Controlled trial of the introduction of a robotic camera assistant (EndoAssist) for laparoscopic cholecystectomy

Endoscope Automation Framework with Hierarchical Control and Interactive Perception for Multi-Tool Tracking in Minimally Invasive Surgery

In the context of Minimally Invasive Surgery, surgeons mainly rely on visual feedback during medical operations. In common procedures such as tissue resection, the automation of endoscopic control is crucial yet challenging, particularly due to the interactive dynamics of multi-agent operations and the necessity for real-time adaptation. This paper introduces a novel framework that unites a Hierarchical Quadratic Programming controller with an advanced interactive perception module. This integration addresses the need for adaptive visual field control and robust tool tracking in the operating scene, ensuring that surgeons and assistants have optimal viewpoint throughout the surgical task. The proposed framework handles multiple objectives within predefined thresholds, ensuring efficient tracking even amidst changes in operating backgrounds, varying lighting conditions, and partial occlusions. Empirical validations in scenarios involving single, double, and quadruple tool tracking during tissue resection tasks have underscored the system's robustness and adaptability. The positive feedback from user studies, coupled with the low cognitive and physical strain reported by surgeons and assistants, highlight the system's potential for real-world application.

Evaluation of the Efficiency of a Joystick-Guided Robotic Scope Holder Compared to That of Human Scopists: A Prospective Trial

PURPOSE

This study aimed to compare motions of the laparoscope tip during a laparoscopic task in a training box using a recent joystick-guided robotic scope holder to those manipulated by human scopists. We hypothesized that laparoscopic manipulation could be positively affected by robotic scope holders due to the elimination of unintentional movement.

METHODS

Twelve surgeons participated as operators, and eight medical doctors participated in this study. Among the human scopists, five were trained surgeons and three were novices who had no experience with laparoscopic surgery. A validated laparoscopic task was used to evaluate the path length of the laparoscope tip using an optical position tracker and operative time. The operators performed the designated camera task under three different laparoscopic manipulations: using a joystick-guided robotic scope holder, expert human scopists, and novice scopists.

RESULTS

The median path lengths (cm) of the laparoscopic tip were 94.0, 110.0, and 122.2 in the robotic scope holder, expert, and novice groups, respectively. The path lengths in the robotic scope holder group were significantly shorter than those in the other groups (P < .01). The median operative times (seconds) were 136.6, 66.4, and 62.3 in the robotic scope holder, expert, and novice groups, respectively. The operative time of the robotic scope holder group was significantly longer than that of the other groups (P < .001).

CONCLUSION

A robotic scope holder can provide shorter camera movement owing to the stable holding and intentional scope manipulation by the operator, although it requires a longer operative time than a human assistant.

Comparison of robotic camera holders with human assistants in endoscopic surgery: a systematic review and meta-analysis

BACKGROUND

Robotic camera holders can overcome the shortcomings of human assistants, such as shaking and accidental rotation in endoscopic surgery. Robotic camera holder is not affected by the operation time and surgical position and reduces the size of the team. However, there is still controversy over the practicality of robotic camera holders.

MATERIAL AND METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library PubMed, Embase, Cochrane Library and Web of Science. The last database search was performed on 30 April 2022. Two reviewers independently reviewed the studies.

RESULTS

A total of eight studies (n = 698, 354 controls and 344 robotic camera holders) were included in our analysis. The results showed that the robotic camera holder significantly outperformed human assistants on the frequency of lens cleaning (SMD, -0.48; 95% CI, -0.90 to -0.05) and inappropriate movements (MD, -3.57; 95% CI, -4.93 to -2.21). There was no difference in total operation time (MD, 6.99; 95% CI, -2.47 to 16.72), preparation time (MD, 2.43; 95% CI, -0.32 to 5.18) or blood loss (MD, 34.47; 95% CI, -8.05 to 76.98) between the robotic camera holder and human assistant. However, the robotic camera holder was significantly slower in the core operation (MD, 5.06; 95% CI, 1.18 to 8.94), and surgeons had mixed reviews of robotic systems.

CONCLUSIONS

The robotic camera holder provided the surgeon with a highly stable environment. Although the robotic camera holder will not increase the total time, it still needs to improve the core operation time. There is much room for improvement in robotic camera holders. Further development of devices with intuitive control systems and a greater range of motion will be required to accommodate more complex surgeries.

Scope actuation system for articulated laparoscopes

BACKGROUND

An articulated laparoscope comprises a rigid shaft with an articulated distal end to change the viewing direction. The articulation provides improved navigation of the operating field in confined spaces. Furthermore, incorporation of an actuation system tends to enhance the control of an articulated laparoscope.

METHODS

A preliminary prototype of a scope actuation system to maneuver an off-the-shelf articulated laparoscope (EndoCAMaleon by Karl Storz, Germany) was developed. A user study was conducted to evaluate this prototype for the surgical paradigm of video-assisted thoracic surgery. In the study, the subjects maneuvered an articulated scope under two modes of operation: (a) actuated mode where an operating surgeon maneuvers the scope using the developed prototype and (b) manual mode where a surgical assistant directly maneuvers the scope. The actuated mode was further assessed for multiple configurations based on the orientation of the articulated scope at the incision.

RESULTS

The data show the actuated mode scored better than the manual mode on all the measured performance parameters including (a) total duration to visualize a marked region, (a) duration for which scope focus shifts outside a predefined visualization region, and (c) number of times for which scope focus shifts outside a predefined visualization region. Among the different configurations tested using the actuated mode, no significant difference was observed.

CONCLUSIONS

The proposed articulated scope actuation system facilitates better navigation of an operative field as compared to a human assistant. Secondly, irrespective of the orientation in which an articulated scope's shaft is inserted through an incision, the proposed actuation system can navigate and visualize the operative field.

