Dexterity enhancement with robotic surgery

Manual Ambidexterity Predicts Robotic Surgical Proficiency

BACKGROUND

The manual dexterity of a surgeon is known to be related with surgical proficiency. Recently, as an objective measurement of surgical skills, inanimate methods using several types of simulators have been introduced. Using these simulators, we aimed to investigate the impact of manual dexterity on laparoscopic and robotic surgical proficiency.

MATERIALS AND METHODS

Fellow surgeons, surgical residents, and medical students (n = 32) participated in this study. For the measurement of dexterity, the sums and differences of the right and left hand performance times for the Grooved Pegboard Test were used as an index of dexterity speed and ambidexterity, respectively. The performance times during three sessions of laparoscopic suturing using a D-box trainer and the performance scores during three sessions using two robotic suturing programs with different degrees of difficulty provided by the da Vinci® Skills Simulator™ (Intuitive Surgical Inc., Sunnyvale, CA) were analyzed according to the measured manual dexterity.

RESULTS

Manual dexterity was not a significant factor for performance time during laparoscopic suturing, which was more influenced by participants' surgical experiences. In robotic suturing, the performance score was impacted significantly by manual dexterity in terms of ambidexterity rather than dexterity speed. For an easy robotic suturing task, the gap of proficiency between the lower and higher ambidexterity groups was decreased successively with each of the three sessions. However, that gap in cases with a difficult task was maintained consistently throughout all three sessions.

CONCLUSIONS

The degree of ambidexterity was an initial predictor for proficiency with simulated robotic suture. However, this relation could be lessened through a few sessions of training, although for a more difficult task further repetitions would be needed.

Evaluating tactile feedback in robotic surgery for potential clinical application using an animal model

INTRODUCTION

The aims of this study were to evaluate (1) grasping forces with the application of a tactile feedback system in vivo and (2) the incidence of tissue damage incurred during robotic tissue manipulation. Robotic-assisted minimally invasive surgery has been shown to be beneficial in a variety of surgical specialties, particularly radical prostatectomy. This innovative surgical tool offers advantages over traditional laparoscopic techniques, such as improved wrist-like maneuverability, stereoscopic video displays, and scaling of surgical gestures to increase precision. A widely cited disadvantage associated with robotic systems is the absence of tactile feedback.

METHODS AND PROCEDURE

Nineteen subjects were categorized into two groups: 5 experts (six or more robotic cases) and 14 novices (five cases or less). The subjects used the da Vinci with integrated tactile feedback to run porcine bowel in the following conditions: (T1: deactivated tactile feedback; T2: activated tactile feedback; and T3: deactivated tactile feedback). The grasping force, incidence of tissue damage, and the correlation of grasping force and tissue damage were analyzed. Tissue damage was evaluated both grossly and histologically by a pathologist blinded to the sample.

RESULTS

Tactile feedback resulted in significantly decreased grasping forces for both experts and novices (P < 0.001 in both conditions). The overall incidence of tissue damage was significantly decreased in all subjects (P < 0.001). A statistically significant correlation was found between grasping forces and incidence of tissue damage (P = 0.008). The decreased forces and tissue damage were retained through the third trial when the system was deactivated (P > 0.05 in all subjects).

CONCLUSION

The in vivo application of integrated tactile feedback in the robotic system demonstrates significantly reduced grasping forces, resulting in significantly less tissue damage. This tactile feedback system may improve surgical outcomes and broaden the use of robotic-assisted minimally invasive surgery.

Comparative study of 2-D and bichanneled 3-D laparoscopic images: Is there a difference?

INTRODUCTION

Lack of depth perception and spatial orientation are drawbacks of laparoscopic surgery. The advent of the 3-D camera system enables surgeons to regain binocular vision. The aim of this study was to gain subjective and objective data to determine whether 3-D systems are superior to 2-D systems.

MATERIALS AND METHODS

Our study consisted of two parts: a laparoscopic training model and an actual operation assessment. In the first part, we compared two groups of surgeon (specialists and trainees) performing a laparoscopic task using a 2-D and a 3-D camera system. In the second part, surgeons were assessed on their performance of standard laparoscopic cholecystectomies using the two different camera systems. At the end of each assessment, participants were required to complete a questionnaire on their impressions of the comparative ease of operation tasks under 2-D and 3-D vision.

RESULT

In the laboratory training model, trainees' performance time was shorter with the 3-D camera system than with the 2-D camera, but no difference was observed in the specialists group. In the surgical (cholecystectomy) assessment, no significant difference was observed between the 2-D and 3-D camera systems in terms of operative time and precision. The questionnaire indicated that all participants did not significantly favor the 3-D system.

CONCLUSION

We believe that the 3-D camera system can allow young surgeons to perform standard laparoscopic tasks safely and quickly, so as to accelerate the learning curve. However, new-generation 3-D systems will be essential to overcome surgeons' discomfort.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS

A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS

A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION

Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

Long-term prospective evaluation comparing robotic parathyroidectomy with minimally invasive open parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Targeted parathyroidectomy is a popular technique for localized pathology. No single technique is established as superior. The purpose of this study was to compare robotic-assisted parathyroidectomy (RAP) with the most common approach.

