Ergonomics

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摘要

The description of ergonomics covers all aspects of ergonomics in the operating room.
The technical key steps of the chapter are presented in a step by step way: specificities of laparoscopy, ergonomics, ideal trocar positioning, basic movements/gestures, knot-tying, complications.

媒體類型

刊物

2005-05

普通的

最愛

音訊

數位出版

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-ot02en321.htm

Ergonomics

1. Introduction

For over 10 years, laparoscopic surgery has evolved and its application has broadened, forcing surgeons to adapt to this new technology. With new and specific equipment, the surgeon has learned new ways to perform time-honored surgical operations. The positioning of the surgeon is different; ergonomics are altered; the view on the operative field is changed; tactile sensations (haptics) are lessened; movements are inversed (fulcrum effect); instruments are longer with restricted articulations.

2. Specificities of laparoscopy

Not only has laparoscopic surgery led to major changes for patients, it has also forced the surgical team to modify its habits.
- changed operating room environment;
- altered posture for the surgeon;
- enlarged 2D vision on a screen of the 3D operative field;
- specific instrumentation;
- diminished proprioception and eye-hand coordination (haptics and fulcrum effect);
- distinct access to the peritoneal cavity;
- particular surgical gestures.

3. Ergonomics

• Operating room

Laparoscopic surgery requires the use of specific equipment. This equipment (insufflator, cold light source, camera, monitor) is placed on a cart, or column. The use of this column implies a good knowledge of its components. The column is connected to the patient by an electrical network; more space is used than during open surgery, and cables and tubes often lie on the floor. A good organization of the operating room allows to prevent damage to cables by rolling carts and trampling feet, and to avoid errors of sterilization. The room should be large enough to allow easy access to and movement around the laparoscopic equipment.
Because cables and tubes are connected to the patient, the column is usually placed within 1 meter. Even if the length of the camera cable or of the insufflation tube allows moving the column away from the operating table, the length of the cold light cable limits this movement, as increasing its length diminishes the amount of light that reaches the end of the cable. Cold light cables have a maximum length of 3 meters. Its exact position and course change according to the procedure performed and the preference of the surgeon. The column usually carries the monitor, and often faces the surgeon.
A second monitor, when placed opposite the first monitor, allows for a better vision for the surgical assistants, and allows the OR personnel and the anesthesiology team to follow the procedure, and to react accordingly. Ideally, a third fixed monitor may be installed in a predefined location of the OR.

• OR organization

One or better two technical arms should be part of an operating room dedicated to laparoscopy. If only one arm is available, it must be placed in a way that allows connecting of the column in all possible operating positions. It is best placed at the foot of the patient. If the OR can be equipped with more arms, it is recommended to place a mobile monitor on an arm at the foot of the table, and to place two other technical arms on each side of the table. This disposition allows the surgeon to face a screen in all conditions; he may then visualize procedures performed in the pelvis on the foot monitor, and all procedures of the upper abdomen on the screen placed on the column.

• Technical arm position

• Generalities

It is advisable to choose an arm that is adjustable in height. The monitor must face the surgeon and be placed at or lower than eye level to minimize fatigue and cervical ache.

• Technical arm 1

Elements of the technical arm:
This technical arm is composed of:
- fluid and CO2 entry, allowing to dispose of limited capacity gas bottles;
- power points with sockets on at least two different phases;
- the electrocoagulation unit and laparoscopic equipment. All electric devices must be plugged on a different phase than that of the video system to avoid image interference.
Ideally, the technical arms will bear video connections to the column, allowing connection without hanging cables.

• Technical arm 2

The technical arm will have video input and output (BNC, S-VHS, RGB, DVI), for arm inter-connection and video output towards outside the operating room. Therefore, recording of quality images will be possible outside the OR with equipment unauthorized for OR use.
- audio input and output (digital and analog), for the future performance of telesurgery or telecompanionship.
- computer input and output socket (RJ45 network, USB 1.1 or 2.0, IEEE 1394=FireWire™ = i.link) for links to computer reconstructed patient data.
- connection to hospital network, allowing direct access to patient imaging.
- telephone input and output for videoconference linkage and for telecompanionship, teleconsulting, and tele-assistance.

• Anesthetic unit

For the anesthesia, the technical arm must include specific fluid delivery: oxygen, N2O, air as well as vacuum and anesthetic gas evacuation system.

