Utility of articulating instruments as an alternative to robotic devices in laparoscopic right hemicolectomy

Abstract

Laparoscopic complete mesocolic excision with central vessel ligation has been widely accepted for its oncological benefits in colon cancer surgery. However, laparoscopic right hemicolectomy involves a risk for vascular injury during dissection around the surgical trunk. This technical difficulty has been attributed to the limited movement of conventional laparoscopic forceps. Although robotic devices can overcome the restricted motion of laparoscopic devices, they are not yet widely used. The ArtiSential is an articulating laparoscopic instrument that has a two-joint end-effector that enables a wide range of motion precisely reflecting the surgeon’s finger movements, and is designed to compensate for the drawbacks of conventional laparoscopic tools. The present study demonstrated the utility of articulating instruments in laparoscopic right hemicolectomy by comparing the authors’ laparoscopic procedures, using articulating instruments, with robotic procedures. Articulating laparoscopic instruments can be successfully maneuvered in virtually the same manner as robotic devices and, as such, represent a viable alternative to robotic surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13691-024-00654-w.

Introduction

Laparoscopic complete mesocolic excision (CME) with central vessel ligation (CVL) has been widely accepted due to its favorable oncological outcomes in colon cancer [1, 2]. However, laparoscopic CVL for right-sided colon cancer increases the risk for vascular injury around the superior mesenteric vein (SMV) and Henle’s trunk, thus making laparoscopic right hemicolectomy still a technically challenging procedure [3]. In addition to anatomical variations along the SMV, the limited movement range of conventional laparoscopic straight forceps makes this approach demanding [4]. The multi-joint, articulating instruments of surgical robots may overcome technical difficulties and enable increased accessibility and tissue manipulation [5]. Although the use of robotic surgery is rapidly spreading, its high cost and prolonged operative duration remain major concerns for many institutions [6, 7].

Several articulating laparoscopic instruments have been developed to compensate for the limited dexterity of conventional laparoscopic forceps [8]. The ArtiSential (LivsMed, Seongnam, Korea) is a multiarticular surgical instrument with a wide range of motion that has been reported to be a useful tool in various types of laparoscopic procedures, including right hemicolectomy [9–12].

Herein, we present a two-case video comparing the surgical technique for laparoscopic right hemicolectomy using the ArtiSential with that of robot-assisted right hemicolectomy, and discuss the utility of articulating instruments in laparoscopic right hemicolectomy.

Technique

Surgical procedure

Patients are placed in the standard lithotomy position, with port placements illustrated in Fig. 1. The procedure begins using a retroperitoneal approach, in which the ascending mesocolon is separated from the retroperitoneum. When the ventral pancreas and duodenum are visualized, a medial approach is initiated. The ileal mesentery is incised toward the SMV after the ileocolic vascular pedicle is detected. For the appropriate CVL, the fat tissue on the anterior wall of the SMV is dissected to its left side to visualize the neural plexus of the superior mesenteric artery (SMA), followed by division of the ileocolic vein (ICV), ileocolic artery (ICA), and right colic artery (RCA) at their roots. Subsequently, the transverse mesocolon is dissected at its distal dissection line and transect the transverse colon using an endoscopic linear stapler. Then, fat tissue around the middle colic artery (MCA) is dissected from its root and the right branch (Rt. Br.) is divided. The mesentery along the proximal transection line of the ileum is also dissected, followed by division of the ileal end using an endoscopic linear stapler. The right-side colon with the tumor is mobilized from the retroperitoneum to achieve a no-touch isolation technique. After completion of right hemicolectomy, intracorporeal anastomosis (IA) is performed using only endoscopic linear staplers. This IA is named the “four-stapled technique” (4ST), because totally four linear stapler cartridges are used without suturing or knot-tying. This series of maneuvers and procedures is exactly the same for the laparoscopic and robotic approaches and performed by the same surgeon. The da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA) is used in the robotic approach.

Fig. 1.

Port placement schema. a For laparoscopic procedures, a camera trocar is placed in a wound-protecting device at the Pfannenstiel incision site. Two 5 mm trocars are placed in the right upper and lower quadrant, an 8 mm trocar is placed in the left lower quadrant, and a 12 mm trocar is placed in the left upper quadrant. The operator stands in the left side and the assistant stands in the right side of the patient. b For robotic procedures using the da Vinci Xi system, the first camera trocar for the second arm is placed in a wound-protecting device at the Pfannenstiel incision. Two 8 mm trocars for the first and third arms are placed in right and left sides of the central camera trocar, respectively. An 8 mm trocar for the fourth retraction arm is placed in the left upper quadrant and a 12 mm trocar for the patient-side surgeon is placed between the third and fourth arms

ArtiSential:

The ArtiSential is equipped with a two-joint end-effector that enables intuitive and precise transmission of the surgeon’s delicate finger movements (Fig. 2). The handle grip can be moved in the horizontal and vertical planes along the forearm axis, and the end-effector can be rotated by 360°, thus enabling operators to reach the target from various directions.

