Flexible next-generation robotic surgical system for transoral endoscopic hypopharyngectomy: A comparative preclinical study

Comparison Between Robotic and Conventional Laparoscopic Hysterectomy Performed Using Single-Port Approach

INTRODUCTION

Robotic surgery is being rapidly implemented globally, and new robotic surgery techniques are being developed. The da Vinci SP surgical system, a new robotic surgery system using a single-port approach, was introduced for the first time in Japan, and its surgical results were compared with those of the conventional single-port plus one-port laparoscopic hysterectomy.

METHODS

The study included 20 patients who underwent single-port robotic hysterectomy using the da Vinci SP surgical system (SP-RH) between March 2023 and December 2023, and 37 patients who underwent single-port plus one-port laparoscopic hysterectomy (SP + 1-LH) between March 2018 and December 2023. The surgical outcomes and complications were retrospectively compared.

RESULT

When the SP-RH group was compared with the SP + 1-LH group, intraoperative blood loss was observed to be significantly lower in the SP-RH group. However, no difference in the incidence of intraoperative complications between the two groups was observed. Furthermore, when comparing postoperative inflammatory responses, C-reactive protein levels were significantly lower in the SP + 1-LH group on the third day after surgery, but no other differences were observed.

CONCLUSION

This study demonstrated that single-port robotic hysterectomy using the da Vinci SP surgical system can be safely introduced and performed in clinical settings. The da Vinci SP surgical system, which uses a single-port platform, can be used in minimally invasive surgeries as a novel operational system.

Design and Motion Control of Master-Slave Control Endotracheal Intubation Robot

BACKGROUND

Master-slave remote control technology allows patients to be treated promptly during transport and also reduces the risk of contagious infections. Endotracheal intubation, guided by endoscopy and a master-slave system, enables doctors to perform the procedure efficiently and accurately.

METHODS

In this paper, we present the development of a master-slave controlled endotracheal intubation robot (EIR). It is based on operation incremental mapping, a weighted recursive average filtering method to reduce vibration, and a virtual fixture designed to reduce mishandling in minimally invasive surgery.

RESULTS

Simulation analysis of the master-slave control demonstrates that the weighted recursive average filtering method effectively reduces vibration, while the virtual fixture assists in confining the operator's movement within a delimited area. Experimental validation confirms the validity of the robot's structural design and control method.

CONCLUSIONS

The developed robot successfully achieves the necessary motion for endotracheal intubation surgery through master-slave control.

Transoral robotic surgery (TORS) in Japan: procedures, advantages and current status

Transoral robotic surgery (TORS), introduced by Weinstein et al. in 2005, has been widely adopted as a minimally invasive procedure, particularly for the treatment of patients with early stage oropharyngeal cancer. TORS is typically performed using the da Vinci Surgical System, similar to robot-assisted surgeries for other malignancies. The main difference between TORS and these other robot-assisted surgeries is that it is performed through the natural orifice of the mouth, which limits the surgical working space, and that it progresses from the lumen of the pharynx to the deeper tissues. The advantages of TORS are mainly due to the benefits of using the da Vinci Surgical System, such as three-dimensional high-definition images, magnification, multiple forceps articulation, tremor-stabilization function and motion scale function. To date, many big data and meta-analyses have shown that TORS is superior to conventional surgeries, such as open surgery, in terms of oncological outcomes, post-operative functionality and quality of life. In Japan, TORS is expected to spread across the country, as it has been covered by health insurance since April 2022. This review highlights the procedures of TORS, its unique aspects, its unparalleled advantages as a minimally invasive surgery for treating laryngeal and pharyngeal cancers, and its current status in Japan.

Evaluation and application of CO2 laser fiber delivery for single port transoral robotic surgery

BACKGROUND

Transoral robotic surgery (TORS) using the Single-Port system (SPS) relies on electrocautery, limiting its applications in the upper aerodigestive tract. We evaluated the feasibility of a CO₂ delivery system for the SPS.

METHODS

Otolaryngology residents performed a cutting exercise using a handheld CO₂ laser and participated in a cadaveric oropharyngeal dissection using the SPS with monopolar cautery (SP + EC) and CO₂ laser (SP + CO₂ ). Residents completed the System Usability Scale (SUS) questionnaire to evaluate these techniques.

RESULTS

The same laser fiber was used for all combined dissections. The handheld CO₂ laser, SP + EC, and SP + CO₂ demonstrated similar SUS scores. On individual domain scores, SP + CO₂ received less favorable ratings compared to the handheld CO₂ laser for complexity, integration, and cumbersome experience (p < 0.05). On subgroup stratification, less TORS experience was associated with worse SUS scores.