• Centralization/OR commands

The large number of instruments has led the industry to offer integrated solution for the control and command of equipment and networking. These systems allow for the control of OR components by keyboard or by voice: positioning of the OR table, electrocoagulation unit, OR and laparoscopic light, insufflator and camera. According to manufacturers, these systems allow to control components of different makes.
Examples (in alphabetical order):
- EndoALPHA™ – Olympus®;
- EndoSuite™ – Stryker®;
- HERMES™ – Computer Motion®;
- OR1™ – Karl Storz®.

• Surgeon’s posture

• Ergonomics

Laparoscopic surgery confronts the surgeon to obstacles that are non-existent in open surgery: difficulties due to the field of view, the handling of laparoscopic instruments, the angle between the arm of the surgeon and the instrument, the limitation of movements of the surgeon because of trocar placement. All these obstacles cause added and new fatigue, especially to the superior limbs and spine.
At the beginning of the laparoscopic era, some surgeons operated in a seated position. This position seemed to be more ergonomic. Since then most surgeons have chosen to stand, allowing them a greater freedom of movements. However the search for better positioning and less fatigue orients back toward operating seated. Both existing surgical robotic systems offer sitting operative stations (Zeus™, Computer Motion®; Da Vinci™, Intuitive Surgical®).
The ideal position is often a compromise between the target organ, the trocar positioning, and the positioning of the patient. The surgeon must however pay attention to his or her own ergonomics, especially for long operations.
The choice of positions depends on the preference of the surgeon. The ultimate goal is to work in the most comfortable and less tiring position.
The position and height of the monitor and of the operating table should allow the following posture for the surgeon:
- straight head, in the axis of the trunk, without rotation or, more importantly, extension of the cervical spine;
- shoulders in a relaxed and neutral position;
- arms alongside the body;
- elbows bent to 70 to 90 degrees;
- forearms in an horizontal or slightly descending axis, prolonging the axis of the instruments;
- hands pronated (physiological resting position);
- hands and fingers lightly grip the handles/handpiece;
- sitting or standing, depending on the preference of the surgeon, on the procedure, and on the instruments used. Nevertheless, the thoracic and lumbar spine and legs should be in a neutral position without rotation, anterior or lateral flexion. These rules should be easy to apply if the height of the table is adjusted properly.
Non-compliance with these principles can cause cervical aches and/or sprains, and pain to the shoulders, forearms, fingers, and even cause paresthesia or hypoesthesia of the thumb.
The center of the monitor should be placed 20 degrees lower than the eyes. The position naturally adopted by the eyes is of 15 to 20 degrees towards the ground when the cervical spine is in a neutral position. This position corresponds to the resting position of the oculomotor muscles. Moving away from this position puts these muscles at strain. In the case of a short procedure, major problems do not occur. However, if the position is to be maintained for a longer period of time, the surgeon will tend to overextend his cervical spine in order to return to this resting position. Therefore, the vertical position of the monitors should be adaptable to each surgeon. If the surgeon wears glasses, the monitors should again be adapted, and placed at a lower position to meet the focus of the glasses. In practice, monitors are set at a fixed height, and are better suited to tall persons. The technical arms reach a limited inferior height, to allow for safe movement of the operating room team and avoid contact with the sterile area.

• Positioning option 1

Patient supine: surgeon to the right and/or surgeon and/or assistant to the left. In this position a monitor should be placed on each side, allowing good vision for people on either side of the table.

• Positioning option 2

Pelvic procedures: operators are on each side of the patient. If the surgery is on the midline, one single monitor at the feet of the patient may be sufficient.

• Positioning option 3

Upper abdomen or flank procedures: The surgeon is placed between the legs (cholecystectomy - European position) of the patient.

• Positioning option 4

Upper abdomen or flank procedures: The operator is placed on the side (cholecystectomy - American position) of the patient.

• Ergonomics of handling

• Basics

The use of instruments that are not always adapted to the surgical movement, the limited sensations, and the obligation to work through ports into the abdomen bring out new difficulties, even for maneuvers that are simple to perform in open surgery.
Good hand-eye coordination is natural in open surgery, but must be learned again for laparoscopic surgery. Training to gain this new coordination is necessary for many reasons.
Long instruments with articulations that are limited (degrees of freedom), diminish the possible movements.

• Divergence

Divergence between the 2D magnified vision on the monitor and the actual operative field.

• Awkward position

Poorly positioned instruments causing pain and increasing awkward movements.
Diminished tactile perception (haptics) because direct contact with organs is impossible.

