The Technical Principles of Endoscopic Surgery

Voorwerk

1. Training adaptive endoscopic surgeons: the didactical paradox

Abstract

Surgical training has a longstanding tradition based on the master-apprentice method. Patient safety and quality of care are intrinsically safeguarded through this approach. However, the surgical environment has changed drastically in recent decades, meaning this concept is no longer a valid method of training. It is time for a change. Technological developments, breaking with the long-hours culture, and increasingly limited opportunities for on-the-job training have resulted in a focus on simulation-based training to complement or even replace learning in the workplace. However, many training programs in skills labs adopt the traditional “see one, do one, teach one” approach, potentially limiting the transfer of what is learned to clinical practice. A paradigm shift in the didactical method is needed; a shift in responsibility is required. This chapter describes a different approach to learning in a simulated surgical environment for both trainees and experts.

Heleen A. T. Miedema, Marleen Groenier

2. The need for technology training for endoscopic surgeons

Abstract

Innovation has always played a major role in surgery, and the advances of the last 50 years have demanded surgeons update their skills along with technological progress. Mastering endoscopic techniques is becoming more relevant with regard to optimizing minimally invasive patient-driven care. Standardized training curricula on different devices are needed to master techniques to ensure safety and proficiency in endoscopic surgery. Training during surgical residency should keep pace with technological advancements, with residents being exposed to robotic and artificial intelligence early on, permitting them to become familiar and develop an open mindset toward these technologies. Simulation-based training is paramount in the learning process, resulting in diminished concentration and less time needed to perform practical procedures. However, expert mentoring cannot be completely replaced, although it is more demanding in terms of time and resources. Fully mastering different techniques and their synergies directly benefits tailored patient care, so continuous education in surgical technologies is fundamental.

Pietro Riva, Deborah Keller, Silvana Perretta

3. The resident training curriculum

Abstract

Training curricula for endoscopic surgery for residents are still mandatory. While endoscopic surgery extensively accommodates and adapts advanced technology, it demands life-long familiarity with every modality used. This includes their potential adverse effects, their use, and trouble-shooting. Although minimally invasive skills are obtained largely while on the job, most countries have guidelines on the core curricula of general surgical, gynecological, and urological training. Although the validity (in terms of its positive effects on clinical performance) of simulation is still surprisingly limited, new technical developments, logical, and ethical reasons justify its inclusion in training curricula. Background information, used to train residents into fully competent endoscopic surgeons, is obtained through a variety of approaches, such as Rasmussen’s theory of planned behavior in three steps: skill-based, rule-based, and knowledge-based. Training in basic MIS skills is therefore a condition that cannot be ignored.

Laurents P. S. Stassen, Frank Willem Jansen

4. Concept and use of Virtual Reality simulators and serious gaming

Abstract

Virtual reality simulators have been incorporated into surgical education to provide opportunities for deliberate practice. A broad range of immersive experiences with virtual reality stimulators are commercially available that range from low fidelity devices to high fidelity systems equipped with haptic feedback. Studies have demonstrated the validity of these devices and their ability to shorten learning curves. Concurrent with simulators, serious gaming has become increasingly popular in medical education. These artificial intelligence driven technologies provide a safe learning environment with the additional advantages of standardization and automated feedback. Current applications include the development of basic and complex surgical skills, warm-up and training prior to complex surgeries, assessment of skill, and preoperative or intraoperative planning. Factors like cost, system design, and learning objectives should be considered when considering virtual reality simulation in surgical education.

Golsa Shafa, Amin Madani

5. Laparoscopy training from global surgery perspective

Abstract

For 5 billion people on this planet, timely access to safe surgical services is in danger, and shortages of healthcare staff resulting in significant peri-operative morbidity and mortality cases. As such, expanding and strengthening the surgical health workforce are two of the most important health policy issues for decisions makers in Low and Middle Income Countries (LMICs). At first sight, investing in minimally invasive surgery should not be prioritized as it may distract from urgent basic health needs. However, there are distinct advantages to laparoscopy compared to open surgery, which may be more pronounced in LMICs. Consequently, surgeons and other members of surgical teams apply contextually relevant, local innovations to enable minimally invasive surgical technology to be deployed effectively in low resourced settings. This has recently been picked up by major players in laparoscopic surgical field.

