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Hindawi Applied Bionics and Biomechanics Volume 2022, Article ID 3057485, 8 pages https://doi.org/10.1155/2022/3057485 Research Article Motion Measurement and Analysis of Different Instruments for Single-Incision Laparoscopic Surgery 1 2 3 Kunyong Lyu, Lixiao Yang, and Chengli Song School of Information Science and Technology, ShanghaiTech University, Shanghai 201210, China Equipment Department, Shanghai Changhai Hospital, Shanghai 200433, China Shanghai Institute for Minimally Invasive Therapy, School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China Correspondence should be addressed to Chengli Song; csong@usst.edu.cn Received 24 March 2022; Revised 21 April 2022; Accepted 10 May 2022; Published 1 June 2022 Academic Editor: Fahd Abd Algalil Copyright © 2022 Kunyong Lyu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To objectively compare and analyze the range of motion of three types of instruments for single-incision laparoscopic surgery. Material and Methods. Ten experienced participants were recruited. Straight instruments (Group A), straight/articulating instruments (Group B), and precurved instruments (Group C) were used to complete the transferring task through one site in a laparoscopic simulator. Straight instruments via two separate sites (Group D) served as control. The operation time of each group was recorded. Instrument positions were measured by an optical tracking system. The inserted length and pivoting angles were derived via MATLAB. Results. There was a significant difference in operation time between groups (D< A< B<C, p <0:01). The range of motion of instruments was different on instrument types and surgical approaches. A significant difference in the inserted length was found between groups. Instrument conflicts and inadequate triangulation were found in Group A; instrument conflicts were found in Group B; no obvious conflicts and triangulation problems were observed in Group C. The operation in Group C was similar to the operation in Group D but differed on the left/right pivoting angles. Conclusion. Different types of instruments have different ranges of motion in single-incision laparoscopic surgery. Working with precurved instruments seems like a compromise to traditional laparoscopic surgery if the transmission property, and shaft curvature of the instruments could be improved. An integrated mechanical platform or robotic system might be the ultimate solution for single-incision laparoscopic surgery to pursue even less trauma. 1. Introduction of the proximity and parallel entry of the working instru- ments through a single small incision [4–6]. Two advanced instrumentations, articulating and pre- Single-incision laparoscopic surgery (SILS) is a potentially curved instruments, have been adopted for SILS to overcome less-invasive technique compared with standard laparo- scopic surgery (LAP) as it decreases the number of abdomi- the aforementioned restrictions. For straight and articulating instruments, cross-wise manipulation is often used to form nal incisions. SILS is owned with many advantages, such as effective triangulation; while for the precurved instrument, fewer scars, less trauma, shorter hospital stay, and fewer true-right and true-left manipulation is used, which can imi- wound infections [1, 2]. However, the hypothesized advan- tate the LAP approach and reduce mental workload. Various tages have not yet been proven thoroughly except its cos- metic effect [3]. In addition, several restrictions make SILS comparisons of performance have been done to find out which instrument of the three is most suitable for SILS. more difficult to learn and perform than LAP. Instrument Manipulation method (cross or uncross) [7, 8] and conflicts and insufficient triangulation are inevitable because 2 Applied Bionics and Biomechanics 2.2. Tasks and Groups. Transferring task (Figure 3) was instrument type [9, 10] through a single site have been com- pared and analyzed. The evaluation criteria include opera- designed based on the basic tasks introduced by the Funda- tion time [9], accuracy [8], electromyography [11], mental mentals of Laparoscopic Surgery program (SAGES/ACS, workload [7], and mechanical load [12]. However, instru- FLS program, Los Angeles, CA) [17]. Operators were ment position has rarely been discussed and investigated in required to transfer four rings from the left- to the right- these studies. After all, it is the change of instrument loca- side columns and then reverse the procedure to complete tion that leads to conflicts and inadequate triangulation in the task. Ten experienced participants were recruited, and SILS. Position measurement and kinematic analysis of the all of them were naturally right-handed. Since surgical skill instruments are a useful way not only to qualitatively under- level is not a determining factor, the groups were not classi- stand the formation of conflicts and triangulation issues in fied between participants. Groups were classified