ArtiSential® Clip Applier Use in Robotic Urologic Surgery: Initial Experience and Outcomes

Introduction

The use of surgical clips in robotic urologic procedures has been well-established. These can be applied with the use of a laparoscopic clip applier via an assistant port or with select robotic clip appliers. The most commonly used surgical clips in urologic surgery are absorbable Hem-o-lok (Weck) clips and titanium (Weck) metallic clips. ¹ Surgical clips are most commonly used to secure vascular and lymphatic structures.^2,3

One of the unique challenges of surgical clip application in urologic surgery is pelvic anatomy. Oftentimes, urologists perform surgery within deep, narrow pelvises. Access to pelvic structures via a transperitoneal robotic approach necessitates adequate maneuvering around bony prominences and major vascular structures. Conventional rigid laparoscopic instruments offer four degrees of freedom (DOF). ⁴ Robotic instruments add 2–3 independent DOFs. The current daVinci Xi® robotic platform (Intuitive Surgical, Sunnyvale, CA) with EndoWrist technology allows for seven DOF, which includes directional steering. ⁵

While robotic surgical clip application allows for the enhanced wrist dexterity that is otherwise not afforded by laparoscopic clip appliers, the need to exchange robotic arms between clip applications, as well as the requirement of removing a working surgical instrument in its stead, proves to be cumbersome and time-consuming to the surgeon. The alternative is laparoscopic clip application performed by the bedside assistant. This has its own limitations, including decreased range of motion of the clip applier, as well as discrepancy between a surgeon’s desired clip location and the assistant’s perceived clip location.

We recently began using a novel laparoscopic clip applier (ArtiSential®, LivsMed, San Diego, CA) with a 360° range of motion as a result of a double-jointed wrist (Fig. 1). The purported benefit of this new technology is more accurate tissue handling and ease of operation. We present our initial case series with this novel technology and preliminary outcomes, including surgeon and bedside assistant perception of device accuracy, as well as user cognitive load. The device was compared with the standard Weck® Hem-o-lok® clip applier (Fig. 2).

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FIG. 1.

The ArtiSential® Clip Applier.

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FIG. 2.

Weck® Hem-o-lok® Clip Applier.

Materials and Methods

A retrospective review of 100 consecutive robotic urologic surgeries completed using the ArtiSential clip applier by two surgeons, with one dedicated urology bedside assist, was conducted from August 2024 to January 2025. Prior to utilization of the new clip applier in practice, a thorough hospital ethics and safety review was performed. Hospital Institutional Review Board approval for chart review was then obtained to review patient outcomes (IRB-32-4198).

The robotic system used was the da Vinci Xi. Surgeries performed were robotic radical prostatectomy (RALP), robotic radical nephrectomy (RARN), and robotic partial nephrectomy (RAPN). All surgeries were performed with a transperitoneal approach. A total of six trocars were used for RALP, including four robotic 8 mm trocars, a 12 mm assistant port, and a 5 mm AirSeal port. A total of five–six trocars were used for RARN/RAPN, including 4 robotic 8 mm trocars, a 12 mm AirSeal port, and, if required for right-sided upper pole RAPN, a 5 mm assistant port. Clips were applied during pelvic lymph node dissection in RALP, during ureteral transection in RARN, and during renorrhaphy in RAPN. Both ArtiSential (Group 1) and Hem-o-lok (Group 2) clips were applied in sequential fashion during similar portions of the cases, with the latter group acting as a control. Clips were passed through the respective 12 mm ports.

The number of successfully deployed clips (no misfires) was recorded and compared between groups. Subjective surgeon and bedside assistant assessment of accuracy of clip application was performed using a dichotomous scale of yes/no and reported in percentages. The cognitive load of the bedside assistant was assessed in each case for each type of clip applier using the NASA Task Load Index (NASA-TLX). A student t-test was performed for continuous variables, and binary logistic regression was performed for dichotomous variables. p-Values were reported. (R core team, R Foundation for Statistical Computing, Vienna, Austria).

