Advanced real-time multi-display educational system (ARMES): An innovative real-time audiovisual mentoring tool for complex robotic surgery

Long-term Oncologic Outcomes of Robotic Total Gastrectomy for Advanced Gastric Cancer

PURPOSE

Although laparoscopic distal gastrectomy has rapidly replaced open distal gastrectomy, laparoscopic total gastrectomy (LTG) is less frequently performed owing to technical difficulties. Robotic surgery could be an appropriate minimally invasive alternative to LTG because it alleviates the technical challenges posed by laparoscopic procedures. However, few studies have compared the oncological safety of robotic total gastrectomy (RTG) with that of LTG, especially for advanced gastric cancer (AGC). Herein, we aimed to assess the oncological outcomes of RTG for AGC and compare them with those of LTG.

MATERIALS AND METHODS

We retrospectively reviewed 147 and 204 patients who underwent RTG and LTG for AGC, respectively, between 2007 and 2020. Long-term outcomes were compared using inverse probability of treatment weighting (IPTW).

RESULTS

After IPTW, the 2 groups exhibited similar clinicopathological features. The 5-year overall survival was comparable between the 2 groups (88.5% [95% confidence interval {CI}, 79.4%-93.7%] after RTG and 87.3% [95% CI, 80.1%-92.0%]) after LTG; log-rank P=0.544). The hazard ratio (HR) for death after RTG compared with that after LTG was 0.73 (95% CI, 0.40-1.33; P=0.304). The 5-year relapse-free survival was also similar between the 2 groups (75.7% [95% CI, 65.2%-83.4%] after RTG and 76.4% [95% CI, 67.9%-83.0%] after LTG; log-rank P=0.850). The HR for recurrence after RTG compared with that after LTG was 0.93 (95% CI, 0.60-1.46; P=0.753).

CONCLUSIONS

Our findings revealed that RTG and LTG for AGC had similar long-term outcomes. RTG is an oncologically safe alternative to LTG and has technical advantages.

Visual modalities-based multimodal fusion for surgical phase recognition

Surgical workflow analysis is essential to help optimize surgery by encouraging efficient communication and the use of resources. However, the performance of phase recognition is limited by the use of information related to the presence of surgical instruments. To address the problem, we propose visual modality-based multimodal fusion for surgical phase recognition to overcome the limited diversity of information such as the presence of instruments. Using the proposed methods, we extracted a visual kinematics-based index related to using instruments, such as movement and their interrelations during surgery. In addition, we improved recognition performance using an effective convolutional neural network (CNN)-based fusion method for visual features and a visual kinematics-based index (VKI). The visual kinematics-based index improves the understanding of a surgical procedure since information is related to instrument interaction. Furthermore, these indices can be extracted in any environment, such as laparoscopic surgery, and help obtain complementary information for system kinematics log errors. The proposed methodology was applied to two multimodal datasets, a virtual reality (VR) simulator-based dataset (PETRAW) and a private distal gastrectomy surgery dataset, to verify that it can help improve recognition performance in clinical environments. We also explored the influence of a visual kinematics-based index to recognize each surgical workflow by the instrument's existence and the instrument's trajectory. Through the experimental results of a distal gastrectomy video dataset, we validated the effectiveness of our proposed fusion approach in surgical phase recognition. The relatively simple yet index-incorporated fusion we propose can yield significant performance improvements over only CNN-based training and exhibits effective training results compared to fusion based on Transformers, which require a large amount of pre-trained data.

Patient-specific virtual three-dimensional surgical navigation for gastric cancer surgery: A prospective study for preoperative planning and intraoperative guidance

Introduction

Abdominal computed tomography (CT) can accurately demonstrate organs and vascular structures around the stomach, and its potential role for image guidance is becoming increasingly established. However, solely using two-dimensional CT images to identify critical anatomical structures is undeniably challenging and not surgeon-friendly. To validate the feasibility of a patient-specific 3-D surgical navigation system for preoperative planning and intraoperative guidance during robotic gastric cancer surgery.

Materials and methods

A prospective single-arm open-label observational study was conducted. Thirty participants underwent robotic distal gastrectomy for gastric cancer using a virtual surgical navigation system that provides patient-specific 3-D anatomical information with a pneumoperitoneum model using preoperative CT-angiography. Turnaround time and the accuracy of detecting vascular anatomy with its variations were measured, and perioperative outcomes were compared with a control group after propensity-score matching during the same study period.

