TIPOLOGIA E CARATTERISTICHE DEI PORT
M.M. Lirici, MD, FACS
One Port: Help or Hype?
Tipologia e caratteristiche dei port
SCAR
SCARLESS
ROADMAP OF MINIMAL INVASIVENESS
IN SURGERY
The Right Balance?
Tipologia e caratteristiche dei port
INDICATIONS
High Volume
Procedures
cholecystectomy
appendectomy
inguinal hernia repair
oopherectomy
salpingectomy
endometriosis surgery
tubal ligation
pyeloplasty
incisional hernia repair
renal cyst decortication
ablative renal surgery
pelvic lymphadenectomy
nephrectomy
gastric banding
colon resection
Intermediate Volume
Procedures
adrenalectomy
splenectomy
hysterectomy
pelvic organ prolapse
donor nephrectomy
ureteral re-implant
ileal interposition
radical nephrectomy
small bowel resection
fundoplication
wedge liver resection
Low Volume
Procedures
Major bariatric procedures
myomectomy
prostate resection
cystectomy
partial nephrectomy
retroperitoneal lymph
node dissection
esophageal myotomy
distal pancreatectomy
formal liver resections
gastric resections
SINGLE PORT VERSUS REDUCED PORT
Tipologia e caratteristiche dei port
PERSONAL RECORD
2008-2011
Cholecystectomy
60
Appendectomy
18
Sleeve gastrectomy
18/6
Annexectomy
4
Colonic procedures
4
Diagnostic laparoscopy 7
Wedge resection liver
1
Inguinal hernia repair
1
Tipologia e caratteristiche dei port
TECNOLOGIES
WORKING ENVIRONMENT
ERGONOMICS
ACCESS
INSTRUMENTS
VISION
PLATFORMS
ROBOTICS
Tipologia e caratteristiche dei port
WORKING ENVIRONMENT
& ERGONOMICS
ONE PORT LAPAROSCOPY: THE LIMITS
•PHYSICAL CONSTRAINTS
•REDUCED DEGREES OF FREEDOM OF THE WORKING INSTRUMENTS
•LACK OF TRIANGULATION, POOR TRACTION
INSUFFICIENT EXPOSURE
IMPAIREMENT OF ADVANCED SURGICAL TASKS
MENTAL, VISUAL, PHYSICAL FATIGUE
HIGH SKILL DEMANDING?
Tipologia e caratteristiche dei port
ACCESS TECHNOLOGIES
AND TECHNIQUES
DISPOSABLE OR REUSABLE
MULTIPORT ACCESS DEVICES
ALTERNATIVE:
SWISS CHEESE TECHNIQUE
Tipologia e caratteristiche dei port
ACCESS DEVICES
CLASSIFICATION
ACCESS TECHNOLOGY
GEL
MULTIPLE CHANNELS
STRUCTURAL ACCESS
Gelpoint (Applied Medical)
Xcone, Endocone (Karl Storz),
Triport, Quadport
(Olympus),
OCTO-port (Dalim surgnet)
SILS (Covidien), Airseal
(Surgiquest)
RETRACTING TECHNOLOGY
SLEEVE
SOFT STRUCTURAL RETRACTION
RIGID STRUCTURAL RETRACTION
Gelpoint (Applied Medical),
Triport, Quadport
(Olympus),
OCTO-port (Dalim surgnet)
X-Gate
SILS (Covidien)
Xcone, Endocone (Karl Storz),
Airseal (Surgiquest)
Modified from Duhname, Diana, Leroy, Marescaux
Tipologia e caratteristiche dei port
SINGLE INCISION
MULTIPLE FASCIA PUNCTURES
TROCAR TECHNOLOGY
LOW PROFILE TROCARS
Dexide ports (Covidien)
AnchorPort (Surgiquest)
Hunt trocars (Appled Medical)
STANDARD CANNULAS
5 mm cannulas
Tipologia e caratteristiche dei port
SINGLE PORT SITE
SKIN INCISION 15-35 mm
NAVEL
Most procedures
Either transumbilical
umbilicus
or
over/below
RIGHT, LEFT FLANK
Incisional Hernia repair,
Colonic resections
MIDLINE MESOGASTRIUM-EPIGASTRIUM
Bariatric surgery
the
Tipologia e caratteristiche dei port
REDUCED SPACE
Working through a single access
STRAIGHT INSTRUMENTS
PARALLEL DIRECTION
FENCING EFFECT
CROSSING THE SHAFTS
RIGHT HAND ON THE LEFT
LEFT HAND ON THE RIGHT
PRESHAPED CURVED INSTRUMENTS
REPRODUCE OPEN SURGERY
TRIANGULATION
PLATFORMS/ROBOTICS
REPRODUCE OPEN SURGERY
ENVIRONMENT
Tipologia e caratteristiche dei port
POSSIBLE SOLUTIONS
INSTRUMENTS
STRAIGHT, CURVED,
ARTICULATED
SUPERELASTIC ALLOY
INTERNAL GRAB
Tipologia e caratteristiche dei port
POSSIBLE SOLUTIONS
VISION
PRESENT
FUTURE
Courtesy of
P Swain - Surg Endosc 2010
Courtesy of
JF Cadeddu - Ann Surg 2007
ARTICULATED, CHIP-ON-TIP 5
mm SCOPES
EXTERNAL MAGNET CONTROL
MICROCAMERAS
Tipologia e caratteristiche dei port
POSSIBLE SOLUTIONS
PLATFORMS &
ROBOTICS
SPIDER
TRANSENTERIC
MODULE FOR
SINGLE SITE SURGERY
COURTESY
D. OLEINIKOV
UNIVERSITY OF NEBRASKA
Tipologia e caratteristiche dei port
POSSIBLE SOLUTIONS
REDUCED PORT SURGERY
POP – PLUS ONE PUNCTURE
Courtesy of Kanehira - Tokyo
Tipologia e caratteristiche dei port
TAKE HOME MESSAGE
IMPROVEMENT OF QoL AND COSMESIS
THE QUEST:
DOES THEY WORTH?
Tipologia e caratteristiche dei port
No evidence
But the need
for
larger
RCTs
and
methanalyses
and further
technology
development
TREND
Ergonomics
Fatigue
Safety?
OP time
OP costs
Postoperative
pain?
EVIDENCE
Single
Port
Laparoscopy:
Cosmetics
Postoperative
pain?
Quality of Life
Prompter
recover?
Easy
conversion
DRAWBACKS
BENEFITS
CONCLUSIONS
Reduced Port
Surgery
Hybrid
Procedures