METHODS

This was a prospective, nonrandomized study. Fifteen consecutive patients who underwent RAP were compared to 15 matched controls undergoing focused lateral parathyroidectomy (FLP).

RESULTS

Biochemical cure occurred in 29 of 30 patients (97%). No major complications occurred, although there was 1 robotic conversion. RAP demonstrated a significant time reduction (R(2)  = 0.436; p = .01) but took much longer to perform than FLP (119 minutes vs 34 minutes; p = .001). RAP was associated with less initial postoperative pain (p = .036) and higher satisfaction with scar cosmesis (p = .002) until 6 months. Quality of life (QOL) improved in both groups (p = .007).

CONCLUSION

RAP provides superior early cosmesis with equivalent global health improvement compared to FLP. The high cost and learning curve may preclude widespread adoption. Further evaluation is necessary to establish its clinical efficacy regarding scar cosmesis. © 2015 Wiley Periodicals, Inc. Head Neck 38: E300-E7, 2016.

Abdominal Hysterectomy: Reduced Risk of Surgical Site Infection Associated with Robotic and Laparoscopic Technique

BACKGROUND

Hysterectomy is one of the most common procedures performed in the United States. New techniques utilizing laparoscopic and robotic technology are becoming increasingly common. It is unknown if these minimally invasive surgical techniques alter the risk of surgical site infections (SSI).

METHODS

We performed a retrospective review of all patients undergoing abdominal hysterectomy at our institution between January 2011 and June 2013. International Classification of Diseases, Ninth edition (ICD-9) codes and chart review were used to identify patients undergoing hysterectomy by open, laparoscopic, or robotic approach and to identify patients who developed SSI subsequently. Chi-square and analysis of variance (ANOVA) tests were used to identify univariate risk factors and logistic regression was used to perform multivariable analysis.

RESULTS

During this time period, 986 patients were identified who had undergone abdominal hysterectomy, with 433 receiving open technique (44%), 116 laparoscopic (12%), 407 robotic (41%), and 30 cases that were converted from minimally invasive to open (3%). Patients undergoing laparoscopic-assisted hysterectomy were significantly younger and had lower body mass index (BMI) and American Society of Anesthesiologists (ASA) scores than those undergoing open or robotic hysterectomy. There were no significant differences between patients undergoing open versus robotic hysterectomy. The post-operative hospital stay was significantly longer for open procedures compared with those using laparoscopic or robotic techniques (5.1, 1.7, and 1.6 d, respectively; p<0.0001). The overall rate of SSI after all hysterectomy procedures was 4.2%. More SSI occurred in open cases (6.5%) than laparoscopic (0%) or robotic (2.2%) (p<0.0001). Cases converted to open also had an increased rate of SSI (13.3%). In both univariate and multivariable analyses, open technique, wound class of III/IV, age greater than 75 y, and morbid obesity were all associated with increased risk of SSI.

CONCLUSION

Laparoscopic and robotic hysterectomies were associated with a significantly lower risk of SSI and shorter hospital stays. Body mass index, advanced age, and wound class were also independent risk factors for SSI.

IRIS: Integrated Robotic Intraocular Snake

Retinal surgery is one of the most technically challenging surgical disciplines. Many robotic systems have been developed to enhance the surgical capabilities. However, very few of them provide the surgeon the dexterity within the patient's eye to enable more flexible, more advanced surgical procedures. This paper presents a sub-millimeter intraocular dexterous robot, the Integrated Robotic Intraocular Snake (IRIS). The variable neutral-line mechanism is used to provide very high dexterity with a very small form factor. The IRIS distal dexterous unit is 0.9 mm in diameter and about 3 mm in length. It enables two rotational degrees of freedom at the distal end of the ophthalmic instruments. The analysis on contact mechanics provides a reference for the adjustment of the wire pretension. Redundant actuation is implemented by using one motor for each wire. A motion scaling transmission is developed to overcome the suboptimal resolution of the motors. A scale-up model of the IRIS is built for initial experimental evaluation. Preliminary results show that the scale-up IRIS can provide large range of motion. For given bending angle, the kinematic model can estimate the desired wire translation when the friction is not significant. The first prototype of the actual-scale IRIS is assembled and tested.

Robotic single-site versus laparoscopic cholecystectomy: Which is cheaper? A cost report and analysis

OBJECTIVE

There is a need for a comparison of costs of robotic single-site cholecystectomy (RSSC) and laparoscopic cholecystectomy (LC) in the US healthcare model. Cholecystectomy is one of the most common procedures in general surgery. Single-incision laparoscopic surgery is beneficial but cumbersome. Robotic surgery is ergonomic but expensive. Costs of RSSC and LC have not been compared within the US healthcare model.

METHODS

Cost categories were compared between RSSC and LC in consecutive outpatient-elective cases during the same period. Cost efficiency of outpatient-elective cases before and after the first 50 institutional RSSC cases (including outpatients, inpatients, emergent, and elective) were compared to investigate for a learning curve that would subsequently affect cost.

