Robotic Surgery of the Kidney, Bladder, and Prostate

Evaluation of a newly developed oral and maxillofacial surgical robotic platform (KD-SR-01) in head and neck surgery: a preclinical trial in porcine models

Traditional open head and neck surgery often leaves permanent scars, significantly affecting appearance. The emergence of surgical robots has introduced a new era for minimally invasive surgery. However, the complex anatomy of the head and neck region, particularly the oral and maxillofacial areas, combined with the high costs associated with established systems such as the da Vinci, has limited the widespread adoption of surgical robots in this field. Recently, surgical robotic platform in China has developed rapidly, exemplified by the promise shown by the KangDuo Surgical Robot (KD-SR). Although the KD-SR has achieved some results comparable to the da Vinci surgical robot in urology and colorectal surgery, its performance in complex head and neck regions remains untested. This study evaluated the feasibility, effectiveness, and safety of the newly developed KD-SR-01, comparing it with standard endoscopic systems in head and neck procedures on porcine models. We performed parotidectomy, submandibular gland resection, and neck dissection, collected baseline characteristics, perioperative data, and specifically assessed cognitive workload using the NASA-TLX. None of the robotic procedures were converted to endoscopic or open surgery. The results showed no significant difference in operation time between the two groups (P = 0.126), better intraoperative bleeding control (P = 0.001), and a significant reduction in cognitive workload (P < 0.001) in the robotic group. In conclusion, the KD-SR-01 is feasible, effective, and safe for head and neck surgery. Further investigation through well-designed clinical trials with long-term follow-up is necessary to establish the full potential of this emerging robotic platform.

How long do we need to reach sufficient expertise with the avatera® robotic system?

PURPOSE

To investigate the learning curve in four basic surgical skills in laparoscopic and robotic surgeries, and evaluate the approximate time needed to reach sufficient expertise in performing these tasks with the avatera® system.

METHODS

Twenty urology residents with no previous experience in dry-lab and robotic surgery were asked to complete four basic laparoscopic tasks (peg transfer, circle cutting, needle guidance, and suturing) laparoscopically and robotically. All participants were asked to complete the tasks first after watching the Uroweb educational material and, second, after undertaking a 2-hour training in robotic and laparoscopic dry-lab. Thereafter, all trainees continued to undertake 2-hour training programs until being able to complete the tasks with the avatera® robot at the desired time. Paired t test and one-way ANOVA test were used to analyze time differences between the groups.

RESULTS

Time needed to complete all tasks either robotically or laparoscopically was significantly less in the second compared to the first attempt for all Groups in each Task. In the robotic dry-lab, time needed to complete the tasks was significantly less than in the laparoscopic dry-lab. A significant effect of previous laparoscopic experience of the participants on the training time needed to achieve most of the goal times was detected.

CONCLUSION

The results of the study highlight the role of previous laparoscopic experience in the training time needed to achieve the performance time goals and demonstrate that the learning curve of basic surgical skills using the avatera® system is steeper than the laparoscopic one.

Open or robotic? Radical cystectomies for patients with non-metastatic bladder cancer: A systematic review and meta-analysis

Background

This systematic review and meta-analysis will review randomized control trials for localized bladder cancer, evaluating surgical and pathologic outcomes of ORC versus RARC.

Methods

Randomized studies evaluating adults with non-metastatic bladder cancer who underwent a radical cystectomy. Randomized trials were selected for final review. Data was extracted and analyzed with Revman 5 software. The primary outcome was complication rates within 90 days. Secondary outcomes included postoperative quality of life, estimated intraoperative blood loss, and other perioperative outcomes. Continuous variables were reported using mean difference with 95% confidence intervals, and dichotomous variables were reported using risk difference with 95% confidence intervals with RARC as the experimental group and ORC as the reference group.

Results

Of 134 articles screened, six unique randomized studies were selected. For Grade I-II complications, the risk ratio (RR) was 0.92 (95% CI [0.79,1.08], p = 0.33), and for Grade III-V complications, RR 0.93 (95% CI [0.73,1.18], p = 0.59). RARC resulted in decreased blood loss (95% CI [-438.08, -158.44], p < 0.00001) and longer operative time (95% CI [55.23, 133.13], p < 0.00001). Quality of life using the EORTC-QLQ-30 global health score at 3 months post-op appeared to favor RARC with a mean difference of 4.46 points (95% CI [1.78, 7.15], p = 0.001). Pathologic outcomes neither statistically nor clinically favored one modality, as there was no significant difference between mean lymph node yield (p = 0.49), positive lymph nodes (p = 1.00), and positive surgical margins (p = 0.85) between the surgical modalities.