• Fulcrum effect

The obligatory passage of the laparoscopic instruments through the abdominal wall generates a fixed point after which all movements are reversed. For instance, when the hand moves to the left, the end of the instruments moves right, and when the hand moves downwards, the end of the instrument moves upwards.
For some surgeons, the fulcrum effect is not a problem, but for others it is an insurmountable obstacle to the performance of advanced laparoscopy.
Force feedback: Because the handling of laparoscopic instruments is through the fixed point at abdominal wall, the force feedback felt by the surgeon will depend on the length of the instrument inferior to this fixed point. Although seemingly problematic, experience has shown that the force feedback sensations depend mostly on past visual and manual experience of the surgeon than on true tactile sensation. This is confirmed by the fact that the absence of force feedback in robotic surgery is but a minor handicap.

4. Ideal trocar positioning

• Principles

Although in open surgery the surgeon usually stands on the right of the patient, it is otherwise in laparoscopic surgery. Because the procedure is performed through fixed trocars, it is necessary to locate all trocars to allow the performance of all parts of the operation. Every procedure has its ideal trocar positioning, which may be changed according to patient anatomy, esthetic considerations, or surgeon’s comfort. Therefore, it always constitutes a compromise taking into account the patient, the target organ, and the surgeon.

Information pertaining to the types of trocars, access to the peritoneal space, and complications can be found in the chapter “Laparoscopic instruments” and in the chapter “Access and trocar complications”.

Although the positioning of trocars differs for every type of surgery, there are basic principles to adhere to depending on the surgical target, independently of the procedure in itself.

Principle of positioning of the surgeon, the optical lens, the target, and the video monitor:
Whatever the procedure to be performed, ergonomics of optics must be respected. Ideally, to reduce visual fatigue and simplify the ergonomics of surgical movements, the surgeon must face the target organ, and be in line with the lens and monitor. Being out of line make surgical gestures difficult, the most difficult being the surgeon facing the lens at 180 degrees.
The same axis of work applies to the operating trocars, and the “surgeon-instrument-target organ-video monitor” sequence must be maintained. Instruments that face the optic are difficult to handle. Only trocars used for exposure may be placed away from this axis.

For an abdominal procedure, the optical trocar is often placed at the umbilicus after insufflation of the abdominal cavity. This central position allows for an overview of the abdominal cavity. Attention must be paid to the anatomy of the patient. In obese patients, the umbilicus is more caudad, and positioning the trocar at the umbilicus will move the optic away from the operative target. Experienced surgeons abide less and less by this rule, and often locate the optic trocar elsewhere. Instruments are positioned for a better spatial organization of trocars. Operating trocars are more easily discerned from exposition trocar, and size of trocars is adapted to instruments used through them (10-12 mm trocar for linear staplers, 2 to 5 mm trocars for dissecting or retracting graspers).

• Spatial organization

• Triangulation

First principle of spatial organization of operating trocars and optical trocars: triangulation
Trocars are positioned on an arc 20 cm from the target. The optical trocar centers the image and operating trocars are located 5 to 7 cm on either side. These 3 trocars form an angle of 60 to 90 degrees at the target. Retracting trocars are placed outside this triangulation zone, either laterally or at the superior portion of the arc, minimizing instrument conflict.
The advantage of triangulation is that it reproduces the usual scheme of work in open surgery, with eyes bordered on either side by hands. It simplifies, at the beginning of the practice of laparoscopy, the performance of 3D movements. However, the camera is necessarily held between the hands of the surgeon, which may bother him/her.

• Sectoring

Second principle of spatial organization of operating trocars and optical trocars: sectoring
The optical trocar is placed to the right or the left of the two operating trocars. A minimal distance of 5 to 7 centimeters is necessary between two trocars for the instruments to meet at such an angle that permits the performance of complex movements (suturing and knot-tying).
The main advantage of sectoring is that it allows the surgeon to move freely, as the camera is away from the operative field and there is no physical contact between the surgeon and the camera holder.
The main disadvantage is that sectoring forces the surgeon to adapt to new ergonomics. New ways to perform the surgery must be learnt, and often do not reproduce what is done in open surgery.

• General trocar positioning

The final position of the trocars depends on the exact location of the target, located after the insertion of the optical lens, and depends on the anatomy of the patient and the ergonomics of the surgeon. The trocars must not be too far from the target for two reasons:
- The length of the instrument is limited. If the trocar is set too far, one must push on the abdominal wall to gain a few centimeters, and movements become less precise;
- The working angle between instruments and the target may be too obtuse, making the manipulation of a curved needle almost impossible.