Results

Among 36 registered patients, 6 were excluded from the study. Patient-specific 3-D anatomy reconstruction was successfully implemented without any problems in all 30 patients using preoperative CT. All vessels encountered during gastric cancer surgery were successfully reconstructed, and all vascular origins and variations were identical to operative findings. The operative data and short-term outcomes between the experimental and control group were comparable. The experimental group showed shorter anesthesia time (218.6 min vs. 230.3 min; P=0.299), operative time (177.1 min vs. 193.9 min; P=0.137), and console time (129.3 min vs. 147.4 min; P=0.101) than the control group, although the differences were not statistically significant.

Conclusions

Patient-specific 3-D surgical navigation system for robotic gastrectomy for gastric cancer is clinically feasible and applicable with an acceptable turnaround time. This system enables patient-specific preoperative planning and intraoperative navigation by visualizing all the anatomy required for gastrectomy in 3-D models without any error.

Clinical trial registration

Clinicaltrials.gov, identifier NCT05039333.

Augmented Reality and Image-Guided Robotic Liver Surgery

Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.

Telemedicine: History and Success Story of Remote Surgical Education in India

Initiation of telemedicine in medical education in India was at par with developed countries but acceptance and progress have been slow. However, the recent coronavirus disease-19 (COVID-19) pandemic leading to disruption of Halstedian model of surgical teaching has changed the traditional dynamics of perception of this mode of education. Sanjay Gandhi PostGraduate Institute of Medical Sciences (SGPGIMS), has been a pioneer and introduced the telemedicine system into surgical education as early as in year 2001. In this article, we reviewed the literature on tele-education in surgical field in Indian scenario, with particular emphasis on tele-education activities at the SGPGIMS, with respect to current thinking and future prospects on surgical training.

Oncological Robot-Assisted Gastrectomy: Technical Aspects and Ongoing Data

Robotic surgery through the da Vinci Surgical System has been widely spread for many procedures across the globe for several years. At the same time, robot-assisted gastrectomy for gastric cancer (GC) remains mostly available only in specialized centers in minimally invasive surgery and stomach neoplasm. The robotic platform has been introduced to overcome possible drawbacks of the laparoscopic approach. The safety and the feasibility of robotic radical gastrectomy have been reported in many retrospective case series and nonrandomized prospective studies. However, the superiority of robotic gastrectomy over the laparoscopic access has not yet been proven. This study aimed to report the technical aspects of robot-assisted gastrectomy for GC as well as the latest evidence on this subject.

Ten Thousand Consecutive Gastrectomies for Gastric Cancer: Perspectives of a Master Surgeon

As radical gastrectomy with lymph node dissection is currently the best strategy to cure gastric cancer, the role of the surgeon remains quite important in conquering it. Dr. Sung Hoon Noh, a surgeon and surgical oncologist specializing in gastric cancer, has treated gastric cancer for 30 years and has conducted over 10000 cases of gastrectomy for gastric cancer. He first adapted an electrocautery device into gastric cancer surgery and has led standardization of surgical procedures, including spleen preserving gastrectomy. His procedures based on patient-oriented insights have become the basis of the concept of enhanced recovery after surgery. He has also contributed to improving patient's survival through adoption of a multidisciplinary approach: he proved the benefit of adjuvant chemotherapy after radical D2 gastrectomy for stage II/III gastric cancer in clinical trials, updating treatment guidelines throughout the world. Dr. Noh also opened the era of precision medicine for treating gastric cancer, as he developed and validated a mRNA expression based algorithm to predict prognosis and response to chemotherapy. This article reviews his contribution and long history of service in the field of gastric cancer. The perspectives of this master surgeon, based on his profound experience and insights, will outline directions for integrative multidisciplinary health care and how can surgeons prepare for the future.

Robot-assisted vitreoretinal surgery: current perspectives

Vitreoretinal microsurgery is among the most technically challenging of the minimally invasive surgical techniques. Exceptional precision is required to operate on micron scale targets presented by the retina while also maneuvering in a tightly constrained and fragile workspace. These challenges are compounded by inherent limitations of the unassisted human hand with regard to dexterity, tremor and precision in positioning instruments. The limited human ability to visually resolve targets on the single-digit micron scale is a further limitation. The inherent attributes of robotic approaches therefore, provide logical, strategic and promising solutions to the numerous challenges associated with retinal microsurgery. Robotic retinal surgery is a rapidly emerging technology that has witnessed an exponential growth in capabilities and applications over the last decade. There is now a worldwide movement toward evaluating robotic systems in an expanding number of clinical applications. Coincident with this expanding application is growth in the number of laboratories committed to "robotic medicine". Recent technological advances in conventional retina surgery have also led to tremendous progress in the surgeon's capabilities, enhanced outcomes, a reduction of patient discomfort, limited hospitalization and improved safety. The emergence of robotic technology into this rapidly advancing domain is expected to further enhance important aspects of the retinal surgery experience for the patients, surgeons and society.