Current status of robotically assisted laparoscopic surgery in reproductive medicine and gynaecology

Influence of pneumoperitoneum pressure on surgical field during robotic and laparoscopic surgery: a comparative study

PURPOSE

Studies on the influence of CO₂ pneumoperitoneum on the abdominal cavity during robotic procedures are lacking. This is the first study to evaluate surgical field modifications related to CO₂ pressure, during laparoscopic and robotic surgery.

METHODS

Consecutive patients scheduled for laparoscopic or robotic hysterectomy were enrolled in the study. To evaluate the level of operative field visualization, a dedicated form has been designed based on the evaluation of four different areas: Douglas space, vesico-uterine fold and, bilaterally, the broad ligament. During the initial inspection, an assistant randomly set the CO₂ pressure at 15, 10 and 5 mmHg, and the surgeon, not aware of the CO₂ values, was asked to give an evaluation of the four areas for each set pressure.

RESULTS

In laparoscopic group, CO₂ pressure significantly influenced the surgical field visualization in all four areas analyzed. The surgeon had a good visualization only at 15 mmHg CO₂ pressure; visualization decreased with a statistically significant difference from 15 to 5, 15-10 and 10-5 mmHg. In robotic group, influence of CO₂ pressure on surgical areas visualization was not straightforward; operative field visualization remained stable at any pressure value with no significant difference.

CONCLUSIONS

Pneumoperitoneum pressure significantly affects the visualization of the abdomino-pelvic cavity in laparoscopic procedures. Otherwise, CO₂ pressure does not affect the visualization of surgical field during robotic surgery. These findings are particularly significant especially at low CO₂ pressure with potential implications on peritoneal environment and the subsequent post-operative patient recovery.

INVESTIGATION OF THE ESSENTIALS FOR INTEGRATING OFF-THE-SHELF INDUSTRIAL ROBOTICS IN PRECISE COMPUTER-ASSISTED SURGERY

Off-the-shelf industrial robotic technologies have achieved significant advancements in the past several decades in terms of mechanics and automation performances. We are expecting to take advantage of the industrial robots for assisting surgeons in surgeries and quick prototyping a robotic surgery system. In precise computer-assisted surgeries (CASs), such as pelvic-acetabular surgery, eye surgery, or neurosurgery, it is extremely important to position the tools accurately and precisely for surgical operations. Some of the industrial robotics arms are able to achieve good repeatability and dexterity while positioning the surgical tools. To enable the application of industrial robots in the surgical rooms, there are several other essential modules to be integrated to the robotic surgery systems, such as real-time navigation system, surgical planning system, and surgeon-guidance system. In this paper, we review the existing studies on the medical robots including the ones using industrial robots, and then investigate the essentials for using industrial robots in computer-integrated surgery.

[Robot technology in the Italian Health-CARE system: cost-efficacy economic analysis]

BACKGROUND

Robotic technology is used in multiple fields of surgery, especially radical prostatectomy in patients with prostate cancer. The purpose of this study was to evaluate the introduction of robotic technology in the Italian Public Heath-care context, from the perspective of the Health Technology Assessment (HTA). An economic analysis that compares the costs and effectiveness of the method was developed. Data were compared with those of the most important international literature, analyzing structural and organizational problems related to the method.

MATERIALS AND METHODS

A systematic review of literature on tertiary literature (Health Technology Assessment reports) and secondary (systematic reviews) published since 2002 was conducted. The review was also conducted on more recent primary literature regarding the clinical effectiveness and the economic analysis in the fields of surgery where Da Vinci robot is most promising.

RESULTS

18 studies were selected out of a total of 65 evaluated. The "Break-Even Point" (BEP) is the minimum number of cases needed to be treated in order to achieve a balance between costs and revenues, below which the system is losing money. It was calculated that the total fixed costs are € 378,000 and variable costs are € 3,810 per surgery. Considering that the current value of DRG (Diagnosis-Related Group) refunded by the public Health-care system is actually € 4,553, the BEP would be achieved performing 508 surgeries, so that the robotic technology does not generate neither profit nor loss.

CONCLUSIONS

It is not possible to demonstrate the superiority of robotic surgery in terms of efficacy. The robotic surgery is safe and effective only if performed by surgical teams with relevant experience. Considering the reported case of an Italian University Hospital with public Health-care system refund, the BEP target of 508 radical prostatectomies could be achieved after a few years. The use of the robot in multiple fields on one hand shortens recovery time costs, but on the other hand increases costs due to organizational issues. The value of the DRG refund does not appear adequate to new robotic technology.