RESULTS

A total of 458 cases included 177 RSSCs and 281 LCs. Non-emergent non-admitted cases included in cost analysis were 46 RSSCs and 175 LCs. Costs were less with RSSC: median total ($1319 vs. $1710, p < 0.001), driven mainly by cost category "Supplies" ($913 vs. $1244, p < 0.001), and to a lesser extent "Operating room" ($196 vs. $232, p < 0.001), and "Anesthesiology" ($127 vs. $168, p < 0.001). Supplies were responsible for 87% of median total cost reduction. Other cost categories were not significantly different. There were 11 and 9% drops (p < 0.006) in RSSC OR times and costs, respectively, after our 50th institutional case.

CONCLUSION

In a hospital that has already acquired infrastructure for robotic surgery, we observed procedural costs for RSSC that were lower than LC. This decreased cost was mainly driven by cutting down on supplies (87% of median total cost reduced), and to a lesser extent OR time. A steep learning curve exists after which RSSC OR times can be significantly shortened. A randomized study is needed.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Laparoscopic robot-assisted versus open total pancreatectomy: a case-matched study

BACKGROUND

The enhanced dexterity offered by robotic assistance could be excessive for distal pancreatectomy but not enough to improve the outcome of laparoscopic pancreaticoduodenectomy. Total pancreatectomy retains the challenges of uncinate process dissection and digestive reconstruction, but avoids the risk of pancreatic fistula, and could be a suitable operation to highlight the advantages of robotic assistance in pancreatic resections.

METHODS

Eleven laparoscopic robot-assisted total pancreatectomies (LRATP) were compared to 11 case-matched open total pancreatectomies. All operations were performed by one surgeon during the same period of time. Robotic assistance was employed in half of the patients, based on robot availability at the time of surgery. Variables examined included age, sex, American Society of Anesthesiologists score, body mass index, estimated blood loss, need for blood transfusions, operative time, tumor type, tumor size, number of examined lymph nodes, margin status, post-operative complications, 90-day or in-hospital mortality, length of hospital stay, and readmission rate.

RESULTS

No LRATP was converted to conventional laparoscopy, hand-assisted laparoscopy or open surgery despite two patients (18.1 %) required vein resection and reconstruction. LRATP was associated with longer mean operative time (600 vs. 469 min; p = 0.014) but decreased mean blood loss (220 vs. 705; p = 0.004) than open surgery. Post-operative complications occurred in similar percentages after LRATP and open surgery. Complications occurring in most patients (5/7) after LRATP were of mild severity (Clavien-Dindo grade I and II). One patient required repeat laparoscopic surgery after LRATP, to drain a fluid collection not amenable to percutaneous catheter drainage. One further patient from the open group required repeat surgery because of bleeding. No patient had margin positive resection, and the mean number of examined lymph nodes was 45 after LRATP and 36 after open surgery.

CONCLUSIONS

LRATP is feasible in selected patients, but further experience is needed to draw final conclusions.

Laparoscopic pancreaticoduodenectomy: a systematic literature review

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD.

METHODS

Our literature review was conducted in Pubmed. Articles written in English containing five or more LPD were selected.

RESULTS

Twenty-five articles matched the review criteria. Out of a total of 746 LPD, 341 were reported between 1997 and 2011 and 405 (54.2 %) between 2012 and June 1, 2013. Pure laparoscopy (PL) was used in 386 patients (51.7 %), robotic assistance (RA) in 234 (31.3 %), laparoscopic assistance (LA) in 121 (16.2 %), and hand assistance in 5 (0.6 %). PL was associated with shorter operative time, reduced blood loss, and lower rate of pancreatic fistula (vs LA and RA). LA was associated with shorter operative time (vs RA), but with higher blood loss and increased incidence of pancreatic fistula (vs PL and RA). Conversion to open surgery was required in 64 LPD (9.1 %). Operative time averaged 464.3 min (338-710) and estimated blood 320.7 mL (74-642). Cumulative morbidity was 41.2 %, and pancreatic fistula was reported in 22.3 % of patients (4.5-52.3 %). Mean length of hospital stay was 13.6 days (7-23), showing geographic variability (21.9 days in Europe, 13.0 days in Asia, and 9.4 days in the US). Operative mortality was 1.9 %, including one intraoperative death. No difference was noted in conversion rate, incidence of pancreatic fistula, morbidity, and mortality when comparing results from larger (≥30 LPD) and smaller (≤29 LPD) series. Pathology demonstrated ductal adenocarcinoma in 30.6 % of the specimens, other malignant tumors in 51.7 %, and benign tumor/disease in 17.5 %. The mean number of lymph nodes examined was 14.4 (7-32), and the rate of microscopically positive tumor margin was 4.4 %.

CONCLUSIONS

In selected patients, operated on by expert laparoscopic pancreatic surgeons, LPD is feasible and safe.

Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study

OBJECTIVES

To describe our initial experience with single-site robotic cholecystectomy (SSRC) and its applicability to a broad segment of patients.

BACKGROUND

At the initiation of our study, there were only 3 published reports on SSRC. These initial studies had limited inclusion criteria. We present our experience with the technical aspects and patient outcomes of SSRC in a broadly inclusive patient population.

METHODS

Prospective cohort study from January 2012 to January 2013, in which 95 patients underwent SSRC. Procedural times, postoperative complications, delayed hospital discharges, and re-admissions were evaluated.