Conclusions

Although one surgical modality is not overtly superior, the choice may be decided by mitigating individual operative risk factors like intraoperative blood loss, operative time, post-operative quality of life, as well as institutional costs and learning curve among surgeons.

Robot-Assisted Laparoscopic Radical Prostatectomy Utilizing Hugo RAS Platform: Initial Experience

Background: The Hugo RAS™ is a newly launched robotic system for clinical use. This article provides the initial outcomes of patients undergoing radical prostatectomy with Hugo RAS. It also attempts to compare the outcomes with a similar set of patients undergoing the procedure with the DaVinci robotic systems. Methodology: Patients undergoing radical prostatectomy for biopsy-proven prostate cancer were included in this study. Institutional ethical approval was obtained, and patients were counseled preoperatively with informed consent. Both intra- and postoperative data were carefully recorded for the Hugo RAS. Patients who underwent radical prostatectomy in DaVinci robotic systems during a similar period were chosen to compare the outcomes of the Hugo systems in a nonrandomized study. Results: A total of 34 patients were included in this study wherein 17 radical prostatectomies were done in the Hugo RAS system and 17 in the DaVinci system were chosen to compare. The total operative time (210 vs 195 minutes) and dock time (190 vs 170 minutes) were similar between the two groups. An R0 or R1 resection and vesicourethral anastomosis were achieved in all cases. There were no notable intra- or postoperative complications in up to 1-month follow-up. Conclusion: The authors believe that the Hugo RAS platform is a safe robotic system for pelvic procedures such as radical prostatectomy, provides comparable results with existing robotic systems, and is a good addition to the existing arsenal of surgical robots.

Sensor-Based Automated Detection of Electrosurgical Cautery States

In computer-assisted surgery, it is typically required to detect when the tool comes into contact with the patient. In activated electrosurgery, this is known as the energy event. By continuously tracking the electrosurgical tools' location using a navigation system, energy events can help determine locations of sensor-classified tissues. Our objective was to detect the energy event and determine the settings of electrosurgical cautery-robustly and automatically based on sensor data. This study aims to demonstrate the feasibility of using the cautery state to detect surgical incisions, without disrupting the surgical workflow. We detected current changes in the wires of the cautery device and grounding pad using non-invasive current sensors and an oscilloscope. An open-source software was implemented to apply machine learning on sensor data to detect energy events and cautery settings. Our methods classified each cautery state at an average accuracy of 95.56% across different tissue types and energy level parameters altered by surgeons during an operation. Our results demonstrate the feasibility of automatically identifying energy events during surgical incisions, which could be an important safety feature in robotic and computer-integrated surgery. This study provides a key step towards locating tissue classifications during breast cancer operations and reducing the rate of positive margins.

The new surgical robotic platform HUGOTM RAS: System description and docking settings for robot-assisted radical prostatectomy

Background:

To date, robotic surgery in urology is well established all over the world. The newest platform on the market is the HUGO™ RAS system, developed by Medtronic. In this paper we provide a brief description of the system and describe our system set-up and surgical approach with this new platform in our initial experience of robotic radical prostatectomy (RARP) series.

Materials and methods:

After an official training, seven consecutive patients affected by localized prostate cancer underwent RARP with HUGOTM RAS system at our Institution. A description of our surgical approach and docking setup is provided. Docking and console times were reported for all precedures together with main suggestions to facilitate the use of this new system at the beginning of the experience.

Results:

Our operating room setup has shown to be safe, effective, and easy replicable. During our series, operative times appeared to be easy reproducible and comparable to those obtained with daVinci system. No major system faults and conflicts between robotic arms were observed after the first procedure.

Conclusions:

Our surgical approach and system configuration for performing RARP with the new HUGO™ RAS system appears to be safe, efficient and easy reproducible.