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Homography-based Visual Servoing with Remote Center of Motion for Semi-autonomous Robotic Endoscope Manipulation

The dominant visual servoing approaches in Minimally Invasive Surgery (MIS) follow single points or adapt the endoscope's field of view based on the surgical tools' distance. These methods rely on point positions with respect to the camera frame to infer a control policy. Deviating from the dominant methods, we formulate a robotic controller that allows for image-based visual servoing that requires neither explicit tool and camera positions nor any explicit image depth information. The proposed method relies on homography-based image registration, which changes the automation paradigm from point-centric towards surgical-scene-centric approach. It simultaneously respects a programmable Remote Center of Motion (RCM). Our approach allows a surgeon to build a graph of desired views, from which, once built, views can be manually selected and automatically servoed to irrespective of robot-patient frame transformation changes. We evaluate our method on an abdominal phantom and provide an open source ROS Moveit integration for use with any serial manipulator. A video is provided.

Efficiency in image-guided robotic and conventional camera steering: a prospective randomized controlled trial

BACKGROUND

Robotic camera steering systems have been developed to facilitate endoscopic surgery. In this study, a randomized controlled trial was conducted to compare conventional human camera control with the AutoLap™ robotic camera holder in terms of efficiency and user experience when performing routine laparoscopic procedures. Novelty of this system relates to the steering method, which is image based.

METHODS

Patients undergoing an elective laparoscopic hemicolectomy, sigmoid resection, fundoplication and cholecystectomy between September 2016 and January 2018 were included. Stratified block randomization was used for group allocation. The primary aim of this study was to compare the efficiency of robotic and human camera control, measured with surgical team size and total operating time. Secondary outcome parameters were number of cleaning moments of the laparoscope and the post-study system usability questionnaire.

RESULTS

A total of 100 patients were randomized to have robotic (50) versus human (50) camera control. Baseline characteristics did not differ significantly between groups. In the robotic group, 49/50 (98%) of procedures were carried out without human camera control, reducing the surgical team size from four to three individuals. The median total operative time (60.0 versus 53.0 min, robotic vs. control) was not significantly different, p = 0.122. The questionnaire showed a positive user satisfaction and easy control of the robotic camera holder.

CONCLUSION

Image-based robotic camera control can reduce surgical team size and does not result in significant difference in operative time compared to human camera control. Moreover, robotic image-guided camera control was associated with positive user experience.

Human–Robot Interfaces of the NeuRoboScope: A Minimally Invasive Endoscopic Pituitary Tumor Surgery Robotic Assistance System

Endoscopic endonasal surgery is a commonly practiced minimally invasive neurosurgical operation for the treatment of a wide range of skull base pathologies including pituitary tumors. A common shortcoming of this surgery is the necessity of a third hand when the endoscope has to be handled to allow active use of both hands of the main surgeon. The robot surgery assistant NeuRoboScope system has been developed to take over the endoscope from the main surgeon's hand while providing the surgeon with the necessary means of controlling the location and direction of the endoscope. One of the main novelties of the NeuRoboScope system is its human–robot interface designs which regulate and facilitate the interaction between the surgeon and the robot assistant. The human–robot interaction design of the NeuRoboScope system is investigated in two domains: direct physical interaction (DPI) and master–slave teleoperation (MST). The user study indicating the learning curve and ease of use of the MST is given and this paper is concluded via providing the reader with an outlook of possible new human–robot interfaces for the robot assisted surgery systems.

Evaluation of a stand-alone robotic camera holding system: technology that improves laparoscopy

INTRODUCTION

In order to perform laparoscopic procedures, a surgeon requires an assistant to hold the camera. Problems with this approach include table crowding leading to poor ergonomics, and miscommunication leading to poor images. AutoLap is a novel FDA-approved camera navigation system. We present our experience with this device and compare it to human camera holders.

MATERIALS AND METHODS

The study design included an initial training period followed by a non-randomized allocation between robotic and human camera holder cohort. Data included set up time, ergonomics and usability (via nurse, surgeon and camera holder questionnaire) and image stability recorded via the Inertial Measurement Unit (IMU), describing linear acceleration (in unit gravity [g]) and horizontal acceleration (Angular Velocity in rad/s).

RESULTS

Twenty-six patients were equally divided between human and robotic camera holders. Image stability were significantly better for the robotic camera holder. Median angular velocity was 0.029 and 0.005 rad/s for human and the AutoLap system, respectively (p-value <.001). Linear acceleration was 0.011 and 0.007 [g] (p-value .015). Positive feedback for the robotic system included greater surgeon comfort (92%) and improved nurse - surgeon interaction (100%).

CONCLUSIONS

The AutoLap system provides improved image stability, team-work, and ergonomic comfort for the surgical team with minimum set-up time.

Surgical experience of using the endoscope manipulator robot EMARO in totally extraperitoneal inguinal hernia repair: A case report

Robot-assisted surgery has advanced rapidly since the 1980s. However, new equipment is still needed to overcome problems in conventional endoscopic surgery, including unique risks, such as camera shake and communication difficulties between the operator and the scopist. EMARO, an endoscope manipulator robot, is the world's first pneumatically driven endoscope-holder robot that can operate flexibly and smoothly with the use of air pressure. We herein report the surgical experience of using EMARO in totally extraperitoneal inguinal hernia repair. A 77-year-old Japanese man presented with bulging in the right groin area. After we diagnosed a right inguinal hernia, endoscopic inguinal hernia repair was performed. We selected the totally extraperitoneal approach with EMARO. The endoscopic procedure time was 100 minutes, and no intraoperative complications occurred. EMARO brings together features of smooth motion and good manipulation performance. This operation was performed safely and was comparable to a conventional operation completed with human assistants. Solo surgery with EMARO was beneficial in this inguinal hernia patient.

