Mini-laparoscopy

Dr Shepherd is Assistant Professor of Obstetrics and Gynecology and Director of Minimally Invasive Surgery at the University of Illinois at Chicago. She reports receiving consulting fees/honoraria from Hologic, Inc.  

Laparoscopic surgery is well established and allows surgeons to use smaller incisions to perform the same procedures done through traditional open surgery. Studies have long shown major benefits of laparoscopic surgery for patients, including decreased bleeding, reduced postoperative pain, shorter hospital stays, and quicker return to normal physical activities and to work. 

In addition to these advantages, patients can expect better cosmesis and, for those who have major comorbidities, lower risk of wound complications. The smaller incisions required for traditional laparoscopy are less likely to become infected than those from open surgery and are less vulnerable to herniation, particularly in overweight and obese patients.

The same advantages apply to surgery performed with the even smaller-diameter instruments used for mini-laparoscopy. With these procedures, postoperative complications such as subcutaneous or subfascial extravasation of blood and possible hematoma formation also are reduced.

The term “mini-laparoscopy” is broad and encompasses all techniques for which smaller incisions are used, alone or in combination with smaller instruments. Other terms used to describe these procedures include “mini-laparoscopic,” “needlescopic,” and “reduced trocar.” The size of instruments and incisions for laparoscopy is continuing to decrease, with instruments smaller than 2 mm being used for what is termed “microlaparoscopy.” Here I discuss mini-laparoscopy, defined as use of a 5-mm laparoscope or smaller with ports smaller than 5 mm. With traditional laparoscopy, in contrast, incisions range anywhere from 5 mm to 12 mm.¹

Mini-laparoscopy instruments are designed to facilitate insertion that is straightforward and efficient, and they also reduce time needed for closure at the end of the procedure, virtually eliminating concerns about scarring. These tools also can be used with traditional laparoscopic instruments, providing supplementary support in cases in which additional manipulation is needed. For pediatric patients, mini-laparoscopy affords access without the need for large incisions and with equivalent visibility and dexterity. The result for these children is less pain and faster healing.

Another major advantage of mini-laparoscopy is that the equipment is reusable and, therefore, significantly less expensive. For patients with infertility of endometriosis, the smaller instruments mean less tissue crushing and devascularization, which is important in cases in which tissue management is essential.²

Studies of mini-laparoscopy have shown that, compared with single-incision surgery, it can be performed safely and is correlated with significantly lower operative time and less postoperative pain.³ It is also associated with cost savings, as was demonstrated in a study that compared cholecystectomies in an outpatient setting. Single-incision surgery was found to cost up to 18% more than conventional laparoscopic and mini-laparoscopic procedures.⁴

In another study, researchers compared 2-mm and 10-mm laparoscopes for differences in visualization. The 2 physicians involved were not able to report any significant variations between the 2 instruments.⁵ These results imply that even with a smaller lens, findings with the 2 scopes are comparable, providing reassurance about use of mini-laparoscopes for visualization as well as for diagnosis for conditions such as endometriosis.⁵

Most of the literature on mini-laparoscopy, albeit limited, focuses on the fact that with smaller incisions, both local postoperative pain and incidence of incisional hernias (and potentially small-bowel incarceration) are reduced.³ Following use of 10-mm and 12-mm ports, incidence of incisional hernia is 0.12% and 0.31%, respectively.²

Design

Instruments for mini-laparoscopy range in size from 2.3 mm to 3.5 mm and can be inserted with either access insertion needles or built-in trocars. Because of their small size, the devices are manufactured for increased durability and tensile strength that allows appropriate manipulation of tissue consistent with that for 5-mm, 10-mm and 12-mm instruments. Mini-laparoscopes also must generate images and achieve visibility comparable to that for the larger devices.

Because of the small diameter of mini-laparascopes, the need for closure of fascia and skin is eliminated and cosmesis and patient satisfaction are improved. Because mini-laparoscopes with built-in trocars are self-sealing, they also are able to maintain pneumoperitoneum.

