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Struebing F, Bigdeli A, Weigel J, Gazyakan E, Vollbach F, Panayi AC, Vogelpohl J, Boecker A, Kneser U. Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5685. [PMID: 38948156 PMCID: PMC11213613 DOI: 10.1097/gox.0000000000005685] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/25/2024] [Indexed: 07/02/2024]
Abstract
Background The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. Methods A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. Results A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Conclusions Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.
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Affiliation(s)
- Felix Struebing
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Amir Bigdeli
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Jonathan Weigel
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Emre Gazyakan
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Felix Vollbach
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Adriana C. Panayi
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Julian Vogelpohl
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Arne Boecker
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- From the BG Trauma Center Ludwigshafen, Department for Plastic, Hand and Reconstructive Surgery, Department of Plastic Surgery for the University of Heidelberg, Ludwigshafen, Germany
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Burns HR, McLennan A, Xue EY, Yu JZ, Selber JC. Robotics in Microsurgery and Supermicrosurgery. Semin Plast Surg 2023; 37:206-216. [PMID: 38444959 PMCID: PMC10911899 DOI: 10.1055/s-0043-1771506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Alexandra McLennan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Erica Y. Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
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Daar DA, Anzai LM, Vranis NM, Schulster ML, Frey JD, Jun M, Zhao LC, Levine JP. Robotic deep inferior epigastric perforator flap harvest in breast reconstruction. Microsurgery 2022; 42:319-325. [PMID: 34984741 DOI: 10.1002/micr.30856] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 10/05/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m2 (range: 20.6-32.4 kg/m2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.
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Affiliation(s)
- David A Daar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Lavinia M Anzai
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Neil M Vranis
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Michael L Schulster
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Jordan D Frey
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| | - Min Jun
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
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Sun HH, Tay KS, Jesse E, Muncey W, Loeb A, Thirumavalavan N. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022; 10:791-799. [PMID: 37051952 DOI: 10.1016/j.sxmr.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The management of chronic scrotal pain is long and varied, with historical treatment algorithms typically ending with orchiectomy. Microsurgical denervation of the spermatic cord (MDSC) is a testicle-sparing option for patients who have failed conservative treatment options and over its forty-year history has seen many technical refinements. OBJECTIVES To review the history and development of MDSC and discuss the outcomes of different surgical techniques. METHODS A literature review using PubMed and Google Scholar was conducted to identify studies pertaining to surgical treatment of CSP, MDSC, and outcomes. Search terms included "chronic," "scrotal pain," "orchialgia," "spermatic cord," "denervation," and "microsurgery." RESULTS We included 21 case reports and series since the first seminal paper describing MDSC technique in 1978. Additional studies that challenged existing conventions or described novel techniques are also discussed. The current standard procedure utilizes a subinguinal incision and a surgical microscope. Open, robotic, and laparoscopic approaches to MDSC have been described, but access to minimally invasive instruments may be limited outside of developed nations. Pain reduction following preoperative spermatic cord predicts success of MDSC. Methods for identifying and preserving the testicular and deferential arteries vary depending on surgeon preference but appear to have comparable outcomes. Future developments in MDSC involve targeted denervation, minimizing collateral thermal injury, and alternative techniques to visualize arterial supply. CONCLUSION For patients suffering from CSP, MDSC is a well-studied technique that may offer appropriately selected patients' relief. Future investigation comparing targeted vs full MDSC as well as in vivo study of new techniques are needed to continue to improve outcomes. Sun HH, Tay KS, Jesse E, et al. Microsurgical Denervation of the Spermatic Cord: A Historical Perspective and Recent Developments. Sex Med Rev 2022;XX:XXX-XXX.
