Experimental trial on solo surgery for minimally invasive therapy - Comparison of different systems in a phantom model

Background: Robotic aid in minimally invasive surgery (MIS) is becoming more and more common. We designed an experimental trial in a phantom model to verify the feasibility of solo surgery for MIS. By performing laparoscopic cholecystectomy on a phantom model, we compared combinations of different systems available in terms of safety, comfort, and time requirements. Methods: Two surgeons skilled in endoscopic procedures tested the following systems as endoscope holders: the robotic system (AESOP), foot-controlled (AESOP 1000), and voice-controlled (AESOP 2000); the remote controlled FIPS Endoarm, electrically driven and controlled by a finger-ring joystic; the passive system TISKA Endoarm, a mechanical arm moved by hand and fixed by electromagnetical brakes. All of these systems combined with a second TISKA Endoarm as an instrument holder. A combination of two mechanical Martin arms, c, also was tested. The results were compared with those from a control group involving an assistant surgeon. A total of 70 experiments were per formed. Results: The shortest dissection time was registered by the combination of two TISKA Endoarms, with a statistically significant difference as compared with the control group (p < 0.05) and experiments using AESOP 1000 (p < 0.05). The TISKA Endoarm also proved to be more comfortable when used as an instrument holder (p < 0.001 vs Martin arm), and rated second only to AESOP 2000 as an endoscope holder. The rating of AESOP 2000 as endoscope holder was significantly higher than that of all other groups (p < 0.001). The study proved the feasibility of solo surgery. The time needed for dissection was shortest when two TISKA Endoarms were used, demonstrating the possible advantages of solo surgery. The TISKA Endoarm received a subjective positive rating when used as both endoscope holder and instrument holder. The voice control of AESOP 2000 seemed to be a major improvement in the development of an optimal man-machine interface. Nevertheless, the system presents considerable space requirements and does not supply control of 30 degrees optics. The principle of the finger-ring joystick adopted by the FIPS Endoarm seemed very intuitive but lacking in ergonomy. Conclusion: Laparoscopic solo surgery can be considered a safe procedure, although further technologic developments should lead to improved ergonomy, intuitiveness of handling, and architecture of the systems, offering the surgeon better control, increased precision of action, and reduction in operation time.