Results

Overall cohort performance

Of the 100 total robotic cases performed, 82 were RALP, 10 were RARN, and 8 wereRAPN. Table 1 describes the baseline clinicodemographic profile of the patients accrued. A total of 340 clips in Group 1 and 360 clips in Group 2 were used. The percent of successful deployments of clips in Group 1 was 97.1% (330/340), while in Group 2 it was 94.4% (340/360) (p < 0.05). Subjective bedside assistant assessment of clip application was 91.2% accuracy in Group 1 (301/330 clips) and 87.6% accuracy in Group 2 (298/340 clips). Subjective surgeon assessment of clip application was 89.1% in Group 1 (294/330 clips) and 83.2% in Group 2 (283/340 clips) (Table 2). The mean NASA-TLX was significantly higher in Group 1 compared with Group 2. Figure 3 shows the change in NASA-TLX between Groups 1 and 2. There was a significant decline in score in Group 1 over 5 months compared with Group 2, with a time until equivalent scores of 3 weeks.

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Table 1.

Patient Demographics Per Surgical Approach

Variable	RALP (n = 82)	RARN (n = 10)	RAPN (n = 8)
Patient age (years)	62 ± 2	58 ± 7	55 ± 4
BMI	26 ± 3.4	27 ± 5.1	25 ± 2.3
Hypertension	85%	60%	50%
Diabetes mellitus	45%	20%	25%
Chronic kidney disease	15%	20%	25%
Prior abdominopelvic surgery	51%	40%	38%

All values reported as mean ± standard deviation unless otherwise noted.

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Table 2.

Outcomes of ArtiSential® Clip Applier

Variable	Group 1 (n = 340)	Group 2 (n = 360)	p-value
Successful deployments	97.1%	94.4%	0.042
Accuracy per bedside assistant	91.2%	87.6%	0.035
Accuracy per surgeon	89.1%	83.2%	0.048
NASA Task Load Index (mean ± SD)	29.64 ± 17.98	20.78 ± 4.37	0.026

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FIG. 3.

NASA Task Load Index Changes Over Time.

Device malfunction and 30-Day complications

There were no reported episodes of ArtiSential device malfunction requiring a new clip applier. Table 3 highlights intraoperative and 30-day complications in the total cohort of patients. In the RALP cohort, a total of 4 patients experienced complications. One patient was readmitted with ileus and required nasogastric tube placement, while another patient developed a urinary tract infection. One patient developed a urine leak, which required replacement of the foley catheter and pelvic drain placement by interventional radiology (IR). One patient in Group 2 developed a lymphocele requiring IR drain placement. In the RARN cohort, one patient with Xanthogranulomatous pyelonephritis (XGP) kidney experienced a Clavien III complication of postoperative abscess requiring drain placement by IR. There were no intraoperative or postoperative complications in the RAPN cohort.

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Table 3.

Intraoperative and 30-Day Complications Per Surgical Approach

Variable	RALP (n = 82)	RARN (n = 10)	RAPN (n = 8)
Any complication	4	1	0
Intraoperative	0	0	0
Clavien Dindo 1–2	2	0	0
Clavien Dindo ≥3	2	1	0

Values reported as total number.

Discussion

Our preliminary results show an equivalent safety profile between the ArtiSential clip applier and the standard Weck Hem-o-lok clip applier across RALP, RARN, and RAPN. Surgeon-specific and bedside-assistant impression of clip application accuracy were significantly improved with the ArtiSential clip applier. These initial results suggest that the novel ArtiSential clip applier may provide equal or even improved accuracy of clip application during robotic urologic surgery in the retroperitoneum and pelvis.

We explored the cognitive load of the new clip applier using the NASA-TLX. This metric was first created by the National Aeronautics and Space Administration (NASA) to measure individual cognitive loads in various tasks among general populations. ⁶ This has since been translated into various surgical disciplines, including cardiac surgery, colorectal surgery, and robotic and laparoscopic surgery.^6–8 Within the realm of urologic surgery, a systematic review of intraoperative workload for surgeons performing RALP showed a range of NASA-TLX values of 22.7 ± 3.2 to 62.0 ± 6.4, suggesting anywhere from medium to high cognitive loads. ⁹ To the best of our knowledge, ours is the only other study exploring NASA-TLX cognitive load in bedside assistants for robotic urologic surgery.

