Revival of needle devices
Needle devices became popular during the latter 1990s and early 2000s, and attention has again focused on the use of 2-mm needle forceps for needlescopic surgery, which originally did not achieve widespread use.
Needle devices facilitate single-port surgery, and their role as auxiliary forceps is being reconsidered. In the last few years, many medical equipment manufacturers have started to develop and sell needle devices with improved strength and durability.
Improved cosmetic results and the ability for surgery to be easily performed by any surgeon at any location
The Needle Forceps – Endo Relief (Hirata Precisions Co., Ltd) are small diameter forceps that improve cosmetic results and reduce surgical invasiveness, without increasing surgical difficulty. In addition, unlike other small diameter forceps with narrow tips, the Endo Relief forceps require no special precautions for grasping or to avoid tissue damage. Endo Relief is the only needle forceps that can be used to grasp the large intestine. This is because the shape and size of the tip are the same as conventional 5-mm forceps. Using the Endo Relief instead of 5-mm forceps is like using “magical” forceps that enable a non-expert surgeon to perform surgery like an expert. Further details are described below. Endo Relief / Splendid configuration The Endo Relief has a 5-mm tip that gradually transitions to a 2.4-mm shaft. This configuration permits surgery similar to that with 5-mm forceps, but the abdominal wall penetration incision is the size of the needle device. The tip grasper and shaft have an integrated structure without a joint in the small diameter area. The absence of a joint between the narrow shaft and tip grasper provides excellent rigidity and durability (Fig. 1).
Conventional 5-mm forceps and the Endo Relief
If the shaft is removed, the tip graspers of 5-mm forceps and Endo Relief needle forceps are exactly the same. Because the tip grasper and shaft of the Endo Relief are connected at the thicker 5-mm region, there are no problems with rigidity or durability (Fig. 2a). Since the small diameter shaft is constructed from a memory-shape titanium alloy, it is very strong and will not remain bent as with stainless steel (Fig. 2b, c).
Endo Relief / Handle
The handle can be attached and detached instead of removing the tip. The forceps end is thin, with the same outer diameter as the shaft because of a special insertion method (Fig. 3).
Endo Relief insertion device / Shaft Guide Plus
To use the Endo Relief, whose tip is larger than the small diameter shaft, with abdominal penetration only the same size as the small diameter shaft, a special insertion device is required. Using a device called the Shaft Guide Plus, the forceps are inserted from the distal end into the peritoneal cavity. There are two methods of insertion: A) puncture with an inner needle in the Shaft Guide Plus, and B) puncture with a shaft guide outer sheath only using a 2-mm trocar (e.g., MiniSite™, MiniPort™, Covidien). Fig. 4 top: Shaft Guide Plus Fig. 4 bottom: The Endo Relief distal end and Shaft Guide Plus tip fit perfectly together.
A. Puncture method Fig. 5A a.
Perform puncture with the Shaft Guide Plus and remove the inner needle. b.While pulling out the laparoscope inserted from a 5-mm trocar, insert the shaft guide outer sheath toward the 5-mm trocar. c. Connect the forceps end to the shaft guide outer sheath exiting from the 5-mm trocar. d. Push in the forceps shaft while being careful to ensure that the forceps and shaft guide outer sheath do not separate. e. Pull out the forceps end away from the 5-mm trocar. f. Attach the handle.
B. Trocar method Fig. 5B
Use a small diameter trocar a’. Perform puncture with a 2.7-mm (outside diameter) trocar (MiniSite™, MiniPort™, Covidien). Insert only the shaft guide outer sheath into the peritoneal cavity from the small diameter trocar. Perform the remaining steps as in the puncture method.
Fig. 5C: The shaft guide is inserted from the small diameter port. The shaft guide tip enters the 5-mm trocar through the peritoneal cavity.
Fig. 5D: While pulling the laparoscope and viewing the peritoneal cavity from the 5-mm trocar, the shaft guide tip is guided towards the 5-mm trocar.