Jurre van Kesteren, Alex J. van Duinen, Jaap H. Bonjer

6. Teleconsultation

Abstract

The use of telemedicine has dramatically changed many parts of surgical care, from pre-operative assessments to post-operative follow-up, and even surgical procedures themselves. This chapter highlights how telemedicine is currently used in medical practices, including remote patient monitoring and mobile health applications, and how this may affect the relationship between the physician and the patient. Moreover, the chapter describes how healthcare providers can use telemedicine to consult with each other to facilitate interdisciplinary care. Importantly, the principal limitations of telemedicine and its future directions in the field of surgery are discussed, including opportunities for distance education and remotely performed surgeries.

Liam Beedling, Tyler Cookson, Karen Barlow, Mehran Anvari

7. The laparoscopic operating room

Abstract

The chapter is devoted to describing the main principles governing the choice and use of equipment in a modern laparoscopic operating room (OR). The complex arrangement of laparoscopic OR is described; namely the laparoscopic stack, operating table, operating lamps, airflow systems of OR, and interaction with anesthetic equipment. The main themes in the development of operating system technologies are also described in detail.

Grigoriy Yu. Gololobov, Alexander I. Burmistrov

8. Operating room workflow and efficiency

Abstract

Operating theaters are complex and high-cost medical workspaces. Optimal efficiency is necessary for both patient care and medical institutions. The goal is to reach optimal outcomes with the fewest possible resources. Workflow and efficiency are influenced by patient, staffing, and system factors, and many stakeholders influence outcomes. Surgeons can play an important role by focusing on the standardization of tasks and optimizing data management and communication.

Jennifer Straatman, Donald L. van der Peet

9. The operating room nurse

Abstract

The modern workspace of the operating room nurse has developed into a highly technological environment. The operating room nurse has gained a wide range of new tasks, which require knowledge and experience to ensure a safe laparoscopic procedure. This chapter elaborates on the critical aspects of laparoscopic surgery regarding tasks, table setups, troubleshooting, and knowledge of laparoscopic instruments. Consistent and proper involvement of the operating room nurse during laparoscopic surgery promotes the flow of the surgical procedure, and it is essential to the surgical achieving the optimal result through treatment.

Perla M. Doornbos- van der Dussen, Frank J. Voskens

10. Anesthesia in laparoscopic surgery

Abstract

In this chapter, we describe how to prepare for patients for laparoscopic operations. We provide an overview of what is important to check pre-operatively. Enhanced recovery is the new strategy; laparoscopy should facilitate enhanced recovery. Short-acting drugs in anesthesia are becoming more important. Medications that are used for anesthesia, analgesia, nausea, vomiting, and relaxation are explained. Abdominal pressure is increased when CO₂ is insufflated, and the chapter explains how to manage the ventilation and what should be monitored in patients. Fluid balance is important, patients lose a lot of fluid during laparoscopy due to evaporation. The positioning of the patients should be checked before the surgery starts because the patient is fully covered with sterile drapes. In short, an overview is provided for the management of a laparoscopic surgery by an operating team.

Dennis L. J. A. Harhangi, Vidhya J. Santokhi

11. OR table and positioning

Abstract

Operating tables should be versatile, easy to use, reliable, have generous height and weight restrictions, and be safe for the patient. The mattress should evenly distribute the body pressure and it should be easy to add positioning and safety equipment to the table. Positioning the patient during anesthesia is a shared responsibility among the care providers in the operating room.

Gabor S. A. Abis

12. Positioning the patient and operating table in endoscopic surgery

Abstract

The positioning of the patient and operating table is even more important in endoscopic surgery than in conventional surgery. In this respect, the overview and exposure of the operative site are paramount, as are the freedom of movement of the surgeon and ergonomics. Every endoscopic operation relates to a specific position of the patient and operating table. It is essential that this is addressed by the operating team during the Time Out procedure, before the operation. Positioning per se, especially with regard to extremes (e.g., low anterior resection of the rectum, adrenal gland resection), occurs without complications if appropriate precautionary measures are taken.

Johan F. Lange

13. Ergonomic concepts in endoscopic surgery

Abstract

Poor body posture during minimally invasive surgery (MIS) leads to physical complaints in the majority of surgeons. Applying basic ergonomic concepts helps to improve this. The surgeon must strive for neutral body posture during surgery. This is affected by the set-up of the patient and equipment in the operating room. Monitor positioning during MIS is a major determinant of body posture, and attention must be given to repositioning the monitors when necessary. Patient and team positioning should be performed with the comfort of the operating team in mind. Surgical tools must be fully functional and require proper use. Several technological developments in MIS can be useful to improve ergonomics. Adhering to basic ergonomic concepts in MIS can reduce the physical and mental strain on surgeons thereby improving surgeons’ health.

