the last 25 years. Around 95% of those cases were endoscopic carpal tunnel procedures - the one with that tiny one-and-a-half-centimeter scar - and the bulk of the patients who come to see him are there due to word of mouth. [Most of the patients that come in have met a patient of mine who had the endoscopic technique, and they really liked the results," says Dr. Marin. [The endoscopic technique is usually what they have on their mind in the first place." Though he does explain both options to prospective surgical patients and occasionally performs open cases, Dr. Marin says it generally only occurs if there`s something inside the carpal tunnel that needs to be cleaned out or it there`s severe synovitis, something that only occurs in only a handful of approximately 250 annual carpal tunnel cases he performs. Single vs. double port While the endoscopic release can be performed either via a single portal (i.e., incision) approach or a dual portal approach, Dr. Marin has only ever worked with a single portal technique, whereby the surgeon makes the lone incision in the wrist crease, enters the carpal tunnel and releases the transverse carpal ligament under direct visualization using a retractable knife that`s connected to an endoscopic device. [It`s an excellent technique, it`s extremely safe and it`s a very good point of entry into the carpal tunnel," says Dr. Marin. [After doing this technique for 25 years, I believe it`s one of the safest ways to get into the palm of the hand." Dr Marin`s word-of-mouth referrals, longevity and track record for reliable outcomes seem to support this. The typical turnaround for the surgery itself is just eight minutes and the patients receive a Bier block, also known as intravenous local anesthesia (IVRA), which is a safe and cost-efficient way to provide short-term anesthesia and analgesia during a procedure on a patient`s extremity. Recovery-wise, Dr. Marin`s patients, whom he does not splint, are encouraged to move their fingers from the get-go and do gentle range of motion exercises. [We leave stitches in for approximately two weeks and tell patients to avoid any compression or trauma to the palm of the hand because it`ll be sore from surgery," he says. [You want to move it, but you don`t want to aggravate it." The dual portal technique, which includes a second incision in the palm of the hand and the insertion of a camera within, puts the surgeon right there in the middle of palm. [There are deep palmar arches, and you have the carpal tunnel nerve, the median nerve branching there, so in my opinion, it`s a little bit more dangerous of a technique," says Dr. Marin. [I`ve actually never performed it." But there are plenty of others who have. That`s the thing about carpal tunnel release surgery - surgeon preference almost always plays a major role in the technique. [You learn from your mentors," says Dr. Marin. [They have such an influence on the people who they`re training." When conservative approaches fail Endoscopic carpal tunnel release is such a common and reliable option that some people believe it`s the first line of treatment when patients present with symptoms. Of course, that`s rarely the case. When patients come to Dr. Marin with typical symptoms - numbness in the radial three-and-one-half digits, weakness in the hand, object dropping and night awakening - his first approach is early management with anti-inflammatories and night splinting. [The night splinting helps because it holds your wrist in a relatively neutral position, which allows the nerve to have the most space to breathe - next to the nine tendons that are in the carpal tunnel next to it," says Dr. Marin. If that fails, sometimes he`ll do cortisone injections in the carpal tunnel. Only then, if the patient is unresponsive to conservative management, does Dr. Marin bring up the single port endoscopic carpal tunnel release in which he`s so experienced. [Patients should fail conservative management first prior to entering surgery," he says. If and when that happens, Dr. Marin is more than equipped to provide surgical relief in as safe, efficient and expedient a manner as possible.

