Minilaparoscopy with Interchangeable,Full 5-mm End Effectors: First Human Use of a New Minimally Invasive Operating Platform

Introduction

The tenet of minimally invasive surgery is to safely perform surgery with equivalent outcomes compared with open surgery, while minimizing the morbidity and complications associated with open laparotomy. To this end, technology is constantly evolving in an effort to provide increasingly less invasive techniques. In an effort to minimize tissue trauma, wound complications, postoperative scarring, and improve cosmesis, various approaches have been described, including the use of single-incision laparoscopic surgery and of needlescopic surgery, in comparison with standard laparoscopic trocar access. The efficacy and safety of these various techniques have been described in many single-institution reports.

Needlescopic surgery was first described by Gagner and Garcia-Ruiz ¹ in 1998 and is defined as surgery using instruments with a diameter equal to or less than 3 mm. Since then, different needlescopic devices have been developed. However, while reducing incision size, the use of needlescopic instruments has been limited by the required downsizing of the end effector and the diminished shaft strength and length.

To address this, the Percuvance™ percutaneous surgical system (Teleflex, Wayne, PA) has been developed with instruments having a 2.9-mm shaft that are inserted percutaneously through the skin, with full, standard 5-mm end effectors that are attached to the shaft end through a separate 5-mm or larger port. This report aims to describe the first human series of patients undergoing surgery performed with the Percuvance needlescopic instruments in a spectrum of general surgical applications.

Materials and Methods

Novel operative instrumentation

The Percuvance system uses a 2.9-mm disposable shaft with reusable, interchangeable end effectors and a ratcheted reusable handle (Fig. 1). The shaft is inserted into the abdomen under direct visualization with a Veress needle tip. Once the shaft is intraabdominal, the end is extracorporealized through an adjacent port that is 5 mm or larger. The Veress needle tip is unscrewed and exchanged for an end effector of choice by hand. Instruments that are currently available include atraumatic grasper, traumatic grasper, Maryland dissector, and scissors. The instruments can be exchanged as many times as necessary; this requires extracorporealizing the shaft through an adjacent 5-mm port for exchange (Fig. 2). Upon completion of the case, the end effector is removed, and the shaft is withdrawn from the abdominal wall.

OPEN IN VIEWER

FIG. 1.

The Percuvance system. Courtesy of Teleflex.

OPEN IN VIEWER

FIG. 2.

Extracorporeal instrument exchange. (A) Extracorporealized Veress needle tip. (B) Attaching the 5-mm end effector. (C) End effector engaged and ready to use.

Results

In March 2015, 15 patients underwent surgery using the Percuvance surgical system at the Cleveland Clinic; procedures included five laparoscopic jejunostomies, two laparoscopic sleeve gastrectomies, one Roux-en-Y gastric bypass, one gastric electric stimulator placement, one gastric electric stimulator explant, one ventroperitoneal shunt revision, one laparoscopic cholecystectomy, one laparoscopic paraesophageal hernia repair, one laparoscopic duodenojejunostomy, and one laparoscopic ventral hernia repair with mesh. The patient demographics are summarized in Table 1, and the intraoperative details are listed in Table 2. We did not need to modify our standard operative technique during use of Percuvance instruments, and operative times were similar to those when using traditional laparoscopic instruments, as was expected length of stay.

There was one conversion to open incision laparotomy during a complex revisional procedure for a feeding jejunostomy placement related to dense adhesions. There was one postoperative complication with a presumed anastomotic leak following laparoscopic duodenojejunostomy requiring exploratory laparotomy and washout. Findings at that time did not demonstrate anastomotic leak. There were no deaths in our series. There were no instrument malfunctions or specific instrument-related complications in our series. Postoperatively, the scarring following Percuvance use was minimal, and there were no wound-related complications with the Percuvance system or other trocar sites.

Figure 3 is an intraoperative photograph demonstrating the difference in skin incision size among 10-mm, 5-mm, and Percuvance access sites immediately prior to closure.

OPEN IN VIEWER

FIG. 3.

Intraoperative demonstration of skin incision sizes using the Percuvance system, a 5-mm port, and a 10-mm port.