A Robotic Camera Holder Controlled by Head Movements: Exploring This New Robot-Surgeon Interface

Background. Most robotic camera steering devices (RCSDs) require active steering by the surgeon and necessarily increase workload. Clinical experience shows that standard laparoscopic procedures can be performed safely as solo surgery aided by RCSDs. No evidence exists concerning exploratory or emergency procedures. We compared the performance during unexpected laparoscopic tasks on surgical simulators aided either by an RCSD controllable by head movements of the surgeon or by a human camera assistant. Methods. Forty-five medical students without previous experience with minimal invasive surgery were randomized in 2 groups, and they performed standard and unexpected laparoscopic tasks requiring complex camera movements on box trainers either using an RCSD or assisted by a human camera assistant. Efficiency and performance parameters were recorded. Results. Performance in simulated standard procedures was equivalent. In simulated exploratory procedures, we saw significantly better performance scores in the conventional group versus the RCSD group. The strongest factor for these differences was the longer camera-adjusting time in the RCSD group versus the conventional group (PEG task = 208 ± 51 seconds vs 170 ± 36 seconds, P = .005; suture task = 563 ± 126 seconds vs 454 ± 201 seconds, P = .041). Conclusion. These results, obtained on surgical simulators, indicate that the solo approach to standard surgical tasks, facilitated by an RCSD controllable by head movements, can most likely be viewed as safe. Exploratory procedures with a relevant chance for complications or procedures that require rapid, often, or complex camera movements should rather be performed with a human camera assistant.

Surgical robotic arm control for tissue ablation

In the technology driven era, robot assisted surgery is gradually emerging as a revolutionized surgical procedure over traditional laparoscopic method. Despite the concerns about robotic surgery for minimally invasive surgical procedures, robotized surgical arms have been used in many hospitals. Certain surgical procedures require removal of a segment of an organ or body part like excision biopsy, linear thin layer of soft tissue, triangular mass, and tangential excision in burn management, where shaving-off at an angle of the tissue layer to be removed. For such minimally invasive procedures, we have designed a surgical arm governed by a rotary flexible joint. The surgical arm has a medical grade scalpel in its one end and the other end is connected to a D.C. servo motor. The motion of the surgical arm is controlled by the newly designed non-integer order controller. We have experimentally demonstrated the functioning of the surgical arm by ablating the tissue in-vitro. Our surgical robotic arm is cost effective, high precision and free from potential human errors.

Comparison of Short-term Outcomes of Laparoscopic-Assisted Colon Cancer Surgery Using a Joystick-Guided Endoscope Holder (Soloassist II) or a Human Assistant

Purpose

This study aimed to compare the short-term outcomes of laparoscopic-assisted colon cancer surgery in the Soloassist II-assisted (SA) group and in the human-assisted (HA) group.

Methods

A total of 76 patients with colon cancer who underwent laparoscopic-assisted right hemicolectomy and anterior resection performed by a single surgeon between January 2017 and May 2018 were recruited from the consecutively enrolled registry and retrospectively analyzed.

Results

Of 76 patients, 43 underwent surgery with human assistance and 33 underwent surgery using the Soloassist II system. The clinicopathologic characteristics were not statistically different between the 2 groups. In both HA and SA groups, no statistical difference was observed between operation time (220.23 ± 47.83 minutes vs. 218.03 ± 38.22 minutes, P = 0.829), total number of harvested lymph nodes (20.42 ± 10.86 vs. 20.24 ± 8.21, P = 0.938), and other parameters of short-term outcomes (length of hospital stay, blood loss, open conversion, time to flatus, time to soft diet, and complication events). Subgroup analyses did not show statistical differences.

Conclusion

Soloassist II can reduce the participation of a human assistant during surgery and is not inferior to human assistance in laparoscopic-assisted colon cancer surgery. Thus, it is a feasible instrument in laparoscopic-assisted colon cancer surgery that can provide positive short-term outcomes.

Laparoscopic inguinal hernia repair with a joystick-guided robotic scope holder (Soloassist II®): retrospective comparative study with human assistant

PURPOSE

The purpose of this study was to evaluate the clinical usefulness of a joystick-guided robotic scope holder (Soloassist II®) in laparoscopic inguinal hernia repair.

METHODS

Among 182 inguinal hernia patients treated by laparoscopic transabdominal preperitoneal repair, 82 cases were completed with a human scope assistant, while Soloassist was used in 100 cases. We retrospectively compared perioperative results of Soloassist group and human scope assistant group. In 139 unilateral cases, we also used logistic regression of perioperative factors for the propensity score calculation to balance the bias.

RESULTS

All operations with Soloassist were carried out laparoscopically as solo-surgery without any system-specific complications. A statistically significant decrease in operation time was observed in Soloassist group compared with human assistant group (93.6 vs 85.9 min, p = 0.05). There was no prolongation of preoperative time or difference in the amount of intraoperative blood loss. Operation time was also significantly shorter in Soloassist group, when analyzing unilateral cases (85.5 vs 76.3 min, p = 0.02) and bilateral cases (126.9 vs 111.8 min, p = 0.01), independently. However, after propensity score matching in unilateral cases, there was no statistically significant difference between the two groups (83.8 vs 77.2 min, p = 0.23).

CONCLUSIONS

The feasibility of Soloassist in laparoscopic inguinal hernia repair was demonstrated with no adverse device-related events. All surgeries could be completed as solo-surgery, while no additional time for preoperative setting was required. The mean operation time tends to be shorter in Soloassist group compared with human assistant group. Soloassist could be an effective device in laparoscopic inguinal hernia repair.

Human–Robot Cooperative Control Based on Virtual Fixture in Robot-Assisted Endoscopic Sinus Surgery

In endoscopic sinus surgery, the robot assists the surgeon in holding the endoscope and acts as the surgeon’s third hand, which helps to reduce the surgeon’s operating burden and improve the quality of the operation. This paper proposes a human–robot cooperative control method based on virtual fixture to realize accurate and safe human–robot interaction in endoscopic sinus surgery. Firstly, through endoscopic trajectory analysis, the endoscopic motion constraint requirements of different surgical stages are obtained, and three typical virtual fixtures suitable for endoscopic sinus surgery are designed and implemented. Based on the typical virtual fixtures, a composite virtual fixture is constructed, and then the overall robot motion constraint model is obtained. Secondly, based on the obtained robot motion constraint model, a human–robot cooperative control method based on virtual fixture is proposed. The method adopts admittance control to realize efficient human–robot interaction between the surgeon and robot during the surgery; the virtual fixture is used to restrain and guide the motion of the robot, thereby ensuring motion safety of the robot. Finally, the proposed method is evaluated through a robot-assisted nasal endoscopy experiment, and the result shows that the proposed method can improve the accuracy and safety of operation during endoscopic sinus surgery.