André S. J. Nijssen, Merel B. Klunder, Marc J. van Det

14. The insufflator

Abstract

This chapter covers the importance of the insufflator. This is a key tool that creates a pneumoperitoneum. There is no optimal insufflation gas. Currently, CO₂ is considered to be the best option, although exceptions can be made for patients with lung disease. Gasless laparoscopic surgery is also possible. The method and materials used to create a pneumoperitoneum are described here and why high pressure should be avoided. Pressure control can be managed with the insufflator. The risks of insufflation, the technical issues that can be confronted, and how to avoid issues are also covered. Finally, this chapter addresses what steps can be taken in the future to optimize insufflation technics.

Dennis L. J. A. Harhangi, Jean-Paul A. van Basten

15. The CO2 pneumoperitoneum

Abstract

The pathophysiological effects of laparoscopic and robot-assisted surgery are mainly a result of elevated intra-abdominal pressure (IAP), neuro-humoral reactions, and the positioning of the patient. Elevated IAP leads to the venous return diminishing, and the preload and cardiac output decrease. The drop in blood pressure is limited by increasing the afterload, elevated symphatico-tone and activation of the renin-angiotensin-aldosterone-system. There are few consequences with regard to hemodynamics with an IAP beneath 15 mmHg. Positioning of the patient also affects preload. Carbon dioxide is used to create a pneumoperitoneum. This gas is vasoactive and causes hypercarbia. Knowledge of and insights into the pathophysiological changes of the pneumoperitoneum is important in recognizing consequences. Patients with increased intra-cranial pressure or in shock have absolute contra-indications for laparoscopic surgery. Complications of laparoscopic surgery and pneumoperitoneum have to be recognized to avoid adverse outcomes.

Ravin R. Mahadewsing, Jean-Paul A. van Basten

16. Access to the abdominal cavity

Abstract

Laparoscopic surgery, by definition, implies working inside a virtual natural cavity, which becomes real after the creation of a pneumoperitoneum. There are three technical approaches:

1

Closed access with Veress needle; this is the oldest and most traditional access to create the pneumoperitoneum for laparoscopic entry.

 

2

The direct vision technique, or optical access technique. This is a quick and safe alternative that requires accessing the abdominal cavity using a specialized trocar with a transparent tip, which allows how the abdominal wall is traversed to be visualized.

 

3

The open-access technique, developed in 1971 by Hasson. 

 

The surgeon should know the technical details, advantages, and potential complications of each method. There are several situations in which the surgeon should be aware of the increased difficulty of establish the pneumoperitoneum, such as, pregnancy, liver cirrhosis, and hostile abdomen (previous surgery). There is a lack of evidence on this topic. What has been proven is the advantage of direct optical trocar entry over the Veress needle technique, with a higher initial successful entry with the optical trocar.

Eduardo M. Targarona, Sonia Fernández Ananín, Jesús Bollo

17. Trocar design and functionality

Abstract

Laparoscopy requires trocars to contain the pressure of the pneumoperitoneum, and have several features to aid insertion, retain the trocar in the tissue, manage smoke, and more. This chapter discusses the different available trocar types and functions. Certain risks of using trocars are discussed, and an outlook to future trocar features are presented.

Daniel P. Robertson, Jenny Dankelman, Tim Horeman-Franse

18. Ergonomic aspects of trocar placement and orientation

Abstract

Laparoscopic surgery has brought new technical challenges to surgeons, which are inherent to working with minimal access ports. The technique also has major implications on the surgeon’s posture in relation to the OR table and the patient. Excessive strain may lead to physical trauma such as lumbar and neck hernias. In this chapter, the concepts of ergonomics in endoscopic surgery are explained with the incentive to optimize patient outcome and minimize physical burden for the surgeon.

Ivo A. M. J. Broeders, Jeroen W. H. J. Meijerink

19. Rigid telescopes

Abstract

Rigid endoscopes are an essential part of the image chain in endoscopic surgery. In this chapter, the history of endoscopes for minimally invasive surgery is described, and the technique of rod lens endoscopes and “chip-on-the-tip” systems is explained in detail. Information is provided on correct use, cleaning, and maintenance.