We found that there was a significant difference in NASA-TLX scores between Groups 1 and 2 from the inception of the study until the accrual of 100 patients. However, mean NASA-TLX scores in both Group 1 and Group 2 were categorized as medium according to the scoring system. Group 1 scores trended downwards over the course of 6 months, with a precipitous drop in scores seen after 11 surgeries (Fig. 3). Scores between the two groups were similar after 21 cases, indicating a learning curve of about 3 weeks in our practice.

A similar learning curve was previously reported by Sánchez-Margallo et al. in their description of a robotic-controlled laparoscopic needle driver. ¹⁰ The authors found that when comparing standard laparoscopic needle drivers with robotic-controlled for intracorporeal suturing, there was not a significant difference in precision and quality of performance, although the suturing time in the robotic-assisted group was longer. This length of time was significantly reduced after training and mirrors the downward trend in NASA-TLX scores in Group 1 in our study.

The sphere of robotic-controlled and steerable laparoscopic instruments has been explored in other surgical disciplines. Dimitrakakis et al. performed a randomized controlled preclinical trial of a novel robotic handle for endonasal skull base surgery. ¹¹ The researchers created two separate robotic-controlled handheld instrument prototypes, the first a forearm-mounted handle that maps the surgeon’s wrist degrees-of-freedom to that of the robotic end-effector, and the second a joystick-and-trigger handle with a rotating body that places the joystick in the position most comfortable for the surgeon. ¹¹ The authors found both prototypes outperformed the standard handheld instruments, which otherwise lacked articulation.

Strengths of this study include standardized surgical techniques and standardized surgical teams, with the bedside assistant being previously trained in proper handling of the ArtiSential clip applier. In addition, each patient served as their own control, with sequential clipping of relevant anatomy performed by both the standard clip applier and the ArtiSential clip applier. Given the inherent heterogeneity of patient anatomy, we believed this approach to be the most seamless way to account for potential anatomical confounders.

Despite these strengths, there were significant limitations to our study. This includes the small sample size and retrospective design. A consequence of this was blinding between the two treatment arms was not possible, and this may have influenced surgeon and bedside assistant interpretation of device performance. Specifically, the endpoints of the surgeon and bedside assistant assessment of clip accuracy are subjective in nature and prone to user bias. Another limitation was, incidentally, the use of a standardized bedside assistant with over a thousand cases of experience in robotic urologic surgery. Specifically, not all practices have consistent bedside assistants, and the cognitive load of the novel clip applier should be tested among different groups, including surgical trainees.

At the inception of this study, only the medium-sized ArtiSential clip applier was available for production until December. In January, a large clip applier was available for use and became the preferred clip applier used by our surgeons, given stronger jaw strength and improved ease of clip loading by the bedside assistant. The use of two different ArtiSential clip sizes again is a product of the retrospective design of this study and introduces some heterogeneity in our results. That being said, the large clip applier was only used in 15 of the total 100 cases described in the overall cohort.

Further prospective randomized trials are underway to better elucidate the procedural differences and outcomes between standard laparoscopic clip application and ArtiSential clip application. While we report favorable accuracy with the new clip applier, cost-based analyses need to be performed to compare intraoperative as well as postoperative health care expenditures (based on clip-related complications and readmissions) between the ArtiSential and Hem-o-lok clip appliers. This is crucial prior to any general adoption of new technology. The novel device does, however, save on disposables by utilizing the same Hem-o-lok clip loads as the standard Weck clip applier.

Conclusion

The ArtiSential clip applier is a double-jointed, multi-articulating laparoscopic clip applier that allows for improved accuracy of clip application when compared to standard Weck Hem-o-lok clip appliers in pelvic and retroperitoneal robotic urologic surgery. Furthermore, standardized trials are required to determine cost-effectiveness and reproducibility of results across diverse practice types.

Authors’ Contributions

Shirin Razdan: conceptualization, methodology, writing—original draft, review and editing, project administration; A.F.: Methodology, data curation, writing—review and editing; Sanjay Razdan: conceptualization, supervision, writing—review and editing.