RESULTS

Patients were predominantly female (71.6%) had mean age of 45.2 ± 6.1 years and mean body mass index (BMI) of 30.1 ± 7.1 kg/m. Overall, mean total operative time (TOT) for all patients (n = 95) was 88.63 ± 32.0 (range: 49-220) minutes. SSRC was not completed in 8 (8.42%) patients: 6 conversions to laparoscopy, 1 conversion to open, and 1 aborted case. The group of patients who were able to complete SSRC (n = 87) had a mean TOT of 83.5 ± 24.5 minutes and mean operative robotic time (RT) of 39.6 ± 15.2 minutes. RT was longer in patients with intra-abdominal adhesions (P = 0.0139) and higher BMI (P = 0.03). A minority of patients required hospital admission (11.6%), readmission (6.3%), or reoperation (1.1%). No bile duct injury or death occurred.

CONCLUSIONS

SSRC is safe and has a manageable learning curve. Patient factors, such as obesity, did not significantly affect conversion rates or TOTs. SSRC is a promising new technique, which can be offered to a wide array of patients.

Robotic thoracic surgery: technical considerations and learning curve for pulmonary resection

Retrospective series indicate that robot-assisted approaches to lung cancer resection offer comparable radicality and safety to video-assisted thoracic surgery or open surgery. More intuitive movements, greater flexibility, and high-definition three-dimensional vision overcome limitations of video-assisted thoracic surgery and may encourage wider adoption of robotic surgery for lung cancer, particularly as more early stage cases are diagnosed by screening. High capital and running costs, limited instrument availability, and long operating times are important disadvantages. Entry of competitor companies should drive down costs. Studies are required to assess quality of life, morbidity, oncologic radicality, and cost effectiveness.

Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study

BACKGROUND

Laparoscopic major hepatectomy (LMH), although safely feasible in experienced hands and in selected patients, is a formidable challenge because of the technical demands of controlling hemorrhage, sealing bile ducts, avoiding gas embolism, and maintaining oncologic surgical principles. The enhanced surgical dexterity offered by robotic assistance could improve feasibility and/or safety of minimally invasive major hepatectomy. The aim of this study was to compare perioperative outcomes of LMH and robotic-assisted major hepatectomy (RMH).

METHODS

Pooled data from four Italian hepatobiliary centers were analyzed retrospectively. Demographic data, operative, and postoperative outcomes were collected from prospectively maintained databases and compared.

RESULTS

Between January 2009 and December 2012, 25 patients underwent LMH and 25 RMH. The two groups were comparable for all baseline characteristics including type of resection and underlying pathology. Conversion to open surgery was required in one patient in each group (4%). No difference was noted in operative time, estimated blood, and need for allogenic blood transfusions. Intermittent pedicle occlusion was required only in LMH (32% vs. 0; p = 0.004). Length of hospital stay, including time spent in intensive care unit, was similar between the two groups, but patients undergoing LMH showed quicker recovery of bowel activity, with shorter time to first flatus (1 vs. 3 days; p = 0.023) and earlier tolerance to oral liquid diet (1 vs. 2 days; p = 0.001). No difference was noted in complication rate, 90-day mortality, and readmission rate.

CONCLUSIONS

This retrospective multi-institution study confirms that selected patients can safely undergo minimally invasive major hepatectomy, either LMH or RMH. The fact that intermittent pedicle occlusion could be avoided in RMH suggests improved surgical ability to deal with bleeding during liver transection, but further studies are needed before any final conclusion can be drawn.

Robot-assisted resection of a retrocaval peridiaphragmatic mass

Herein the authors report on the advantages of robotic surgery in the removal of a peridiaphragmatic mass in the retrocaval space.

A peridiaphragmatic mass that is located in the retrocaval space typically requires a wide incision and retraction of the peritoneal organs or great vessels to remove the mass. The laparoscopic method is very challenging because of unsatisfactory visual fields and a lack of range of movement from the instruments. We present the advantages of robotic surgery in the removal of deep retrocaval tumors, a procedure that requires careful dissection and minimal retraction.

Effects of robotic manipulators on movements of novices and surgeons

BACKGROUND

Robot-assisted surgery is widely adopted for many procedures but has not realized its full potential to date. Based on human motor control theories, the authors hypothesized that the dynamics of the master manipulators impose challenges on the motor system of the user and may impair performance and slow down learning. Although studies have shown that robotic outcomes are correlated with the case experience of the surgeon, the relative contribution of cognitive versus motor skill is unknown. This study quantified the effects of da Vinci Si master manipulator dynamics on movements of novice users and experienced surgeons and suggests possible implications for training and robot design.

METHODS

In the reported study, six experienced robotic surgeons and ten novice nonmedical users performed movements under two conditions: teleoperation of a da Vinci Si Surgical system and freehand. A linear mixed model was applied to nine kinematic metrics (including endpoint error, movement time, peak speed, initial jerk, and deviation from a straight line) to assess the effects of teleoperation and expertise. To assess learning effects, t tests between the first and last movements of each type were used.