Use of a robotic camera holder (FreeHand®) for laparoscopic appendicectomy

Introduction: Use of a mechanical arm to hold the laparoscopic camera has many advantages. FreeHand^® (FreeHand Ltd, Guildford, United Kingdom) is a robotic camera holder which uses head movement and infrared technology. This trial assessed the usefulness of FreeHand^® in laparoscopic appendicectomy.Material and methods: This was a single center prospective cohort study on patients undergoing emergency laparoscopic appendicectomy using FreeHand^®. Patient demographics, operative details, conversion to human camera holder and surgeon discomfort were recorded. Utilization of assistant time while not assisting was also recorded.Results: Twenty-two participants were included, with a mean age of 32 years and a mean BMI of 25.3. The mean set up time was nine minutes. There were five conversions to a manual camera holder (22.7%). There were 22 lens cleaning episodes with nine (40.9%) not requiring any lens cleaning and six (27.3%) requiring one clean. There were no peri-operative complications. Most surgeons reported minimal or no discomfort. Assistant's time was used for ward work (57%), clerking patients (36%) and for a break (7%).Conclusions: FreeHand^® can be safely used in laparoscopic appendicectomy. It provides a stable image, puts the surgeon in control of the surgical field, causes minimal user discomfort, and frees up personnel.

Towards Expert-Based Speed–Precision Control in Early Simulator Training for Novice Surgeons

Simulator training for image-guided surgical interventions would benefit from intelligent systems that detect the evolution of task performance, and take control of individual speed–precision strategies by providing effective automatic performance feedback. At the earliest training stages, novices frequently focus on getting faster at the task. This may, as shown here, compromise the evolution of their precision scores, sometimes irreparably, if it is not controlled for as early as possible. Artificial intelligence could help make sure that a trainee reaches her/his optimal individual speed–accuracy trade-off by monitoring individual performance criteria, detecting critical trends at any given moment in time, and alerting the trainee as early as necessary when to slow down and focus on precision, or when to focus on getting faster. It is suggested that, for effective benchmarking, individual training statistics of novices are compared with the statistics of an expert surgeon. The speed–accuracy functions of novices trained in a large number of experimental sessions reveal differences in individual speed–precision strategies, and clarify why such strategies should be automatically detected and controlled for before further training on specific surgical task models, or clinical models, may be envisaged. How expert benchmark statistics may be exploited for automatic performance control is explained.

Comparative effectiveness of human scope assistant versus robotic scope holder in laparoscopic resection for colorectal cancer

BACKGROUND

Several types of robotic scope holders have been developed to date, but there are only some experimental reports or the results of small clinical cases. The Soloassist® system is a unique robotic scope holder with which the surgeon can control the field of view by a joystick. We evaluated the efficacy of Soloassist in laparoscopic resection for colorectal cancer.

MATERIALS AND METHODS

We investigated operative time, blood loss, setup time, length of hospital stay, and the number of participating surgeons in 273 laparoscopic colorectal resections, including 130 cases with human assistant (HA group) and 143 cases with Soloassist (SA group). Additionally, we also used logistic regression of the perioperative factors for the propensity score calculation to balance the bias.

RESULTS

The number of participating surgeons was apparently less in the SA group (HA group: 3.3 vs. SA group: 2.5, p < 0.01). The average operative time was shorter in the SA group, but there was no statistical difference (HA group: 287.0 min vs. SA group: 268.5 min, p = 0.07). No significant difference was found in setup time, conversion rate, perioperative complications, and length of hospital stay. There was no conversion case to human scope assistant and no system-specific adverse event. Similar results were observed between two groups after propensity score matching.

CONCLUSION

Laparoscopic colorectal resection with Soloassist is safe and feasible. The present study demonstrated that Soloassist system provided the possibilities of saving human resources in laparoscopic colorectal resection without prolonged operative time or system-specific morbidity. Soloassist is an effective robot-assisted surgical instrument for colorectal surgery.

Single-incision robotic cholecystectomy versus single-incision laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND

Single-incision laparoscopic cholecystectomy (SILC) is the result of the ongoing trend to minimally invasive of laparoscopy, but some surgeons thought that the SILC can increase the risk of bile duct injure or bile spillage, and the single-incision robotic cholecystectomy (SIRC) can overcome the drawbacks of SILC. Some articles described that the SIRC had longer operative time and more cost than SILC. The advantages and disadvantages of SIRC have still not been extensively studied. We aimed to investigate the outcomes of SIRC compared to SILC and evaluate the safety and feasibility of SIRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were searched to seek information in English literature from 2011 to 2017. Studies comparing SIRC to SILC, for any indication, were included in the analysis. This systematic review and meta-analysis were performed with RevMan Version 5.3.

RESULTS

Six comparative studies (n = 633 patients) were included in our analysis. The data showed that the SIRC and SILC had equivalent outcomes for operative time [mean difference (MD) = 17.32, 95% confidence interval (CI): -8.93-43.57, P = .20], intraoperative complications [odd ratio (OR) = 0.48, 95% CI: 0.17-1.39, P = .18], postoperative complications (OR = 0.62, 95% CI: 0.21-1.86, P = .39), hospital stay (MD = -0.01, 95% CI: -0.21-0.19, P = .90), readmissions rate (OR = 0.70, 95% CI: 0.09-5.63, P = .74), and conversion rate (OR = 0.52, 95% CI: 0.14-1.96, P = .33), but total cost was statistically significant (MD = 3.7, 95% CI: 3.61-3.79, P < .00001).

CONCLUSION

SIRC is a safe and feasible procedure for cholecystectomy, and the operative time is same as SILC, but the total cost of SIRC is significantly higher than SILC.

Robotic Camera Assistance: The Future of Laparoscopic and Thoracoscopic Surgery?

INTRODUCTION

Minimally invasive techniques have become the standard for a variety of procedures across all surgical specialties. There has been a recent move to integrate robotic technology into standard laparoscopic and thoracoscopic surgery with the aim of improving stability of the visual field with the use of robotic camera assistance. The aim of this study was to report on and examine the use of a headset-controlled robotic camera holder, FreeHand.