Alexander H. R. Frank, Viktor H. von Ehrlich-Treunstätt, Konrad W. Karcz, Maureen M. Kraayenbrink

20. Light sources

Abstract

Light sources for endoscopic surgery couple focused bundles of white light with the surgical lightguide in the endoscope. Traditional xenon lamps are being replaced by Light Emitting Diodes (LEDs), which are more efficient and require less cooling. A color temperature of about 5,000 K and a Color Rendering Index (CRI) ≥ 90 are advisable. LEDs can be so small that some endoscopes have them in their tip. The biggest challenge in endoscopy is getting enough light inside for good visualization, while avoiding tissue overheating. The term “cold light” is misleading, and the term “heat radiation” does not exist: all light can heat up tissue. The balance of light absorption and reflection determines the induced radiation heat. UV and IR light should only be emitted if they serve the medical procedure (e.g., fluorescence, photo-dynamic diagnosis, photo-dynamic therapy) and are restricted to exposure safety limits. Never neglect light source maintenance, and use original lamps and LEDs!

Fokko P. Wieringa

21. Cameras and image processing

Abstract

Image processing and cameras play an important role in endoscopic surgery. Most developments concern the increase in resolution and sensitivity, which is now at its end. New developments will move towards more sensors and different wavelength sensing techniques. Image processing will become more dominant in future developments.

Richard J. C. Meester, Fokko P. Wieringa, Sandy S. Kalisingh

22. Image storage

Abstract

In this chapter, a number of factors are discussed that are important for the implementation of an image storage system. There is no ideal solution unfortunately, not least because the wishes of end-users vary significantly. However, by considering the desired image quality beforehand, the purpose of the storage, the way images are stored, and all technical implications these various options form, you should be able to make a well informed decision between the various available systems. Of course, collaboration with the technical and IT departments in your hospital is crucial.

Alain R. Viddeleer

23. 2D and 3D endoscopic surgery

Abstract

Endoscopic surgery has relied on two dimensional images for decades. Recent innovations in imaging technology have provided high quality three dimensional systems, which may improve surgical performance. In this chapter, the core concepts of three dimensional view are explained, and technical details on equipment are provided. The advantages and challenges of three dimensional view are supported by an extensive literature review.

Amir Szold

24. History of near-infrared fluorescence

Abstract

Near infrared immunofluorescence (NIRF) is based on the excitation of fluorophores by light in a wavelength outside the visible spectrum. This excitation is visualized with a dedicated camera, which can display standard view, the excitation of the fluorophores on a grayscale background, or a combined image.

Daan J. Sikkenk, Esther C. J. Consten, Wouter B. Nagengast

25. Electrical dissection techniques

Abstract

High-frequency energy was introduced in surgery to improve dissection and coagulation. The separation of tissues with hemostasis is defined as dissection. Dissection consists of a sensory visual and tactile component, an access component with tissue manipulation and instrument maneuverability. Several mechanisms have been used to separate tissue and enable hemostasis, and these techniques are discussed in this chapter. They all involve some form of physical energy applied to the tissue in question. The amount of energy required for dissection depends on the type and composition of the tissue. If one can achieve careful hemostasis and is tissue-selective without causing unintended tissue damage, the ideal dissection technique can be achieved.

Sandy S. Kalisingh

26. Advanced hemostasis and dissection

Abstract

Hemostasis originally depended on ligation with sutures. The next big step was electrocoagulation with alternating high frequency current. This technique is still commonly applied in monopolar and bipolar settings. Over the past few decades, new techniques have been developed, which have taken hemostasis and dissection to the next level. The advanced techniques most commonly applied are computer controlled bipolar sealing and ultrasonic dissection. The concepts of these techniques are explained in this chapter.

Ivo A. M. J. Broeders, Ruud M. Verdaasdonk

27. Summary on electro-surgery in minimal invasive procedures

Abstract

Electro-surgery consists of the application of electrical current passing through tissue. Because tissue forms a resistance, heat is generated, which ensures a coagulation. An alternating current with a frequency above 300 kHz will not result in muscle contractions, and it is therefore suitable for electro-surgery. Depending on the signal waveform and voltage, different effects varying from purely cutting to purely coagulation can be achieved. There is monopolar and bipolar diathermia. A monopolar instrument has a small contact surface, resulting in a high energy density at the tissue level with subsequently a high temperature for cutting and/or coagulation. The other electrode is a broad contact diathermy plate. Comparatively, a bipolar instrument contains two electrodes united in one device, with an active electrode and a return electrode. The electro current is confined to a direct path between the electrodes. Other forms of electro-surgery include ultrasonic electro-surgery and vessel sealing techniques, which produce heat by rapid mechanical vibrations. Laparoscopic and robotic instruments are usually long and must be completely isolated to prevent unintended damage to adjacent tissue by current conduction. Only a small active tip of the instrument should be bare for safe electro-surgery. The minimally invasive surgeon should be familiar with electro-surgery and its risks. The background and risks of electro-surgery in minimal invasive procedures are summarized in this chapter.

