What's New in Minimally Invasive Surgery

Minimally invasive surgery seems to be a big buzz word in the ambulatory surgery center industry. Everyone wants to know what’s new and what’s coming soon to an ASC near you. Here are a couple of items — one a new piece of equipment to make the surgeon’s (and staff’s) lives in the operating room a little easier; the other a new form of laparoscopy that’s gaining attention.

Business is BOOM-ing

Many operating rooms are filled with clutter. Clutter from the numerous carts and cords that either line the walls or run their way up to the ceiling, creating a potential hazard for both physician and staff as they make their way around the room. CompView Medical has come up with a solution by creating the NuBOOM, an all-in-one equipment and visualization system. Instead of being mounted to the ceiling, it’s bound to the floor, creating a little breathing room for the OR.

“Basically it’s combined into our cabinet and shelf space that’s designed to efficiently house all of the existing medical and video equipment,” says Stephen Heniges, vice president of sales and marketing for CompView Medical. In addition to the freed-up space, there are two 9-foot booms that come off with a 35-inch extension arm that allows precise positioning of up to four monitors. Plus it also includes a touch panel control system that allows the user to select the video source that they want on each monitor. “Images can split from a C-arm, an ultrasound, a PACS, as well as the surgical site,” states Heniges.

Along with the improved safety conditions, other benefits include an ergonomic environment for both surgeons and staff that are easier on each. “You now have monitors in locations that you want where you can easily visualize, as opposed to being tied to a cart, which may not be the most ergonomic position for a surgeon, and/or their assistant, or anybody else on the team to view what’s going on,” declares Heniges. Also a plus for ORs are reduced neck and back pain, allowing surgeons to complete additional cases during the day, and decreased turnaround time over video carts in between cases.

Mariano Catbagan can attest to the usefulness of the NuBOOM. In 2006, as director of the outpatient surgery department at Community Hospital of the Monterey Peninsula in Monterey, Calif., he was part of the team that introduced the state-of-the-art design to their new inpatient critical care wing. When it was time to revamp the outpatient OR, “the surgeons wanted to have that kind of equipment in the outpatient surgery center, of course. They wanted the new stuff,” he says. “For the system that we have and for all the money-saving aspects of it all, they’re working out very nicely. And the staff has adjusted to them very nicely as well.”

When it came time to choose between a ceiling-mounted system and the NuBOOM, the financial and time aspects of construction came into play heavily for Catbagan. “The big deal with it is if you have to pay for all the support of retrofitting your ceiling with heavy duty support systems to hold up these heavy monitors and equipment. That’s going to be extra money. And then you have the downtime for the OR, because you have to bring all your contractors to put the supports in the ceiling, re-fit it all and get all your gases (lines) re-certified. That can be anywhere from one to three months...so that can add up.” The NuBOOM was placed in two operating rooms literally over a weekend, saving Catbagan’s department millions of dollars.

“On day one...we place it without bolting it to the ground, and the surgeons, anesthesiologists, the key nurses, etc. can position their equipment to the ideal location.” Heniges points out. “Once they decide, it’s bolted to the floor and it’s done within two days.”

Single Port Laparoscopy

Single port laparoscopy (SPL) is the newest frontier in minimally invasive surgery. SPL uses just one port buried in the umbilicus (or navel) to accommodate both the instruments and camera. This would eliminate the use of up to five separate trocars for the performance of typical laparoscopic procedures and the patient with no visible scars.

In December 2007, Jihad H. Kaouk, MD, director of robotic urologic surgery at Cleveland Clinic and a pioneer of a SPL methodology in the field of urology, performed the world’s first radical prostatectomy and radical urinary cystectomy —cystoprostatectomy — entirely through a single incision in the navel. The conventional laparoscopic approach to radical prostatectomy for prostate cancer and cystoprostatectomy for bladder cancer utilizes five or six abdominal wall incisions. The true SPL trans-umbilical approach employed by Kaouk is a variant of the laparoscopic operation that uses only a single small umbilical incision through which a single specially-designed port is placed. There is no utilization of any other accessory ports inside or outside the umbilicus.

Kaouk has successfully performed many urological reconstructive, ablative and excisional operations with this new approach. These procedures include the first SPL radical prostatectomy, radical urinary cystectomy, trans-abdominal sacral colpopexy for vaginal prolapse, kidney tumor cryoablation and radical nephrectomy. Kaouk also used the single port technique to perform the first single port retroperitoneal kidney surgery and single port laparoscopic pediatric surgery.

So far, no intra-operative or postoperative complications have been observed. There were no conversions to conventional laparoscopic approaches or to traditional open procedures.

The initial experience in SPL by Kaouk and his colleagues at the Cleveland Clinic was presented at the American Urological Association conference in May. This ground-breaking clinical work was accepted for publication in October of 2007 in the Urology Journal. This represents the first peer-reviewed article on the first accomplished cases in SPL in urology. It also includes the largest experience in ablative and reconstructive single port surgery, where all instruments used were passed through the single port without the use of any 2 or 3 millimeter instruments for retraction or assistance.

“Although more clinical experience and scientific studies are required in order to define the patient and health care benefits, the SPL has the potential of improving the patient’s outcomes and saving health care dollars,” states Kaouk.

While still in its infancy, SPL offers substantial opportunity to reduce the risk of penetration injuries, infection rates and post-operative pain while shortening recovery time and improving cosmetic outcome.