Year : 2012 | Volume
: 28 | Issue : 4 | Page : 466--467
Spider: The next frontier in urological surgery
Deepak S Nagathan
|How to cite this article:|
Nagathan DS. Spider: The next frontier in urological surgery.Indian J Urol 2012;28:466-467
|How to cite this URL:|
Nagathan DS. Spider: The next frontier in urological surgery. Indian J Urol [serial online] 2012 [cited 2022 Aug 16 ];28:466-467
Available from: https://www.indianjurol.com/text.asp?2012/28/4/466/105799
Laparo-endoscopic single-site surgery (LESS) is a term to describe various techniques that aim at performing laparoscopic surgery by consolidating all ports within a single skin incision, often concealed within the umbilicus. The current acceleration in the interest for these techniques has been promoted by the recent introduction of new instrumentation and access devices, incorporation of novel approaches, robotic platforms, and the familiarity of current practitioners with advanced laparoscopic techniques.
In the present study, the authors have described their initial laboratory experience and first clinical application with the use of SPIDER (Single Port Instrument Delivery Extended Reach) surgical platform (TransEnterix, Morrisville, NC, USA) for LESS urologic procedures. Surgeons with different levels of expertise without any prior exposure to the SPIDER system were involved. The spider platform consisted of single port with an outer diameter of 18 mm consisting of four working channels. Two channels allowed the use of flexible and two for rigid working instruments. Two flexible instrument delivery tubes were deployed to guide flexible surgical instruments.
For the dry lab, three tasks were conducted based on the fundamentals of laparoscopic surgery program,  which included peg transfer, pattern cutting, and suturing using intracorporeal knot tying. The time required for completion of each task and numbers of errors were recorded. The surgeons could perform the various tasks while registering penalties in cutting and suturing tasks. Three surgeons, with low level of expertise, were unable to complete the suturing task within the cut-off time limit.
For the animal lab, four male pigs were used to perform nine LESS procedures (pyeloplasty, partial nephrectomy (PN), nephrectomy and partial cystectomy) requiring both extirpative and reconstructive surgical steps. Various task assessed included setup and insertion of the surgical system, operative time, time to manage the pedicle, warm ischemia time, suturing time, estimated blood loss, complications, and the use of additional ports. Surgeons were asked to subjectively score their performance (entry and exit of instruments; triangulation; dissection up, down, laterally, retraction and precision) using a Likert-type scale. The mean time to set up the platform was 3 minutes with no complication related to insertion and a mean operative time of 71±21 minutes. For procedures requiring suturing, the mean time to complete the suture was 26±6.9 minutes. Blood loss was negligible except for two cases of injury to the renal vein. An additional 5 mm port was placed in one nephrectomy case to control bleeding. Mean warm ischemia time for PNs was 29 minutes.
For the clinical case, renal cyst decortication was performed on a 64-year-old woman for Bosnaik type-II cyst by an experienced surgeon. The SPIDER surgical system was inserted through the Gelpoint port. The cyst was initially aspirated and then held up by marionette suture. Later, the cyst wall was circumferentially excised. The operative time was 180 minutes and hospital stay was 36 hours. The patient was satisfied with cosmetic result and the visual pain analogue score was 1.5.
LESS procedures are typically performed by a variation of one of two approaches. The first is single-site surgery, where more than one port can be used through common incision site. The second involves single-port surgery, where a single device, through which multiple instruments and optics can be passed, is used to access the peritoneal cavity via the umbilicus or extra-umbilical. Specific access devices used include TriPort (Olympus), SILS (Covidien), GelPOINT or GelPort (Applied Medical), and X-CONE (Storz,). These traditional devices have been hampered by poor ergonomics, loss of triangulation, and with lack of additional ports, most of the procedures are performed with one hand, as the other is necessary for appropriate retraction. Therefore, it is often cumbersome, frustrating, and therefore, not easy for the average surgeon to adopt. ,
The SPIDER system offers intuitive manoeuvrability of instruments in the abdominal cavity, restored triangulation without external instrument clashing and no significant gas leakage. Other benefits include smaller scar, superior cosmesis, and less pain during follow-up. Initial experience with the SPIDER in gastrointestinal surgeries has shown this system to be effective. Surgeons have also showed feasibility of applying the da Vinci surgical system to LESS (Robotic -- LESS) performed on the VeSPA platform in the porcine model.  However, there were technical limitations such as gas leak and tear in a multichannel port. Other drawbacks of the first-generation SPIDER include difficulty in retraction, depth control with cutting and poor stability of the instrument tip when completely deployed. Hopefully, these limitations will be overcome with improved technology and design. More clinical data such as estimation of pain score and patient satisfaction surveys are necessary to assess its benefit with this new technology.
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