Robotic-assisted abdominal aortic surgery: evidence and techniques

In various disciplines, robotic-assisted surgery is a well-proven routine procedure, but have never been established in vascular surgery so far. This review summarizes the results to date of robotic-assisted abdominal aortic surgery (RAAS) in the treatment of aorto-iliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Web-based literature search of robotic-assisted surgical procedures on the abdominal aorta and iliac arteries between 1990 and 2020 including the Cochrane Library, OVID Medline, Embase, and PubMed medical databases. All studies conducting Robotic-assisted surgery were included in the quantitative analysis regarding operative and cross-clamping times, conversion rates, mortality and morbidity within the first 30 days, and in-hospital stay. Case reports and case studies (< 5 patients) were not included. Twenty-four studies were deemed thematically eligible for inclusion; after exclusion of duplicate publications, nine met the inclusion criteria for further analysis. A total of 850 patients who had either abdominal aortic aneurysm or aorto-iliac occlusive disease underwent RAAS. One study of abdominal aortic aneurysm, three of aorto-iliac occlusive disease, and five studies of both disease entities were analyzed quantitatively. For AAA, conversion rates ranged from 13.1 to 20% and perioperative mortality ranged from 0 to 1.6% with in-hospital stay of 7 days. For aorto-iliac occlusive disease, conversion rates ranged from 0 to 20%, and perioperative mortality ranged from 0 to 3.6% with in-hospital stay of 5–8 days. RAAS has been shown to be technically feasible with acceptable short-term outcomes and questionable benefits in terms of in-hospital stay and complication rates. RAAS is currently considered only an outsider procedure. Randomized-controlled trials are indispensable for regular use in vascular surgery as well as a clear approval situation for the vascular sector.

Evaluation of Hugo RASTM system in major urological surgery: Our Initial Experience

BACKGROUND

The Hugo RAS is a newly launched robotic system for clinical use. This paper provides the initial experience of the authors using Hugo RAS in urological procedures.

METHODOLOGY

Patients undergoing major urological procedures including nephrectomy and prostatectomy were included in this prospective clinical trial. Institutional ethical approval was obtained, and patients were counselled preoperatively with informed consent. Both intra-operative and post-operative data were carefully recorded.

RESULTS

A total of 7 patients were included in this initial study. This includes radical prostatectomy ( n=3) , simple prostatectomy ( n=1) , radical nephrectomy ( n=1) and simple nephrectomy ( n=2) . The total operative time, port placement time, time to dock the ports, blood loss and length of hospital stay and 30-day morbidity and mortality were recorded. There were no intra-operative or post-operative complications up to one month follow up.

CONCLUSION

From the early experience with the Hugo RASTM platform, it appears to be a safe robotic platform for major urological procedures and is a good addition to the existing arsenal of surgical robots.

Robotic-assisted completion cholecystectomy: A safe and effective approach to a challenging surgical scenario - A single center retrospective cohort study

BACKGROUND

Reoperation following a previous subtotal or aborted cholecystectomy presents a challenging surgical scenario that has traditionally required an open completion cholecystectomy. The aim of this study was to describe an institutional experience with a robotic-assisted approach to completion cholecystectomy.

METHODS

A database was retrospectively audited to identify all patients who underwent robotic-assisted cholecystectomy performed by two hepatopancreatobiliary surgeons at a single centre from 2010 to 2019.

RESULTS

Twenty six patients who underwent a robotic-assisted completion cholecystectomy were identified. Median operative time was 142 min (48-247 min) with a blood loss of 50 cc (0-500 cc). Minor complications (Clavien-Dindo ≤ II 90 days) occurred in three patients (11.5%) with no major complication or mortality reported. Median hospital length of stay was 1 day (0-6 days) with one patient readmitted.

CONCLUSION

This study represents to our knowledge the largest series of robotic-assisted completion cholecystectomies to date. The robotic approach appears to be a safe and effective procedure associated with a low morbidity and high success rate.

Using Wearable Technology to Measure the Association Between Neck Posture and Neck Pain During Urologic Open and Robotic Surgery

PURPOSE

Chronic neck pain is the most prevalent work-related musculoskeletal injury among surgeons. Urologists may be at higher risk of neck injury due to extended time spent operating in deep anatomical structures during open surgery. Our goal was to use wearable technology to quantify the relationship between neck posture and pain during open and robotic surgery.

MATERIALS AND METHODS

Urologic attendings and residents who spent at least 1 day per week performing surgery for over 6 hours took part in this study. Neck posture was measured in real time during surgery using inertial measurement devices attached at the occipital protuberance and 7th cervical vertebrae. Self-reported neck pain scores were obtained throughout their workday.

RESULTS

30 participants and 202 hours of surgery were included in the study (21 attendings, 9 residents). There was a significant association between neck posture and pain (p = 0.04). Surgeons performing open procedures spent on average 147 minutes with their head in neck flexion postures of 30° or greater compared to 68 minutes for those performing robotic procedures (p =0.007). Surgeons performing open procedures reported a mean change in neck pain of 2.0 on the numeric analogue scale, compared to 1.3 for those performing robotic procedures (p = 0.04).