The principles of trocar positioning are adapted to fit specific procedures, and generally reproduce the principles defined above. Most experts have their own standardized trocar positioning for specific procedures.

The principles of trocar positioning chosen (sectoring or triangulation) will depend mostly on the surgeon. Sectoring is not recommended initially to beginners because of greater complexity.

• Size of trocars

Ideally, the size of trocars will be close to the size of the instruments used through them. A trocar that is larger than the instrument will not guide as well as a more fitted trocar, and pointing precisely with the tip of the instrument will be difficult. For instance, a 5 mm instrument through a 10 mm trocar is not fixed at its point of passage into the abdomen, and is handled with more difficulty. However, the surgeon is sometimes forced to use larger trocars. Typically at the end of dissection, clips or staplers need to be applied through a 10-12 mm trocar. If disposable trocars are used, the largest trocar that is needed will be used from the beginning of the operation on. If reusable trocars are used, it is preferable to first use a smaller sized trocar, which will be replaced by a larger one when necessary at the end of the procedure.
The use of a reducer (preferably with a valve) for reusable trocars is helpful. If disposable trocars are used, it is possible to reduce tremor by resting the hand on the trocar.

5. Basic movements/gestures

• Basic movements

Bimanual work:
Principles of surgical movements in laparoscopy do not fundamentally differ from those of open surgery, but the basics tend to be forgotten by the surgeon, when he/she faces new problems.
During the early years of laparoscopy, surgery was performed without a camera, and the surgeon used to look directly through the handheld lens. Therefore, he could only use one hand to operate. The assistant had no vision of the operative field. That state of things accounts for the absence of true interventional surgery until the advent of endoscopic cameras. With the help of the camera and video monitor, the surgeon may now free his other hand and work bimanually. It is very important to use the non-dominant hand to achieve proper exposure, while the dominant hand performs the active operation. The non-dominant hand must follow the dominant hand closely, to help achieve adequate exposure and increase the precision of movements.
Bimanual work allows performing movements of blunt dissection, by coagulation and dissection with monopolar or bipolar graspers, by scissors held ajar, or by blunt gauze dissection.

Proper tissue tension:
Using the traction (by the surgeon) counter-traction (by the assistant) principle, the area of work must be well exposed and under tension to permit a precise and efficient dissection. The softer the tissue, the closer the non-dominant or assisting hand must be to the area of dissection, to prevent movement of the tissue and loss of precision.

Visual control of movements:
During laparoscopic procedures, the field of vision is reduced to that of the camera, which corresponds, if compared to ocular vision, to central vision without peripheral vision. Hence, every structure outside the field of the camera is invisible. All mobile instruments must remain in the field of vision to avoid unrecognized traumas, and all instruments not readily in use must be removed out of the peritoneal cavity, hence out of trocars. Abrupt and impulsive movements of the body or arm may lead to a tissue trauma caused by an instrument not held by the surgeon or assistant.

• Dissection

• Generalities

Dissection in laparoscopy is performed with the same means as in open surgery. The surgeon must always keep in mind that force feedback is lower in laparoscopy. The risk of tissue trauma is increased; coagulation must be done immediately to avoid oozing of blood that will obscure the operative field by absorption of light by hema. Whenever possible, the tissue must be handled by atraumatic instruments, and dissection performed by section and progressive coagulation.

Blunt dissection
Some surgeons prefer to dissect by a method of traction and counter-traction. This method is widely used for laparoscopic hernia repair, to reduce the hernia sac. We do not recommend this technique because it is, much like blunt gauze dissection, responsible for blood oozing.

• Cold scalpel

Use of the cold scalpel:
Some instruments bear integrated blades or disposable blades and allow performing cold section of tissues, in a fine and precise manner. However, most are difficult to control in the laparoscopic environment, and are of limited use. They are mostly used to incise the common bile duct for common bile duct exploration.

• Blunt gauze dissection

Blunt gauze dissection was the first type of dissection described in laparoscopic surgery. It was widely used because of the lack of experience of surgeons, poor quality of the lens, and absence of proper coagulating devices. Gauze is available as pre-packaged disposable instruments or in units to use at the tip of graspers. Blunt gauze dissection may be responsible for the oozing of blood.

• Dissection/other types

• Scissor dissection

Scissor dissection in laparoscopy is similar to scissor dissection in laparotomy. Ideally, blades of the scissors are left ajar, and tissues are dissected progressively. When connected to the electrocautery, scissors allow simultaneous coagulation of small vessels that would otherwise bleed. The electrocautery should be set on soft, and on low voltage for laparoscopic dissection.