Seeing clearly Years ago, high definition (HD) was all the rage. But technology is advancing so rapidly that, in the operating room, HD is now actually considered low resolution. 4K is now the baseline resolution we aim for anytime we build out or install systems. 4K provides enhanced color, sharpness and clarity that offers surgeons visualization advantages without the multimillion-dollar price tag that comes with a robotic platform. The potential of 3D imaging has always been of interest, but it hasn`t exactly taken off yet. It was very gimmicky when it was first demoed. The cameras were larger, the optics were not as clear, and the technology required the surgeon to wear 3D goggles that were usually inconvenient and, depending upon the axis by which they looked to, the screen would change the optical resolution. Some companies are still developing 3D imaging technology, but many surgeons who are interested in 3D moved over to the robotics space. Pieces of the puzzle The camera head is a key piece of the broader imaging puzzle. With laparoscopy equipment, you have the camera head that you hold in your hand, and then you attach a detachable lens to it - just like you would a camera. There are different angles and different shapes of lenses, like a 30-degree down (urologists like to use a 45- or 70-degree lens depending on the view they need). The image clarity is dictated by the quality of the lens as well as the camera head in your hand. That camera head acts like a processor, shooting all the images to a computer in the room that digitally enhances the images and creates image overlays. A cable connects the lens to the processor. Some of those processors now feature an embedded light source, while others require you to plug into an external one. The video processor is placed in the back of the room, where it acts like a centralized command center. It places CT scans on monitors and is able to manipulate things for us. Some of the newer processors also offer video recording and broadcasting for teaching purposes. If you are looking to upgrade your laparoscopy equipment, the first thing I would start with is a new camera head and new lenses. These imaging upgrades will eventually require a new computer processor system, but you can usually get away with staggering the update on your monitors. One thing administrators need to seriously consider when making upgrades to their ORs is how these changes will effect a surgeon`s ergonomics. With laparoscopy, the surgeon is accessing a patient`s anatomy through a straw in a straight instrument, and that`s how it has always been. Recently, a few companies have developed wristed instruments using laparoscopy that mimics robotics in a way. This development aims to fill the need that we`ve had to eliminate the straight sticks, which ultimately improves a surgeon`s ergonomics. I know multiple surgeons with orthopedic injuries, neck injuries and back injuries that stem from long careers in laparoscopy who have switched to robotics just to prolong their careers. Proper training When you`re looking at a laparoscopic image, there are limits. The greens can be only so green, the reds only so red and the blues only so blue. However, the clarity, size and image density are all impressive with the newer technology. The most significant change we`re going to see is not necessarily in bigger, better and clearer images, but rather in what`s beyond the white light we`re currently looking at. That`s why there`s a huge push towards fluorescence imaging to look at the perfusion of tissue, where nerves and urinary structures sit. With fluorescence imaging, you are extending your vision beyond the spectrum of white light. Laparoscopy improvements have basically plateaued not because of the development of robotics but rather because robotics wraps all these items - the image, the instruments and the haptic feedback - into one ecosystem that is completely unified and easy to operate. There are external factors that we don`t really talk much about but that play a huge role in efficiency and patient and surgeon satisfaction. At the top of this list is the perioperative team that choreographs the surgery. It involves those who properly position the patient, secure them to the bed, hand you the instruments that you are missing and make sure the trays are prepped correctly. It can be a wonderful thing to watch when your staff is properly trained and know exactly what their roles entail. Whether your facility is still performing laparoscopy or you`ve invested in robotics, understanding the technology is paramount to providing safe patient care. Your operating room team must work together to ensure all the equipment is functioning properly and understand what to do if a problem arises. While robotics is taking minimally invasive surgery to new heights, advances to laparoscopic imaging equipment prove you can still deliver the safest possible outcomes without the flashiest technology.