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Affiliation(s)
- Helen H Sun
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Kimberly S Tay
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Erin Jesse
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Wade Muncey
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Aram Loeb
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nannan Thirumavalavan
- Urology Institute, University Hospitals/Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Othman W, Vandyck KE, Abril C, Barajas-Gamboa JS, Pantoja JP, Kroh M, Qasaimeh MA. Stiffness Assessment and Lump Detection in Minimally Invasive Surgery Using In-House Developed Smart Laparoscopic Forceps. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2022; 10:2500410. [PMID: 35774413 PMCID: PMC9216325 DOI: 10.1109/jtehm.2022.3180937] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 05/01/2022] [Accepted: 05/16/2022] [Indexed: 11/23/2022]
Abstract
Minimally invasive surgery (MIS) incorporates surgical instruments through small incisions to perform procedures. Despite the potential advantages of MIS, the lack of tactile sensation and haptic feedback due to the indirect contact between the surgeon’s hands and the tissues restricts sensing the strength of applied forces or obtaining information about the biomechanical properties of tissues under operation. Accordingly, there is a crucial need for intelligent systems to provide an artificial tactile sensation to MIS surgeons and trainees. This study evaluates the potential of our proposed real-time grasping forces and deformation angles feedback to assist surgeons in detecting tissues’ stiffness. A prototype was developed using a standard laparoscopic grasper integrated with a force-sensitive resistor on one grasping jaw and a tunneling magneto-resistor on the handle’s joint to measure the grasping force and the jaws’ opening angle, respectively. The sensors’ data are analyzed using a microcontroller, and the output is displayed on a small screen and saved to a log file. This integrated system was evaluated by running multiple grasp-release tests using both elastomeric and biological tissue samples, in which the average force-to-angle-change ratio precisely resembled the stiffness of grasped samples. Another feature is the detection of hidden lumps by palpation, looking for sudden variations in the measured stiffness. In experiments, the real-time grasping feedback helped enhance the surgeons’ sorting accuracy of testing models based on their stiffness. The developed tool demonstrated a great potential for low-cost tactile sensing in MIS procedures, with room for future improvements. Significance: The proposed method can contribute to MIS by assessing stiffness, detecting hidden lumps, preventing excessive forces during operation, and reducing the learning curve for trainees.
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Affiliation(s)
- Wael Othman
- Engineering Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Kojo E. Vandyck
- Engineering Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Carlos Abril
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Juan S. Barajas-Gamboa
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Juan P. Pantoja
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Digestive Disease Institute, Abu Dhabi, United Arab Emirates
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic Ohio, Digestive Disease and Surgery Institute, Cleveland, OH, USA
| | - Mohammad A. Qasaimeh
- Engineering Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
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Gómez Rivas J, Toribio-Vázquez C, Taratkin M, Marenco JL, Grossmann R. Autonomous robots: a new reality in healthcare? A project by European Association of Urology-Young Academic Urologist group. Curr Opin Urol 2021; 31:155-159. [PMID: 33332877 DOI: 10.1097/mou.0000000000000842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Artificial intelligence appears as a potential revolution in the general process of medical training, disease diagnosis and treatment. A novel disruptive technology of the 21st century will be 'learner' robots from artificial intelligence systems able to use all the combination of the available knowledge in medical repositories to give the best standard of care. RECENT FINDINGS The autonomy level of robots depends on three factors: the complexity of the task; the environment in which the robot operates, and the required level of human-robot interaction. Autonomous robots in healthcare may be classified in delivery, nurse, and surgical robots. The increasing capability of robots to perform independent actions and complex tasks raises responsibility and accountability issues in a wide variety of application domains. Ethical analyses of these issues are underway and are mostly oriented toward the development of ethical policies requiring a law frame on robotic autonomous behaviors. SUMMARY Autonomous robots have the potential to improve current medical practice offering a more secure, reliable, and reproducible medicine. Many advancements are required for these new technologies to be fully integrated. Furthermore, the ethical implications of these technologies are yet to be evaluated.