CONCLUSION

SP-guided CO₂ laser delivery is a viable alternative to electrocautery in robotic surgery, and should be considered when performing TORS.

Single-port laparoscopic appendectomy for perforated appendicitis using ArtiSential® wristed articulated instrument

Single-port laparoscopic appendectomy (SPLA) was firstly introduced in 1998 and has been suggested potential advantages including better cosmetic outcome, less post-operative pain and avoidance of possible haemorrhagic complications from injuring epigastric vessels. However, single-port laparoscopic approach using conventional straight instruments may lead to internal and external conflicts and ergonomic discomfort, and new laparoscopic articulating instruments were developed to overcome these limitations of straight instruments. The ArtiSential® (LIVSMED Inc., Republic of Korea) is an 8-mm diameter pistol-handle instrument that has complete articulating function like human wrist and intuitive controllability. We present a technical report of SPLA for perforated appendicitis using ArtiSential® wristed articulated instrument. A 78-year-old female with a body mass index of 23.5 was referred to our emergency room with right lower quadrant abdominal pain. Abdominal computed tomography scan showed a distended tubular structure in the right lower quadrant (1.2 cm in diameter) with periappendiceal fluid collection. The patient's clinical presentation was highly indicative of perforated acute appendicitis. We performed SPLA with ArtiSential® grasper with the left hand, and this instrument helped us to allow greater manoeuvrability and dexterity with double triangulation technique. The total operation time was 40 min, and the patient was discharged without complications on the 1st day after surgery.

Research progress and development trend of surgical robot and surgical instrument arm

BACKGROUND

In recent years, surgical robots have become an indispensable part of the medical field. Surgical robots are increasingly being used in the areas of gynaecological surgery, urological surgery, orthopaedic surgery, general surgery and so forth. In this paper, the development of surgical robots in different operations is reviewed and analysed. In the type of master-slave surgical robotic system, the robotic surgical instrument arms were located in the execution terminal of a surgical robot system, as one of the core components, and directly contact with the patient during the operation, which plays an important role in the efficiency and safety of the operation. In clinical, the arm function and design in different systems varies. Furtherly, the current research progress of robotic surgical instrument arms used in different operations is analysed and summarised. Finally, the challenge and trend are concluded.

METHODS

According to the classification of surgical types, the development of surgical robots for laparoscopic surgery, neurosurgery, orthopaedics and microsurgery are analysed and summarised. Then, focusing on the research of robotic surgical instrument arms, according to structure type, the research and application of straight-rod surgical instrument arm, joint surgical instrument arm and continuous surgical instrument arm are analysed respectively.

RESULTS

According to the discussion and summary of the characteristics of the existing surgical robots and instrument arms, it is concluded that they still have a lot of room for development in the future. Therefore, the development trends of the surgical robot and instrument arm are discussed and analysed in the five aspects of structural materials, modularisation, telemedicine, intelligence and human-machine collaboration.

CONCLUSION

Surgical robots have shown the development trend of miniaturisation, intelligence, autonomy and dexterity. Thereby, in the field of science and technology, the research on the next generation of minimally invasive surgical robots will usher in a peak period of development.

Robotic surgery may improve overall survival for T1 and T2 tumors of the hypopharynx: An NCDB cohort study

BACKGROUND

Hypopharyngeal cancer is associated with poor survival. Robotic surgery is emerging as a treatment for hypopharyngeal tumors, but no rigorous data are available to assess its effect on survival.

METHODS

The National Cancer Database (NCDB) was used to identify patients with T1 and T2 hypopharyngeal tumors undergoing robotic surgery, laser surgery, and primary radiation with or without chemotherapy from 2010 to 2016. All adult patients with available staging and no distant metastasis were included.

RESULTS

We compared 57 patients undergoing robotic surgery, 236 undergoing laser surgery, and 5,742 undergoing primary radiation. Compared to laser surgery, patients undergoing robotic surgery were significantly more likely to have negative margins, neck dissection, lower incomes, and care at an academic center. Rates of robotic surgery also significantly increased from 2010 to 2015. After multivariate regression, robotic surgery was associated with significantly improved overall survival compared to laser surgery and primary radiation.

CONCLUSION

Robotic surgery improves overall survival for T1 and T2 hypopharyngeal tumors compared to laser surgery and primary radiation in this NCDB cohort. This effect may be mediated by decreased positive margin rates relative to laser surgery. Rates of hypopharyngeal robotic surgery are expected to increase with wider adoption of robotic platforms and may improve overall survival rates for hypopharyngeal cancer.