METHODS

Between May 2013 and Dec 2016, 105 procedures were observed where the FreeHand robotic camera assistant was used. Observations were made of 43 consultant surgeons in 30 hospitals performing 21 different surgical procedures. During the surgery, the number of scope cleans and collisions were quantified, and surgeons were asked to score from 0 to 5 the setup, ergonomics, usability, and overall experience in a questionnaire.

RESULTS

Overall surgeon satisfaction was rated as "good" for setup (4.29), ergonomics of the system (4.12), usability (4.39), and overall experience of the system (4.34). In 8 operations (7.6%), there was a conversion from robotic camera assistant to manual assistant. There were no reported adverse events attributable to the use of the system.

CONCLUSION

This study demonstrates the breadth of surgical procedures that can be performed with a robotic camera assistant. The robotic camera assistant was found to be safe and simple to use and was positively perceived on assessment in multiple procedures spanning several surgical specialties. This work suggests that robotic camera assistants may offer significant benefits to laparoscopic and thoracoscopic surgeons.

Single-site robotic cholecystectomy versus multi-port laparoscopic cholecystectomy: A systematic review and meta-analysis

OBJECTIVE

To investigate the outcomes of single-site robotic cholecystectomy (SSRC) compared to multi-port laparoscopic cholecystectomy (MLC), evaluate the safety and feasibility of SSRC.

METHODS

To find relevant studies, the electronic databases PubMed, MEDLINE, The Cochrane Library, and EMBASE were used to seek information in English literature from 2011 to 2017. Studies comparing SSRC to MLC, for any indication, were included in the analysis. This systematic review and meta-analysis was performed with RevMan Version 5.3.

RESULTS

Seven studies (two randomized control trails (RCTs) and five comparative studies, n = 1657 patients) were included in our analysis. The data showed that the SSRC and MLC had equivalent outcomes for operative time (MD = -3.06, 95% CI: -7.61-1.49, p = 0.19), bleeding (OR = 1.63, 95%CI: 0.40-6.56, p = 0.49), postoperative complications (OR = 1.11, 95%CI: 0.35-3.51, p = 0.86), bile leakage (OR = 0.38, 95%CI: 0.07-2.00, p = 0.26), wound infection (OR = 1.92, 95%CI: 0.86-4.32, p = 0.11), conversion rate (OR = 1.30, 95% CI: 0.71-2.37, p = 0.40), and hospital stay (MD = -0.02, 95% CI: -0.60-0.57, p = 0.96). However, in the SSRC group the risk of incisional hernia is higher than the MLC group (OR = 4.23, 95% CI: 1.87-9.58, p = 0.0005), incidence of incisional hernia rate in SSRC group is higher than MLC group (5.8% vs. 0.9%), and the total costs in the SSRC group is higher than MLC group (MD = 3.51, 95% CI: 0.31-6.71, p = 0.03).

CONCLUSIONS

The medical cost is significantly higher in SSRC compared with MLC, and SSRC can increasing the risk of incisional hernia. Therefore, surgeons must be carefully balanced its advantage, disadvantage and risk.

Feasibility and Usefulness of a Joystick-Guided Robotic Scope Holder (Soloassist) in Laparoscopic Surgery

Introduction

The Soloassist® system is a joystick-guided robotic scope holder. We evaluated the efficacy of Soloassist in laparoscopic surgery.

Methods

We investigated operative time, blood loss, set-up time, length of hospital stay, and the number of participating surgeons in laparoscopic cholecystectomy cases before and after the introduction of Soloassist. Furthermore, we evaluated these factors in each group of 20 elective and emergency cholecystectomy cases by single surgeon after matching their background. To evaluate the performance level of operating Soloassist, we divided the operative field into three areas. Then we counted the frequency of energy device activation in initially 10 cases by a single surgical resident and observed its change.

Results

The number of participating surgeons was significantly less and postoperative hospital days were fewer in the Soloassist group. There was no significant difference between set-up time and blood loss both in elective and emergency cases. The total number of energy device activations and that in the dangerous area decreased in accordance with the experience.

Conclusion

Considering our results and previous reports, the combination use of an ideal active scope holder and a commercially available 3D scope is currently considered the best approach in laparoscopic surgery. In the near future, development of active scope holders might play an important role in laparoscopic surgery.

Robotic Endoscopy

Endoscopes extend the eyes of the physician into the patient's body. They are widely used in gastrointestinal (GI) diagnostics and minimally invasive surgery. Endoscopes can be classified into 3 types: rigid, flexible, and capsule endoscopes. Rigid and flexible endoscopes are traditionally held and manipulated by the physician to visualize the region of interest, while capsule endoscopes move passively along with the GI peristalsis. With the advancement of technology, robotic endoscopy has been increasingly developed and accepted. In this work, robotic endoscopy from 3 categories (robot-assisted rigid endoscopy, robot-assisted flexible endoscopy, and active GI endoscopy including active flexible colonoscopy and active capsule endoscopy) is reviewed by PubMed search with the criteria ('Robotics' OR 'Robot') and ('Endoscopy' OR 'Endoscope').

Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis

Importance

This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs).

Objectives

We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure.

Evidence review

A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria.

Findings

CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05).

Conclusions

Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.

First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device

BACKGROUND

Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology.

METHODS

A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction.

RESULTS

Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system.

CONCLUSION

Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Review of Kinematics for Minimally Invasive Surgery and Tele-Echography Robots

This paper deals with the survey of kinematic structures adapted to specific medical robots: minimally invasive surgery (MIS) and tele-echography. The large diversity of kinematic architectures that can be found in medical robotics leads us to perform a statistical analysis to inform and guide design of medical robots. Safety constraints and some considerations in design evolution of medical robots are presented in this paper. First, we describe the spectrum of medical robots in minimally invasive surgery and tele-echography applications and particularly the variety of kinematic architectures used. We present the robots and their kinematic architectures and highlight differences that occur in each medical application. We perform a statistical analysis which can serve as a resource in topological synthesis for each specific medical application. Safety is an important specification in medical robotics, and for that reason we show the means used to take into account this constraint. This study demonstrates that the nature of medical robots implies specific requirements leading to different kinematic structures. The statistical analysis gives information on choice of kinematic structures for medical applications (minimally invasive surgery and echography). The safety constraint as well as the interaction between doctor and robot leads to investigate new mechanical solutions to enhance medical robot safety and compliance. We expect that this paper will serve as a significant resource and help the design of future medical robots.