• Hook dissection

The hook is inserted between two tissue layers and a slight coagulation is applied. This leads to a separation of tissues.

• Dissection

Tissues under tension may also be dissected with the electrocautery set at medium voltage (500 Volt-fulguration). This current creates small sparks in the proximity of tissues and leads to the separation of tissues when traction is applied on each side of the tension line. The risk is overheating, which might cause necrosis of tissue and postoperative leak or hemorrhage. This method offers a precise dissection but does not prevent trauma of vessels.

• New technologies

• Different types

Newer technologies are now made available by numerous companies. Some have become more popular than others.
Laser dissection:
Laser dissection has lost some of its popularity because of bleeding and visceral trauma complications. Laser is not frequently used in laparoscopic surgery.
Water dissection:
Water dissection has been used for many years in open and laparoscopic surgery. However, it is rarely indicated, and the cost of the technology is prohibitive.

• Ultrasonic dissection

Ultrasonic dissecting devices are used with graspers that allow dissection and coagulation without the direct use of electricity on tissues. They allow for wide and rapid dissection and lessen bleeding.

• Electrothermal power

Dissection with tissue sealing devices (electrothermal power):
The latest systems offer tissue sealing with integrated section, and are now widely used. They create important tissue division without prior dissection or identification of key vascular and nervous structures. They are not indicated for all types of procedures.

6. Knot-tying

• Equipment

• Sutures

A vast array of sutures and needles are available on the market for laparoscopic knot-tying. They usually resemble the equipment used in open surgery, with some specificities.
Sutures are either threaded, non-threaded (monofilament), absorbable or non-absorbable, and can be found in all materials offered in open surgery. Regular sutures can be used, if cut to a length of 15 to 20 cm for intracorporeal knot-tying. Some sutures are specially adapted for laparoscopy. They are either shorter (15-20 cm) to allow for intracorporeal knot-tying, or longer (minimum 70 cm), with an added piece to adapt to a knot-pusher for extracorporeal knot-tying.

• Needles

The same needles as in open surgery are used: half-circle, 3/8-circle, composite or straight needles. Ski or reversed-ski shapes are also made available especially for laparoscopy use. The choice of needle depends on the surgeon’s preference and on the angle at which the needle is to be used (curved needle for acute angles, ski, reversed-ski, straight needle for obtuse angles).
Triangular tips are available for hard and calcified tissues, but blunt-tipped needle for fragile tissues are most often used.

• Instruments

Two needle-holders or one needle-holder and flat graspers can be used to fashion the knot intracorporeally. Multiple shapes of needle-holders are offered, with a variety of tips, handles, and ratchet systems, and the choice is a matter of preference.

For extracorporeal knot-tying, a knot-pusher is used. Different types are available, depending on the type of knot and depending on the suture (with or without integrated adaptor).

• Needle

• Insertion

It is preferable to insert needles through 10 to 12 mm trocars and to open the valve of the trocar manually to avoid damaging the needle. If the needle is small, it may go through a so-called 5 mm trocar (internal diameter of 5.5 mm).

The classical technique consists in holding the suture at approximately 1 cm of the needle, which will allow the needle to lay parallel to the needle-holder during its course through the trocar.

In the case of a small needle passing through a 10-12 mm trocar, the needle may be placed backwards directly on the needle-holder.

The extraction of the needle is simply done by holding the suture 1 cm from the needle and pulling it through the trocar.

• Positioning

Positioning the needle on the needle-holder:
The needle must be placed properly on the needle-holder once inserted into the peritoneal space. The most ergonomic means is to grasp the tip of the needle firmly with the flat grasper (or the non-dominant needle-holder) and the suture with the needle-holder (held by the dominant hand) 1 cm from the needle. It is very important to grasp the suture and not the needle itself:
- to orient the needle in all directions effortlessly and without conflict of instruments.
- to feel by proprioception the orientation of the needle, which is impossible to see with a 2D vision.
- once the needle in the appropriate position, the needle is grasped with the needle-holder at the 2/3-1/3 junction.

• Suturing

• Option 1

The needle must meet the tissue at a 90-degree angle, and be passed through it while following the curve of the needle until the needle is out, to avoid tearing the structure.
To follow the curve of the needle, one must remember to avoid a movement of translation, but only to rotate the wrist (supination); this rotation allows passing through tissue without injury. It is important to insist on the fact that the absence of force feedback is the cause of tissue trauma if, for instance, needles are not used in a proper way.

