Current issues and future considerations for the wider implementation of robotic-assisted surgery: a qualitative study

Advancements in microsurgery: A comprehensive systematic review of artificial intelligence applications

Machine learning (ML) is a branch of artificial intelligence (AI) that enables computers to learn from data and discern patterns without direct instruction. This review explores cutting-edge developments in microsurgery through the lens of AI applications. By analyzing a wide range of studies, this paper highlights AI's transformative role in enhancing microsurgical techniques and decision-making processes. A systematic literature search was conducted using Ovid MEDLINE, Ovid Embase, Web of Science, and PubMed (2005-2023). Extensive data on ML model function and composition, as well as broader study characteristics, were collected from each study. Study quality was assessed across 7 methodological areas of AI research using an adapted methodological index of nonrandomized studies (MINORS) tool. Seventeen studies met the inclusion criteria. ML was used primarily for prognosis (35%), postoperative assessment (29%), and intraoperative assistance/robotic surgery (24%). Only 2 studies were conducted beyond phase 0 of AI research. Fourteen studies included a training group, but only one of these reported both validation and training sets. ML model performance was assessed most frequently using accuracy, specificity, and sensitivity. Scores for the adapted MINORS criteria ranged from 10 to 14 out of 14, with a median of 12. Through collation of all available preclinical and clinical trials, this review suggests the efficacy of ML for various microsurgical applications. Despite this, widespread adoption of this technology remains scarce, currently limited by methodological flaws of individual studies and structural barriers to disruptive technologies. However, with growing evidence supporting its use, microsurgeons should be receptive to implementing ML-incorporated technologies or may risk falling behind other specialties.

Modified Delphi Procedure to Achieve Consensus for the Concept of a National Curriculum for Minimally Invasive and Robot-assisted Surgery in Germany (GeRMIQ)

The rapid development of minimally invasive surgery (MIS) and robot-assisted surgery (RAS) requires standardized training to ensure high-quality patient care. In Germany, there is currently a lack of a standardized curriculum that teaches these specialized skills. The aim of this study is to find a consensus for the development of a nationwide curriculum for MIS and RAS with the subsequent implementation of the consented content.A modified Delphi process was used to reach consensus among national experts in MIS and RAS. The process included a literature review, an online survey and an expert conference.All 12 invited experts participated in the survey. They primarily achieved consensus on 73% and secondarily within the expert conference on 95 out of 122 questions (77.9%). The preference for a basic curriculum as a foundation on which specialized modules can build on was particularly clear. The results support the development of an integrated curriculum for MIS and RAS that includes step-by-step training from theoretical knowledge via e-learning modules to practical skills in dry lab simulations and in the OR. Emphasis was placed on the need to promote clinical judgment and decision making through targeted assessment during the learning curve to ensure effective application of learned skills in clinical practice. There was also a consensus that training content must be aligned with learners' skill acquisition using objective performance assessments in line with the principle of proficiency-based progression (PBP). The continuous updating of the curriculum to keep it up to date with the latest technology was considered essential.The study underlines the urgent need for a standardized training curriculum for MIS and RAS in Germany in order to increase patient safety and improve the quality of surgical care. There is broad expert consensus for the implementation of such a curriculum. It aims to ensure a contemporary and internationally competitive uniform quality of training and to increase the attractiveness of surgical training.

Impact of Centralisation of Radical Prostatectomy Driven by the Introduction of Robotic Systems on Positive Surgical Margin and Biochemical Recurrence in pT2 Prostate Cancer

BACKGROUND

To assess how centralisation of cancer services via robotic surgery influenced positive surgical margin (PSM) occurrence and its associated risk of biochemical recurrence (BCR) in cases of pT2 prostate cancer (PC).

METHODS

Retrospective analysis of all radical prostatectomy (RP) cases performed in the West of Scotland during the period from January 2013 to June 2022. Primary outcomes were PSM and BCR. The secondary outcomes compared the impact of centralisation and surgical approach on PSM and BCR; and margin length and location on BCR. Propensity score matching and Cox regression models were performed using R.

RESULTS

A total of, 907 patients were included; 662 robot assisted radical prostatectomy (RARP), 245 open RP. PSM rate was 17.7% (161/907), similar in RARP and open cohorts. Patients with PSM had higher rates of BCR; 26.7%, compared to 8.7% in patients with no PSM. Patients with margins of ≥ 1 mm had higher risk of developing BCR. Patients who underwent open RP had increased incidence of PSM ≥ 1 mm; 40/43 (93%) compared to 83/117 (71%) in robotic approach (p = 0.003). Limitations include the study being retrospective, introduction of centralisation and robot concurrently, and evolution of practice.

DISCUSSION

PSMs in pT2 PC are associated with higher rates of BCR. Introduction of centralisation via the robot had no impact on PSM occurrence or BCR, although did demonstrate a reduction in PSM length.

Economic Evaluations of Robotic-Assisted Surgery: Methods, Challenges and Opportunities

BACKGROUND

The use of robotic-assisted surgery (RAS) is growing rapidly. However, economic evaluation of this technology is challenging. This study aims to identify and discuss the different economic evaluation methods which have been used to evaluate RAS.

METHOD

This scoping review systematically searched PubMed and Embase from 2015 to 2023. We included economic evaluation studies comparing RAS versus laparoscopic or open surgery. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to aid data extraction and was extended to cover additional features relevant to RAS, including learning curve, organisational impact, incremental innovation and dynamic pricing.