CONCLUSIONS

Real time measurements of neck flexion during urologic surgery shows that greater duration and higher degree of neck flexion were associated with increased neck pain. Raising awareness about ergonomics in the operating room during residency will enable future generations of surgeons to make conscious decisions regarding their neck posture in surgery.

Robotic radical antegrade modular pancreatosplenectomy (RAMPS) versus standard retrograde pancreatosplenectomy (SRPS): study protocol for a randomized controlled trial

Background

Data from meta-analysis suggest that robotic radical antegrade modular pancreatosplenectomy (RAMPS) is a safe and effective procedure for treating adenocarcinoma in the body or tail of the pancreas, and is oncologically superior to standard retrograde pancreatosplenectomy (SRPS). RAMPS is an operation that actively expands the scope of resection, and achieves a higher R0 resection rate and lymph nodes acquisition through expanded resection. However, previous studies on RAMPS were conducted under open and laparoscopic surgery. Robotic surgery, on the other hand, plays a role in ergonomics and offers several advantages, including less fatigue, tremor filtering, 7° of wrist-like motion, motion scaling, and three-dimensional vision. At present, there is still a world-wide lack of clinical studies to observe the safety and clinical efficacy of robotic RAMPS. Hence, prospective randomized controlled trials (RCTs) comparing robotic RAMPS and SRPS are required. We begin an RCT to compare short-term surgical and oncological outcomes of robotic RAMPS and SRPS in patients undergoing distal pancreatectomy.

Methods

This is a randomized, single-center clinical trial. All participants are adult patients with primary pancreatic cancer, who are undergoing RAMPS or SRPS. The primary endpoints are R0 rate (resection margins are classified by a margin to tumor distance ≥ 1 mm). The secondary endpoints are the number of harvested lymph nodes, perioperative complications and perioperative indicators (duration of surgery, blood loss, blood transfusion volume, costs).

Discussion

We are undertaking a prospective RCT to evaluate the surgical and oncological outcomes of robotic RAMPS. This procedure may become a standard approach to robotic pancreatosplenectomy.

Trial registration

Chinese Clinical Trial Registry: ChiCTR1900020833, Registered on 20 January 2019.

Endoscopic-assisted robotic pyelolithotomy: a viable treatment option for complex pediatric nephrolithiasis

INTRODUCTION AND OBJECTIVE

Endourological and percutaneous approaches are the standard of care for treatment of pediatric urolithiasis. However, in certain situations, an endoscopic-assisted robotic pyelolithotomy (EARP) can be an acceptable alternative. Limited data exist on pediatric EARP; thus, the authors describe their experience.

METHODS

Patient selection: The authors retrospectively analyzed the records of all robotic procedures performed at five institutions from 7/09-10/17 to identify patients who underwent EARP. The authors collected demographics data, indications, operative time, and postoperative complications. Stone composition was reported as the majority composition (≥50%), unless any uric acid or struvite was noted, and those stones were classified as such.

TECHNIQUE

Through a traditional or hidden incision endoscopic surgery (HIdES) robot pyeloplasty approach, the authors are able to easily pass a flexible endoscope through a robotic trocar and into the renal collecting system to perform pyeloscopy or ureteroscopy. Stones were primarily retrieved via the pyelolotomy and, if indicated, treated with laser lithotripsy.

RESULTS

The authors identified 26 patients who underwent EARP in 27 renal units. Median patient age was 12.2 years (interquartile range [IQR] 6.1-14.5 years), and body mass index was 17.5 kg/m² (IQR 16.5-25.4 kg/m²). The median pre-operative dimension of the largest stone was 9.0 mm (IQR 5.8 mm-15.0 mm). Reasons for EARP: 21 (77.8%) concomitant pyeloplasty, four (14.8%) altered anatomy precluding other techniques, and two (7.4%) multiple large stones. Multiple stones were present in 20 renal units (74.1%). Stones were located in the renal pelvis in nine (33.3%), lower pole in 10 (37.0%), ureter in one (3.7%), and multiple locations in seven (25.9%). Hidden incision endoscopic surgery approach was used in 14 (51.9%), and the median operative time was 237.5 min (IQR 189.8-357.8 min) with a median length of stay 1.0 day (IQR 1.0-2.0 days). Stone composition included calcium oxalate in 14 (51.9%), calcium phosphate in five (18.5%), cysteine in two (7.4%), struvite in two (7.4%), and unknown in four (14.8%). Overall stone free status was 19 (70.4%); of the eight (29.6%) renal units with residual stones, four underwent ureteroscopy, two extracorporeal shockwave lithotripsy (ESWL), one spontaneously passed, and one underwent percutaneous nephrolithotomy (PCNL). After secondary treatment, final stone free rate was 96.3%. Complications included stent migration and admission for urosepsis. At a median follow-up of 12 months (IQR 6.2-19.2 months), five (18.5%) had stone recurrence.