Jean-Paul A. van Basten, Harrie P. Beerlage

28. Surgical smoke

Abstract

Safety concerns regarding exposure of operating room teams to surgical smoke have been expressed for some time. However, most surgeons have been somewhat complacent about this issue, trusting in relatively scarce direct proof of occupational-related illness as a professional consequence of positive pressure room air ventilation and habitual masking. The onset of the COVID-19 pandemic, however, forced many to focus on the importance of smoke management and, indeed, all surgical gas effluvium, especially during minimally invasive operations. This led to greater advocacy for mindful practice and existing smoke evacuation devices. However, as yet, there has been little further innovation. In tandem with increasing legislative workplace reforms regarding operative smoke management in Europe and the USA, there is considerable opportunity for better understanding and appreciating gas leaks in minimally invasive surgery to upgrade our routine standard of care, especially through the smarter engineering of basic products used routinely in endoscopic surgery, including access trocars, energy instrumentation, and gas insufflators.

Ronan A. Cahill, Jeffrey Dalli, Mohammad F. Khan, Kevin P. Nolan

29. Essentials of instrument manipulation

Abstract

Endoscopic surgical instruments consist of three parts: a tip that is used to manipulate tissues, a shaft to transmit the motion of the handle to the tip, and a handle to control the tip. Conventional handles are based on mediaeval scissor handles. They can result in ergonomic discomfort and even a possibility of neural injury to the surgeon’s hand. This chapter deals with alternative handle designs and their benefits, as well as with general issues related to performing surgery through small incisions, resulting in a limited range of motion, mirroring and scaling of hand movements, and a lack of tactile information. These effects make it hard to carry out complex surgical procedures endoscopically. This chapter describes a number of solutions, such as dedicated semi-automated instruments and low-cost steerable instruments with graspers or scissors that can be articulated in all directions to increase the range of motion and reduce ergonomic discomfort.

Paul Breedveld, Vera G. Kortman, Aimée Sakes

30. Developing the planes and tissue manipulation

Abstract

Optimal tissue dissection in the correct planes is the foundation of safe and proficient surgery. The transition from open to endoscopic surgery forced surgeons to reinvent their techniques, due to completely altered visualization, haptic feedback, retraction, and freedom of instrument steering. The core concepts of correct tissue dissection in the right planes are explained in this chapter, beginning with the importance of knowledge of anatomy and embryology.

Miguel A. Cuesta, Alfredo Alonso-Poza

31. Disposable and reusable instruments in endoscopic surgery

Abstract

Surgical instruments for endoscopic surgery can be reusable, in which case they need to be sterilized after use, or disposable, in which case they are discarded after a single use. Reusable instruments can save costs and have a lower environmental impact, while disposable instruments may optimize sterility and have practical advantages. In this chapter, an in depth review is provided on the advantages and drawbacks of reusable and disposable instruments.

Myrthe M. M. Eussen, Martine Moossdorff, Nicole D. Bouvy

32. Future concepts of instrument design

Abstract

Conventional medical devices are manufactured using standard techniques such as injection molding and CNC. Conventional instruments usually consist of many individual parts based on standard components, such as pulleys, that are used in other technical fields in much larger dimensions. Squeezing down these components into miniature dimensions and fitting everything together, requires elaborate manufacturing and assembly, increasing costs and limiting further size decrease. This chapter deals with the benefits of bio-inspiration, applying smart working principles from nature within innovative medical devices, combined with the incredible manufacturing possibilities of additive manufacturing or 3D printing, enabling the manufacture of prototypes that are much simpler and with higher functionality than conventional tools. The chapter also deals with the limitations of 3D printing at small dimensions, requiring new design approaches and clever ways to merge sterilization with the 3D printing process, to realize broad acceptance for use in the future OR.

Aimée Sakes, Paul Breedveld

33. Cleaning, sterilization, and maintenance

Abstract

Following a medical procedure, any reusable invasive medical devices used is classified as contaminated. These devices must be reprocessed in a hospital’s central sterile supply department using automated decontamination equipment that is validated to international standards. Contaminated devices should be washed manually to remove any organic matter. Disinfection can be carried out to three levels: high, medium, and low. Medical devices that are deemed invasive must be reprocessed using high level disinfection. With the chemical agents used and the temperatures achieved in the washer disinfectors this is classed as a high-level disinfection. Disinfection is a process that kills or inactivates microorganisms. It does not eliminate all microorganisms but reduces them to safe levels for handling. Disassembled and opened medical devices that have successfully passed a high level disinfection cycle should be inspected for functionality to ensure that the item still works correctly. Once these visual checks have been completed, the medical device must be sterilized. Sterilization is a process that destroys all living microorganisms, including bacteria spores. It renders the medical device free from viable organisms. The most rapid and effective way of killing microorganisms is with moist heat. This is achieved by exposing microorganisms to steam, generated to a temperature of 134 °C for three minutes under pressure of 2.1 bar in a sealed chamber, commonly referred to as an autoclave. There are also a number of other methods of sterilization, including dry heat sterilization, gas sterilization, chemical sterilization, and radiation sterilization.