Solo Single-Incision Laparoscopic Resectional Roux-en-Y Gastric Bypass for Morbid Obesity with Metabolic Syndrome

With the advancement of laparoscopic devices and surgical technology, the era of minimal invasive surgery has progressed to reduced-port surgery, and finally to single-incision laparoscopic surgery (SILS). Several reports show successful application of SILS to various types of bariatric surgery. Oftentimes, this requires a skilled and experienced scopist to perform the procedure. To overcome the technical difficulties of single-incision Roux-en-Y gastric bypass, a manual scope holder was used instead of an assistant scopist, greatly stabilizing the field of view. This allows the surgery to be performed at any time without being influenced by the need of a highly experienced scopist. In this report, we describe in detail the world's first solo single-incision laparoscopic resectional Roux-en-Y gastric bypass.

Is the Use of a Robotic Camera Holder Economically Viable? A Cost Comparison of Surgical Assistant Versus the Use of a Robotic Camera Holder in Laparoscopic Liver Resections

The laparoscopic approach has gained acceptance in the field of hepatopancreaticobiliary surgery. It offers several advantages including reduced blood loss, reduced postoperative pain, and shorter length of stay. However, long operating times can be associated with surgeon and assistant fatigue and image tremor. Robotic camera holders have been designed to overcome these drawbacks but may come with significant costs. The aim of this study was to economically evaluate their use compared with standard assistants using a single surgeon consecutive series of laparoscopic liver resections from January 2014 to May 2015. Only use of nurse assistants with no advanced training and postgraduate year 2 doctors were cheaper than utilization of the device. We suggest the use of a robotic camera holder is cost-beneficial and may have wider service and educational benefits.

Robotic cholecystectomy versus conventional laparoscopic cholecystectomy: A meta-analysis

BACKGROUND

Robotic cholecystectomy is a novel approach that offers the surgeon improved high-definition, 3-dimensional views and enhanced instrument ergonomics, which represent a technical development from previous operative platforms that include conventional and single-incision laparoscopy. This review compares its short-term outcomes with conventional laparoscopic cholecystectomy by a meta-analysis.

METHODS

A literature search was conducted using the MEDLINE, EMBASE, and PubMed databases (January 1990-October 2015). Studies identified were appraised with standard selection criteria. Data were extracted and a meta-analysis performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses.

RESULTS

Thirteen studies, 12 retrospective trials and one randomized controlled trial comprising 1,589 patients (laparoscopic cholecystectomy, n = 921; robotic cholecystectomy, n = 668) were examined. There was a trend of a greater median total operative time (115.3 min vs 128.0 min; pooled MD = 31.22, 95% confidence interval = -2.48 to 59.96; Z = 2.13; P = .03) and preoperative time (32.4 min vs 53.4 min; pooled MD = 20.98, 95% confidence interval = 15.74 to 26.23; Z = 7.84; P < .001) in the robotic cholecystectomy group. Intraoperative complications (P = .52), conversion rate (P = .06), estimated blood loss (P = .55), postoperative complications (P = .28), duration of hospital stay (P = .36), and readmission rate (P = .85) were similar between both groups.

CONCLUSION

Robotic cholecystectomy is associated with greater operative times related primarily to the preparatory phase of the operation but with similar safety and perioperative outcome as conventional laparoscopic cholecystectomy. For it to gain acceptance, future studies are required to define specific measures to quantify equipment benefits to the surgeon and to evaluate the potential advantage of its use in the acute setting.

Viewpoint matters: objective performance metrics for surgeon endoscope control during robot-assisted surgery

Background

Effective visualization of the operative field is vital to surgical safety and education. However, additional metrics for visualization are needed to complement other common measures of surgeon proficiency, such as time or errors. Unlike other surgical modalities, robot-assisted minimally invasive surgery (RAMIS) enables data-driven feedback to trainees through measurement of camera adjustments. The purpose of this study was to validate and quantify the importance of novel camera metrics during RAMIS.

Methods

New (n = 18), intermediate (n = 8), and experienced (n = 13) surgeons completed 25 virtual reality simulation exercises on the da Vinci Surgical System. Three camera metrics were computed for all exercises and compared to conventional efficiency measures.

Results

Both camera metrics and efficiency metrics showed construct validity (p < 0.05) across most exercises (camera movement frequency 23/25, camera movement duration 22/25, camera movement interval 19/25, overall score 24/25, completion time 25/25). Camera metrics differentiated new and experienced surgeons across all tasks as well as efficiency metrics. Finally, camera metrics significantly (p < 0.05) correlated with completion time (camera movement frequency 21/25, camera movement duration 21/25, camera movement interval 20/25) and overall score (camera movement frequency 20/25, camera movement duration 19/25, camera movement interval 20/25) for most exercises.

Conclusions

We demonstrate construct validity of novel camera metrics and correlation between camera metrics and efficiency metrics across many simulation exercises. We believe camera metrics could be used to improve RAMIS proficiency-based curricula.

Is the image "right" for everyone? Introduction to the parallax effect in laparoscopic surgery

AIM OF THE STUDY

During minimally invasive abdominal surgery, a laparoscope is used to film the procedure, which is transmitted to a flat screen monitor. The horizontality of the image depends on the orientation in space and the visual comfort of the surgeon. Observing the screen via a lateral angle of incidence frequently results in the camera assistant making errors in determining the horizontality of the image. Thus, what is "right" for the camera assistant is not necessarily 'right' for the surgeon. We aimed to explain the impact of these errors in laparoscope manipulation, by the description of the parallax effect.

PATIENTS AND METHODS

To describe this phenomenon of perceptions changing depending on the angle of view, from the basis of the parallax effect, we observed the change of position and for two observers, (the surgeon and the camera assistant) seated at two different locations, using an experimental set up (i.e., photography equipment, a screen and a pelvitrainer).