Initial experience with a suprapubic single-port robotic right hemicolectomy in patients with colon cancer

BACKGROUND

We developed a novel suprapubic single-port robotic right hemicolectomy (spRHC) procedure for patients with right colon cancer using a da Vinci SP Surgical System. The aim of this study was to determine the safety and feasibility of this technique.

METHODS

We performed the spRHC procedure on five patients with right colon cancers between July and September 2020. All procedures including colon mobilization, D3 lymphadenectomy, and intracorporeal anastomosis were completed using the single-port robotic platform through a mini-transverse suprapubic incision and an additional assistant port. Data regarding patient characteristics, perioperative outcomes and pathologic results were analyzed.

RESULTS

Four of the five patients were males. The median age was 69 years (range, 58-77 years).Two patients received preoperative chemotherapy for advanced colon cancer. The median total operative time was 160 min (range, 150-240 min). The median docking time was 4 min 40 s (range, 2 min 10 s-5 min 10 s). The median console time was 105 min (range, 100-120 min). There were no conversions to multiport or open surgeries. The median hospital stay was 7 days (range, 5-12 days). One patient experienced a wound infection. The median number of harvested lymph nodes was 41 (range, 39-50 lymph nodes).

CONCLUSIONS

SpRHC is safe and feasible. However, further comparative studies are needed to assess whether this procedure can provide patients with significant benefits compared with multiport robotic surgery.

Precision head and neck surgery: robotics and surgical vision technology

PURPOSE OF REVIEW

As the molecular basis of head and neck cancer becomes more clearly defined, precision medicine has gradually refined the multidisciplinary treatment paradigm for patients with oropharyngeal cancer. Although precision medicine is often thought to refer to new molecular diagnostics or unique medical therapy, the recent adoption of robotic surgery has ushered in the era of 'precision' head and neck surgery.

RECENT FINDINGS

Surgeons now routinely utilize a virtual reality environment to reduce the morbidity of head and neck surgical care and improve oncologic and functional outcomes. The development and subsequent FDA approval of the da Vinci SP system, a single-arm system with a flexible camera, has allowed for improved visualization and access to the deep oropharynx and larynx. Groups investigating anti-EGFR antibodies tagged with fluorescent dye as well as inherent autofluorescence differences between normal and cancerous mucosal tissues show promise for improving positive surgical margin rates.

SUMMARY

The evolution of robotics and visualization for oropharyngeal cancer represents a novel and innovative utilization of new technology to improve care. Further advancements in techniques, from refinement of the robotic platform itself, to novel real-time tumour imaging options will be critical to further advance precision care for these patients.

Robotic transmaxillary approach to the lateral infratemporal fossa: A preclinical cadaveric study using a next-generation single-port robotic system

Robotic transmaxillary skull base surgery has been described using multiport systems. This cadaveric study investigates the feasibility of transmaxillary skull base surgery using a next-generation robot. An extended Caldwell-Luc antrostomy, measuring 3.3 cm by 4.0 cm, was performed in 15 min using a Kerrison rongeur and the robotic endoscope. A single-port, robotic system (da Vinci Sp®, Intuitive Surgical, Inc, Sunnyvale, CA, USA) was then deployed throught the extended Caldwell-Luc approach and provided sufficient reach, visualization, and maneuverability to work within the pterygopalatine fossa (PPF) and the infratemporal fossa (ITF) using three surgical instruments. The ITF dissection was easiest with two instruments using the third instrument to retract the muscles of mastication. This study demonstrates the feasibility of single-port robotic transmaxillary approaches to the lateral ITF. Using a single-port robotic system, the operating surgeon can for the first time work in the PPF and ITF using two functional arms for tumor dissection and a third to retract.

Cadaveric feasibility study of a teleoperated parallel continuum robot with variable stiffness for transoral surgery

Robot-assisted technologies are overcoming the limitations of the current approaches for transoral surgeries, which are suffering from limited vision and workspace. As a result, we develop a novel teleoperated parallel continuum robot with variable stiffness for collision avoidance. This paper focuses on the feasibility study on a cadaveric model for the robotic system as a first trial. We introduce the configuration of the robotic system, the description of the processes of the trial, including the setting of the robotic system, the test of stiffness, and the action of the manipulation. The contact force between the manipulators with different stiffness and the surrounding tissues and a series of surgical operations of the manipulator, including grasping, cutting, pushing, and pulling tissues under the master-slave control mode, were recorded and analyzed. Experimental results suggest that the typical surgical procedure on a cadaveric model was successfully performed. Moreover, the efficacy and feasibility of the developed robotic system are verified to satisfy the requirements of transoral robotic surgery (TORS). Graphical abstract.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Augmented reality for image guidance in transoral robotic surgery

