TThe LAPMAN® (Medsys, Gembloux, BELGIUM) is a dynamic laparoscope holder guided by a joystick

clipped onto the laparoscopic instruments under the index finger of the operator. It confers optimal

control of the visual field while operating, ensures stable and smooth displacement of the laparoscope,

and allows the operator to work in conditions of restricted surgical assistance, due to either unavailability of

staff or economic constraints. It has been tested successfully in pilot studies in laparoscopic gynecologic

surgery.

Using a Laparoscope Manipulator (LAPMAN®)

in Laparoscopic Gynecological SurgeryROLAND POLET, M.D.

CONSULTANT

JAQUES DONNEZ, M.D., PH.D.PROFESSOR

DEPARTMENT OF GYNECOLOGYCLINIQUES UNIVERSITAIRES SAINT-LUC

LOUVAIN-EN-WOLUWE, BELGIUM

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ABSTRACT

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Currently almost all gynecologicprocedures performed by opensurgery can be carried out by a laparo-scopic approach. This transposition ofclass ic open procedures to theirlaparoscopic equivalents is the resultof development of both human skillsand better-adapted instrumentation,and surgical environments during thelast decades. However, while surgeonswere busy investigating the feasibilityof operations and working on theirstandardization, the quest forimproved surgical comfort was effec-tively abandoned.1 Currently, with thefeasibil ity phase considered to belargely complete, and with surgeonmorbidity being described directlyrelated to the discomfort of minimalaccess surgery,2 it is probably time tothink about how the conditions andcomfort of laparoscopic surgery can beenhanced.

Technolog ical effor ts are nowfocusing on all aspects: instrumentdesign, instrument multi-functionality,full integration of the operating room,etc. The LAPMAN® laparoscopemanipulator aims to improve the sur-geon’s control with respect to dis-placement and posit ioning of theendoscope, and provide him with anintuitive means of directing the cam-era himself.

This manuscript reviews the rationalfor using a laparoscope-holding system,explains the indications, and investi-gates its applicability in laparoscopicgynecologic surgery.

RATIONALE FOR A LAPARO-SCOPE-HOLDING DEVICE

Two main arguments support theuse of laparoscope-holding devices:ergonomics and economics.

ErgonomicsErgonomically, the laparoscopic

approach exposes the surgeon toencounter premature fatigue muchmore than open surgery conditions.Fatigue, in this context, should beunderstood in its complete sense:2,3

subjective (characterized by a decline inmental alertness, mental concentra-tion, motivation, and other psycholog-

ical variables); objective (a measurabledecline in the quality and amount ofwork accomplished) and physiologic(demonstrated by disturbances in theongoing physiologic processes).

Fur thermore, besides the usualcauses that contribute to fatigue andstress, such as standing for hours inawkward body and joint positions, fac-tors that relate to management of thevisual operative field by a human cam-era holder should also be taken intoconsideration. A tremor on the part ofthe assistant holding the laparoscope;for example, and the subjectiveimpression of lack of translational androtational stability of the image whiledisplacing the endoscope are signifi-cant sources of mental stress, whichfatigue the operator.

In addition, loss of laparoscopeauto-control, the endoscope neverbeing exactly where it should be andwhen it should be, adds to the sur-geon’s mental frustration. In fact, thisproblem is new and specific to laparo-scopic surgery: the symbiotic workingrelationship that links the operator’shands and eyes during open surgery isaffected. Vision is controlled by anoth-er person whose quality, interest,skill, and even availability, may bevariable.

EconomicsThe economics also must be taken

into consideration. Many Europeanhospitals currently have a serious lackof human assistance for several rea-sons: limited numbers of residents intraining, reduction in nursing staff,cost of human assistance, etc.4 Laparo-scopic surgery, as a high consumer ofspecially trained staff (the operatorhimself, the assistant and, sometimes,a scrub nurse for instrumentation),suffers directly from this situation.

Substitution of a human cameraholder by a surgeon-controlled laparo-scope holder could, therefore, be aninteresting proposit ion on bothaccounts.

CAMERA-HOLDING SYSTEMS

The idea of laparoscope-holdingsystems is not new. An extensivedescription of all available devices waspublished by Jaspers et al.5 Most weredeveloped to al low laparoscopic

surgery without the need for a humancamera holder, in operating conditionsof “solosurgery.”

