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Official Journal of the
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| Original Article « PDF file » |
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SITRACC - Single Trocar Access: A New Device for a New Surgical Approach
Marcus Vinicius Dantas de Campos Martins1; James Skinovsky2; Djalma Ernesto Coelho3; MARIA FERNANDA TORRES4
1 Estácio de Sá University, Rio de Janeiro, Brazil; Rio de Janeiro Federal University, Brazil; 2 Phd, Positivo University, Jacques Perissat Institute, Curitiba, Brazil ; 3 Estácio de Sá University, Rio de Janeiro, Brazil; 4 Positivo University, Curitiba, Brazil.
ABSTRACT
Background: The advent of the endoscopic surgery has
radically changed the surgical approach among the
scientific world. The concept of minimally invasive procedures has spread very fast through the planet, allowing less pain
and faster recovery for patients. We have been exploring this new surgical path and developing a new device for a
new surgical approach, the single trocar access, a concept that links flexible endoscope, a single surgical access and
flexible instruments. We report our technique and initial experience in experimental cholecystectomy in porcine models.
Methods: From December 2007 to March 2008, ten Single Trocar Access - Sitracc Cholecystectomies were performed in
ten female pigs. The surgeries consisted of the classical steps of a laparoscopic cholecystectomy, using special
flexible instruments and a flexible endoscope. In the first three cases, a second 5mm trocar was placed to retract the liver.
Since the development of the second generation of instruments, all procedures have been performed through a single
trocar. Results: There were no conversions to totally laparoscopic or conventional approach. The operative time ranged from
40 to 150 minutes. The animals were submitted to euthanasia at the end of the procedures, according to
experimental surgical rules in Brazil. Conclusions: The cholecystectomy by the Single Trocar Access method is feasible in
porcine models. The technique needs improvement and its further use in human beings has to be carefully tested. It will
become a new option to the minimally invasive surgical field, as well as a new weapon in a continuous struggle to benefit
our patients.
Key words: Minimally Invasive Surgery, Single Trocar Access, Cholecystectomy.
Bras. J. Video-Sur, 2008, v. 1, n. 2: 061-063
| Accepted after revision: April, 24, 2008. |
INTRODUCTION
 |
he endoscopic surgery has been the most important advance with respect to the
surgical field in the last decades. The continuous
improvement of this technique has allowed complex procedures
to be performed in a minimal invasive fashion,
adding huge advantages regarding post-operative
pain, recovery, metabolic response and cosmetics.
With the development of this concept, the execution of surgical procedures through the
human natural orifices is presented as a new approach,
which has to be validated in the next years.
Since Kalloo[1] reported his first experience in natural orifice
translumenal endoscopic surgeries, using transgastric access
in porcine models, many researchers around the world have been working on new technologies
for this approach and looking for definitions of feasibility and potential
advantages.
The meeting which took place in New York City, in 2005, was an important fact for the
development and research of this new technology,
gathering members from the American Society of Gastrointestinal Endoscopy
(ASGE) and from the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES). This group, so
called NOSCAR (Natural Orifices Surgery
Consortium for Assessment and Research) produced a
document called White Paper, in order to define guidelines
for researches, potential benefits and priorities to be
used in the practical field[2].
The training and demand of new work stations, which is the goal of this research, as well as the
access to the abdominal cavity, the gastric closure,
potential infections, new suture devices and spatial
orientation are among the main difficulties for the
development of this technique.
We first published our experience about this kind of procedure in 2006 in the Brazilian
Laparoscopic Surgery Journal[3] and concluded that some
barriers needed to be surmounted for the adequate development of this new technology.
MATERIALS AND METHODS
As a first step, we have been developing a single trocar access (SITRACC®, Edlo®
Company) for abdominal surgery, whose protocol was
approved at Positivo University (Curitiba-Brazil).