CONCLUSIONS

Endoscopic-assisted robotic pyelolithotomy is a reasonable treatment option for select pediatric patients with concomitant ureteropelvic junction obstruction and nephrolithiasis or pediatric patients with stones inaccessible by standard methods.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Strategies for New Skill Acquisition by Practicing Surgeons

OBJECTIVE

To understand how practicing surgeons utilize available training methods, which methods are perceived as effective, and important barriers to using more effective methods.

DESIGN

Online survey designed to characterize surgeon utilization and perception of available training methods.

SETTING

Two large Midwestern academic health centers.

PARTICIPANTS

150 faculty surgeons.

METHODS

Nominal values were compared using a McNemar's Test and Likert-like values were compared using a paired t-test (IBM SPSS Statistics v. 21.0; New York, NY).

RESULTS

Survey response rate was 81% (122/150). 98% of surgeons reported learning a new procedure or technology after formal training. Many surgeons reported scrubbing in expert cases (78%) and self-directed study (66%), while few surgeons (6%) completed a mini-fellowship. The modalities used most commonly were scrubbing in expert cases (34%) and self-directed study (27%). Few surgeons (7%) believed self-directed study would be most effective, whereas 31% and 16% believed operating under supervision and mini-fellowships would be most effective, respectively. Surgeons believed more effective methods "would require too much time" or they had "confidence in their ability to implement safely."

CONCLUSIONS

Practicing surgeons use a variety of training methods when learning new procedures and technologies, and there is disconnect between commonly used training methods and those deemed most effective. Confidence in surgeon's ability was cited as a reason for this discrepancy; and surgeons found time associated with more effective methods to be prohibitive.

Robotics in urology

Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies

Rates and Predictors of Conversion to Open Surgery During Minimally Invasive Radical Cystectomy

OBJECTIVE

To assess the frequency of minimally invasive radical cystectomy (MIRC) conversion to open surgery, what factors influence conversion, whether or not the benefits of MIRC vs open radical cystectomy (ORC) persist after conversion, and compare ORC and MIRC outcomes.

MATERIALS AND METHODS

We performed a retrospective cohort study from the National Cancer Data Base (2010 to 2013) analyzing patients who underwent completed MIRC (n = 5750), converted MIRC (n = 245), and ORC (n = 12,053) without prior radiotherapy. Multivariable logistic and linear regression analyses were used to assess the association between covariates, open conversion as well as surgical approach, and secondary outcomes such as positive surgical margins (PSMs), use of lymphadenectomy, lymph node yield, hospital length of stay (LOS), and 30-day readmission.

RESULTS

Rates of conversion were independent of patient factors such as race, sex, use of neoadjuvant chemotherapy, and clinical stage. Conversion occurred in 245 of 5750 MIRCs (4.3%) and declined over time (5.8% in 2010 vs 3.2% in 2013, odds ratio [OR] 0.50, 95% confidence interval [CI] 0.34-0.75, p = 0.001). MIRC was associated with fewer positive margins, higher lymph node yield, shorter LOS, and fewer readmissions compared with ORC, however, patients requiring open conversion had longer median hospital stays (8 days vs 7 days, p = 0.013), lower median lymph node yields (14 vs 17, p = 0.007), more PSMs (17% vs 11%, p = 0.006), and more 30-day readmissions (14% vs 9%, p = 0.008) compared to nonconverted. Converted MIRC had similar hospital LOS and 30-day readmission rates compared to ORC.

CONCLUSION

Open conversion during MIRC is uncommon and has decreased in recent years despite the rising use of MIRC. MIRC had better short-term outcomes compared with ORC. These benefits were negated with open conversion; however, outcomes were similar compared to planned ORC.

Robotic stone surgery - Current state and future prospects: A systematic review

Objective

To provide a comprehensive review of robot-assisted surgery in urolithiasis and to consider the future prospects of robotic approaches in stone surgery.