RESULTS

All the users moved slower during teleoperation than during freehand movements (F(1,9343) = 345; p < 0.001). The experienced surgeons had smaller errors than the novices (F(1,14) = 36.8; p < 0.001). The straightness of movements depended on their direction (F(7,9343) = 117; p < 0.001). Learning effects were observed in all conditions. Novice users first learned the task and then the dynamics of the manipulator.

CONCLUSIONS

The findings showed differences between the novices and the experienced surgeons for extremely simple point-to-point movements. The study demonstrated that manipulator dynamics affect user movements, suggesting that these dynamics could be improved in future robot designs. The authors showed the partial adaptation of novice users to the dynamics. Future studies are needed to evaluate whether it will be beneficial to include early training sessions dedicated to learning the dynamics of the manipulator.

How does the surgeon's experience of abdominal operations influence the learning curves for robot-assisted vascular anastomosis?

OBJECTIVE

Endoscopic vascular anastomosis of abdominal aortic aneurysms is rarely performed and requires standardization. Here, we examined the impact of the surgeon's experience of abdominal aortic aneurysm surgery on the learning curve for robot-assisted endoscopic vascular anastomosis.

METHODS

Three vascular surgeons with more than 10 years' experience (group A), three vascular surgeons with less than 10 years' experience (group B), and three medical students with no experience (group C) of performing vascular surgery used the da Vinci surgical system to anastomose 8-mm-diameter vascular prostheses in an end-to-end manner with continuous 5-0 Prolene sutures. The procedure was performed five times by each participant. Outcomes were anastomosis time, number of actions, visual score, and pressure test. Snapping of the prolene thread was recorded as a procedural failure.

RESULTS

Procedural failure occurred only in group C (3/15 trials, 20%; P < 0.0001). Learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions. Between trials 1 and 5, learning curves were apparent in all three groups for anastomosis time and in groups A and C for the number of actions but were not apparent for leakage or visual score in any group. Visual score and leakage were not significantly different among the three groups in each trial (P = 0.10 and P = 0.45, respectively).

CONCLUSIONS

By using the da Vinci surgical system, experienced vascular surgeons and surgically naive students showed marked improvements in vascular anastomosis techniques with a short period of training.

Laparoscopic robot-assisted major hepatectomy

BACKGROUND

We herein present a systematic review of English literature on robot-assisted major hepatectomy (MH).

METHODS

Major hepatectomy was defined as resection of three or more liver segments. A literature search was performed using the Pubmed database. Articles containing more than five robotic MH were selected. In case of multiple publications from the same institution, only the most recent article was considered in order to avoid double counting of patients between series.

RESULTS

Five articles were included in this review. A total of 68 robotic MH were analyzed, including 38 right hepatectomies and 30 left hepatectomies. There were no deaths. Two right hepatectomies (5.2%) and one left hepatectomy (3.3%) were converted to open surgery. Weighted average of operative time and intraoperative blood loss were 418.6 min and 411.4 ml, respectively. Four patients received blood transfusions (6.3%) and 17 developed postoperative complications (26.9%). Information on tumor type were available for 57 patients of whom 42 were diagnosed with malignant tumors (73.6%) and 15 with benign diseases (26.3%). No port site metastasis, peritoneal carcinomatosis, or intrahepatic recurrence were reported. Three patients had microscopic margin positivity.

CONCLUSIONS

Major hepatectomy can be performed under robotic assistance. Further experience is needed before final conclusions can be drawn.

Skills learning in robot-assisted surgery is benefited by task-specific augmented feedback

BACKGROUND

Providing augmented visual feedback is one way to enhance robot-assisted surgery (RAS) training. However, it is unclear whether task specificity should be considered when applying augmented visual feedback.

METHODS

Twenty-two novice users of the da Vinci Surgical System underwent testing and training in 3 tasks: simple task, bimanual carrying (BC); intermediate task, needle passing (NP); and complex task, suture tying (ST). Pretraining (PRE), training, and posttraining (POST) trials were performed during the first session. Retention trials were performed 2 weeks later (RET). Participants were randomly assigned to 1 of 4 feedback training groups: relative phase (RP), speed, grip force, and video feedback groups. Performance measures were time to task completion (TTC), total distance traveled (D), speed (S), curvature, relative phase, and grip force (F).

RESULTS

Significant interaction for TTC and curvature showed that the RP feedback training improved temporal measures of complex ST task compared to simple BC task. Speed feedback training significantly improved the performance in simple BC task in terms of TTC, D, S, curvature, and F even after retention. There was also a lesser long-term effect of speed feedback training on complex ST task. Grip force feedback training resulted in significantly greater improvements in TTC and curvature for complex ST task. For the video feedback training group, the improvements in most of the outcome measures were evident only after RET.

CONCLUSIONS

Task-specific augmented feedback is beneficial to RAS skills learning. Particularly, the RP and grip force feedback could be useful for training complex tasks.

Ask the Experts: The current status of robotic surgery for colorectal cancer

Alessio Pigazzi is the current chief of the colon and rectal surgery division at the University of California, Irvine (CA, USA). He specializes in minimally invasive surgery of the colon and rectum, including laparoscopic, robotic and endoscopic techniques. He performed the world’s first robotic-assisted total mesorectal resection for rectal cancer. Dr Pigazzi is also an expert in hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis. The procedure, combined with cytoreductive surgery, is an important and difficult-to-find option for patients with this complicated disease.