Their classification was based on themode of activation: passive or dynamic.Passive holders are static systemsmanipulated physically by the operatorhimself; the laparoscope is first placedin an optimal position and the surgeonsubsequently manipulates his instru-ments, as necessary. Any change in theposition of the endoscope requires thesurgeon to put down one instrument,reposition the system, then pick up hisinstrument again.

Dynamic holders are motorizeddevices and positioning of the endo-scope can be achieved through remotecontrol interfaces: voice, foot pedal,helmet, hand control, joystick, etc.This technology allows the surgeon toorientate the laparoscope while he oper-ates with no interruption of surgery,and no need to drop one instrument toreposition oneself. The AESOP® series(1000 to 3000) (Computer Motion,Santa Barbara, CA, USA) was the firstrobotic manipulator of laparoscopes,activated initially by a foot pedal andlater by voice control.6-9

The ENDOASSIST® (ArmstrongHealthcare, High Wycombe, UK) is aconsole posit ioned alongside thepatient, controlled by an association offoot and head activation throughinfrared technology.10 Both systemshave been compared in experimentalconditions.11,12

Manipulation of instruments iswhat makes the difference betweenlaparoscope holders and fully opera-tional robots, such as the DaVinci®

(Intuitive Surgical, Sunnyvale, CA,USA). Thanks to 7-DOF laparoscopicinstruments, these robots allow thesurgeon to perform meticulous dissec-tions and microsutures in restrictedand difficult-to-reach areas. However,their exorbitant price, their volume,their technological complexity, andlong set-up time, mean they have notyet entirely won-over the surgicalcommunity and their cost-effective-ness still needs to be evaluated.13 Itshould be made perfectly clear that therationale for fully operational robotsand laparoscope holders is different:robots are not meant to address eco-nomic concerns or lack of assistance inthe Operating Room (OR); therefore,they are probably not for every generalhospital.

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INTRODUCTION

RATIONALE FORLAPAROSCOPE-HOLDING DEVICE

CAMERA-HOLDING SYSTEMS

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The LAPMAN®

The Manipulator (Fig. 1) The technology behind this manipu-

lator is based on the electromechanicalcontrol of brakes that regulate the dis-placement of a series of articulated armsconstructed to cover the three-dimen-sions (3Ds) of space (Fig. 2). It is com-posed of a rolling unit that contains theengines, fitted with a sterile autoclavableshaft; the endoscope is connected to theshaft at the start of the operation. Theoverall dimension of the manipulator is37 cm x 63 cm at the base, with a heightof 110 cm that extends to 150 cm,depending on the needs.

The machine displaces the shaft inthe 3Ds that translates the displacementof the laparoscope connected to it.These displacements naturally convergeupon the geometric center of themanipulator. To have optimal translationof movements to the laparoscope, thisgeometric center must be aligned withthe geometric center of the patient—the umbilicus—through a laser pointer.

The InterfacesTwo interfaces are available to con-

trol the manipulator: one for OR staff(remote control) and one for the sur-geon (LAPSTICK®, Medsys, Gem-bloux, Belgium).1. The Remote Control

This is the nurses’ unit used by ORstaff during the phase of alignment ofthe LAPMAN® with the patient’sumbilicus.

2. The Joystick (LAPSTICK )The ergonomics of PC joysticksinspired the development of an inter-face adaptable to laparoscopic surgi-cal instruments. This cord-freedevice (LAPSTICK®) (Fig. 3) is thesize of a matchbox and is positionedon the handle of the instrument, onthe right or left side, at the level ofthe index finger; the position isadjustable to the anatomy of thehand. It boasts two 4-DOF joysticksthat command both in/out penetra-tion and right/left lateralization; theup/down movement is managed by aflap, whose design makes it distin-guishable to the index finger. It canbe adapted through a clip to regularhandles from major instrument com-panies, and has an autonomy of fivehours of continuous radiofrequencyactivation.

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Figure 1. LAPMAN®: external view.

Figure 2. LAPMAN®: principle.