Fig. 2.

Motion of ArtiSential^®. An end-effector (a) moves upward in accord with the handle grip (b) turning upward. The end-effector (c) moves downward in accord with the handle grip (d) turning downward. The white arrow indicates the direction of each part’s motion

Results

Use of the ArtiSential in laparoscopic surgery can yield successful CME with CVL and IA, using virtually the same procedures as robotic surgery (Video S1 and Fig. 3). There was no remarkable difference between these two cases in terms of intraoperative outcomes, pathological findings, and postoperative outcomes (Table 1).

Fig. 3.

Representative images of intraoperative procedure. a A mesocolic plane was exposed by retroperitoneal approach. b Division of the ICV. c Division of the ICA. d Division of the RCA. e Division of the Rt. Br. MCA. f Final view of CME with CVL. In each figure, a left side image displays laparoscopic surgery and a right side image displays a robotic surgery, respectively

Table 1.

Operative outcomes in each surgery

Surgery	ArtiSential	Robotic Surgery
Operation time (min)	208	261
Estimated blood loss (ml)	0	0
Intraoperative complications	None	None
Pathological T factor	3	2
Dissected lymph nodes	43	25
Metastatic lymph nodes	0	0
Postoperative complications	None	None
Postoperative Hospital stay (days)	9	11

Discussion

It has been suggested that laparoscopic CME with CVL demonstrates feasibility and safety comparable with open surgery in terms of short- and long-term outcomes [2, 13]. However, it is technically difficult to use conventional, straight-fixed laparoscopic forceps and devices, especially for right hemicolectomies [4]. Consistent with a previous report [14], we successfully maneuvered the Artisential in virtually the same manner as a surgical robot throughout the right hemicolectomy, resulting in no apparent differences between the two procedures (Video S1).

Right hemicolectomy can be technically demanding, because it involves lymph node dissection around anatomically complex regions, including the surgical trunk, to achieve CME and CVL [15]. In particular, the limited range of motion of conventional laparoscopic instruments makes it difficult to expose the surface of the SMV for complete CVL during laparoscopic surgery, because the SMV line is orthogonal to the axis of the surgeon’s forceps. Here, we safely expose the SMV and skeletonize its branches by exploiting the functionality of the articulating joint. Bipolar forceps in the surgeon’s left hand can be used to hold the tissue perpendicular to the line of dissection without interfering with the view of the laparoscopic camera. A monopolar spatula in the right hand can be used to dissect the tissue at an angle parallel to the SMV and expose the branches by bending the articulation and inserting the tip behind the vessels, which is often performed in robotic surgery (Fig. 3b–e). Therefore, articulating instruments may be useful in laparoscopic right hemicolectomy to compensate for the drawbacks of conventional laparoscopic instruments.

There are, however, some caveats to the use of articulating instruments. These new devices have a learning curve and may require practice before use, similar to surgical robots [11]. In our experience, the surgeon practiced dry-box peg transfer training with ArtiSential for 2 days before use (Online Resource 1). In addition, the instruments are slightly larger than those used in conventional laparoscopic surgery, which, again, is similar to surgical robots [10]. However, we believe that, considering the cost-related advantage of the ArtiSential (the cost of the ArtiSential is 600 USD while that of the surgical robot is 1.5–2 million USD [16, 17]), the ArtiSential is one of the most useful tools as a laparoscopic device.

We demonstrated the utility of articulating instruments in laparoscopic right hemicolectomy by comparing them with robotic procedures. With the functionality of articulating joints, these instruments can be used as alternatives to robotic devices.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

All authors contributed to the study conception and design. Material preparation and data collection were performed by YS and YI. The first draft of the manuscript was written by YS and YI, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Data availability

The data of this study are not openly available, but are available from the corresponding author upon reasonalbe request.

Declarations

Conflict of interest

Y.I., N.H. and K.O. have collaborative researches with LiveMed. The others have no conflict of interest.

Research involving human participants and/or animals

For this type of study, formal consent is not required.

Informed consent

Written informed consent was obtained from all the patients for publication of this video article and any accompanying images.