When it comes to patient safety and surgeon comfort, gasless laparoscopy is my preferred method of GYN surgery. Not only does the gasless method eliminate the dangers of CO2 gas, but it also lets your docs use the conventional instruments of laparotomy for better tactile sense. How? By combining the fundamentals of minimally invasive technique with the conventions of open surgery. Here's how it works: Instead of insufflating the abdominal cavity, the surgeon inserts a special lift system via a small cut in the lower umbilicus and raises the abdominal wall mechanically. By not having to insufflate, the surgeon can use instruments for open conventional laparotomy, get a similar view into the abdominal cavity as that afforded by laparoscopy with gas and still get to use patient-friendly minimally invasive techniques. Interested in the technique for your facility? Here are the four key benefits to gasless laparoscopy. 1 Eliminate side effects of CO2 Endoscopic technique means good results for the patient: smaller scars, less pain and faster recovery. But CO2 gas, one of the necessities of this technique, is a patient safety risk. When performing endoscopic procedures, the surgeon needs to insufflate the abdominal cavity with carbon dioxide in order to obtain a sufficient workspace and view of the surgical field. The cold gas causes considerable build-up of pressure in the abdominal cavity and reduces the body temperature; these factors cause the patient pain that, in some cases, can persist for several days, radiating to the shoulder and neck regions, and prolonging and complicating recovery. I've found that patients need fewer painkillers and that recovery time is faster with gasless laparoscopy. For example, in my experience the complete recovery period after a gasless hysterectomy is about two weeks. Though rare, insufflation can lead to gas accumulation in the vascular systems of the lungs (gas embolism), heart (decrease in coronary blood supply) and kidneys (poorer perfusion), or to the accumulation of carbon dioxide in the subcutaneous tissue of the skin (emphysema). While such side effects of carbon dioxide are extremely rare, they can prove fatal (kidney failure, heart attack and pulmonary embolism, for example). Moreover, the gas has been linked at least loosely to further side effects including decrease in the pumping action of the heart and overloads of carbonic acid (which can cause acidosis of organs). More important is that carbon dioxide changes the milieu of the peritoneal cells and provokes hypoxemia and acidosis, which can act as a co-factor in adhesion formation. Avoid gas laparoscopy for an adhesiolysis or longer procedures. 2 Widen the patient population By not using CO2, you avoid all these side effects, risks and potential complications. Surgeons are also able to perform procedures under regional anesthesia (other laparoscopic procedures necessitate general anesthesia because of the massive pressure from the pneumoperitoneum in the abdominal cavity, which causes pain and organ compression of the diaphragm and lung). So in addition to young and healthy patients, you can offer minimally invasive surgery to older or other at-risk patients. You can also operate on pregnant women using gasless laparoscopy, as there is no pressure build-up caused by gas on the expanding uterus - which can induce miscarriage, or decrease perfusion of the placenta and of the baby. Gasless laparoscopy also avoids acidity of the blood of the fetus, which prevents organ damage. 3 Return to familiar instrumentation Unlike when using the long endoscopic instruments, the gasless technique lets the surgeon preserve his tactile manual perceptions and feel what he's cutting, holding or compressing. With the magnification conferred by the endoscope, the operation unfolds more precisely and more safely. In addition, I've found that the learning curve associated with the gasless technique for the surgeon is markedly shorter, because he need only learn how to interact with the monitor. The surgical technique remains the same as that practiced in open abdominal surgery. The complication rate for endoscopic procedures is higher than in open surgery, especially in the case of surgeons who aren't optimally trained. Typical complications of an endoscopic procedure can occur while inserting the Verres needle - for gas insufflation - or the trocars. The insufflation needle is pierced blindly into the abdominal cavity. After the abdominal cavity has been filled with gas, the first trocar for the optic is inserted (also without visual control). Both can, in rare cases, injure vessels or organs (the bladder, intestines or stomach, for example), and this in turn can trigger emergency situations (such as bleeding) that warrant immediate action. An undetected bowel injury after coagulation often results some time later in acute ileus and massive infection. With the gasless technique, you can apply sutures using the tried and tested needle-and-thread method instead of clip-and-suture apparatuses or electrical coagulation, which are expensive or can cause complications, such as injuries to the ureter during an endoscopic hysterectomy. 4 Cut procedure costs Laparoscopic instruments not only are more expensive, but also they're more labor-intensive and difficult to maintain and reprocess (you can see why open techniques persist). It's been estimated that minimally invasive operations using laparoscopy with carbon dioxide are about seven times more expensive than laparotomy. Minimally invasive operations with gasless laparoscopy are even more cost-effective than open procedures because they dispense with systems that render laparoscopy with gas expensive. You can manually clean and autoclave instruments; you don't need any special washer-disinfectors. In addition, you eliminate the risk of infection posed by the difficulties of cleaning endoscopic instruments and by different tubular and pumping systems. Conventional instruments last longer and require fewer repairs than the delicate instruments needed to perform laparoscopy. It's also not necessary to use every novel instrument and technique promising to improve the safety and maneuverability of gas laparoscopy. With the gasless method, no disposables (such as expensive titanium clips) are used. By combining the benefits of minimally invasive technique (short hospital stay and recovery period) with the cost effectiveness of the gasless method, this method of surgery is overall markedly more favorable than laparoscopy with gas. Progress through regress Gasless laparoscopy prevents or minimizes all the aforementioned disadvantages, risks and complications of endoscopic operations that use CO2, while preserving all the advantages of laparoscopy - minimal scars, better cosmetic results, less wound pain, faster recovery and shorter stays. You might say that converting to this technique means progress (the combination of newest techniques of endoscopic surgery) through regress (established and proven conventional techniques of open surgery).