Lineup of forceps
There are currently 7 types of tip graspers. If the same tip as an existing 5-mm forceps is used, it can be produced. Fig. 6
Advantages of Endo Relief
- Handling of the device is easy. After set-up, handling is the exactly the same as with 5-mm forceps. The tip is not sharp, so it can be safely handed to an assistant. The Endo Relief is the only needle device that can safely grasp the large intestine and small intestine. Several types of surgical procedures are facilitated. By using one or two during single-port surgery, surgical procedures can be performed easily.
- Contributes to smaller umbilical incisions. Because the number of trocars inserted from the umbilicus can be reduced in single-port surgery, umbilical incision size with single-port surgery can be decreased. This is so-called wound dispersion.
- Endo Relief is reusable, so it is cost-effective.
- Can be used without a trocar.
By puncture with the Shaft Guide Plus, Endo Relief can also be used without a trocar.
Introduction of Ultra-minimally invasive Reduced Port Size surgery for Gynecology
Introduction: The desire for minimal scar surgery promoted the advent of new approaches such as mini-laparoscopy. We introduced our reduced port size laparoscopy and have been expanding the applications. Our aim is to describe the application of the latest technology ultra-fine instrumentation in minimally invasive surgery for benign and malignant uterine disease.
Material & Methods: For this method we use two 5mm and two 2mm ports, as well as two ultra-fine graspers. After becoming accustomed to this approach with hysterectomy of small sized uterus, we extended the application to myomectomy cases and then finally to radical hysterectomy cases.
Results: As the skin and peritoneal incision were quite small, patient recovery was quick. The skin incision on healing, were almost invisible.
Discussion: This surgery offers the least invasive and most cosmetically appealing result desired by patients. Reduced port size mini -laparoscopic surgery has the possibility of greater future potential.
Figure 1. setup of Endo Relief Setup of the forceps The grasper is inserted through the 5mm port. The shaft is pushed out through the 2mm port and connected to the handle.
Figure 2. Configuration of trocars (TLH) (Figure 1,2【Setup】 Our surgery required two 5mm, umbilical and midline port and two 2mm lateral ports. The two lateral ports carry newly developed 2mm graspers which hold 5mm heads with atraumatic jaws. These instruments have to be assembled after ports are established by port cross-introduction. The shaft of the grasper is fed first through the umbilical port and out the 2mm port where the handle is attached outside of the body. )
Figure 3. Transection of the Rt infundibulopelvic and the Lt round ligament (TLH)
Figure 4. Suturing and transection of the Lt cardinal ligament
Figure 5.Opening and development of the paravesival and pararectal space(LRH)
Figure 6. Pelvic Lymphadenectomy (LRH)
Figure 7. Isolation and transection of the Lt cardical ligament (LRH)
Figure 8. Closure of the vagina (LRH) Conclusion: We could apply the ultra-fine instruments to each of these cases without difficulty. Ultra-fine instrumentation is another future trend in minimally invasive surgery.
Possibilities with Endo Relief
Specific precautions have long been advised in needlescopic surgery when using needle forceps, because of their needle-like tip configuration. Despite the availability of evidence from needlescopic surgeons, widespread use has not been achieved. However, although the Endo Relief is also a needle device, handling after insertion is the same as with 5-mm forceps, and no specific precautions are required. Therefore, Endo Relief needle forceps do not require specific expertise for use. Any surgeon who performs laparoscopic surgery with 5-mm forceps can easily use Endo Relief without the need for other specific devices or precautions. In addition, surgery by non-expert surgeons can be performed as minimally invasive surgery. With respect to 5-mm trocar incisions where forceps exchange is not necessary, all can be 2-mm incisions not requiring suturing by using Endo Relief. Prudent surgeons will soon realize that many 5-mm forceps are unnecessary once they actually use the Endo Relief.