Improvements in robotic natural orifice surgery with a novel material handling system

Background: Natural orifice translumenal endoscopic surgery (NOTES) has many potential advantages over other minimally invasive surgical techniques, but it presents a number of challenges introduced by the restrictive natural access points. Fully insertable dexterous in vivo robots have been developed that eliminate the spatial restrictions of the entry point, but they also are isolated within the abdomen. A material handling system (MHS) developed to bridge the gap between the in vivo robots and the surgical team promises a number of improvements over other current technologies. Methods: The MHS was implemented with two different nonsurvival swine models to validate the utility and benefits of the system. The first procedure was attempted transgastrically but proved too difficult because the geometry of the esophagus was prohibitively small. The system was instead inserted via a 50-mm GelPort and tested for robustness. The second procedure used a transvaginal insertion via a custom 25-mm trocar. Throughout both procedures, the practitioners were asked for qualitative feedback regarding the effectiveness of the device and its long-term efficiencies. Results: The MHS was able to deliver a standard surgical staple securely to the peritoneal cavity. The practitioner was able to use the laparoscopic grasper both to insert and to remove the staple from the MHS. The system also proved capable of maintaining insufflation pressure throughout a procedure. It was cycled a total of five times in both the insertion and the retraction directions. Visualization from the MHS camera was poor at times because the lighting on the system was somewhat inadequate. No excessive bleeding or collateral damage to surrounding tissues was observed during the procedure. Conclusions: This study demonstrated that the MHS is fully capable of achieving payload transport during a NOTES operation. The system is intuitive and easy to use. It dramatically decreases collateral trauma in the natural access point and can advantageously reduce the overall duration of a procedure.