Minimally invasive surgery is tough on surgeons, who constantly struggle to manage the technique's inherent challenges: access to the abdominal cavity, and clear views of tissue and anatomy. Luckily, newer laparoscopes offer promising solutions. Here are some of the latest improvements and the impact they can have on surgical visualization: High-definition video. One of the first big improvements was the development of the 5mm deflectable HD laparoscope with a charge-coupled device (CCD) at the tip, says Sharona Ross, MD, director of minimally invasive surgery and surgical endoscopy at Florida Hospital's Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery in Tampa. "Having the CCD image sensor at the tip delivers a brighter, larger depth-of-field picture, and it has a focus-free operation," she says. "It was also very advantageous cost-wise, because it removed the rod lens system, which reduces repair costs. The fact that it's autoclavable also reduces costs." Improved ergonomics. The all-in-one design of the deflectable tip laparoscope, with its integrated light cable and camera system, also represents an ergonomic improvement. "Eliminating the (external) light source coming in at 90 degrees from the actual shaft of the camera was very useful, especially for single-incision laparoscopy," says Dr. Ross, "because you can lean it down and parallel to the patient's body. It lets you have more range of motion for the other instruments." Bariatric length. Another step forward, says Dr. Ross, was one company's decision to provide high-definition articulating laparoscopes in 45cm lengths. "The technology is similar," she says, "but the advantage is the bariatric length. When we use the single-incision laparoscopic approach, all the instruments are bariatric length because you're working from a single port. It lets you stagger instruments and the scope nicely." 180-degree articulation. Unquestionably one of the most dramatic improvements, articulation "adds another level of safety," says Dr. Ross. "It lets you visualize the surgical field from different angles, so there's no question in your mind as to what it really is. You can direct the scope behind the tissue you're about to cut and make sure it's what you think it is." 3D imaging and recording. This is truly state of the art, and it lives up to the hype. "It's absolutely amazing. Three-dimensional perspective is an immediate game-changer with regard to patient safety," says Dr. Ross. "It provides you with more information and lets you be very careful with your dissection. You can visualize the blood vessels and see the tissue planes clearly, which lets you avoid injuries." The HD 3D laparoscope provides more information with better precision and resolution, adds Dr. Ross. "All the advantages that you have while sitting at a robot console and visualizing tissues in 3 dimensions, you're now able to have with the laparoscopic approach," she says. "It's ideal for tasks such as suturing. It's truly beautiful." Another plus: At least one company allows you to add the upgraded 3D scope to its existing imaging system. "Some companies force you to purchase an entire tower when you buy a new, upgraded scope," says Dr. Ross. "Being able to use the same tower system decreases the capital investment and simplifies training." The only disadvantage is that the 3D technology currently requires 10mm scopes, which means you need a slightly larger incision than might be ideal under some circumstances - at least, that is, until the next improvement comes along. Oh, and you also need to wear 3D glasses. Not a problem, says Dr. Ross, who was given an early prototype. "They showed me these ugly, ugly glasses and I said, 'Listen, if I need to wear this in the operating room, there's no way I'm wearing these. I've got to have something designer-like,'" she laughs. "And wouldn't you know, they came up with glasses now that are really like designer glasses. They're really very nice." What's next? ALL IN ONE With bariatric-length articulating HD scopes, instruments can be staggered, allowing surgeons to work from a single port. So, has the technology gone about as far as it can go? "I think if you asked an older surgeon, he'd say it's probably pretty close to where it's going to be," says Alexander Rosemurgy, MD, director of the Surgical Digestive Disorders and GERD Center at Florida Hospital. "But if you ask a young surgeon what kind of improvement there will be over the next 25 years well, if you go back to 1989, they were just beginning to do laparoscopic cholecystectomies in a couple of places then. I don't think we foresaw 25 years ago what's going on today." Drs. Ross and Rosemurgy are also working with various companies to implement other improvements that may become more widely available. One of the devices they've developed reorients the laparoscopic view so that it's able to be broadcast onto the patient's abdominal wall, says Dr. Rosemurgy. "It's reformatted so people can see where their instruments are," he explains. "One of the problems with novice surgeons is that they don't know where their instruments are until they're in the view of the camera. If they've got to pull the camera back, find out where they are and then advance the camera with the instrument sets, it takes some time. If you have an operation where you have to do that 30 times, and each time takes a minute, you've just made the operation 30 minutes longer." They're also working to develop what they call laparoscopic "no-fly zones." It's possible with the new camera they've developed to designate areas as off limits, and if a surgeon ventures into the zone, an alarm will sound. "I think the answer to the question of what the future holds lies in some of these things," says Dr. Rosemurgy. "The trocars will be smaller, the cameras will be brighter, but more importantly, we're going to come up with new paradigms for patient safety, and develop new techniques for education and training."