according SILS but also to quantitatively obtain the range of motion to instrument type and approach: straight instruments via (ROM) and relative position of the instruments to the simu- SILS (Group A), straight and articulating instruments via lator. Studying the ROM of the laparoscopic instrument can SILS (Group B), precurved instruments via SILS (Group help to determine the operation range inside the human C), and straight instruments via LAP (Group D, control) abdomen and facilitate strategies for SILS, such as the inno- as shown in Figure 4. vative instrument design and surgical plan. 2.3. Coordinate System on the Simulator. A coordinate sys- In general, several commercial tracking systems (electro- tem Oxyz based on the simulator was established magnetic, mechanical, and optical) are available to measure (Figure 5). Points A and B were the insertion points of the positions and movements. The feasibility of an optical track- instruments on the simulator, which were the centers of ing system for the measurement of the motion parameters the universal bearings, while Point C was the center of the was verified [13–16]. Studies show that the ROM of laparo- task board. The middle point of A and B (O) was defined scopic instruments is determined by surgical approaches, as the origin point. O→B was the positive direction of the operation tasks, and left- or right-hand operation, while sur- x-axis, and O→C was the positive direction of the z-axis. gical experience is not viewed as a determining factor [14]. The inserted length, pivoting angles, and relative position In this study, we utilize the optical tracking system to the coordinate system of the instruments were calculated. MicronTracker, H3-60, to measure the ROM of the three The range was calculated as the difference between the max- most-used types of instruments via the SILS approach. imum value and the minimum value. Manipulation features of the three instruments are analyzed based on the movement and ROM of the instruments, and 2.4. Procedure. Before the measurement, the mark templates optimal configuration of the instrument for SILS is and instrument tips were registered in the tracking system. proposed. Each participant performed Group D three times, then Group A three times, then Group B three times, and 2. Material and Methods followed by Group C three times. Locations of the mark and instrument tip were recorded during the operation. 2.1. Apparatus and Setting. The tasks were performed with a Measurement results, including instrument position and ref- laparoscopic simulator (SIMIT Scientific Co., Ltd., Shanghai, erence points for the coordinate system, were imported into China), and the positions of the instrument during the oper- MATLAB R2015a (MathWorks, Inc., Natick, MA, USA) for ation were measured by an optical tracking system (Micro- data processing and analysis. The data were smoothed with a nTracker®, H3-60, Claron Technology Inc., Toronto, moving average filter (window length n =3)at first, and Canada). Both LAP and SILS can be simulated with the mul- ROM was then calculated. Operation time was also tifunctional laparoscopic simulator (Figure 1(a)). Universal recorded, and a one-way analysis of variance (ANOVA) bearings were integrated into the insertion position of the was used to investigate the difference in the completion time simulator to guarantee the stability of the insertion point and ROM between groups. p <0:05 was considered statisti- during instrument movement. Figure 1(c) shows the SILS cally significant. access with two universal bearings. The optical tracking system (Figure 1(b)) works by iden- 3. Results tifying marks in the visible spectrum. Two types of the mark were designed. One is for the left instrument, and the other 3.1. Operation Time. Figure 6 demonstrates the operation is for the right instrument. Fixation of the marks at the time and ROM of the instruments in each group. A signifi- instrument handle (Figure 1(d)) did not interfere with the cant difference was found in the time required to perform normal use of the instrument. Instrument positions were the task in different groups (D< A< B<C, p <0:01). In determined by the location of the marks and instrument tips, SILS groups, operation time with the straight instruments which can be recorded by the tracking system. Two straight (A) was the shortest, followed by the straight/articulating graspers (Figure 2(a)) (SIMIT Scientific Co., Ltd., Shanghai, instruments (B) and precurved instruments (C), respec- China), one articulating grasper (the instrument with the tively. The accomplishment of tasks in LAP (D) took a white handle in Figure 2(b)) (Cambridge Endoscopic shorter time compared with the SILS groups. Devices Inc., Framingham, MA, USA), and two precurved graspers (Figure 2(c)) (Olympus (China) Co., Ltd., Shanghai, 3.2. Range of Motion. As shown in Figure 6, the larger range China) were used to complete the tasks. of the inserted length was necessary to complete the task Applied Bionics and Biomechanics 3 Figure 1: Apparatus and setting. (a) Laparoscopic simulator. (b) Tracking system. (c) SILS access with universal bearings. (d) An instrument with tracking marks. (a) (b) (c) Figure 2: Location of the marks in the instruments. (a) Straight instruments. (b) Straight and articulating instruments. (c) Precurved instruments. using the straight instrument (A) in comparison to the artic- ulating (B) or precurved instruments (C). A significant dif- ference was found (p <0:05). The range of left/right pivoting angles between the three groups had no obvious difference, but a clear difference between the upper and lower limits could be noticed (Figure 6). The range of up/ down pivoting angle of the straight instruments (A) was the largest, followed by the precurved instruments (C), and straight/articulating instruments (B), respectively. Taking straight instruments in LAP (D) into consider- ation, the inserted length of the instruments in the LAP Figure 3: Transferring task. In this image, the straight instruments group was smaller than that in the SILS groups (p <0:05). via LAP (Group D) are illustrated. 4 Applied Bionics and Biomechanics (a) (b) (c) (d) Figure 4: The schematic diagrams of the four groups of ABCD. (a) Group A, two straight instruments via SILS. (b) Group B, one straight instrument and one articulated instrument via SILS. (c) Group C, two precurved instruments via SILS. (d) Group D, two straight instruments via LAP. The range of pivoting angles in group D had no obvious dif- instruments, and the marks were located at the proximal end ference compared to that in SILS. However, the upper and of the handle (Figure 2(a)). The location of the marks and lower limits of the left/right pivoting angle of the instru- tips indicated that instrument conflicts happened internally ments were quite different. or externally. In Group B, there were straight and articulat- ing instruments. The articulating instrument (dominant) 3.3. Instrument Position. Figures 7(a)–7(d) are the xz plane was kept deflection at the distal tip, and there was a small view of the position of the mark, insertion point, and instru- pivoting angle at the handle as well. Therefore, instrument ment tip in Groups A, B, C, and D, respectively. From the xz conflicts were not as severe as in Group A, but the cross- plane view, left/right movement can be observed, and the wise approach restricted the movement of the instruments, left/right pivoting angles can be calculated in this plane. In especially in the up-down direction. In Group C, there were Groups A, B, and C, the insertion points are close to each precurved instruments, and true-right and true-left manipu- other (SILS), while in Group D, they are far from each other lations were used. It seemed that instrument clashes hap- (LAP). Cross-wise manipulation was observed in Groups A pened externally, but the location of the marks was on the and B. The tip of the left instrument is on the right side, proximal side of the shaft (Figure 2(c)). Handles were apart and the tip of the right instrument is on the left side. In from each other due to the curved feature of the shaft. So, Groups C and D, true-right and true-left manipulations were there were no handling conflicts. However, the straight por- used. The xz plane view also indicated the conditions of con- tion of the instrument shaft was too long which caused slight flicts and triangulation. In Group A, there were two straight conflicts between the left and right instruments. In Group D, Applied Bionics and Biomechanics 5 Figure 5: Coordinate system on the simulator. there were two straight instruments in LAP. No instrument and then the ROM of three types of instruments in SILS conflicts happened internally and externally, and true-right and LAP was measured and analyzed. The position of the and true-left manipulations were adopted. Considering the mark, instrument tip, and insertion points clearly showed profile of the instrument shaft and the xz plane view of the the actual spatial position that the instrument could reach position, triangulation deficiency is obvious in Group A. In during operation. Considering the profile of the instrument groups B and C, the triangulation problem was compensated shaft, it is easy to analyze the issue of instrument conflicts by the curved profile of the instrument shaft, while in Group and triangulation. However, it is hard to draw a sound con- clusion on which instrument is the best. D, triangulation was compensated by the location of the insertion points. Straight instruments are most commonly used in clinics. Figures 7(e)–7(h) are the yz plane view of the position of Operation skills are accumulated during the long-term use the mark, insertion point, and instrument tip in Groups A, of straight instruments either in the operation room or in B, C, and D, respectively. From the yz plane view, up/down the training, and even special tips have been developed. As movement can be observed, and the up/down pivoting expected, the operator spent less time with straight instru- angles