• Option 2

To avoid shearing of the tissue with the suture while the thread is being pulled, this traction is performed using an instrument that will act as a pulley and bear the shearing force.

• Knot-tying

• Intracorporeal

The knot is fashioned entirely inside the body cavity. There are many ways to tie knots, moving only one instrument or alternating between left hand and right hand. Combinations are also possible. The ultimate goal is to achieve a properly tied knot. Basic principles may facilitate the confection of intracorporeal knots.
- the free end of the suture must be kept short (1-2 cm);
- the free end of the suture is accessible, ideally in the axis of the instrument that will pick it up;
- the length of the suture from the tissue to the instrument is 5 to 7 cm, to give ample room to loop around the instrument, but short enough not to hang down;
- orient the suture between the tissue and the instrument in the axis of the other instrument (essential!);
- move only one instrument at a time;
- slip the loop out of the instrument before tying it, to prevent it from being caught in the articulations of the instrument;
- tie the knot by pulling the longest end of the suture, to save some suture (running suture);
- alternate the direction of the throws (clockwise and counter-clockwise) to have a secure knot.

To illustrate these principles, here is the square knot, which can be locked and unlocked at will.

• Extracorporeal

The suture is fashioned inside the body and the knot is tied outside before being pushed inside the body. Two options exist:
- tie a knot that may slides in only one way (knot of Roeder or of Weston);
- hand-tie the suture as in open surgery, and push the throws in one by one.
Several types of knot-pushers are available, and are most often used to tie extracorporeal knots. It is also possible, when a knot-pusher is not available, to use the needle-holder.

7. Complications

• Vascular complications

Complications are similar whether in laparotomy or in laparoscopy. However, laparoscopic surgery has its specific complications, some of which are described below and must be kept in mind:
Vascular complications are of different types:
- injuries secondary to the introduction of trocars, Veress needle, or instruments;
- injuries secondary to dissection;
- injuries secondary to mobilization of and traction applied to parenchyma of organs or to the omentum.
The prevention of most of these traumas is possible if all movements are performed under direct vision, instruments are always under control, and anatomy is perfectly known.

• Bowel injuries

Bowel injuries observed in laparoscopy are due to the introduction of the Veress needle or trocars, especially in the presence of adhesions. Trauma of bowel may also occur when instruments are manipulated under direct vision. Most of these traumas can be avoided if instruments are handled with care and control, and never blindly.

• Intraoperative complications

The positioning of trocars and the performance of surgical procedures are responsible for intraoperative complications and late postoperative complications. Some of the latter are cited below:
Bleeding at the removal of trocars:
Bleeding was contained by compression of the trocar, and starts again when the trocar is taken out.
Bleeding of retroperitoneal vessels:
A large retroperitoneal vessel is punctured by the Veress needle and the hemorrhage is contained by the pneumoperitoneal pressure. The bleeding starts at the moment of exsufflation of intraperitoneal gas.
Fall of eschars secondary to burns:
A viscus (common bile duct, small bowel, etc.) is accidentally burnt, but a normal postoperative period follows until the eschar falls, and peritonitis ensues. Diagnosing these injuries is difficult; when diagnosis is made, prompt intervention is crucial.

8. Future

As technology evolves, an increasing number of products become available to surgeons. The first era of instrument development was the securing of existing instruments. One of the typical examples is the improvement of the safety of monopolar and bipolar electrocoagulation. The progress in bipolar coagulation technology has allowed the development of new tissue sealing devices.
The same type of progress is present in combination movement instruments, or remote control devices, such as:
- linear staplers, now also articulated;
- vocal control of the camera;
- developments leading to surgical robots.

The surgical robot is used more and more frequently. Some of its advantages over laparoscopic surgery are:
- no constraints of ergonomics for the positioning of trocars: trocars can be introduced closer to the target (arc of a circle of 10 cm), and closer from one another;
- one or two additional degrees of liberty;
- computer correction of the fulcrum effect.

Nowadays, robots available are evaluated in many surgical procedures. No direct benefit to the patient can be measured, but studies assess the feasibility and safety of robotically performed procedures.

The future probably lies in the automation of certain movements, as suturing and knot-tying eventually. One can certainly picture being able to predefine for the robot the beginning and the end of a suture line, and letting the robot perform it, with measurable and reproducible parameters (tension, distance, etc.).

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