Background/purpose We have invented multi-piercing surgery (MPS) which could potentially solve the triangular formation loss and device clashing which occur in singleport surgery (SPS), as well as restricted visual field, organ damage by needle-type instruments, and impaired removal of a resected organ from the body which occur in needlescopic surgery (NS). MPS is natural orifice translumenal endoscopic surgery (NOTES)-assisted NS. We used 3-mm diameter robots as needle-type instruments for MPS to examine the possibility of local immune cell therapy and regenerative therapy using stem cells for pancreatic cancer. Methods In MPS using two robots, the therapeutic cell suspension was injected into a target region of pancreas in two pigs. Both retention of a capsule of liquid cell suspension and invasive level were evaluated. Results Triangular formation could be ensured. The use of small-diameter robots allowed (1) the surgical separation of the pancreas and the retroperitoneum, and (2) the formation of the capsule containing the immune cell and stem cell suspension. The endoscope for NOTES provided a clear visual field and also assisted the removal of a resected organ from the body. The visual field of the endoscope could be oriented well by using an electromagnetic navigation system. Conclusions MPS using small-diameter robots could potentially solve the issues inherent in SPS and NS and could allow minimally invasive local immune cell and stem cell therapy.
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