Table I Gynecologic Laparoscopic Procedures Performed

with the LAPMAN® 14 Adnexectomy 18 (*)

Ovarian cystectomy 7

Salpingostomy (ectop pregn) 2

Salpingectomy 5

Myomectomy (subserosal) 4

LASH 4

Diagnostic laparoscopy 8

(*) = One case with severe adhesions that requires one assistant in a patient with a history of pelvic surgery. LASH = Laparoscopic Subtotal Hysterectomy

THE LAPMAN®

®

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The LAPSTICK® has replaced a pre-vious interface (hand control), insertedunder the surgeon’s glove, because of itsgreater intuitiveness.14

USE IN GYNECOLOGY

Set-Up (Fig 4)In normal conditions for laparoscopic

gynecologic surgery, three suprapubiccontra-incisions are generally required:the total number of hands needed is five,to occupy the umbilical port and thethree suprapubic ports, as well as for theuterine manipulation (Fig. 5). The oper-ating surgeon uses his two hands to man-

age two instruments, the assistant twohands to hold the laparoscope and oneinstrument, and a nurse often lends ahand to manipulate the uterus whileinstrumentating. This means that threepersons are scrubbed up to operate inoptimal conditions: the surgeon, assis-tant, and nurse.

The LAPMAN®, by providing anextra hand, reduces the total number ofhands needed to four: the surgeon’s twohands and the nurse’s two hands. Theassistant is superfluous in this scheme ofthings and can be used for other taskswhile the nurse’s competencies can bemore fully used for installation of thepatient, instrument preparation and dis-tribution, holding of instruments ifrequired, manipulation of the uterus,preparation of sutures, and so on.

As three hands are the absolute mini-mum for laparoscopic surgery (two tomanage the instruments and one to holdthe laparoscope), the LAPMAN® alsoallows the surgeon to operate in case oftotal absence of assistance (strict solo-surgery), a situation that occurs notinfrequently during night calls in hospi-tals, where the availability of assistance islimited (ectopic pregnancy, acuteabdomen of gynecologic origin, etc.).

As a result of experience gained instrict solo-surgery in such circum-stances, this concept has now beenextended to the elective laparoscopicmanagement of simple adnexal condi-tions and limited volume uteri. There-fore, it is possible to better gauge theneed for an operative assistant andaddress the financial concerns of oper-ating theaters. The authors published apilot series of 48 cases in these condi-tions, and achieved satisfactoryresults14 with the hand-control inter-face (Table I).

Finally, if wished, a last possible con-figuration is to operate with aLAPMAN® and a front assistant inbetween, using a long version of theshaft, which allows the operator to enjoycamera positioning, auto-control, andimage stability provided by the system.

Indications in Gynecologic Surgery

With the currently available inter-faces, the size of structures to be oper-ated on and extent of pelvic adhesionsmay constitute limiting factors thatappear to compromise the comfort of

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Figure 3. LAPSTICK®: external view.

Figure 4. LAPMAN®: setup in gynaecological laparoscopic surgery.

Figure 5. LAPMAN®: The LAPMAN® reduces the surgical team from three (S = surgeon, A = assistant, N =scrubbed nurse) to two (surgeon and nurse), possibly to one (solosurgery), for less complex procedures.

USE IN GYNECOLOGY

INDICATIONS IN GYNECOLOGIC SURGERY

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the LAPMAN®. With the new joystickinterfaces, however, one can expectthese difficulties to resolve with timeand practice.

All normal to moderate-size adnexalsurgery can, thus, be performed instrict solo-surgery conditions if theneed arises; normal-to-moderate uter-ine pathology (less than 8 to 9 weekssize) and suture-requiring surgery, casesare probably more comfortably treatedin the presence of a scrub nurse.

Conclusion

Unavailability and variability in quali-ty of human camera holders should notbe an obstacle to performing satisfacto-ry laparoscopic surgery. Therefore,some form of standardization of assis-tance is required and laparoscope-hold-ing systems are a first step in thisdirection.

Substitution for human assistance(with all its economic implications),significant ergonomic benefits (repre-sented by recovery of the visual fieldcontrol by the surgeon), and image sta-bility are the three main advantages ofan efficient laparoscope holder. Intu-

itiveness of the man-machine interfaceis also crucial to facilitate a natural andspontaneous response to the surgeon’scommand.

The LAPMAN® and then newlydeveloped LAPSTICK® certainly appearto meet all these criteria.

REFERENCES

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CONCLUSION

STI