Trevor Duffy

34. Laparoscopic suturing techniques

Abstract

This chapter describes the essentials of laparoscopic suturing and focuses on optimal trocar placement, different materials, and threads for both intracorporal and extracorporal suturing. The basic technical steps are explained, and an introduction to robotic suturing and training possibilities is provided.

Werner A. Draaisma, Sandy S. Kalisingh

35. Endostaplers and endoloops

Abstract

This chapter describes the use and development of endostaplers and endoloops in endoscopic surgery. The use of the endostapler and endoloops should be done with the utmost care, and with full understanding of the concept and the product. Both endoloops and endostaplers have comparable outcomes. The surgeon should use the method they are more experienced with.

Werner A. Draaisma, Sandy S. Kalisingh

36. Advanced laparoscopic techniques

Abstract

Dissection is the separation of tissues and fascial structures with parallel maintenance of hemostasis. The basic principles of laparoscopic dissection are adequate tissue tension, knowledge of anatomical avascular planes, sufficient exposure, and thorough hemostasis. There are several types of dissection used in laparoscopic surgery, among which blunt dissection and sharp dissection can be distinguished. Any method has both positive and negative sides, which determines the need for an integrated approach to their use, taking into account the specifics of the operation.

Grigoriy Yu. Gololobov, Alexander I. Burmistrov

37. Single Incision Laparoscopic Surgery (SILS)

Abstract

The first cases of laparoscopy at the beginning of the 20^th century were diagnostic laparoscopic procedures performed with a single cystoscope. From 1986 onwards, laparoscopy evolved into an accepted multiport technique due to technological improvements. Once it was established, pioneers developed new operative techniques and strategies, tumbling over each other to minimize incisions. Around the beginning of the 21^st century, Single Incision Laparoscopic Surgery was introduced. Only one incision is made and can be used for the introduction of instruments and for specimen extraction. For many experienced laparoscopic surgeons, the differences between the technique and multiport methods proved to be too cumbersome. As a result, single port laparoscopy is not widely used. Its application depends on individual surgeons and institutions, and preferences for particular procedures. We discuss technical details, ergonomic aspects, and the spectrum of favorable and less favorable indications for single incision laparoscopy.

Rogier H. P. M. Crolla, Paul D. Gobardhan

38. Flexible endoscopy during surgery

Abstract

Over the last few decades, there has been a constant surgical trend to push forward to less invasive organ-sparing function-preserving procedures. In this respect, flexible endoscopy has rapidly evolved, establishing better diagnostic standards, and improving therapeutic modalities to handle diseases and complications within the lumen of the gastrointestinal (GI) tract. While flexible endoscopy was formerly considered as a subspecialty in the surgical field, it is currently considered a mandatory set of skills in surgical practice. Surgeons perform endoscopy as an essential component of surgical practice and as a set of skills that are critical to treat patients, using increasingly less invasive approaches. As a matter of fact, over the past decade, the American Board of Surgery (ABS) has mandated that all graduated surgeons should be proficient in flexible endoscopy in order to guarantee the best level of care to patients. It is expected that the management of several GI conditions will mostly shift to purely endoscopic therapies in the near future. Although differences in surgical endoscopy expertise requirements may be found worldwide, surgical societies are showing a growing interest in including endoscopic training in the surgical education curriculum. This chapter highlights the use of endoscopy during the most commonly-performed digestive surgeries and it evaluates the future perspectives of this rapidly evolving cutting-edge field.

María R. Rodríguez Luna, Silvana Perretta

39. In-fluid endoscopic interventions

Abstract

Visibility in the uterine cavity depends on the degree of distension and illumination. For proper visualization for any meaningful procedure, the uterus needs to be distended with liquid media. Various types of liquid media are available. The technique is described in this chapter.