Wissam J Halabi is a research fellow in the division of colon and rectal surgery at the University of California, Irvine (CA, USA). His research interests include clinical outcomes research in the field of colon and rectal surgery, and he has a particular interest in minimally invasive techniques, such as laparoscopic and robotic surgery. Dr Halabi has published several articles in peer-reviewed journals on the use and outcomes of laparoscopic and robotic surgery.

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.

Pilot study on effectiveness of simulation for surgical robot design using manipulability

Medical technology has advanced with the introduction of robot technology, which facilitates some traditional medical treatments that previously were very difficult. However, at present, surgical robots are used in limited medical domains because these robots are designed using only data obtained from adult patients and are not suitable for targets having different properties, such as children. Therefore, surgical robots are required to perform specific functions for each clinical case. In addition, the robots must exhibit sufficiently high movability and operability for each case. In the present study, we focused on evaluation of the mechanism and configuration of a surgical robot by a simulation based on movability and operability during an operation. We previously proposed the development of a simulator system that reproduces the conditions of a robot and a target in a virtual patient body to evaluate the operability of the surgeon during an operation. In the present paper, we describe a simple experiment to verify the condition of the surgical assisting robot during an operation. In this experiment, the operation imitating suturing motion was carried out in a virtual workspace, and the surgical robot was evaluated based on manipulability as an indicator of movability. As the result, it was confirmed that the robot was controlled with low manipulability of the left side manipulator during the suturing. This simulation system can verify the less movable condition of a robot before developing an actual robot. Our results show the effectiveness of this proposed simulation system.

Is there a difference in laterality during robot-assisted radical prostatectomy? Assessment of lymph node yield and neurovascular bundle dissection

BACKGROUND AND PURPOSE

The da Vinci Surgical System (dVSS) has been reported to eliminate innate hand dominance of the surgeon. There are no studies to date, however, that specifically address whether the dVSS has its own inherent "handedness" resulting from the fixed left-right preference of specific instrument docking and assistant positioning. We identified the pelvic lymph node (LN) and neurovascular bundle (NVB) dissections as well as positive surgical margin rates as procedure points during robot-assisted radical prostatectomy (RARP) that could be influenced by laterality and sought to illustrate left-right consistency.

PATIENTS AND METHODS

Patients who underwent RARP by a single right-handed surgeon (KKB) between 2008 and 2010 were identified. Surgeon instrument preference and port placement were consistent across all cases. Pathologic LN yield was stratified by the intended limits of dissection (limited or extended) and laterality. In addition, fascial widths (FW) were prospectively measured for 93 consecutive patients, a narrower FW indicating a more precise intended NVB dissection. The pathologists were blinded to intended dissections.

RESULTS

A total of 340 limited, 11 bilateral extended, 11 right extended, and 5 left extended LN dissections were performed. For patients undergoing limited LN dissection, the mean LN yield was greater on the right compared with the left (3.26 vs 2.76, P=0.010). This difference was not seen in the extended LN dissection (P=0.96). Average FW was narrower on the right surgical margin compared with the left (1.99 vs 2.64 mm, P<0.001).

CONCLUSIONS

Our findings suggest that a greater number of LNs and a closer NVB dissection are achieved on the right compared with the left using the dVSS during RARP. This can be attributed to surgeon handedness, robotic instrument laterality, or assistant instrument laterality. Surgeon awareness of these potential differences is important for the preoperative planning before RARP.

Three-dimensional vision enhances task performance independently of the surgical method

BACKGROUND

Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance.

METHODS

In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system.

RESULTS

Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P < 0.0001-0.02). Simple tasks took 25 % to 30 % longer to complete and more complex tasks took 75 % longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P = 0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P < 0.001-0.015).

CONCLUSIONS

The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical method.

Robotic surgery applications in the management of gynecologic malignancies

This review evaluates the use of robotic-assisted laparoscopic surgery in the treatment of gynecologic malignancies and objectively evaluates the use of these systems in performing radical hysterectomies and surgical staging of gynecologic malignancies. The review focuses on surgical length, blood loss, complications, recovery time, and adequacy of surgical staging of robotic-assisted surgery compared to abdominal and non-robotically assisted laparoscopic surgery for malignancies.

Experience with Robotic Lobectomy for Lung Cancer

Objective

In this study, we analyze our experience so far with robotic pulmonary lobectomy, compare it with published data, and suggest a learning curve for the operation.

Methods

Ninety-one patients with suspected or proven clinical stage I–III lung cancer underwent robotic lobectomy. Selection criteria included lesion ≤5 cm and normal respiratory function. One surgeon performed the operations using the da Vinci system with three ports and a 3-cm utility thoracotomy.

Results

Median duration of operation was 239 (range 85–411) minutes, 260 minutes in the first 18 patients and 221 minutes in the remaining 73 cases (P = 0.01). Median hospitalization declined from 6 days in the first 18 cases to 5 days in the remaining cases (P = 0.002). Conversion rate and number of complications reduced nonsignificantly from the initial to later series. Major complications occurred in 11% of the first 18 cases and 4% of the later cases. The number of lymph nodes removed did not change over the two series. There was no 30-day postoperative mortality. After a median follow-up of 24 months, 80 of 91 patients were alive with no sign of disease.