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Affiliation(s)
- Juan Gómez Rivas
- Department of Urology, Clinico San Carlos University Hospital, Madrid, Spain
- Young Academic Urologist-Urotechnology Working Party (ESUT-YAU), European Association of Urology, Arnhem, The Netherlands
| | | | - Mark Taratkin
- Young Academic Urologist-Urotechnology Working Party (ESUT-YAU), European Association of Urology, Arnhem, The Netherlands
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - Jose Luis Marenco
- Young Academic Urologist-Urotechnology Working Party (ESUT-YAU), European Association of Urology, Arnhem, The Netherlands
- Department of Urology, Instituto Valenciano De Oncologia, Valencia, Spain
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Zhou Q, Lei E, Ren H, Yuan Q, Ou Y, Liu W. Is robot-assisted retroperitoneal adrenalectomy safe? An investigation of perioperative hypertensive crisis among hypertensive and normotensive patients. Int J Med Robot 2020; 17:e2202. [PMID: 33205859 DOI: 10.1002/rcs.2202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/28/2020] [Accepted: 11/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Objective: We examined the incidence of perioperative hypertensive crisis in robot-assisted retroperitoneal laparoscopic adrenalectomy. METHODS A consecutive series of 120 patients with adrenal tumours undergoing robot-assisted retroperitoneal laparoscopic adrenalectomy were included. Patients were divided into two groups: group A (hypertension group, 58 cases, mean age 43.59 years) and group B (normotension group, 62 cases, mean age 48.01 years). General anaesthesia was applied using endotracheal intubation and haemodynamic changes were closely monitored. RESULTS A total of nine (7.5%) hypertensive crisis cases were observed. After intravenous infusion of sodium nitroprusside, seven cases of them were quickly controlled and two cases experienced transient severe hypertension. The incidence of hypertensive crisis was 13.7% and 1.6% in groups A and B, respectively (p < 0.05). CONCLUSION These findings highlight the importance of strengthening the monitoring of anaesthesia and taking various measures to effectively control the blood pressure in robot-assisted retroperitoneal laparoscopic adrenalectomy, especially among hypertensive patients.
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Affiliation(s)
- Qiqi Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Enjun Lei
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Haijing Ren
- Department of Medicine, Graduate School, Nanchang University, Nanchang, China
| | - Qian Yuan
- Department of Medicine, Graduate School, Nanchang University, Nanchang, China
| | - Yangru Ou
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Wei Liu
- Department of Anesthesiology, The First Affiliated Hospital of Nanchang University, Nanchang, China
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Lai CS, Lu CT, Liu SA, Tsai YC, Chen YW, Chen IC. Robot-assisted microvascular anastomosis in head and neck free flap reconstruction: Preliminary experiences and results. Microsurgery 2019; 39:715-720. [PMID: 30977562 DOI: 10.1002/micr.30458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 02/21/2019] [Accepted: 03/22/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The da Vinci Surgical System has facilitated considerable advancements in surgery. The process and results of robot-assisted microvascular anastomosis in real clinical situations have rarely been reported. This study presents our experience of performing robot-assisted microvascular anastomosis in free flap reconstruction in patients with oropharyngeal cancer. PATIENTS AND METHODS This was a retrospective study of reconstructive operations using a free radial forearm flap for oropharyngeal defects after tumor extirpation in 15 consecutive adult patients (12 men and 3 women). In total, 17 robot-assisted microvascular vessel anastomoses (2 arteries and 15 veins) were performed; moreover, 13 arteries and 13 veins were anastomosed using the standard operating microscope and hand-sewing technique. RESULTS The recipient and donor vessel diameters were 2.5 ± 0.7 and 2.1 ± 0.8 mm, respectively. The donor blood vessel diameter selected for anastomosis using da Vinci Surgical System was significantly smaller (2.1 ± 0.8 vs. 2.5 ± 0.6 mm) than that for a standard operating microscope and hand-sewing technique (p = .021), the operating time spent (38.4 ± 10.4 vs. 28.0 ± 7.7 min) was significantly longer (p < .001). The vascular patency rate was 100%, and all flaps survived without requiring additional operation for revision. CONCLUSION Robotic surgical systems can facilitate vascular microanastomosis and provide a blood vessel patency rate comparable to that of a standard operating microscope and hand-sewing technique.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Shih-An Liu
- Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Republic of China
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - Yen-Wei Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Republic of China
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Nakamura Y, Kuroda M, Ito Y, Masuda T, Nishijima S, Hirano T, Hisasue S. Left Internal Thoracic Artery Graft Assessment by Firefly Fluorescence Imaging for Robot-Assisted Minimally Invasive Direct Coronary Artery Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 14:144-150. [PMID: 30885086 DOI: 10.1177/1556984519836810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) cannot give tactile feedback to surgeons. This shortcoming may increase the risk of left internal thoracic artery (LITA) injury during its harvest. We utilized Firefly Fluorescence Imaging (Firefly) to assess LITA quality in robot-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). METHODS We retrospectively reviewed clinical records and intraoperative videos of 30 consecutive patients who underwent R-MIDCAB with LITA-left anterior descending (LAD) coronary bypass. All patients had post-harvest assessment of LITA blood flow by Firefly with 1 mL (2.5 mg/mL) of indocyanine green injection through a central line. RESULTS Twenty-seven of the patients were male, mean age was 67.7 ± 10.7 years. In post-harvest assessment performed before transection of the distal LITA, blood flow in LITA was well visualized in 28 patients. In the remaining 2 patients, 1 had dissection and the other had severe spasm of the LITA. Firefly was also useful for locating LITA and LAD and for assessing blood flow of the graft after anastomosis. Time required for each Firefly assessment was approximately 20 seconds. There were no side effects or complications due to Firefly intraoperatively and postoperatively. Twenty-six patients had postoperative coronary computed tomography; LITA patency rate was 100% (26/26). CONCLUSION Firefly is fast, simple, and effective for locating and assessing flow in LITA and LAD before and after anastomosis in R-MIDCAB.
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Affiliation(s)
- Yoshitsugu Nakamura
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Miho Kuroda
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Yujiro Ito
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Takahiko Masuda
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Shuhei Nishijima
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Takahisa Hirano
- 1 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Matsudo, Japan
| | - Shinichi Hisasue
- 2 Department of Urology, Chiba-Nishi General Hospital, Matsudo, Japan
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Chan P, Parekattil SJ, Goldstein M, Lipshultz LI, Kavoussi P, McCullough A, Sigman M. Pros and cons of robotic microsurgery as an appropriate approach to male reproductive surgery for vasectomy reversal and varicocele repair. Fertil Steril 2019; 110:816-823. [PMID: 30316417 DOI: 10.1016/j.fertnstert.2018.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Peter Chan
- Male Reproductive Medicine, Royal Victoria Hospital, Montreal, Quebec, Canada; Department of Urology, McGill University, Montreal, Quebec, Canada
| | - Sijo J Parekattil
- South Lake Hospital, Orlando Health & University of Central Florida, Orlando, Florida
| | - Marc Goldstein
- Department of Reproductive Medicine and Urology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Larry I Lipshultz
- Division of Male Reproductive Medicine and Surgery, Scott Department of Urology, Baylor College of Medicine, Houston, Texas
| | | | | | - Mark Sigman
- Division of Urology, Alpert Medical School of Brown University, Providence, Rhode Island; Lifespan, Providence, Rhode Island.