RESULTS

The position of the camera assistant positioned at an angle of incidence of 45° from the surgeon, the observation of the screen with a lateral incidence changes the perception of the image viewed on the screen. For correcting the conflict between the subjective visual perception of the camera assistant and the actual image horizon, the camera assistant instinctively rotates the image, which can lead to an "incorrect" image, deleterious for the surgeon.

CONCLUSIONS

This article introduces a previously unexplained concept in medical literature, called the parallax effect. The parallax effect results in the camera assistant making systematic errors in determining image horizontality on the screen.

Attention-Aware Robotic Laparoscope Based on Fuzzy Interpretation of Eye-Gaze Patterns

Laparoscopic robots have been widely adopted in modern medical practice. However, explicitly interacting with these robots may increase the physical and cognitive load on the surgeon. An attention-aware robotic laparoscope system has been developed to free the surgeon from the technical limitations of visualization through the laparoscope. This system can implicitly recognize the surgeon's visual attention by interpreting the surgeon's natural eye movements using fuzzy logic and then automatically steer the laparoscope to focus on that viewing target. Experimental results show that this system can make the surgeon–robot interaction more effective, intuitive, and has the potential to make the execution of the surgery smoother and faster.

Concurrent use of a robotic uterine manipulator and a robotic laparoscope holder to achieve assistant-less solo laparoscopy: the double ViKY

Three patients requiring gynecological surgery had uterine manipulation using a VCare(®) controlled by a ViKY(®) at the same time as having a ViKY(®) robotic arm controlling the laparoscope. The setup time for each varied from 6-9 min for the uterine manipulator and 3-5 min for the laparoscope holder. In all cases (one endometriosis and two dermoid cysts) the operative field was good. Two patients were discharged within 24 h of surgery. One patient required an extra day in hospital after she went into acute urinary retention once the catheter was removed. This work demonstrated that assistant-less solo gynecological surgery is feasible using two ViKY robotic arms for both uterine manipulation and laparoscope holding.

Solo Intracorporeal Esophagojejunostomy Reconstruction Using a Laparoscopic Scope Holder in Single-Port Laparoscopic Total Gastrectomy for Early Gastric Cancer

Single-incision laparoscopic total gastrectomy for gastric cancer has recently been reported by Seoul National University Bundang Hospital. However, this is not a popular procedure primarily because of the technical difficulties involved in achieving consistent intracorporeal esophagojejunostomy. At Seoul National University Bundang Hospital, we recently introduced a simple, easy-to-use, low-profile laparoscopic manual scope holder that enables the maintenance of a stable field of view, the most demanding condition in single-port gastrectomy. In this technical report, we describe in detail the world's first solo single-incision laparoscopic total gastrectomy with D1+ lymph node dissection and intracorporeal esophagojejunostomy for proximal early gastric cancer.

Technical and instrumental prerequisites for single-port laparoscopic solo surgery: State of art

With the aid of advanced surgical techniques and instruments, single-port laparoscopic surgery (SPLS) can be accomplished with just two surgical members: an operator and a camera assistant. Under these circumstances, the reasonable replacement of a human camera assistant by a mechanical camera holder has resulted in a new surgical procedure termed single-port solo surgery (SPSS). In SPSS, the fixation and coordinated movement of a camera held by mechanical devices provides fixed and stable operative images that are under the control of the operator. Therefore, SPSS primarily benefits from the provision of the operator’s eye-to-hand coordination. Because SPSS is an intuitive modification of SPLS, the indications for SPSS are the same as those for SPLS. Though SPSS necessitates more actions than the surgery with a human assistant, these difficulties seem to be easily overcome by the greater provision of static operative images and the need for less lens cleaning and repositioning of the camera. When the operation is expected to be difficult and demanding, the SPSS process could be assisted by the addition of another instrument holder besides the camera holder.

Solo-surgical laparoscopic cholecystectomy with a joystick-guided camera device: a case-control study

BACKGROUND

This study aimed to evaluate the implementation of a joystick-controlled camera holder (Soloassist; Actormed, Barbing, Germany) in laparoscopic cholecystectomy as so-called solo-surgery compared with the standard operation.

METHODS

Of the 123 patients included in this study, 63 underwent laparoscopic cholecystectomy using the Soloassist system and were compared with 60 patients who underwent laparoscopic cholecystectomy with human assistance. The two groups did not differ significantly in terms of age, sex, body mass index, or American Society of Anesthesiology classification. The surgeons were divided into those highly experienced and those experienced with the new camera holder. The operation times were measured, including setup and dismantling of the system. The assessment also included complications, postoperative hospital stay, measurement of human resources in terms of personnel/minutes/operation, and subjective evaluation of the camera-guiding device by the surgeons.

RESULTS

The hospital stay and operation-related complications were not enhanced in the Soloassist group. The differences in core operation time (p = 0.008) and total operating time (p = 0.001) significantly favored the human assistant. Whereas the absolute duration of surgery was longer, the relative operating time (in personnel/minutes/operation) was significantly shorter (p < 0.001). In 4.8 % of the cases, the operation could not be performed completely with the camera-holding device. Clinically relevant postoperative complications did not occur. The experience of the surgeons did not differ significantly. The subjective evaluation regarding handling, image quality, effort, and satisfaction demonstrated high acceptance of the Soloassist system.

CONCLUSIONS

The camera-guiding device can be implemented without increased complications. The Soloassist system is safe and can be operated even by colleagues without system experience. All the surgeons rated their satisfaction with the system as very good to excellent. Although the operating times were longer than with the standard camera guidance, the absolute overall staff time was reduced.

Medical Robotics

Many research and development projects are being performed worldwide to develop new products and applications for computer-assisted and medical robotic systems. In this paper, an overview of selected state-of-the-art applications of robotic technology in medicine is presented. Four key areas of image-guided surgery, virtual reality in medicine, surgical robots, and robotic rehabilitation systems, are studied. As well, current challenges in research and development are discussed.

Miniaturized robotic laparoscope-holder for rectopexy: first results of a prospective study

INTRODUCTION

Thanks to the technical progress in instrumentation, laparoscopic surgery has made considerable advances over the last decade. Various robotic systems have been introduced to assist laparoscopic procedures. A new prototype of miniaturized laparoscope-holder (called the Light Endoscope Robot [LER]) has been developed by the TIMC-IMAG-CNRS Laboratory in Grenoble, France and is now currently marketed by the French company Endocontrol™ (La Tronche, Grenoble). The aim of this pilot study was to assess the LER in clinical practice.

