An in vivo analysis of safe laparoscopic grasping thresholds for colorectal surgery

Abstract

BackgroundAnalysis of safe laparoscopic grasping thresholds for the colon has not been performed. This study aimed to analyse tissue damage thresholds when the colon is grasped laparoscopically, correlating histological changes to mechanical compressive forces.MethodsAn instrumented laparoscopic grasper was used to measure the forces applied to porcine colon, with data captured and plotted as a force–time (f–t) curve. Haematoxylin and eosin histochemistry of tissue subjected to 10, 20, 40, 50 and 70 N for 5, 30 and 60 s was performed, and the area of colonic circular and longitudinal muscle was compared in grasped and un-grasped regions. The area under the f–t curve was calculated as a measure of the accumulated force applied, known as the force–time product (FTP).ResultsFTP ranged from 55.7 to 3793 N.s. Significant differences were observed between the muscle area of the grasped and un-grasped regions in both longitudinal and circular muscle at 50 N and above for all grasping times. For the longitudinal muscle, significant differences were observed between grasped and un-grasped areas at 20 N force for 30 s (mean difference = 59 mm2, 95% CI 41–77 mm2, P = 0.04), 20 N force for 60 s (mean difference = 31 mm2, 95% CI 21.5–40.5 mm2, P = 0.006) and 40 N force for 30 s (mean difference 37 mm2, 95% CI 27–47 mm2, P = 0.006). Changes in histology correlated with mechanical forces applied to the longitudinal muscle at a FTP over 300 N s.ConclusionsThis study characterizes the grasping forces that result in histological changes to the colon and correlates these with a mechanical measurement of the applied force. The findings will contribute to the development of smart laparoscopic graspers with active constraints to prevent excessive grasping and tissue injury.

Tool-tissue forces in surgery: A systematic review

“…In regard to study demographics, all studies were primarily conducted at North American (n = 19) [ 2 , 4 , 14 , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] ] or European (n = 26) [ 1 , 3 , 5 , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] ] institutions ( Supplementary Information 2 ). Articles were published in medical (n = 26) [ [2] , [3] , [4] , 14 , [21] , [22] , [23] , 25 , 27 , 29 , 35 , 36 , 43 , [46] , [47] , [48] , [49] , 51 , 53 ] or engineering (n = 19) [ <...>…”

“…Articles were published in medical (n = 26) [ [2] , [3] , [4] , 14 , [21] , [22] , [23] , 25 , 27 , 29 , 35 , 36 , 43 , [46] , [47] , [48] , [49] , 51 , 53 ] or engineering (n = 19) [ 1 , 5 , [17] , [18] , [19] , [20] , 24 , 26 , 28 , [30] , [31] , [32] , [33] , [34] , [37] , [38] , [39] , [40] , [41] , [42] , 44 , 45 , 50 , 52 , 54 , 55 ] journals between 1999 and 2020 ( Supplementary Information 3 ). Evidently, this is a new and expanding field, with more articles published in the last 5 years (n = 24) [ [2] , [3] , [4] , 14 , 17 , 19 , 22 , 23 , 25 , 26 , 28 , [32] , [33] , [34] , [35] , 39 , 41 , [45] , [46] , …”

“…In terms of surgical specialty ( Supplementary Information 2 , Table 1 ), the highest proportion of studies (in-vivo and ex-vivo models) were in general surgery (n = 14, 31.1%) [ 3 , 5 , 20 , 26 , 27 , 35 , 38 , [41] , [42] , [43] , 49 , 51 , 54 ] with the majority of these involving laparoscopic procedures (n = 11) [ 3 , 5 , 26 , 34 , 38 , [41] , [42] , [43] , 49 , 54 , 55 ]; followed by neurosurgery (n = 13, 28.89%) [ 1 , 2 , 4 , 14 , 22 , 23 , 25 , 28 , 33 , 37 , 44 , 52 ], ophthalmology (n = 5, 11.11%) [ [17] , [18] , [19] , 21 , 32 ], cardiothoracic (n = 3, 6.67%) [ 26 , 30 , 53 ], vascular surgery (n = 3, 6.67%) [ 29 , 40 , 50 ], obstetrics & gynaecology (n = 2, 4.4%) [ 39 , 45 ], orthopaedics (n = 2, 4.4%) [ 47 , 48 ], otorhinolaryngology (n = 2, 4.4%) [ 36 , 46 ] and urology (n = 1, 2.2%) [ 24 ]. Ten studies (22.2%) involved robotic surgery platforms [ 1 , 14 , [17] , [18] ,…”

“…Generally, across tasks and models, specialities requiring the smallest amount of mean forces were: ophthalmology (mean of average 0.04N) [ [17] , [18] , [19] , 21 , 32 ], vascular (mean of average 0.07N) [ 29 , 40 , 50 ], neurosurgery (mean of average 0.68N) [ 1 , 2 , 4 , 14 , 22 , 23 , 25 , 28 , 33 , 37 , 44 , 52 ] and cardiothoracic surgery (mean of average 1.47N) [ 26 , 30 , 53 ]. Higher mean of average forces, in ascending order, were seen in general surgery (mean of average 4.67N) [ 3 , 5 , 20 , 26 , 27 , 35 , 38 , [41] , [42] , [43] , 49 , 51 , 54 ], otorhinolaryngology (mean of average 8.49N) [ 36 , 46 ], obstetrics and gynaecology (mean of average 8.69N) [ 39 , 45 ], urology (mean of average 9.79N) [ 24 ] and orthopaedic surgery (mean of average 210N) [ 47 , 48 ].

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“…The field of surgery is defined by the application of physical force in order to manipulate or incise tissue for the treatment of medical disorders. Surgical forces must be applied judiciously, in a precise and controlled manner, in order to carry out procedures efficiently without causing unnecessary tissue injury [ [1] , [2] , [3] ]. The discrimination between appropriate and excessive force is a skill acquired over years of rigorous training, with junior surgeons tending to apply more force than more senior colleagues [ 4 , 5 ].…”