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Clarke NS, Price J, Boyd T, Salizzoni S, Zehr KJ, Nieponice A, Bajona P. Robotic-assisted microvascular surgery: skill acquisition in a rat model. J Robot Surg 2017; 12:331-336. [DOI: 10.1007/s11701-017-0738-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/01/2017] [Indexed: 12/16/2022]
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Intraoperative localization of the parathyroid glands with indocyanine green and Firefly(R) technology during BABA robotic thyroidectomy. Surg Endosc 2016; 31:3020-3027. [PMID: 27864717 DOI: 10.1007/s00464-016-5330-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/31/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND It is unclear whether near-infrared (NIR) light-induced indocyanine green (ICG) fluorescence can effectively identify, and thus permit the preservation of, parathyroid glands in bilateral axillo-breast approach (BABA) robotic thyroidectomy. This case-control study with a prospectively recruited consecutive series and a retrospectively selected control group assessed the usefulness of ICG with Firefly(R) technology to identify the parathyroid glands intraoperatively during BABA robotic thyroidectomy. METHODS All consecutive patients (N = 22) who were scheduled to undergo BABA robotic thyroidectomy for papillary thyroid carcinoma in December 2013-August 2015 and met the study eligibility criteria were recruited prospectively. ICG fluorescence was used with the Firefly system (NIR illuminator: 805 nm; filter: 825 nm) integrated in the da Vinci Si robot system to identify the lower parathyroid glands. Parathyroid hormone levels were recorded on postoperative days 0, 1, 2, and 14. Propensity score matching was used to identify an age-, gender-, tumor size-, and operation type-matched group of control patients who underwent BABA robotic thyroidectomy without the Firefly system. The two groups were compared in terms of parathyroid-related outcomes. RESULTS ICG fluorescence-mediated identification of the parathyroid and thyroid glands required on average (range) 203 ± 89 (125-331) and 207 ± 112 (130-356) s, respectively. The mean (range) fluorescence duration in these glands was 20.8 ± 6.0 (16.6-35.8) and 20.1 ± 7.3 (15.5-33.8) min, respectively. The ICG group had a significantly lower rate of incidental parathyroidectomy than the control group (0 vs. 15.9%, P = 0.048). CONCLUSIONS ICG with NIR light may feasibly and safely identify the parathyroid glands in BABA robotic thyroidectomy.
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A Comparison of Robotically Assisted Microsurgery versus Manual Microsurgery in Challenging Situations. Plast Reconstr Surg 2016; 137:1317-1324. [PMID: 27018686 DOI: 10.1097/prs.0000000000002030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Microsurgery can be challenging secondary to orientation of the vessels, accessibility, or depth of the wound. Robotically assisted microsurgery reduces tremors and improves visualization and may improve the quality of anastomosis compared with traditional microsurgery. The purpose of this study was to compare robotically assisted microsurgery to traditional microsurgery in technically challenging situations with respect to time of anastomosis, quality of anastomosis, and Objective Structured Assessment of Technical Skills. METHODS Two investigators with no prior surgery or microsurgery experience performed 160 anastomoses on artificial microvessels after undergoing standardized traditional and robotically assisted microsurgery courses. Five different exposure groups were created with depths of 0, 10, and 20 cm and sidewall angles of 20 and 30 degrees. A comparison of 80 manual with 80 robotically assisted microsurgery anastomoses in different exposure groups was undertaken. The modified Objective Structured Assessment of Technical Skills scoring system, duration per anastomosis, and a subjective comfort scale were evaluated. RESULTS In the most difficult exposure, Objective Structured Assessment of Technical Skills scores were similar in both groups (p = 0.98), the duration was higher in the manual group (p = 0.004), and the subjective comfort rating was higher in the robotically assisted microsurgery group (p < 0.001). In the easiest (0-cm depth, flat) exposure, Objective Structured Assessment of Technical Skills scores were higher in the manual group (p = 0.018) and the duration was longer in the robotically assisted microsurgery group (p = 0.008). CONCLUSIONS Manual surgery was superior to robotically assisted microsurgery in technically easy exposures. In difficult exposures (greater depth and lower sidewall angles), however, robotically assisted microsurgery had a shorter surgery time and a higher comfort rating, with Objective Structured Assessment of Technical Skills scores similar to those assessing traditional microsurgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Herz D, DaJusta D, Ching C, McLeod D. Segmental arterial mapping during pediatric robot-assisted laparoscopic heminephrectomy: A descriptive series. J Pediatr Urol 2016; 12:266.e1-6. [PMID: 27321559 DOI: 10.1016/j.jpurol.2016.04.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 04/30/2016] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The incidence of innocent moiety injury during heminephrectomy is estimated to be 4-5%. This complication can have long-term consequences for the child. Selective arterial mapping (SAM) with indocyanine green (ICG)-aided near infrared fluorescence (NIRF) imaging using the Firefly™ system on the da Vinci(®) surgical robotic console has proven to be valuable in robotic partial nephrectomy for adult renal tumors. However, there is nothing in the literature for using this technique in pediatric robot-assisted laparoscopic heminephrectomy (RALHN). OBJECTIVE To present a descriptive series of children who had SAM RALHN using ICG-aided NIRF imaging. To determine the feasibility of using ICG-aided NIRF SAM during RALHN, and to study if real-time delineation of the selective arterial anatomy of the upper and lower moieties would be helpful or change the immediate outcomes of the surgery. STUDY DESIGN A descriptive series of six children who received RALHN at the present institution. RESULTS Selective arterial mapping was performed safely without toxicity or vascular complications; it did not extend the operative time and did not change the complexity of the operation. As shown in the summary table below, SAM added value by increasing safety of the operation. The individual operation cost increase of using SAM was only related to the single-use vial of ICG. DISCUSSION Inadvertent injury to the innocent moiety in pediatric heminephrectomy is seldom noted intraoperatively, and many times only becomes evident postoperatively when there is acute ischemia or a chronic reduction in renal function. Although there is no replacement for good surgical technique and judgment, SAM during RALHN is a useful real-time way of alerting the surgeon to unexpected anatomy, and possible unintended or occult injury to the innocent moiety that could have devastating short-term and long-term consequences to the child, despite immediate recovery from surgery. CONCLUSIONS This report achieved its aim of reporting the feasibility of SAM on a small descriptive series of children who had RALHN.