Conclusions

Our data suggest that about 20 operations are required to achieve surgical competence. Robotic lobectomy appears safe, oncologically radical, and associated with shorter postoperative hospitalization than open surgery.

The da Vinci(®) Surgical System overcomes innate hand dominance

BACKGROUND AND PURPOSE

The robotic surgical platform has allowed for improved ergonomics, tremor filtration, and more precise surgical movements during minimally invasive surgery. We examined the impact of the da Vinci(®) Surgical System on the lateralization of manual dexterity, or handedness, innate to most surgeons.

METHODS

Manual dexterity assessments were conducted among 19 robotic novices using two different skills tests: The Purdue Pegboard Test and a needle targeting test. After an initial robotic basic skills training seminar, subjects underwent testing using both open and robotic approaches. Test performance using both approaches was then compared among all subjects.

RESULTS

The majority of subjects (84%) were right handed, and all subjects described their dominant hand as significantly or moderately more dexterous than their nondominant hand. The participants had significant differences between the dominant and nondominant hand in open skills tasks using the Purdue Pegboard test (15.4 vs 14.6 pegs, P=0.023) and needle targeting test (4.5 vs 3.7 targets, P=0.015). When the same tasks were performed using the robot, the differences in handedness were no longer observed (P=0.203, P=0.764).

CONCLUSION

The da Vinci robot is capable of eliminating innate dexterity or handedness among novice surgical trainees. This provides evidence of another beneficial aspect of robot-assisted surgery over traditional laparoscopic surgery and may facilitate operative performance of complex tasks.

Robotic-Assisted Parathyroidectomy

Objective. Targeted parathyroidectomy is the gold standard for localized parathyroid disease. A robotic-assisted approach has not been investigated. The aim was to assess the feasibility of a robotic technique that avoids a neck scar.

Study Design. Feasibility study.

Setting. Tertiary referral center.

Subjects and Methods. Eleven patients with primary hyperparathyroidism were prospectively evaluated. Triple modality concordant localization was a prerequisite. All patients underwent robotic-assisted parathyroidectomy (RAP). Outcome variables assessed were operative time, voice change, biochemical cure, and histopathological confirmation. Patient-reported outcome measures (PROMs) included subjective assessment of pain and scar cosmesis, Voice Handicap Index 2, and EQ-5D quality-of-life assessment. Mean follow-up was 6 months (range, 3-12 months).

Results. The parathyroid adenoma was successfully excised in all cases with negligible blood loss (<5 mL). There was 1 conversion. There was no voice change in any case. Robot docking time plateaued to 10 minutes after 8 cases. Mean exposure and console times (31 and 51 minutes, respectively) were affected by body habitus. The mean visual analog scale for scar cosmesis was 75% on the first postoperative day, improving to 92% at 6 months and 95% at 1 year. Pain scores decreased to 8% at 2 weeks. All 5 EQ-5D quality-of-life parameters significantly improved following surgery.

Conclusion. The robotic approach is feasible for performing targeted parathyroidectomy that avoids a neck scar. The clinical efficacy and cost-effectiveness of the robotic approach compared with conventional targeted parathyroidectomy warrant further evaluation to establish if this represents a viable alternative to the existing targeted techniques.

Role of robotic surgery in urogynecologic surgery and radical hysterectomy: how far can we go?

PURPOSE OF REVIEW

The purpose is to review the current literature regarding robotic assistance in urogynecologic surgery and radical pelvic surgery and to discuss the future of robotics in these two areas of gynecology.

RECENT FINDINGS

When the first and only Food and Drug Administration-approved robot-assisted device, the daVinci surgical system, was approved for use in gynecology in April 2005, many procedures were translated to a robotic approach. In the field of urogynecology, much attention was given to the use of robotic assistance for sacrocolpopexy. In oncology, there was an attraction to the use of robotics for radical hysterectomies. There are a number of published observational studies comparing the outcomes of both robot-assisted laparoscopic sacrocolpopexy (RALS) and robot-assisted radical hysterectomy (RRH) to their conventional laparoscopic and open versions. Overall, the literature suggests that the use of robotics for these procedures increases operative time and cost, but decreases estimated blood loss and length of stay. The complication rates appear to be similar. Recurrence of apical prolapse after RALS appears to be similar to that in conventional laparoscopic or open sacrocolpopexy. The number of lymph nodes harvested is the same or increases with RRH, whereas the disease-free progression and overall survival are similar for all the methods of radical hysterectomy.

SUMMARY

Literature suggests that RALS and RRH have equivalent outcomes when compared to conventional laparoscopic and open techniques. The question is whether the use of robotics that combines the outcomes of an open procedure, the benefits of minimally invasive surgery, and easy adoptability will outweigh the increased cost and time associated with robotic surgery.

[A role of robotic-assisted surgery to preserve female fertility? Comments about the first paratubal cystectomy performed with the "Da Vinci S" robotic system in a young girl]

In the field of adnexal surgeries in children, robotic surgery seems to make easier the realization of minimal invasive surgery. It could lead to a decrease of post-surgical adherences and therefore preserve the fertility of young patients. We report the first paratubal cystectomy performed using robotic assistance on a child in order to preserve her future fertility and discuss advantages and disadvantages of this technology.