Mark Hans Emanuel, Jean-Paul A. van Basten, Sandy S. Kalisingh

40. Laparoscopic sonography

Abstract

Minimally invasive instrumentation has driven the technological “revolution”. General surgeons are increasingly using advanced technology to accomplish surgical procedures. Ultrasound is currently used by surgeons to varying degrees based on geographic location, practice patterns, traditional delegation of use, and evolving procedures. While no competence in ultrasound is currently a required part of training for board certification in surgery besides FAST, simultaneously, while vastly performed by radiologists, it constitutes an everyday part of clinical pathways, and it involves every area of abdominal surgery and almost every patient. With all the latest advances in abdominal imaging in MRI, CT, functional modalities, including virtual reality embedded imaging, there is still no real time intraoperative imaging that is applicable and available at every moment during the operation. Today, only intraoperative sonography provides real-time, hands-on imaging.

Andrei Keidar, Idan Carmeli

41. Mechanical and robotic camera holders

Abstract

Endoscopic surgery depends on the visualization of the inner body using a camera system. The optic and camera head are usually steered and controlled by a member of the OR team, such as an OR assistant, resident, or second surgeon. They provide a view from their perspective that is not necessarily in line with the first surgeon’s preferences. Many attempts have been made to bring control of the field of view back to the surgeon, but it is difficult for one person to control both instruments and camera without disrupting the flow of surgery. Many methods of steering have been explored and deemed insufficient. Artificial intelligence in image analysis may bring new perspectives to robotized camera steering. An overview of techniques is provided in this chapter.

Frank J. Voskens, Paul J. M. Wijsman

42. Robotic systems for endoscopic surgery

Abstract

The introduction of robot assisted surgery in 1998 marked the next big step in surgical technology. Originally designed for remote surgery telemanipulation, these systems appeared well suited to deal with the core disadvantages of endoscopic surgery. Robotic systems provide an optimal three dimensional view and deal with inversion of movement, scaling, and limited degrees of freedom. They return camera control to the first surgeon and demonstrate significantly better ergonomics. The history of robotic surgery is described in this chapter and an overview of current and net future systems is provided.

Ivo A. M. J. Broeders, Sandy S. Kalisingh, Jelle P. Ruurda

43. Single incision robots

Abstract

Minimally invasive surgery has progressed significantly over the past few decades. The drive to reduce surgical trauma to improve surgical outcomes has ultimately resulted in single incision surgery, which was introduced around the beginning of the 21^st century. Robot-assisted single incision surgery was initially adapted in cholecystectomy and has gradually expanded to other surgical procedures, such as colectomy, hysterectomy, and esophagectomy. The da Vinci surgical system is the most commonly used interface worldwide, however, robots developed by other manufacturers are expected in the coming years. The scientific evidence regarding the added value of robot-assisted single incision surgery is mainly focused on cholecystectomy, and comparative studies remain scarce. A clear case for single incision surgery can be found in the field of natural orifice surgery, such as transoral, transvaginal, and transanal surgery. The initiation of single incision robot-assisted surgery is challenging and requires adequate surgical experience, careful patient selection and consent, and extensive guidance from experienced colleagues.

Robin B. den Boer, Richard van Hillegersberg, Jelle P. Ruurda

44. Mechanical articulating instruments

Abstract

Standard laparoscopic instruments have limited dexterity due to their rigidity, making some surgical tasks extremely challenging. Robotic surgery was developed to overcome these issues, but it is associated with high costs. In recent years, many companies have designed and produced hand-held articulating instruments for laparoscopic surgery, to improve dexterity and ergonomics but with greater cost effectiveness. This chapter describes the main commercially available handheld mechanically articulating instruments for minimally invasive surgery, with a focus on the technology, advantages, and disadvantages of each device. These instruments have different designs and mechanisms to achieve higher degrees of freedom.

Ludovica Baldari, Amir Szold

45. Electromechanical instruments

Abstract

Complex minimally invasive procedures still pose challenges that limit their adoption because they require technical skills that are difficult to develop. One of the most important issues that needs to be addressed is the use of long and stiff instruments that are difficult to manipulate inside the abdomen and are ergonomically unfavorable. The leading solutions are large, console-based robotic systems, but they are too big and too expensive to be widely accepted and universally marketable. The effort to provide the missing link between robotics and laparoscopy have led to the introduction of handheld instrumentation that provides enables surgeons to directly handle the instruments without the mediation of a bulky platform and to move them mimicking the surgeons’ hand motion. The aim of this chapter is to offer an overview of the currently available hand-held electromechanically controlled articulating instruments and to highlight their advantages and drawbacks compared to conventional laparoscopic instrumentation.

