SPIDER and flexible laparoscopy: the next frontier in abdominal surgery.

With the introduction of natural orifice translumenal endoscopic surgery (NOTES), there has been interest in the general surgery community for developing safe, scarless surgery. NOTES itself brought additional risks to GI surgery, and as such it has not achieved mainstream acceptance. Single site is considered by many surgeons as a bridge between traditional laparoscopic surgery and NOTES without the inherent risks of NOTES. However, initial single-site procedures using standard instrumentation are technically challenging due to the absence of instruments that facilitate triangulation, avoid conflicts between the instruments and the camera, maintain pneumoperitoneum, and reduce operative stress. The TransEnterix SPIDER platform has been created to overcome these difficulties. The SPIDER is a sterile and disposable device that contains 4 working channels (2 flexible instrument delivery tubes positioned laterally and 2 rigid channels, superiorly and inferiorly to accommodate an endoscope or any of the shelf rigid surgical instruments). Procedures facilitated by this platform are considered to use a hybrid flexible laparoscopic technique. Initial experience in over 100 cases with the SPIDER, including colectomy, cholecystectomy and adjustible gastric banding, has shown this system to be effective. Technical pearls when using the SPIDER include pulling rather than pushing, and increased use of electrocautery. These learning curve lessons for flexible laparoscopy will be described in detail, including a discussion of advantages and disadvantages. The SPIDER platform facilitates safe and straightforward single-site laparoscopic surgery.