With the advent of precision surgery, there have been attempts to integrate imaging with robotic systems to guide sound oncologic surgical resections while preserving critical structures. In the confined space of transoral robotic surgery (TORS), this offers great potential given the proximity of structures. In this cadaveric experiment, we describe the use of a 3D virtual model displayed in the surgeon's console with the surgical field in view, to facilitate image-guided surgery at the oropharynx where there is significant soft tissue deformation. We also utilized the 3D model that was registered to the maxillary dentition, allowing for real-time image overlay of the internal carotid artery system. This allowed for real-time visualization of the internal carotid artery system that was qualitatively accurate on cadaveric dissection. Overall, this shows that virtual models and image overlays can be useful in image-guided surgery while approaching different sites in head and neck surgery with TORS.

Transoral robotic thyroidectomy on two human cadavers using the Intuitive da Vinci single port robotic surgical system and CO2 insufflation: Preclinical feasibility study

BACKGROUND

Transoral vestibular approach endoscopic thyroidectomy has gained popularity worldwide because it avoids a cutaneous incision. Some surgeons have expressed reservations about operating with only 2 instruments in the endoscopic technique, and some therefore utilize an axillary incision as an adjunct to facilitate dissection. The Intuitive da Vinci single port robotic system offers the potential to overcome this limitation without an axillary incision.

METHODS

In this study, the Intuitive da Vinci single port robotic surgical system was used to perform transoral thyroidectomy on 2 human cadavers.

RESULTS

A total thyroidectomy was performed in 2 cadavers using the da Vinci single port (SP) robot via transoral vestibular technique. The dissections were performed with removal of the thyroid gland and preservation of the recurrent laryngeal nerves and parathyroid glands.

CONCLUSION

In our evaluation, transoral vestibular approach robotic thyroidectomy using the Intuitive da Vinci SP system facilitated dissection without the need for an axillary incision.

Curved Laryngopharyngoscope With Flexible Next-Generation Robotic Surgical System for Transoral Hypopharyngeal Surgery: A Preclinical Evaluation

Objectives:

The indication of transoral robotic surgery for hypopharyngeal cancer is limited because of poor accessibility. The aim of this study was to explore the efficacy of a curved laryngopharyngoscope used in combination with a next-generation flexible robotic surgical system for accessing and resecting the hypopharynx.

Methods:

A comparative evaluation of the curved laryngopharyngoscope versus standard straight-blade retractors using the flexible robotic surgical system was conducted on 2 cadavers. End points measured included visualization, accessibility, and ease of dissection for accessing and resecting the hypopharynx.

Results:

Visualization, accessibility, and dissection were superior with the curved laryngopharyngoscope in all subareas of the hypopharynx. The advantages of accessibility and visualization were much more evident in the cadaver with a high body mass index.

Conclusions:

These preclinical data suggest that using a curved laryngopharyngoscope in combination with a flexible robotic surgical system may lead to technical innovations concerning transoral surgery of the hypopharynx.

Robotic-Assisted Transrectal Cholecystectomy in a Porcine Model

Background. With increasing experience and technological advancement in surgical instruments, surgeons have explored the feasibility of single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery (NOTES). These techniques aim to further reduce surgical trauma, but are not popular due to their inherent pitfalls including clashing of instruments, lack of counter traction, lengthy operating time, and so on. A novel surgical robotic system was designed to overcome the limitations of the existing technologies. Animal trials were conducted to demonstrate its feasibility in performing robotic-assisted transrectal cholecystectomy in a porcine model. Method. The Novel surgical robotic system is a high dexterity, single access port surgical robotic system that enables surgeons to carry out single-port surgical procedure or NOTES. The proposed system’s main features include the ability to perform intraabdominal and pelvic surgeries via natural orifices like the vagina or rectum. The system is equipped with multiple miniaturized (16 mm diameter) internally motorized robotic arms, each with a minimum of 7 degrees of freedom, a dual in vivo camera system, a cannula, and an external swivel system. Results. Robotic-assisted transrectal cholecystectomy was successfully performed in 3 adult male pigs. The estimated blood loss was <10 mL in all 3 cases. There were no intraoperative complications. The system provided good dexterity and clear vision. Conclusions. The trial demonstrated that the system can provide the surgeon a stable platform with adequate spacing for the transrectal insertion of robotic arms, 3-dimensional vision, and enhanced dexterity in performing NOTES cholecystectomy.