Are automatic laparoscopic suturing devices worth the expense? The question is easy, but depending on whom you ask, the answers are considerably more complex and sometimes paradoxical - as is often the case when considering costs in relation to the benefits devices provide. 'They are efficient and technically very good, as far as the function of the devices goes, and they are certainly technically easier,' says Sabi S. Kumar, MD, of the NorthCrest Medical Center in Springfield, Tenn., and a member of the clinical faculty at Vanderbilt University in Nashville, Tenn. 'But the cost is definitely a problem.' For Dr. Kumar, who is already equipped with the confidence years of experience brings, the tradeoff doesn't warrant the expense. 'I have looked at all of them and I do manual tying,' he says. 'I don't use them.' But others say expense can be a motivating factor rather than a deterrent. James Presthus, MD, of Minnesota Gynecology and Surgery in Edina, Minn., says that, while he is equally confident in his ability to do things the old-fashioned way, the devices are potential cost-cutters. 'When I started doing laparoscopic procedures, I learned conventional instrumentation,' he says. But today, if he can get a stitch done faster with a device than with his hands, he'll go with the device. How do you know whether to stick with manual methods or to stock automatic laparoscopic suturing devices at your facility? Here's what you need to know to help you discuss the issue with your surgeons and decide. Navigating the curves For laparoscopic surgeons, the challenge of performing intricate operations in a three-dimensional world based solely on the images they see on a two-dimensional screen has always been daunting. As Dr. Kumar says, it's technically demanding because 'you're working in a monoplane field of vision without feedback or depth perception.' Dr. Presthus compares it to 'playing video games. You have to dissociate your hands from what you see on the video screen.' Nonetheless, it's viewed as an important skill for surgeons to master and, having done so, some surgeons feel no need to use devices that are designed to make suturing less skill-reliant. David L. Crawford, MD, an associate professor of clinical surgery at the University of Illinois in Peoria who also runs a private practice, sees the devices as very useful, but insists that his students learn to function without them. 'I tease the residents,' he says. 'I tell them they don't get to use any crutches when they're working with me. There's a very steep learning curve with conventional suturing, and it can be back-breaking for residents.' Back-breaking, but important, says Dr. Crawford. 'What if sometime in some situation the gadget isn't available?' he asks. 'It's good to have that skill set as a backup.' Bridging the gap Surgeons who are used to conventional suturing are concerned about the learning process, too, but their concern is about learning the new technology. 'There's going to be a learning curve [with new devices], and you like to learn in situations when it's not critical,' says Robert Grant, MD, of New York Presbyterian Hospital/Columbia University Medical Center. 'That means sitting down and spending time with a representative.' And despite the efforts of professors like Dr. Crawford to ensure residents are adequately trained in manual suturing, it's 'the newer generations of surgeons [who] are very quick to embrace new technologies,' says Dr. Grant. With more experienced physicians, he says, 'it depends on the ease and the familiarity of the surgeons who want to use them. If they find it really helps speed things along, they're going to want them as part of their practice.' Convincing the skeptics Jude Sauer, MD, has heard all the arguments and takes them in stride. 'I never try to persuade people who are not comfortable with a device,' says Dr. Sauer, a longtime innovator in the field and a principal in LSI Solutions, which manufactures Sew-Right. 'More often than not, people who suture well are innately gifted or people who have gone through extensive training programs. But the reality is that there are certain things technology lets you do better,' Dr. Sauer says. And concern about the learning curve is unfounded, he says: 'We can have a person doing a great job in his first case. The learning curve is very, very short.' So who can profit most from the existence of suturing devices? Herein lies yet another paradox. 'If someone does suturing very rarely, they're probably not going to care about the cost,' says Dr. Crawford. 'If you can take time off the operation, cut it down from 10 minutes to one minute, it's going to pay for itself. That's good for people who haven't mastered the skill to begin with.' But, says Dr. Sauer, the devices are most valuable to people at the opposite end of the spectrum. 