RESULTS

A total of 50 economic evaluations of RAS were included. Cost-utility analysis (46%) was the most commonly applied economic evaluation method, followed by cost-consequence analysis (32%). The studies focused on the specialties of urology (42%), hepato-pancreato-biliary (20%), colorectal (14%) and gynaecology (6%). Distinctive features related to the assessment of RAS were under-addressed in economic evaluations. Only 40% of the included studies considered learning curve and organisational impact and less than 12% of the included studies reflected on incremental innovation and dynamic pricing.

CONCLUSIONS

This review found that some studies have incorporated challenges specific to RAS in their evaluations. However, most studies still lack key aspects of importance. In particular, studies rarely considered the ability of RAS platforms to be shared across multiple specialities. Incorporating these distinctive features offers an opportunity for economic evaluation to provide decision-makers with a more realistic assessment of the cost-effectiveness of this technology and to ensure its optimal utilisation in clinical practice.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Understanding the challenges of robotic-assisted surgery adoption: Perspectives from stakeholders and the general population on human-interaction, built environment, and training

This study aims to explore adoption barriers from three aspects critical to facilitating robotic-assisted-surgery (RAS) adoption: the human-robot-interaction, built-environment, and training. Guidelines for research and design are identified from these perspectives. This study consisted of three phases: 1) surveys to RAS stakeholders and a crowd-sourcing survey; 2) stakeholder focus groups; and 3) a workshop with subject-matter experts to prioritize future research for RAS. Barriers from the human-robot-interaction perspective include hesitancy among clinicians to trust automation and physical discomfort during prolonged RAS. Barriers impeding communication and workflow disruptions were identified considering the built-environment. Training barriers were exemplified by varying curriculums from formal (courses) to informal (peer training) for surgeons. Crowd-sourced survey results suggest socio-economic status plays a role in RAS perception. Design guidelines include: 1) improved ergonomics; 2) deliberate introduction of automation; 3) sufficient in-room storage for prospective operating rooms; and 4) the development of compact RAS devices for older/smaller rooms.

The general public's perception of robotic surgery - A scoping review

INTRODUCTION

Robotic surgery is typically characterized by the telemanipulation of robotic arms controlled by a surgeon via a command system. Medical technology advancements have caused variations in how robotic surgery is conceptualised. It is important to ascertain the public's perception of robotic surgery, as this impacts decision making.

METHODS

A study protocol was developed in accordance with the PRISMA guidelines. All original research articles, abstracts, conference proceedings or grey literature were eligible. The Medline (Pubmed), Scopus, and Cochrane Databases, Google Scholar, white and green statement papers, and international guidelines were searched. A preliminary search identified key terms. Title and abstract screening was conducted. Full texts were appraised for eligibility. An inductive extraction process was utilized, grouping data into themes by content analysis, and developing a coding framework. Heterogeneity limited pooling of data and prevented aggregated data analysis. Therefore, NVivo software was used to augment this qualitative process and develop a meta-synthesis.

RESULTS

The search yielded 8818 articles across the bibliographic databases. After inclusion of the grey literature 132 full text manuscripts were assessed. 35 of which were included. Three main themes were identified from the coding framework: understanding of robotic surgery, acceptance of robotic surgery, and perceptions of robotic surgery. Micro-construct subthemes included 'understanding of robotic autonomy, surgeon role, and outcomes', 'determinants of understanding', 'sources of information', 'intention to use', and 'determinants of acceptance'. Robotic surgery is perceived as a risky modality by the general public. They have a limited understanding of this surgical approach and the extent of autonomy a robotic system has. Sex, age, and residence are important factors effecting the degree of understanding and intention to undergo robotic surgery.

CONCLUSION

Robotic surgery is perceived as a risky procedure by the general public. They have limited understanding of the modality, and low rates of acceptance to undergo it fearing greater complications.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

Tracing the evolution of robotic-assisted total knee arthroplasty: a bibliometric analysis of the top 100 highly cited articles

Robotic-assisted surgical systems hold promise in enhancing total knee arthroplasty (TKA) outcomes and patients' quality of life. This study aims to comprehensively analyze the literature on robot-assisted total knee arthroplasty (r-TKA), providing insights into its current development, clinical application, and research trends. A systematic search was conducted in the Web of Science Core Collection (WOSCC) to identify relevant articles. Data were collected from the top 100 highly cited articles. Article evidence levels were assessed following established guidelines. Statistical analyses and visualizations were performed to reveal publication trends, citations, research hotspots, and collaborative networks. The analysis covered 100 highly cited articles meeting the research criteria, with a focus on the last five years. The United States emerged as a major contributor, with most publications and citations in the Journal of Knee Surgery and Knee Surgery Sports Traumatology Arthroscopy. Research priorities revolved around clinical outcomes, accuracy, and alignment of r-TKA. Notably, higher evidence levels correlated with more citations, indicating greater attention. Interest in and research on r-TKA is steadily increasing, with a few countries at the forefront of these endeavors. While numerous studies have already reported short- to medium-term follow-up results, it is crucial to conduct longer-term investigations to gain a more comprehensive understanding of the clinical benefits that r-TKA offers compared to conventional techniques. Through ongoing research and a greater embrace of robotic technology, we can continue to improve the quality of life for patients undergoing knee arthroplasty.