Materials and methods

We performed a systematic PubMed© literature search using predefined Medical Subject Headings search terms to identify PubMed-listed clinical research studies on robotic stone surgery. All authors screened the results for eligibility and two independent reviewers performed the data extraction.

Results

The most common approach in robotic stone surgery is a robot-assisted pyelolithotomy using the da Vinci™ system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Several studies show this technique to be comparable to classic laparoscopic and open surgical interventions. One study that focused on ureteric stones showed a similar result. In recent years, promising data on robotic intrarenal surgery have been reported (Roboflex Avicenna™; Elmed Medical Systems, Ankara, Turkey). Initial studies have shown its feasibility and high stone-free rates and prove that this novel endoscopic approach is safe for the patient and comfortable for the surgeon.

Conclusions

The benefits of robotic devices in stone surgery in existing endourological, laparoscopic, and open treatment strategies still need elucidation. Although recent data are promising, more prospective randomised controlled studies are necessary to clarify the impact of this technique on patient safety and stone-free rates.

Safety considerations in learning new procedures: a survey of surgeons

BACKGROUND

There exists a tension between surgical innovation and safety. The learning curve associated with the introduction of new procedures/technologies has been associated with preventable patient harm. Surgeon's perceptions regarding the safety of methods for learning new procedures/technologies are largely uncharacterized.

MATERIALS AND METHODS

A survey was designed to evaluate surgeons' perceptions related to learning new procedures/technologies. This included clinical vignettes across two domains: (1) experience with an operation (e.g., colectomy) and (2) experience with a technology (e.g., laparoscopy). This study also focuses on a surgeon's perceptions of existing credentialing/privileging requirements. Participants were faculty surgeons (n = 150) at two large Midwestern academic health centers.

RESULTS

Survey response rate was 77% (116/150). 69% of respondents believed the processes of credentialing/privileging is "far too relaxed" or "too relaxed" for ensuring patient safety. Surgeons most commonly indicated a mini-fellowship is required to learn a new laparoscopic procedure. However, that requirement differed based on a surgeon's prior experience with laparoscopy. For example, to learn laparoscopic colectomy, 35% of respondents felt a surgeon with limited laparoscopic experience should complete a mini-fellowship, whereas 3% felt this was necessary if the surgeon had extensive laparoscopic experience. In the latter scenario, most respondents felt a surgeon should scrub in cases performed by an expert (38%) or perform cases under a proctor's supervision (33%) when learning laparoscopic colectomy.

CONCLUSIONS

Many surgeons believe existing hospital credentialing/privileging practices may be too relaxed. Moreover, surgeons believe the "one-size-fits-all" approach for training practicing surgeons may not protect patients from unsafe introduction of new procedures/technologies.

Instrumental tactile diagnostics in robot-assisted surgery

BACKGROUND

Robotic surgery has gained wide acceptance due to minimizing trauma in patients. However, the lack of tactile feedback is an essential limiting factor for the further expansion. In robotic surgery, feedback related to touch is currently kinesthetic, and it is mainly aimed at the minimization of force applied to tissues and organs. Design and implementation of diagnostic tactile feedback is still an open problem. We hypothesized that a sufficient tactile feedback in robot-assisted surgery can be provided by utilization of Medical Tactile Endosurgical Complex (MTEC), which is a novel specialized tool that is already commercially available in the Russian Federation. MTEC allows registration of tactile images by a mechanoreceptor, real-time visualization of these images, and reproduction of images via a tactile display.

MATERIALS AND METHODS

Nine elective surgeries were performed with da Vinci™ robotic system. An assistant performed tactile examination through an additional port under the guidance of a surgeon during revision of tissues. The operating surgeon sensed registered tactile data using a tactile display, and the assistant inspected the visualization of tactile data. First, surgeries where lesion boundaries were visually detectable were performed. The goal was to promote cooperation between the surgeon and the assistant and to train them in perception of the tactile feedback. Then, instrumental tactile diagnostics was utilized in case of visually undetectable boundaries.

RESULTS

In robot-assisted surgeries where lesion boundaries were not visually detectable, instrumental tactile diagnostics performed using MTEC provided valid identification and localization of lesions. The results of instrumental tactile diagnostics were concordant with the results of intraoperative ultrasound examination. However, in certain cases, for example, thoracoscopy, ultrasound examination is inapplicable, while MTEC-based tactile diagnostics can be efficiently utilized.

CONCLUSION

The study proved that MTEC can be efficiently used in robot-assisted surgery allowing correct localization of visually undetectable lesions and visually undetectable boundaries of pathological changes of tissues.