MICRO-LAPAROSCOPY – AN ALTERNATIVE OR A COMPLEMENT TO THE SINGLE ACCESS VIDEO-SURGERY TECHNIQUES?

JOSÉ M. SCHIAPPA

Hospital CUF Infante Santo, Lisbon, PORTUGAL

Clínica CUF Cascais, Cascais, PORTUGAL

Introduction: In 1997, some companies producing surgical equipments started to develop and to place in the market laparoscopic equipment with 2 and 3 mm. diameter. The basic idea was of minimizing further the agressivity of the surgical approach by creating abdominal entry ports with much reduced dimensions. As usual, immediately after this introduction of the novel equipments reports started to come and presentations of its use in some of the routinely used techniques of laparoscopic surgery by then were also published. Also in Portugal the presentation of this tools were made and we did a few surgeries with it. There were existing some instruments with 3 and some with 2 mm. diameter. As well, the trocars, cannulae had correspondent diminutive diameters and the optics were 3mm. The technical advantages of the use of this approach, called micro-laparoscopy or “needlescopy” seemed very logic and applicable but the practical use did not confirm it because of several types of problems. The first one – which led to an early interruption of the use of the instruments – had to do with the fragility of the equipments. The access trocars and the instruments, as well as the optics, were biased by an obvious frailty, having no resistance whatsoever to torque. In the hands of OR professionals, surgeons, nurses and sterilization technicians, used to handle the 5 and 10mm equipments, by then designated already as “classic”, these had a short life, suffering bending and breaking in the several phases of its process of use. The second problem was even more serious and, added to the first one, gave also a strong contribution for the stopping of using this technique: the 3mm optics had not enough quality to guarantee the viewing of the operative field in good conditions. There was a safety issue which could not be ignored.

Situation Nowadays: In 2008 and 2009, a new generation of equipments, similar to the ones mentioned above, was launched to the surgical market; several companies produce it.

Some of the problems mentioned before are now much less marked. The quality of the tools and its resistance is superior although – obviously – some frailty is still existing; all of these equipments have, anyway, to be carefully handled. The biggest difference lays in the optics and on what they can nowadays show image wise. Visualisation can be considered quite good with a very visible difference.

Technique and Results: The technique of Cholecystectomy by Micro-laparoscopy is similar to the one we use normally in laparoscopic Cholecystectomy with the usual “classic” instruments. Two points need to be stressed as they are crucial for the success of the technique: 1) access ports need to be placed closer to the “working target” than usual. This, not only because some of the instruments are shorter than the usual 5 mm ones, but also because it is mandatory to minimise the possible torque forces existing while working. 2) it is necessary to consider, beforehand, i fone is going to use clips; if so, port placement has to allow the use of a 5 mm clip applier. During that step, visualization is done with the 3 mm optic. 3) if an organ removal is going to be performed (gallbladder or other), it can be more efficient to start by placing immediately a 10-12 mm port at navel level to allow organ removal at the end of surgery; this can also allow, if necessary, the use of larger diameter instruments during the course of surgery. This solution depends on the size of the organ to be removed as, in quite a few cases safe removal of the gallbladder can be done through the 5 mm port.

Using 3 or 4 access ports depends on the surgeon’s choices and on how easy or difficult it is, case by case, to perform a given surgery. In general, we take the decision during surgery, depending on local conditions. Usually we use the umbilical port for the 5 mm optic and we place 2 ports more, 2 or 3 mm. Positioning of ports is our usual, only closer to the “working target”, which is the middle area of the lower rib cage in the right hypocondrium. Dissecting technique, identification and freeing structures, namely at the biliary pedicle, is similar to the one we use in the “classic” laparoscopic Cholecystectomy. After identifying clearly the structures (cystic channel and artery), it is necessary to change optics and its positions. A 3 mm optic is placed in the left hypocondrium port and the umbilical port is used for the clip applier (5 or 10 mm depending on the port and decision taken). After clipping and cutting the structures one can go back to the initial positioning to finalise the surgery. Clinical application of this micro-laparoscopy technique was done by us in 1997 (5 cholecystectomies and 3 diagnostic laparoscopies) and resumed in 2009 (32 cases of cholecystectomies) All surgeries went well, without any incidents and with normal post-operative course. Mean operation time was identical to the one of the “classical” cholecystectomy. Cosmetic wise only a 5 or 12 mm scar is visible at umbilical level, as there is no scar left in the points of application of other ports (needle “puncture” of 2 or 3 mm) Patients refer almost complete absence of pain and a very satisfactory cosmetic result

Final Comments: Using Micro-laparoscopy, by our experience, has advantages over the “Classic Laparoscopy”, by diminishing pain and the use of pain killers; patients are happy with this and with the cosmetic result as almost invisible scars are left. Access by “Single Port” is very much mentioned nowadays. Many surgeons have performed this type of surgery, by using the different possible approaches. Clearly there are technical difficulties for its performance and those difficulties raise questions regarding its broad use. Micro-laparoscopy has to be looked at with an open mind to completely get all of its potential. It really has – despite not possessing still scientific foundings – advantages in use easily grabbed by the surgeons and by the patients. If we consider a “conjoint” use of both techniques (Single Port as main approach, visualisation and work, and Micro-laparoscopy to use working instruments and, in certain steps, optics) we will have, under my point of view, the solution for many of the existing problems for both techniques and a very good solution to obtain excellent final results.

Complementing both techniques and equipments is evident and the way to pursue.

Date: 2014-12-28; view: 997