A new direction for the innovation and development of minimally invasive surgical technologies and devices

Authors: Zheng Minhua, Zhao Xuan, Ma Junjun

Source: Chinese Journal of Digestive Surgery, 2023, 22(1)

summary

The application of minimally invasive surgery in the field of surgery has experienced rapid development for more than 30 years, and the continuous development of minimally invasive technology and instruments in the fields of energy platforms and imaging equipment has continuously promoted the progress of laparoscopic surgery to be more accurate and safer, and the development of laparoscopy itself has also continuously fed back the innovation of minimally invasive technology and instruments. In recent years, the innovation and development of minimally invasive technologies and devices have been more closely integrated with the current frontiers of science and technology, and innovative achievements have been made in new concepts such as robotization, screenlessness, intelligence, electrification, and virtualization. Minimally invasive surgeons in the new era need to keep an eye on the frontier of science and technology, always think about the combination of surgery and technology, apply advanced technology to solve the current surgical pain points, and inject new vitality into the next development of minimally invasive surgery.

Minimally invasive surgery based on laparoscopic vision system has been popularized and promoted in surgery for more than 30 years, and it is not difficult to complete the resection of diseased organs and the reconstruction of anatomical structures under laparoscopy. With the development of surgical technology and minimally invasive platform, minimally invasive surgery has gone from precision to extreme, even extreme, and minimally invasive surgery has entered a high plateau stage. Although the innovation and development of equipment and instruments are very rapid, the core essence is still the safety of resection and reconstruction of diseased organs; Although minimally invasive surgery has become the mainstream surgical method and is widely accepted by surgeons and patients, the current measures to improve the rate of minimally invasive surgery are more driven by the demand of the minimally invasive surgery industry chain, and it is difficult to achieve breakthroughs in the long-term efficacy of cancer patients by relying solely on surgical technology. With the mainland government's promotion of scientific and technological innovation, domestic substitution and other strategies, the clinical application of various high-tech and cost-effective minimally invasive surgical equipment and instruments at home and abroad has been continuously improved. In the high-level plateau of minimally invasive surgery, it remains to be seen whether the future will be driven by disease spectrum or technology-driven discipline development. As a discipline with technology as the core, the only way out for the development of minimally invasive surgery is the new technological revolution and industrial revolution, and new concepts and development trends such as robotization, unmanned, intelligent, electrification, and virtualization will lead us forward. Combined with the achievements and trends of the development of minimally invasive surgical equipment and instruments in recent years, the author summarizes and looks forward to the current and future development.

1. Innovation of imaging equipment: a new "vision" of minimally invasive surgery

(1) Screenless

At present, 4K and 3D laparoscopes have become conventional surgical instruments, and 6K, 8K, naked-eye 3D laparoscopes and other imaging equipment have also appeared on the market. But the resolution of the human eye is limited, and the clarity of imaging does not need to evolve endlessly, and high-definition devices also make display screens more and more bulky. This restricts the space planning, equipment placement, and intraoperative equipment position adjustment in the operating room. Reducing the burden and screenless imaging equipment may become one of the future development directions.

With the development and introduction of augmented reality and virtual reality technologies to the market, their application scenarios are also expanding. Augmented reality devices are currently being used in surgery. For example, in liver surgery, detailed imaging data is input before the operation, and a 3D model of the liver and lesions is generated by modeling in the later stage, and the tumor and blood supply vessels can be located through the augmented reality display on the headset during the operation, so as to achieve the purpose of fine planning before surgery and precise operation during the operation. Relying on the special virtual reality laparoscopic lens, the virtual reality display device has a more realistic 3D imaging effect than the flat display screen, and the surgeon can directly select the viewing angle by turning the head, reducing the requirement of manually adjusting the observation angle of the 30° lens with the lens hand in the past, and greatly improving the degree of cooperation between the surgeon and the lens hand. However, there are still many problems in virtual reality equipment at present, because the immersion of virtual reality equipment is greatly enhanced, therefore, it is easy to cause the surgeon's vertigo when moving the lens, and the eyes are close to the screen, the equipment is relatively heavy, and long-term wearing and observation may cause the surgeon's head and neck fatigue, visual fatigue, vision damage and other related problems. In the future, how to lightweight display devices and reduce the dizziness of observers is the key to the further application of virtual reality.

(2) Integration

Relying on the progress of imaging equipment and the addition of high and new technology, laparoscopic imaging equipment has become less and less satisfied with the simple display function, and the integration of more advanced functional modules and imaging equipment is one of the development directions of laparoscopic imaging equipment at present and in the future. At present, the main integrations include near-infrared fluorescence laparoscopic system and real-time intraoperative anatomical recognition system based on computer vision and deep learning.

1. Near-infrared fluorescence laparoscopic system

In recent years, the fluorescence laparoscopic system integrating near-infrared technology and laparoscopy has been applied, so that the fluorescent contrast agent represented by indocyanine green has been widely developed. Traditional tracers have relatively poor tissue penetration and affect the surgical clarity of the injection area, while indocyanine green has better tissue penetration and imaging effect. Indocyanine green has been performed in a number of subspecialty laparoscopic surgeries, including: gastric cancer lymphatic drainage scintigraphy, gastrointestinal surgery anastomotic blood supply scintigraphy, liver segment staining for liver cancer surgery, biliary tract scintigraphy, thyroid surgery lymph node scintigraphy, etc. Recently, there have been many high-quality clinical studies to explore the application of indocyanine green in gastrointestinal surgery. The results showed that the intraoperative injection of the tissues around the tumor, combined with the laparoscopic fluorescence imaging technology during the operation, could clearly display the lymph nodes in the drainage area of the lesion, which had an indicative effect on the dissection range of lymph nodes during surgery, and could effectively improve the number and non-conformance rate of lymph nodes obtained during surgery.

Regardless of whether it is a traditional tracer or a fluorescent tracer represented by indocyanine green, its development follows the normal lymphatic or blood flow and is not tumor-specific. Therefore, in theory, if we want to achieve precise tumor tracing and resection in the true sense, the clinical significance of the existing tracers is still limited. At present, some scholars have designed specific targeted tracers for tumor-specific markers, and in vivo experiments have been carried out in related animals, in order to make breakthroughs in laparoscopic tumor-specific tracing. Another way to strengthen the specific binding ability of indocyanine green to tumors is to load tumor-specific binders on nanomaterials to form stable aggregates with indocyanine green, which can enter tumor tissues through passive high osmotic long retention effect and active magnetic targeting. Through the above strategies, it is expected that the tracer can be specifically bound to metastatic lymph nodes, so that it can be more practical in laparoscopic gastric cancer lymph node navigation and dissection.

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A new direction for the innovation and development of minimally invasive surgical technologies and devices

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