Monica Ortenzi, Amir Szold

46. Low cost and alternative robotic surgical systems: a future perspective

Abstract

Robotic surgical systems have been gaining considerable popularity in the medical world because of their benefits, but they are not always as accessible. In general, the costs related to the development of a robotic system are considerable and can easily hit the 100 million dollar (USD) mark for a first system that is ready for clinical use. Most surgical robotic systems generate revenue through service contracts and disposable consumables according to the “razor blade” sales model, making them less suitable for low resource settings. In order to gain acceptance of a technical innovation at a low-resource hospital, a different design approach is often required. By following a “bare-minimum design” methodology, with a strong focus on component interaction analysis (BMD-CIA), robotic systems can be developed that are modular, versatile, and work with reusable instruments. Although some robots are being developed to be more cost efficient, more work is needed to facilitate surgeons all over the world.

Tomas A. Lenssen, Sem F. Hardon, Tim Horeman-Franse

47. The business of endoscopic innovation

Abstract

Innovation in surgery has tended to be characterized by periods of incremental improvements with distinct epochs of fundamental “disruptive” change. Open access to laparoscopic, laparoscopic to robotic, rigid endoscopy to flexible endoscopy: these shifts have brought about fundamental improvements in patient experience but have also required significant shifts in surgical practice. The process of medical innovation is driven by networks of physician innovators, entrepreneurs, investors, and large companies who identify and support innovative ideas and guide them to the market. This chapter explores this ecosystem and describes some of the fundamental disruptive technologies set to change current surgical practice.

Dennis L. M. McWilliams

48. Data privacy, storage, and access

Abstract

The healthcare industry is in a position to undergo a digital transformation in the domain of data storage, privacy, and access. The move to cloud-based storage is a cost-effective way to transition from legacy systems to newer technology with tighter security. Furthermore, it opens up new possibilities to apply state-of-the-art analytics, machine learning, and artificial intelligence to improve personalized healthcare.

Sandjai Bhulai, Egge van der Poel

49. Data analytics and new horizons

Abstract

Data analytics continues to grow in importance in various fields, like healthcare, finance, marketing, and more. The increasing availability of data, the development of new technologies, and the growing recognition of the value of data have revolutionized healthcare and will continue to do so. Data helps healthcare professionals make more informed decisions for improving patient outcomes, reducing costs, enhancing research, and improving population health. In light of these opportunities, there are also growing concerns about data ethics. Data ethics involves considering the potential impacts of data on individuals and society, and ensuring that data is handled responsibly without creating biases. The AI act helps regulate data analytics-powered applications so that innovation can safely progress to bring healthcare to the next level.

Sandjai Bhulai, Egge van der Poel

50. Risk prevention and regulations for the introduction of new devices

Abstract

This chapter describes the procedures such as risk prevention, and regulations for the introduction of new medical devices. The categories and levels are explained.

Fokko P. Wieringa, Ruud M. Verdaasdonk, Keshen R. Mathura

51. Artificial intelligence in endoscopic surgery

Abstract

Artificial intelligence (AI) is the dominant computer technology, driving innovation in almost all industrial and societal sectors in the early 21^st century. The options for AI in healthcare are explored on a large scale, and numerous successful applications are brought to market. Surgery is not a frontrunner in this field because diagnosis is often apparent and surgical images, with constantly changing illumination and quality and tissue deformation are a huge challenge for self-learning systems. Nonetheless, options are apparent in decision making and preparation, during surgery, and in evaluation and prognosis after surgery. In this chapter, the core concepts are explained and options for the complete surgical process are described.

Frank J. Voskens, Julian R. Abbing, Beerend G. A. Gerats, Ivo A. M. J. Broeders

52. The future of medical robotics

Abstract

Research and the commercialization of novel surgical and medical technologies for human application have initiated a major paradigm shift in the diagnosis and treatment of acute and chronic diseases. Associated advantages, such as reduced post-operative trauma, patient-individual approaches, and faster patient recovery, substantiate the technology-based transformation of future global healthcare systems and domains. One major driver is the highly relevant domain of minimally invasive surgery. Dexterous and miniaturized instruments (e.g., recent endoluminal devices) are integrated into surgical navigation and artificial intelligence frameworks, enhancing traditional clinical workflows, operator skills, and patient outcomes. Strategies for the autonomous execution of surgical tasks are also being targeted. Despite great leaps in research and industry, the healthcare transformation must be accompanied by monitoring resulting ethical, legal, and safety concerns. This chapter provides an overview of novel research directions, trends and, challenges in endoluminal and endoscopic applications.

Dennis Kundrat, Giulio Dagnino, Stefano Stramigioli

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