This new device consists of a trocar with multiple channels, adding concepts of
flexible endoscopy and laparoscopy. This trocar could be
used through the umbilicus or the vagina (Figure 1).
A flexible optical system and flexible
instruments, specially developed for this purpose, are
inserted through four individual channels.
 |
Figure 1 - Trocar with multiple channels. |
Articulated graspers, scissors, hooks and clip appliers have been developed (Figure 2). These
new instruments are very similar to the
conventional laparoscopic instruments, except for the
new articulated mechanism. This articulation allows
the surgeon to work with several different movements
in a single axis.
 |
Figure 2 - New flexible instruments. |
From December 2007 to March 2008, ten SITRACC® Cholecystectomies were performed
in ten female pigs, average weight 30 Kg. For pre-operative sedation, the animals received
ketamine, xylasine and acepromazine. Right before the
beginning of the procedure, the pigs underwent
general anesthesia induced by thiopenthal (10 mg/Kg)
and maintained with halothane.
In the first three cases, a second 5mm trocar was placed to retract the liver. Since the
development of the second generation of instruments, all
procedures have been performed through a single trocar.
The surgeries consisted of the classical steps of a laparoscopic cholecystectomy.
RESULTS
There were no conversions to totally laparoscopic or conventional approach. The
operative time ranged from 40 to 150 minutes and the
procedure was completed in all cases.
The euthanasia was performed using a fast shot of tiophental, 20 mg/Kg.
DISCUSSION
Several natural human body orifices allow access to the abdominal cavity, such as the
mouth, anus and, in women, the vagina. None of these
orifices has direct access to the peritoneal cavity, but to
an organ inside it.
In 2007, Zhu published his first experience using the umbilicus to access the peritoneal
cavity. This new access technique was described as transumbilical endoscopic surgery
(TUES)4.
The flexible endoscopy has reached a huge development in the last years and
nowadays therapeutic procedures may be a possibility for a
high or even low path. A lot of instruments have
been developed and are inserted through the
endoscope work channels. These devices have limited
movement to perform more advanced surgeries due to their
small diameter and great length.
We propose the use of this new device, which consists of a trocar with multiple channels,
adding concepts of flexible endoscopy and
videolaparoscopy and using it through the umbilicus or vagina. A
flexible optical system and flexible instruments,
specially developed for this platform, are inserted through
four individual channels, allowing the execution of
abdominal surgeries.
In the first protocol, ten pigs have been submitted to single trocar access
cholecystectomies, without major complications.
In this manuscript we show the new device, the instruments and earlier stages of this
surgical procedure and its first experimental surgeries of a
new minimally invasive approach.
CONCLUSIONS
The SITRACC® _ Single Trocar Access Cholecystectomy is feasible in pigs. The possibility
to become in the future an alternative to minimally
invasive approach in human beings depends on the
development of this new technique and its new instruments.
REFERENCES
1. Kallo NA, Sibgh VK, Jagannath SB, Niiyama H, Vaugh
CA, Magee CA, Kantsevoy SV (2004) Flexible
transgastric peritoneoscopy: a novel approach to diagnostic
and therapeutic interventions. Gastrointest Endosc 60: 114-7.
2. ASGE/SAGES Working Group on Natural
Orifice Translumenal Endoscopic Surgery White Paper
(2006). Gastrointest Endosc 63:199-203.
3. Martins MVDC, Coelho DE, Coelho JF, Rios M
(2006) Initial experience with natural orifices
transluminal endoscopic surgery. Rev Bras Videocir 4(2): 75-77.
4. Zhu, JF(2007) Scarless endoscopic surgery: NOTES
or TUES. Surg Endosc 21:1898-1899.
Correspondence address:
MARCUS VINICIUS DANTAS DE CAMPOS MARTINS
Av. das Américas, 1981 - Casa 64 - Barra da Tijuca
Rio de Janeiro, RJ - Brazil
CEP: 22631-000
Tel.: 2484-3850 - Cel.: 9989-1036