Procedural use

Mini-laparoscopes can be used for various procedures, including diagnostic laparoscopy, hysterectomy, myomectomy, and sacrocolpopexy. The trocars and instruments can be used as the sole instruments or as accessories to traditional-sized instruments. The benefit of mini-laparoscopy in comparison with single-incision procedures is that triangulation is maintained, therefore reducing the need for a learning curve while retaining fundamental principles of conventional laparoscopy.⁶

The 2.3-mm ports of the Mini-Lap Graspers from Stryker Japan KK are mainly used to grasp tissue and to assist with grasping and retraction of tissue by providing counter traction, rather than for manipulation and operation. In studies of mini-laparoscopic graspers, their use did not increase operative difficulty. These devices are available with types in multiple styles. They require no incision and are inserted into the abdominal cavity through an access needle. A stainless steel instrumentation tip and stabilizing pivot disk provide maximum strength for securing, retracting, and manipulating tissue and organs.

The SLIMpac Mini-Laparoscopy system from Blue Endo has a 2.7-mm instrument system, which allows manipulation of tissue and is manufactured with technology that is stated to increase its overall strength and performance. It is inserted with the use of a trocar that is small and still provides the expected cosmetic benefit. These instruments are also reusable and, therefore, cost-efficient.

Karl Storz has developed the Slim Line instrument line, another set of tools with mini-laparoscopic advances. With a 3-mm diameter and 36-cm length, these instruments are inserted with 3.5-mm trocars and can be used instead of standard instruments. They are designed for use as primary instrumentation and are lightweight. The trocars are 15 cm, have silicone leaflet valves, and can be used in nearly all interventions.

Vessel sealing can also be accomplished with mini-laparoscopic electrocautery instruments. Both the 3-mm PKS MOLly forceps by Olympus Gyrus and the 3-mm rotating, bipolar ROBI forceps will coagulate vessels, and monopolar scissors can be used to transect pedicles. Other accessory instruments include needle holders and knot pushers, as well as a suction tip that is available in sizes less than 5 mm. Suturing can be accomplished by introducing the needle through a colpotomy or placing a suprapubic 8-mm trocar for passage of a suture on a CT-2-sized needle. For wound closure, sutures are not required; they can be reapproximated with Steri-Strips at the end of the procedure.

Drawbacks

New products and instrumentation usually have both advantages and disadvantages. With smaller instrumentation, there is a smaller view of the operative field, which can decrease visualization in cases such as endometriosis or severe adhesions.

Mini-laparoscopic electrosurgery instruments limit the vessel size capability and can create difficulty with hemostasis. If visualization is compromised, a 5-mm laparoscope can be inserted in the umbilicus and used interchangeably with a mini-laparoscope. Instrumentation for electrosurgery also can be introduced through the 5-mm trocar.

Summary

Mini-laparoscopy is a valid alternative to traditional laparoscopy for difficult minimally invasive procedures and has been proven to be a technique that can be learned easily by surgeons. Patient satisfaction improves with 3-mm incisions and no suturing is required for closure. Mini-laparoscopy also is associated with significantly less operative time and postoperative pain compared with single-incision surgery and a decreased learning curve. The benefit to patients is undergoing surgery that does not produce visible scars.

For surgeons, the advantage is familiarity with standard laparoscopic surgical technique and instrumentation options. Mini-laparoscopic surgery creates cost savings for hospitals and payees because it is 5% less expensive than traditional laparoscopy, which can result in savings to patients, improved practice patterns, and a significant reduction in hospital costs. 

REFERENCES

1. Novitsky YW, Kercher KW, Czerniach DR, et al. Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial. Arch Surg. 2005;140(12):1178–1183.

2. Hidetaka N, Okuda K, Saito N, et al. Mini-laparoscopic surgery versus conventional laparoscopic surgery for patients with endometriosis. GMIT. 2013:85–88.

3. Fanfani F, Fagotti A, et al. Minilaparoscopic versus single-port total hysterectomy: a randomized trial. J Min Invasive Gynecol. 2012;20:2;192–197.

4. Chekan E, Moore M, Gunnarsson C. Costs and clinical outcomes of conventional single port and micro-laparoscopic cholecystectomy. JSLS. 2013;17(1):30–45.

5. Faber B, Coddington C. Minilaparoscopy-A comparative study of diagnostic accuracy. Fertil Steril. 1997;67:5;952–954.

6. Ghezzi F, Cromi A, Siesto G, et al. Minilaparoscopic versus conventional laparoscopic hysterectomy: results of a randomized trial. J Minim Invasive Gynecol. 2011;18:455e461.