7 Exciting Advances in Laparoscopy and Endoscopy

TransEnterix

Senhance Surgical System

transenterix.com

Everybody talks about Intuitive Surgical. They're without a doubt the industry standard for soft tissue robotics, they have a huge market share in robotic surgery and their single port robot that was here is exciting. But everyone who does robotic surgery is looking for competition in the marketplace. TransEnterix's Senhance Surgical System has been around a couple years now, but they've made some refinements on their system. I won't pass any judgment on how it competes with the da Vinci robot, but it's good to see competition. They have a slightly different business model and a slightly different approach to the technology. But awesome — more robots in the operating room!

I'm a firm believer that anytime you can put a computer between the surgeon and the patient, you can improve care. You're eliminating the human factor and you're eliminating judgment errors, potentially. More importantly, though, computers can do things we can't. We can create superhuman visualization and take my hands and put them inside the patient through a tiny little hole, but still get them to do the same things that my hands can do. This robot is cleared for laparoscopic colorectal, gynecological, inguinal hernia and cholecystectomy surgery.

Stryker

1588 Advanced Imaging Modalities (AIM) Platform

stryker.com

I've always had this bee in my bonnet about how, for 30 years of laparoscopic surgery, the only thing we've really ever done with the image is go from standard definition to high definition to 4K. Obviously, increased image resolution is great, but there's also so much potential to manipulate the image and give surgeons superhuman abilities to see things they otherwise can't, or just see them more clearly and distinctly. With conventional white light, it's tough for a surgeon to see specific structures. With near-infrared fluorescence imaging, you can see anatomic structures like blood vessels and vascular perfusion much more easily during surgery, which saves time and improves accuracy. That's why it's exciting that a growing number of companies, Olympus and Karl Storz among them, now offer fluorescence imaging.

Stryker provides that same sort of fluorescent technology, with an important twist. In most cases, when fluorescence imaging is activated, you go to a black-and-white image and it kind of glows wherever the fluorescence is. With the Stryker system, you see the full-color white light image, and it overlays a color, like green, based on where the computer says the fluorescence is coming from. This is a classic case of augmented reality (AR). Fluorescence imaging is, in itself, a huge area for surgery, expanding our ability to identify landmarks. This is the next level.

Xenocor

Xenoscope

xenocor.com

We all basically use the same laparoscopic camera — the Hopkins rod-lens system — for minimally invasive surgery. Most technology being developed right now is still backwards-compatible with this camera. But there are frustrations with it. It sometimes fogs up; because the inside of the human body is warm and moist, when the camera becomes room temperature and you put it back inside, you get condensation right away. We try to avoid this problem by dripping anti-fogging liquid on the end of the camera like you use on your ski goggles, or by heating the camera so it's the same temperature — not the most elegant solutions. These guys have developed a laparoscope that abandons the Hopkins rod-lens system, and actually heats its own tip. So it gets rid of fogging from cautery smoke, which sometimes obscures the field. They also have a way of manipulating the wavelength of light so you can see right through the fog. This is actually a disposable laparoscope, and while that business model needs to be discussed, it could have appeal for infection control purposes.

Pacira Pharmaceuticals

Exparel

exparel.com

I know Exparel isn't new, but it continues to grow in importance and relevance. Surgeons are very interested in opioid-sparing anesthesia these days, and for good reason. Quicker recovery, shorter hospital stays and, in a societally topical way, fewer opioid prescriptions are some of the major ones. Pacira makes a liposomal bupivacaine you can inject in and around the incision to reduce the patient's need for taking supplemental analgesia for 72 hours. It freezes the trocar sites, freezes the small incision site and probably accelerates discharge. It's definitely cutting down on the volume of opioid prescriptions, and that is so important right now.

CDx Diagnostics

WATS3D (Wide-Area Transepithelial Sampling)

wats3d.com

The goal of this system is to more reliably spot pre-cancerous cells for removal in patients with chronic heartburn or Barrett's esophagus. It synthesizes dozens of 2D optical slices of each 3-micron focal plane into one 3D image of the entire 150-micron thick specimen. The pathologist gets an in vivo, en face view of the gland to better diagnosis dysplasia that might have been reported as "indefinite" with traditional methods. WATS3D not only addresses the sampling error inherent in relying on random forceps biopsies, but its three-dimensional computer-assisted analysis of the tissue sample provides the GI pathologist with diagnostic information that is not typically available using standard tissue-based histopathology, says the company.

With this company's technology, you use a stiff brush on a wide area of tissue. So it's not really random biopsies; you're sampling a much larger area, and you send all that tissue to their lab. That in itself is no particular innovation. But the clever thing is that they then put all those tissue samples into a neural network that scans them. And based on its experience with a large volume of previous samples, it selects the samples most likely to possibly represent dysplastic or malignant tissue. Then they present those to the pathologist for further examination. So it lets you take a large volume of sampling, but you don't need to ask a pathologist to look at every single slide. Instead, you're using AI to select the most suspect slides, and then the human expert can view just those, and confirm if there's a problem.

Olympus

FlexDex

medical.olympusamerica.com

There's some interest now in developing mechanical systems that aren't necessarily mechatronic. The idea is that instead of investing in a multimillion-dollar robot, you'd still be giving the surgeon an instrument with a flexible wrist at the end, but at a much lower cost. The disposable FlexDex device is an example. It's mechanical, but not mechatronic. It gives the surgeon a wristed instrument that allows you to do what you could do with a robot, without buying a robotic system. It's a 3-axis gimbal that attaches to the surgeon's wrist, and essentially translates all of the surgeon's physical movements into corresponding movements of an end-effector inside the patient. And it combines with Olympus's Endoeye Flex laparoscope, which enables you to wear 3D glasses to get immersive imaging while you're operating with these dexterous instruments.

Human Xtensions

Artefficient Surgery

human-x.com

A handheld robot? What an ingenious idea. Instead of a robotic system, this bionic surgical glove "combines the capacity of robotics with the benefits of handheld innovation," says the company. You're performing minimally invasive surgery, but it feels more like open surgery to surgeons — as if their hands are inside the patient's body, moving precisely and smoothly. Interestingly, you needed an appointment to go inside the company's big black box of a booth to see the product. OSM