title: Percutaneous Externally Assembled Laparoscopic Instruments: Creation of a New Surgical Paradigm.
abstract: OBJECTIVE
  Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact.
  
  
  METHODS
  Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study.
  
  
  RESULTS
  PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116).
  
  
  CONCLUSIONS
  PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Javier L
authors.initials: JL
authors.lastname: Arenas
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Muhannad
authors.initials: M
authors.lastname: Alsyouf
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Michael
authors.initials: M
authors.lastname: Jang
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Kristene
authors.initials: K
authors.lastname: Myklak
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Daniel
authors.initials: D
authors.lastname: Faaborg
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: Nazih
authors.initials: N
authors.lastname: Khater
authors.affiliation: Department of Urology, Loma Linda University Medical Center , Loma Linda, California.
authors.forename: D Duane
authors.initials: DD
authors.lastname: Baldwin
mesh_terms: D000818:Animals; D002102:Cadaver; D005260:Female; D006801:Humans; D007668:Kidney; D019060:Minimally Invasive Surgical Procedures; D023421:Models, Animal; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation*; D009392:Nephrectomy / Q000295:instrumentation*; D061646:Operative Time; D011312:Pressure; D013552:Swine