SUBJECTS AND METHODS

This was a prospective, single-center study. The LER had already been successfully validated on preclinical laboratory and cadaveric trials. The study was conducted at the Grenoble University Hospital during standardized laparoscopic rectopexies on adult patients. Demographic and operative data and qualitative results were collected prospectively and analyzed retrospectively. All patients provided written informed consent, and the study was approved by the Regional Committee for Medical and Health Research Ethics.

RESULTS

Between March 2008 and September 2010, 16 adult patients underwent laparoscopic rectopexy assisted by the LER. All the patients were women with an average age of 63.6 years and an average body mass index of 24 kg/m(2). The procedure was completed in 15 patients. No conversion to open surgery was required. The postoperative mortality rate was 0%, and a complication occurred in 1 patient. The surgeon graded ease of use as 7 ± 2, global comfort as 8 ± 2, and quality of vision as 8 ± 2.

CONCLUSIONS

This pilot study demonstrated the feasibility, safety, and comfort for the surgeon of the laparoscopic rectopexy assisted by the miniaturized light endoscope-holder LER.

Voice recognition interfaces (VRI) optimize the utilization of theatre staff and time during laparoscopic cholecystectomy

During laparoscopy, members of staff spend time setting up and de-activating the light source, camera and insufflator. Voice Recognition Interface (VRI) devices, such as HERMES (Stryker Europe, Montreux, Switzerland), enable the surgeon to perform and control these and other functions. They recognize the surgeon's voice and adjust the instruments in response to programmed verbal commands. The aim of this study was to evaluate HERMES with regards to the utilization of time and theatre staff during laparoscopic cholecystectomy. A total of 100 patients were randomized to either HERMES-assisted or standard laparoscopic cholecystectomy. Three time variables were measured for performing three VRI tasks: (1) The initial setting up of the light source and camera, (2) the activation of the insufflator, and (3) the deactivation of the insufflator and light source at the end of the operation. The mean (and standard deviation) of the time in seconds required for setting up the light source and camera was 27.6 (26.9) in non-HERMES operations and 11.7 (4.7) in HERMES-assisted cases (p<0.001). Insufflation time was 19.8 (13.3) vs. 6.7 (2.5) (p<0.001), and switch-off time was 19.5 (11.8) vs. 11.8 (5.7) (p<0.001). HERMES optimized the operating time and the utilization of theatre staff during laparoscopic cholecystectomy.

Robot assistant versus human or another robot assistant in patients undergoing laparoscopic cholecystectomy

BACKGROUND

The role of a robotic assistant in laparoscopic cholecystectomy is controversial. While some trials have shown distinct advantages of a robotic assistant over a human assistant others have not, and it is unclear which robotic assistant is best.

OBJECTIVES

The aims of this review are to assess the benefits and harms of a robot assistant versus human assistant or versus another robot assistant in laparoscopic cholecystectomy, and to assess whether the robot can substitute the human assistant.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded (until February 2012) for identifying the randomised clinical trials.

SELECTION CRITERIA

Only randomised clinical trials (irrespective of language, blinding, or publication status) comparing robot assistants versus human assistants in laparoscopic cholecystectomy were considered for the review. Randomised clinical trials comparing different types of robot assistants were also considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors independently identified the trials for inclusion and independently extracted the data. We calculated the risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) using the fixed-effect and the random-effects models based on intention-to-treat analysis, when possible, using Review Manager 5.

MAIN RESULTS

We included six trials with 560 patients. One trial involving 129 patients did not state the number of patients randomised to the two groups. In the remaining five trials 431 patients were randomised, 212 to the robot assistant group and 219 to the human assistant group. All the trials were at high risk of bias. Mortality and morbidity were reported in only one trial with 40 patients. There was no mortality or morbidity in either group. Mortality and morbidity were not reported in the remaining trials. Quality of life or the proportion of patients who were discharged as day-patient laparoscopic cholecystectomy patients were not reported in any trial. There was no significant difference in the proportion of patients who required conversion to open cholecystectomy (2 trials; 4/63 (weighted proportion 6.4%) in the robot assistant group versus 5/70 (7.1%) in the human assistant group; RR 0.90; 95% CI 0.25 to 3.20). There was no significant difference in the operating time between the two groups (4 trials; 324 patients; MD 5.00 minutes; 95% CI -0.55 to 10.54). In one trial, about one sixth of the laparoscopic cholecystectomies in which a robot assistant was used required temporary use of a human assistant. In another trial, there was no requirement for human assistants. One trial did not report this information. It appears that there was little or no requirement for human assistants in the other three trials. There were no randomised trials comparing one type of robot versus another type of robot.

AUTHORS' CONCLUSIONS

Robot assisted laparoscopic cholecystectomy does not seem to offer any significant advantages over human assisted laparoscopic cholecystectomy. However, all trials had a high risk of systematic errors or bias (that is, risk of overestimation of benefit and underestimation of harm). All trials were small, with few or no outcomes. Hence, the risk of random errors (that is, play of chance) is high. Further randomised trials with low risk of bias or random errors are needed.

[Use of a mechatronic robotic camera holding system in head and neck surgery]

BACKGROUND

It has been shown that a third hand is useful for holding the endoscope during endoscopic surgery so that both hands of the surgeon are free for instrumentation.

MATERIAL AND METHODS

Experimental tests were performed with the mechatronic robotic camera holding system Soloassist on anatomical specimens in the area of the nose, nasopharynx and larynx.

RESULTS

An ergonomic set-up and the practical application are easily possible. The third hand enables a still and clear picture without undesired camera movement and all instruments can be controlled by the surgeon. There would appear to be some room for improvement as the working area is limited due to an additional instrument. The camera holding system shows a very high velocity for head and neck surgery.

CONCLUSION

Until the active holder can be used regularly in clinical practice in the field of head and neck surgery, more technical modifications have to be implemented.