can be calculated in this plane. ments to complete the transferring task in SILS than with the other two types of instruments, although instrument conflicts and triangulation problems were the most severe 4. Discussion during the three. Familiarity with the tools is an important factor for the operation time. The introduction of the artic- The position of the insertion points in SILS is quite different compared to that in LAP, which is the main reason that ulating instrument in Group B abated the triangulation con- causes a series of problems in SILS [4, 6]. In this study, a straints to some extent, and cross-wise manipulation was coordinate system was established based on the simulator, still used. Bending of the instrument tip and handle during 6 Applied Bionics and Biomechanics Operation time and ROM of instruments Time (s) Inserted length Le/right (deg) Up/down (deg) (mm) A-L C-L A-R C-R B-L D-L B-R D-R Figure 6: Operation time and ROM of instruments. Group A, straight instruments SILS; Group B, straight/articulating instruments SILS; Group C, precurved instruments SILS; Group D, straight instruments LAP. Significant difference was found between groups in the operation time and interested length. p<0:05. 300 300 300 300 200 200 200 200 100 100 100 100 0 0 0 0 –100 –100 –100 –100 –200 –200 –200 –200 –300 –300 –300 –300 –200 0 200 –200 0 200 –200 0 200 –200 0 200 x (mm) x (mm) x (mm) x (mm) (a) (b) (c) (d) 300 300 300 Instrument tip 200 200 200 200 100 100 100 In Ins se er r rtion 0 0 0 p po oin i in nt t t –100 –100 –100 –100 Ma Ma ark –200 –200 –200 –200 –300 –300 –300 –300 –200 0 200 –200 0 200 –200 0 200 –200 0 200 y (mm) y (mm) y (mm) y (mm) (e) (f) (g) (h) Figure 7: Position of the mark, insertion point, and instrument tip. (a–d) The xz plane view of instrument position in Groups A, B, C, and D. (e–h) The yz plane view of instrument position in Groups A, B, C, and D (red points: left instrument; black points: right instrument). The middle point of A and B (O) was defined as the origin point. O→B was the positive direction of the x-axis, and O→C was the positive direction of the z-axis as shown in Figure 5. the operation facilitated the use and measurement of the with at least one curved segment. In this study, double- instrument. Although triangulation was easily formed com- curved instruments from Olympus were used. Theoretically, pared to the straight instruments, operation time with the instrument conflicts and cross-wise manner could be straight and articulating instruments was longer than that avoided, and triangulation could be easily formed. Measure- ment results indicated that a cross-wise manner was avoided with the straight instruments alone, which is in accordance with the results in [10, 18]. indeed, and triangulation was easily formed as well [19]. The The precurved instrument is a recent development in the ROM and operation manner were similar to the straight instrumentation of SILS. The shaft of the instrument is rigid instruments in LAP. But operation time using precurved z (mm) z (mm) z (mm) z (mm) z (mm) z (mm) z (mm) z (mm) Applied Bionics and Biomechanics 7 instruments was the longest. There were several reasons. Authors’ Contributions First, although there are two curved segments in the instru- Kunyong Lyu and Lixiao Yang contributed equally to this ment shaft, the straight part of the instrument is too long work. that the middle part of the instrument works like the straight instruments. Instruments conflicted internally if the inserted length increases or conflicted externally if the inserted length Acknowledgments decreases. Second, the transmission property of the pre- curved instrument is a problem. Due to the friction inside This project was supported by the National Natural Science Foundation of China under grants 51735003 and 51901137, the instrument shaft, opening or closing the jaws is awkward and might cause severe aches to the hands. In addition, rota- in part by the Ministry of Science and Technology of tion of the tip always lagged with the rotation of the knob at National Key Project under grant 2019YFC0120402, and by the Research Project of the Second Military Medical Uni- the handle. And this might cause misoperation because of the inaccurate transmission. Third, as analyzed above, the versity (2016QN16). precurved instrument is new to the operator, and familiarity plays an important role here. References Among the three types of instruments, the precurved instrument works most similar to the traditional LAP oper- [1] S. Dutta, “Early experience with single incision laparoscopic ation [19] and has the potential to be well used for SILS if the surgery: eliminating the scar from abdominal operations,” curvature of the shaft and transmission property could be Journal of Pediatric Surgery, vol. 44, no. 9, pp. 1741–1745, improved. 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Applied Bionics and Biomechanics – Hindawi Publishing Corporation
Published: Jun 1, 2022
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