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Affiliation(s)
- D Herz
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - D DaJusta
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - C Ching
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - D McLeod
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
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Herz D, Smith J, McLeod D, Schober M, Preece J, Merguerian P. Robot-assisted laparoscopic management of duplex renal anomaly: Comparison of surgical outcomes to traditional pure laparoscopic and open surgery. J Pediatr Urol 2016; 12:44.e1-7. [PMID: 26443241 DOI: 10.1016/j.jpurol.2015.04.046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 04/14/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Surgical management of duplex renal anomaly (DRA) is complex because of individual anatomic variation, competing priorities of vesicoureteral reflux (VUR) and ureteral obstruction present in the same child, the varied differential function of the different renal moieties, and the presence of voiding dysfunction and recurrent urinary tract infection (UTI). Robot-assisted laparoscopic (RAL) surgical management has been under-reported in this group of children but is becoming a viable alternative to traditional open surgery. OBJECTIVE The aim was to report the surgical outcomes of a series of children with DRA who had RAL surgery and compare these outcomes to historical cohorts of open and laparoscopic surgery. STUDY DESIGN This was a retrospective analysis of a prospective series of children who had RAL surgery for DRA over an 8-year period. Forty-five RAL surgeries were performed in 47 children. RAL heminephrectomy (RAL HN) was performed in 19 children for poorly or non-functional renal moiety. One had staged bilateral RAL HN. RAL ureteroureterostomy (RAL UU) was performed in 14 children for upper pole ureteral obstruction. Thirteen RAL common sheath ureteral reimplants (RAL csUN) with or without ureteral tapering were performed in 12 children with VUR and UTI. Diagnosis and demographics, results of preoperative imaging, intraoperative time stamps, perioperative complications, success rate, and renal outcomes were recorded. RESULTS Low-grade VUR present preoperatively in the RAL UU group all resolved within the follow-up period. Four (25%) children in the RAL HN group developed de novo VUR after surgery, which resolved in two (50%) and required surgery in two (50%). Grade I VUR after RAL csUR that occurred in two (14.3%) children was asymptomatic and observed when off preventative antibiotics. DISCUSSION Most children with DRA who need surgical treatment can be offered RAL surgery. We report good outcomes and improved operative times for RAL HN and UU that approach historical open and pure laparoscopic cohorts. However, RAL csUR, especially with ureteral tapering, is more complex and inherently susceptible to complications, and has not met the outcomes of the open gold standard. The limits of this study are that selection bias is present, and there is no study control cohort. CONCLUSIONS This report achieves its aim to report surgical outcomes of children who had RAL surgery for DRA.
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Affiliation(s)
- Daniel Herz
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Jennifer Smith
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daryl McLeod
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Megan Schober
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Janae Preece
- Division of Pediatric Urology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Paul Merguerian
- Division of Pediatric Urology, Seattle Children's Hospital, Seattle, WA, USA
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