Resection of ectopic mediastinal parathyroid glands with the da Vinci® robotic system

Background

Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot-assisted dissection for mediastinal ectopic parathyroid glands.

Methods

Two patients with recurrent secondary hyperparathyroidism and three with complicated primary hyperparathyroidism were operated on between July 2004 and August 2008 for ectopic mediastinal parathyroid glands. Fusion of single-photon emission computed tomography and computed tomography led to an exact identification of the culprit glands. Surgery was performed thoracoscopically with the da Vinci® robotic system using a three-trocar approach.

Results

All procedures were completed successfully with the robotic system. No perioperative morbidity or mortality was noted. Median operating time was 58 (range 42–125) min. Intraoperative parathyroid hormone reduction indicated complete resection. Median hospital stay was 3 (range 2–4) days.

Conclusion

Robot-assisted dissection is a promising approach for resection of ectopic parathyroid glands in remote narrow anatomical locations such as the mediastinum.

A comparison of laparoscopic and robotic assisted suturing performance by experts and novices

BACKGROUND

Surgical robotics has been promoted as an enabling technology. This study tests the hypothesis that use of the robotic surgical system can significantly improve technical ability by comparing the performance of both experts and novices on a complex laparoscopic task and a robotically assisted task.

METHODS

Laparoscopic experts (LE) with substantial laparoscopic and robotic experience (n = 9) and laparoscopic novices (LN) (n = 20) without any robotic experience performed sequentially 10 trials of a suturing task using either robotic or standard laparoscopic instrumentation fitted to the ProMIS surgical simulator. Objective performance metrics provided by ProMIS (total task time, instrument pathlength, and smoothness) and an assessment of learning curves were analyzed.

RESULTS

Compared with LNs, the LEs demonstrated significantly better performance on all assessment measures. Within the LE group, there was no difference in smoothness (328 +/- 159 vs 355 +/- 174; P = .09) between robot-assisted and standard laparoscopic tasks. An improvement was noted in total task time (113 +/- 41 vs 132 +/- 55 sec; P < .05) and instrument pathlengths (371 +/- 163 vs 645 +/- 269 cm; P < .05) when using the robot. This advantage in terms of total task time, however, was lost among the LEs by the last 3 trials (114 +/- 40 vs 118 +/- 49 s; P = .84), while instrument pathlength remained better consistently throughout all the trials. For the LNs, performance was significantly better in the robotic trials on all 3 measures throughout all the trials.

CONCLUSION

The ProMIS surgical simulator was able to distinguish between skill levels (expert versus novice) on robotic suturing tasks, suggesting that the ProMIS is a valid tool for measuring skill in robot-assisted surgery. For all the ProMIS metrics, novices demonstrated consistently better performance on a suturing task using robotics as compared to a standard laparoscopic setup. This effect was less evident for experts who demonstrated improvements only in their economy of movement (pathlength), but not in the speed or smoothness of performance. Robotics eliminated the early learning curve for novices, which was present when they used standard laparoscopic tools. Overall, this study suggests that, when performing complex tasks such as knot tying, surgical robotics is most useful for inexperienced laparoscopists who experience an early and persistent enabling effect. For experts, robotics is most useful for improving economy of motion, which may have implications for the highly complex procedures in limited workspaces (eg, prostatectomy).

Evolving role and current state of robotics in minimally invasive gynecologic surgery

Advancements in conventional laparoscopy afford gynecologists the ability to treat disease with minimally invasive interventions. Procedures such as hysterectomy are still performed predominantly via laparotomy. Instrumentation, complex disease, and steep learning curves are often cited as obstacles to minimally invasive surgery. The advent of robotic technology may provide a means to overcome the limitations of conventional laparoscopy through the use of 3-dimensional imaging and more dextrous and precise instruments. Current studies clearly demonstrate the feasibility and safety of applying robotics to the entire spectrum of gynecologic procedures. Rigorous scientific studies and long-term data are needed to determine the appropriate applications of robotics in gynecology. Numerous questions still exist pertaining to costs, credentialing and privileging, and training.

Optimization of a pneumatic balloon tactile display for robot-assisted surgery based on human perception

Robot-assisted surgery is characterized by a total loss of haptic feedback, requiring surgeons to rely solely on visual cues. A compact, flexible, and lightweight pneumatic balloon tactile display has been developed suitable for mounting on robotic surgical master controls. The tactile display consists of a molded polydimethylsiloxane substrate with cylindrical channels and a spin-coated silicone film that forms the array of balloons. Human perceptual studies were conducted to determine the optimal diameter, spatial resolution, and temporal resolution of the balloon actuator design. A balloon diameter of 3.0 mm provided the highest average accuracy ( >or= 95%) while offering five detectable inflation levels. Spatial accuracy in a two-actuator discrimination task reached 100% with 1.5 mm edge-to-edge spacing, and the accuracy of determining the order of two successive stimuli was greater than 90% when the time separation was 100 ms. Design optimization based on the results from this study enables the described tactile display to provide the effective tactile feedback that is otherwise unavailable during robotic surgery.