Discussion

There is a continued interest in the development of less invasive technology in general surgery. The most common paradigm in minimally invasive surgery is entry of a single trocar through separate incisions in the abdomen. However, in an effort to decrease postoperative pain and minimize scarring, alternative techniques have been described. Innovations have ranged from natural orifice surgery to single-incision surgery. Well-known limitations to these include reduced surgeon ergonomics, difficulty in instrument triangulation, and decreased quality of optics that may be encountered. Single-access surgery minimizes the number of incisions but results in worsened ergonomics with unclear effects on postoperative pain and rates of hernia incidence, ² and some have shown that there is increased cosmesis at the expense of increased hernia occurrence. ³ Furthermore, these technologies are associated with learning curves. ⁴

Needlescopic surgery, first described by Gagner and Garcia-Ruiz ¹ in 1998, is defined by the use of instruments 3 mm or less in diameter in an effort to decrease access-related tissue trauma, including pain, hernia, and wound infection. In this initial 60-patient series undergoing laparoscopic cholecystectomy, they found that the operating time was longer for the needlescopic group but that postoperative analgesia use was reduced. The use of needlescopic instruments in a similar configuration as standard laparoscopy obviates the need to relearn how to perform a procedure, eliminating the steep learning curve associated with other proposed technologies. Patient positioning and surgeon ergonomics are identical to those for standard laparoscopy. The use of needlescopic instruments has been previously demonstrated to be feasible in a range of laparoscopic surgeries, including cholecystectomy, appendectomy, splenectomy, Nissen fundoplication, thyroidectomy, axillary lymph node dissections, and video-assisted thoracoscopic surgery.^5,6

Potential advantages of needlescopic instruments include decreased abdominal wall trauma and risk of future herniation, decreased risk of wound infection with a smaller skin incision, and a virtually invisible scar, improving postoperative cosmesis.^6,7 Needlescopic surgery has been demonstrated to have decreased sympathetic nervous system activation compared with traditional laparoscopy and likely contributes to decreased narcotic requirements in the postoperative period. ⁸ Needlescopic instruments have also been described as a valuable adjunct to single-incision laparoscopic surgery, and their use has been shown to shorten operative times and minimize port-site abdominal wall trauma. ⁶

However, the use of such needlescopic instruments has been limited in application by the small size of the instrument head (less than 3 mm), lack of strength of the instruments themselves in tissue handling, and limited instrument heads available for use. ⁶ The smaller end effector can have an increased risk of tissue trauma due to the pointed head required for insertion. ⁶ The use of 3-mm shafts with 5-mm end effectors has been described in the past, ⁹ but their widespread adoption may have been limited by unclear indications for their use as well as a learning curve associated with end-effector exchange.

In our experience, we found that the Percuvance system was a comparable alternative to a 5-mm port with similar performance to a traditional laparoscopic instrument. Extracorporealizing the 2.9-mm shaft through a separate 5-mm or larger trocar was technically simple, as was the actual exchange of different end effectors. The needlescopic tips (and other instrument tips) are screwed on, and this entire process takes place outside of the abdominal cavity. We did not experience any disengagement of instrument tips during this study, nor did we experience any laxity or looseness of the tip that would make us concerned about the durability of the needlescopic tip. When the shafts were removed from the abdominal wall, we experienced no loss of pneumoperitoneum; this would potentially allow the surgeon to resite the Percuvance instruments multiple times without opening new instruments or needing to address loss of pneumoperitoneum.

Our series had only one conversion from laparoscopic to open surgery, and this was not attributable to the Percuvance instruments. Rather, it was a re-operative case with unclear anatomy requiring conversion to open. However, we were able to complete a significant portion of the initial dissection laparoscopically, facilitating the open portion of the procedure. Prior trials have demonstrated that the conversion rate from laparoscopic to open cholecystectomy is similar in needlescopic versus conventional laparoscopic surgery. ¹⁰

Needlescopic surgery has been demonstrated to improve cosmesis and decrease postoperative pain. We believe that widespread adoption has been somewhat limited by unclear indications for their use. In our series, we used the Percuvance in an unselected cohort of patients in exchange for the traditional 5-mm port(s). Due to the limited variety of end effectors currently available, the needlescopic instruments were used primarily for grasping (e.g., running the bowel) or retracting (as in the lateral port sites during a sleeve gastrectomy and cholecystectomy). However, it should be noted that both surgeons were able to successfully use the grasping instruments for nontraditional use, including intracorporeal suturing when the percutaneous site offered a better approach. Limitations of this study are that it is a retrospective review with a small sample size and limited patient follow-up. However, the aim of our article is to demonstrate feasibility and flexibility of using a novel needlescopic instrument device. As our experience with the technology grows, the utility as well as long-term outcomes may become more evident. As the variety of end effectors grows, the flexibility in exchanging the percutaneous instruments for 5-mm port sites should expand.

Conclusions

This initial experience with the Percuvance system demonstrated effective exchange of 5-mm port sites for needlescopic instruments with similar handling to traditional laparoscopic instruments. The Percuvance system may provide a viable option in minimizing the number of larger incisions while providing a more durable end effector compared with traditional needlescopic instruments and may allow maintenance of basic, safe laparoscopic principles in the setting of decreased caliber access.