First experience using the Senhance surgical system in laparoscopic local gastrectomy for gastrointestinal stromal tumor

Various innovative robotic systems have been developed to improve surgery precision. The Senhance Surgical System (SSS) is a digital laparoscopic system offering eye tracking and haptic feedback. Several reports have described application of the SSS to general surgeries, including cholecystectomy and colectomy. However, use of the SSS for gastric tumor has not been reported. We experienced a case of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) with the SSS. A 74‐year‐old man diagnosed with GIST underwent LLG with the SSS. Operation, docking, and console times were 117, 11, and 59 minutes, respectively. No perioperative complications were encountered. This study is the first to report LLG for GIST with the SSS. LLG with the SSS was safe and feasible. The SSS can use reusable forceps and contribute to reducing medical costs. The development of instruments is also progressing, and various kinds of surgery are likely to be indicated.

Keywords: GIST; laparoscopic local gastrectomy; Senhance surgical system

Laparoscopic surgery has become widespread in the field of general surgery, and treatment outcomes have also improved with the advances in surgical technology and devices. Surgical robots have been developed to enable more elaborate surgeries and treatment of more difficult cases. The da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) is the most popular robotic surgery system, and its feasibility has been reported in several areas. However, this system has a few specific limitations, including the absence of tactile feedback and high cost. The Senhance Surgical System (SSS) (TransEnterix Surgical, Morrisville, NC) is a digital laparoscopic surgical platform designed to enhance the precision, sensory feedback, and control of surgeons in performing minimally invasive laparoscopic procedures. The SSS has shown benefits such as haptic feedback, comfortable ergonomics, eye‐sensing camera control, and reusable instruments (Table 1).1,2 The SSS received FDA clearance in 2000 and was approved for use by the Japanese Ministry of Health, Labor and Welfare in 2019, and offers a broad procedural reimbursement. The SSS has been used in several facilities in the European Union and the United States, and its utility and safety have been reported in the fields of gynecologic, urologic, and general surgery.3‐7

1 TABLEFeatures of the Senhance surgical system

Here we report our first experience of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) using the SSS.

A 74‐year‐old man with no chief complaints was referred to our hospital after an abnormality was detected on endoscopic screening. He had a history of hypertension, atrial fibrillation, cerebral infarction, and Guillain–Barré syndrome. BMI was 26.2 kg/m2. A 3‐cm submucosal tumor located in the anterior wall of the lower gastric body was identified on endoscopy, and GIST was diagnosed by endoscopic ultrasound fine‐needle aspiration.

The operation was performed with the patient under general anesthesia in a reverse Trendelenburg position with the legs apart. A 12‐mm port was inserted into the umbilicus for the endoscope arm, along with a 12‐mm port in the right lower quadrant (RLQ) and a 5‐mm port in the left lower quadrant (LLQ) for operation arms (Figure 1). A 5‐mm port was also inserted in the right upper quadrant. The endoscope was 10 mm in diameter with 0° direction of view. We used Maryland forceps for the arm through the RLQ port and scissors with electrodes for the arm through the LLQ port. The three manipulator arms were positioned at the 3, 6, and 9 o'clock positions for each. After docking the arms and instruments, the console operator controlled the three arms through a 3‐dimensional monitor (Figure 2). Full‐thickness resection was performed while securing the field of view with the eye‐tracking system. The arm through the LLQ port was switched to a needle holder and all layers were sutured with four needles to lift the defect (Figure 3). All manipulator arms were removed and converted to standard laparoscopy, and the defect in the gastric wall was completely closed with an end linear stapler.

Operation, docking, and console times were 117, 11, and 59 minutes, respectively. Intraoperative blood loss was too small to measure. The patient resumed oral intake the day after surgery and was discharged from the hospital on postoperative day 8 without complications.

Laparoscopic surgery is widespread in the field of general surgery. For cholecystectomy and colectomy, laparoscopic surgery has become more common than open surgery in Japan.8 Surgical robots have been developed to enable more precise surgery. Several reports have found robot‐assisted surgeries to be safe and feasible. The present study demonstrated that LLG can be safely performed using the SSS.

The SSS offers several unique functions, such as eye‐tracking control, haptic feedback, and independent manipulator arms. The advantages we identified in this surgery with the SSS were as follows. Accurate excision and suturing were possible with appropriate view and stable forceps operation without shaking. Haptic feedback allowed correct tension to be felt in the tissue and suture thread, and it made surgeon in the cockpit possible to avoid the risk of injuries to organs and delicate structures. The independent manipulator arms allowed for easy movement and attachment of forceps. However, some disadvantages were apparent, namely, that the operation time was longer than that of normal laparoscopic surgery, and that an ultrasonically activated device (USAD) could not be used, thus requiring frequent hemostasis. In terms of operation time, the docking time was 11 minutes in this case, but has been reported as 6–9 minutes in a report of surgery for inguinal hernia with the SSS.7 The console time was 59 minutes. However, further reductions in docking and console time should be readily obtained as clinicians become accustomed to the manipulator setting, grip, and eye‐tracking operations. The USAD of the SSS is used clinically in the European Union and the United States. Hemostatic effects and quick incision using the USAD can be expected to further shorten the operation time. Articulated forceps are also expected, and will allow tissue approaches from any angle and more precise surgery.

The biggest problem with da Vinci systems is cost. In Japan, such costs are covered by health insurance, but the medical remuneration points remain the same as those for laparoscopic surgery, and robot costs cannot be added.

Economic burdens on hospitals are thus increasing due to maintenance costs and expendable supplies such as disposable forceps for robots.

The cost of SSS was estimated to be 1.3 million dollars. But hospital expenses remain relatively unchanged despite increased case volume due to reusable instruments. Reusable SSS devices have the potential to contribute more to reducing hospital medical costs than other systems.9

Recently, the health of surgeons has also been a problem. Park et al reported that 87% of laparoscopic surgeons suffer from performance‐related symptoms.10 The open cockpit of the SSS enables surgery in a comfortable ergonomic position, and may free the surgeon from physical distress.

This is the first report of LLG for GIST with SSS. Surgery using SSS was readily performed safely and precisely. By understanding the characteristics of the system, more difficult operations should be able to be introduced. The SSS will allow surgeons and hospitals the opportunity to bring the benefits of robotics to a broader patient population.

H.S. wrote the article. All other authors reviewed the article. All authors read and approved the final article.

The authors have no conflicts of interest or financial ties to disclose.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

The patient provided informed consent for publication of the details of this case. Approval from an ethics committee was unnecessary for this case report.