'Our best customers are people who do the most surgery, because they like to go really fast and do an excellent job,' he says. 'We look for people who want to do six operations a day and be just as good on the last one they do that night as they were on the first one they did that day. 'If you're doing one hysterectomy every two months, you don't need it. But if you want to be a high-volume, very successful surgeon, having other technology available makes sense,' he adds. Talk to the hands There may be another important consideration in the discussion. Laparoscopic surgeons who spend large amounts of time doing manual suturing may be in for trouble down the road. 'I study OR ergonomics,' says Dr. Sauer. 'We already know that with interventional cardiologists, approximately 50 percent have their backs ruined because they wear lead aprons while performing surgery. There's an epidemic of spinal injuries out there. 'Now, there's already a cadre of physicians who have been hurt by using [conventional suturing] equipment,' continues Dr. Sauer. 'So whether your hands hurt really matters to us, too. Some of our best customers are people who are doing three to five hysterectomies a day, and want to make sure their hands aren't numb at the end of the day.' Here again, while surgeons appreciate that effort, they aren't convinced it will make much of a difference. 'I'm delighted to hear that manufacturers are trying to make devices more comfortable for surgeons,' says Dr. Grant. 'But unless there's a real dollar value associated with that, it won't be a factor for administrators.' One case at a time Ultimately, the case itself will probably determine usage, says Dr. Presthus. 'I will assess at the time of surgery,' he says. 'It depends on how much you have to do and what the access is. Time is money in the operating room. If you're struggling using more conventional means, you're much better off [using a suturing device], and you'll get more consistent results. 'But if it's a simple stitch across the cervix, I'll do it with conventional material rather than get a device out that costs a lot more,' he says.

Laparoscopic colorectal surgery got off to a slow start in the 1990s because of concerns that the "little sticks" made it more difficult for the surgeon to effectively remove enough cancerous tissue and lymph nodes, compared to open surgery, as well as concerns over post-operative ileus, which can last 24 hours to a week. But experts we talked to say laparoscopy in colorectal surgery is making a comeback, thanks to better equipment, more positive evidence from clinical studies and more experienced colorectal surgeons. Here are seven signs pointing to colorectal surgeons doing more laparoscopic procedures. 1. Keyhole surgery is here to stay. Since minimally invasive techniques have been taught in medical schools for more than a dozen years, a whole generation of surgeons is comfortable with laparoscopy. Older surgeons are catching up and realizing that they get better results through smaller holes. But often the more complicated cases are passed on to younger surgeons, says Eric Haas, MD, FACS, program director of minimally invasive colon and rectal surgery at the University of Texas at Houston, who five years ago founded Colorectal Surgical Associates in Houston, which specializes in minimally invasive approaches to colorectal disease. 2. Hands-on laparoscopy is catching on. Hand-assisted laparoscopy, using laparoscopic instruments and a camera as well as a hand through a larger incision, is becoming more common. For some surgeons, it's a way to transition from open surgery, reduce procedure time or manage complications. David Rosenfeld, MD, a colorectal surgeon who operates at Simi Valley Hospital in Simi Valley, Calif., says he's doing more and more hand-assisted procedures through a 5cm- to 6cm-incision whenever he needs to remove all or part of the colon. "Pure laparoscopists say you're cheating," says Dr. Rosenfeld. "But you're making the same size incision to get the organ out." The hand-assisted technique - sometimes using a balloon trocar - can reduce procedure time, gives the surgeon more control over bleeding and puts less stress on the bowel tissue. With this method the colon can be resected outside the abdomen. 