INVESTIGATION OF NAVIGATION AND ROBOTIC SYSTEM FOR COMPUTER ASSISTED ORTHOPEDIC SURGERY: STATE-OF-ART AND PRELIMINARY RESULTS

In order to help surgeons improve tool insertion accuracy in pelvic-acetabular surgery, it is very important to take advantage of the emerging navigation, guidance and robotics technologies. The computer integrated surgical system is promising for pelvic-acetabular surgery. In most of the procedures of pelvic-acetabular surgery, such as drilling or milling operations, there are many delicate operations involving inserting the tools accurately and precisely in a confined workspace. This article mainly investigates the most important two subsystems: navigation and robotic system, which perform sensing and actuating tasks, respectively.

For navigation subsystem, a remark is made between the state-of-art optical tracking systems (OTS). A hybrid tracking method is proposed to integrate optical tracking and inertial sensing techniques, and some preliminary results are given through the proof-of-concepts experiments. For robotics subsystem, we survey the existing studies on the orthopedic compliant robot arms, together with our proposals for the pelvic surgery. We investigate some of the industrial robotics arms with good repeatability and dexterity while positioning the surgical tools.

Facilitators and barriers to adopting robotic-assisted surgery: contextualizing the unified theory of acceptance and use of technology

Robotic-assisted surgical techniques are not yet well established among surgeon practice groups beyond a few surgical subspecialties. To help identify the facilitators and barriers to their adoption, this belief-elicitation study contextualized and supplemented constructs of the unified theory of acceptance and use of technology (UTAUT) in robotic-assisted surgery. Semi-structured individual interviews were conducted with 21 surgeons comprising two groups: users and nonusers. The main facilitators to adoption were Perceived Usefulness and Facilitating Conditions among both users and nonusers, followed by Attitude Toward Using Technology among users and Extrinsic Motivation among nonusers. The three main barriers to adoption for both users and nonusers were Perceived Ease of Use and Complexity, Perceived Usefulness, and Perceived Behavioral Control. This study's findings can assist surgeons, hospital and medical school administrators, and other policy makers on the proper adoption of robotic-assisted surgery and can guide future research on the development of theories and framing of hypotheses.

[Microsurgical tubal desterilization: an efficient procedure. Evaluation of a 42 cases cohort according to Guzick's biparametric method]

OBJECTIVE

Tubal ligation tends to be a contraceptive method used by younger women. Regrets may then become more frequent. Although less tough today, microsurgical tubal reversal is a reliable technique and we report results taking into account exposure time and curing rate.

PATIENTS AND METHODS

We studied 42 cases operated from 1990 and 1997. The patients were selected following the same protocol and operated according to the same surgical way. The results were analyzed by Guzick biparametric method, and comparison assessed by Log-rank test. We compared results depending on age, type of sterilization (mechanical and non mechanical), duration of laparotomic time, and interval between sterilization and reversal.

RESULTS

There is an overall hope of 80% of pregnancy at 49 months. Even if there is no statistical difference between the different parameters studied, there is a trend to better reversal results after mechanical sterilization and intervention duration less than 90 minutes.

DISCUSSION AND CONCLUSION

Microsurgical tubal reversal is a trustworthy technique, which may be offered to patients regretting their sterilization. Analyzing results by Guzick method is interesting, but insufficiently used although more precise to express a curing (= pregnancy) result than a simple Kaplan-Meier surviving curve. Microsurgical reversal may be proposed to carefully selected patients, even after 40 years.

Controversies in the management of ectopic pregnancy

Ectopic pregnancy is a common clinical problem, but there appears to be much controversy surrounding the surgical management of its occurence. This paper reviews the available evidence on the management of ectopic pregnancy. The discussion focuses initially around the choice of medical versus surgical treatment. Next, the question is addressed that if surgical management is deemed necessary, whether the approach should be laparoscopic or via open laparotomy. Lastly, if surgery is undertaken, should salpingectomy or salpingotomy be performed? Laparoscopy will remain the main method of treatment for women with ectopic pregnancy, as it provides obvious advantages over open surgery. On balance, salpingotomy should be the surgical treatment of choice for the majority of women with ectopic pregnancy, as it results in a higher subsequent pregnancy rate, although there is a slightly higher recurrent ectopic pregnancy rate and persistent trophoblastic disease rate when compared with women treated with salpingectomy. There is also a place for medical treatment of women with low concentrations of human chorionic gonadotrophin. A variable dosing methotrexate regimen is more effective compared with single dose regimen, and the fixed multiple regimen is associated with a high rate of side effects.