3. Smaller tools, smaller holes. In the last few years, laparoscopic instruments have become smaller, letting surgeons make more 5mm incisions rather than 10mm incisions, which used to be more common. Digital cameras, graspers, ultrasonic scalpels and tissue sealers can now pass through a 5mm trocar. The smaller the incision through the abdominal wall, the less the chance of an incisional hernia developing. With 5mm incisions, surgeons can access organs through more ports with more precision without worrying about hernias, scarring and adhesions. "We say fives are free," says Dr. Haas. Scars and adhesions can make a patient unsuited for future laparoscopic surgery. The instruments are thinner and allow more articulation. But there's still a ways to go when it comes to precision with a light touch. "You need delicate instruments to hold on to the bowel," says Sonia Ramamoorthy, MD, FACS, assistant professor of colorectal surgery at the University of California, San Diego. She adds that there's not much of a selection of laparoscopic instruments designed for colorectal surgery. Camera optics and widescreen high-definition displays have improved over the years, letting surgeons see better and OR teams follow the procedure. New digital 5mm cameras create a clearer and much brighter image compared to the analog cameras of a few years ago, says Dr. Haas. 4. More energy sources. Facilities now have a wider choice of energy sources to offer surgeons for cutting, sealing and welding tissue, including ultrasound, electrocautery and electrosurgical devices. During a laparoscopic procedure, blood vessels and vascular tissue can be more easily sealed with bipolar thermal energy than with sutures or staples. At the same time, staplers have improved to equalize the compression. The current generation of staplers spread pressure across the staple rather than just at the edges, says Dr. Rosenfeld. With each new generation, devices become easier to use and less traumatic on tissue, which translates to better healing, less scarring and adhesion and patients leaving the hospital sooner. "I keep most patients three days," says Dr. Rosenfeld. 5. Improved efficacy. Laparoscopic surgery is tricky because the surgeon is using long instruments through a trocar while looking up at the display screen. Colorectal surgery presents its own set of challenges because the colon is curved and not stationary like most other organs. The rectum is a difficult area to work in because of its size and proximity to other organs such as the prostate. "There's a steep learning curve to laparoscopic surgery," says James Celebrezze, MD, FASCRS, FACS, an assistant professor of surgery at Drexel University College of Medicine and a staff surgeon at Allegheny Hospital in Pittsburgh. It takes about 50 procedures to become comfortable. The more laparoscopic colorectal procedures a surgeon performs, the better the outcomes. Researchers have recently begun to release positive outcome data for colorectal procedures. A Cochrane Collaboration meta-analysis published in May found no significant differences between open and laparoscopic surgery in relation to long-term survival and colorectal cancer recurrence rates. In another study, Dr. Haas and his colleagues at two Texas hospitals analyzed 100 consecutive laparoscopic surgeries for rectal cancer and found no remaining markers for cancer. At least 12 lymph nodes should be removed to prevent recurrence. Dr. Haas and his colleagues were able to remove an average of 15 nodes, more than the standard for open surgery. "Technique matters, especially with rectal patients," says Dr. Haas. "Technical outcome has been linked to long-term survival." 6. Here comes the robot. Surgeons are still experimenting, trying to figure out which procedures are best suited for robots. In general, it seems that more surgeons are using robots for rectal procedures than for colon procedures. In part that's because the rectum is small and stationary, the perfect application for a robot. The success of robotic prostate surgery, however, has piqued the interest of colorectal surgeons, says Dr. Haas. "We're learning from the urologists." With the robot, colorectal surgeons often are able to spare the sphincter and avoid colostomy, says Dr. Haas. But during colon procedures, the robot often needs to be moved a few times during the surgery because the colon is curved and not contained like the rectum or prostate. While still uncommon, robotic technology looms large for minimally invasive colorectal procedures. 7. Better instruments coming? Robots are not cheap. They cost about $1.3 million each, which makes them unsuited for every facility. Regardless, robots will eventually play a large role in colorectal surgery, possibly indirectly. "Because of the robot, we're going to have better laparoscopic instruments," says Dr. Rosenfeld, who hopes that laparoscopic instruments will one day be able to mimic the articulation of robot arms. Dr. Celebrezze would like to see the development of cordless instruments to eliminate the spaghetti-like mess that grows around the surgical site as the surgery progresses. "If someone could make cordless laparoscopic instruments, they'd make a mint," he says.