First Experiences with the New Senhance® Telerobotic System in Visceral Surgery

Experiences in robotic colorectal surgery: comprehensive insights from a multi-center analysis using the Senhance Robotic System

Robotic-assisted surgery has revolutionised minimally invasive approaches, particularly in colorectal surgery. While many single-center studies on colorectal surgeries exist in present literature, including experiences with Senhance® Robotic Systems, comprehensive multi-center studies are lacking. This study, conducted through the TransEnterix European Patient Registry ("TRUST"), aims to assess the safety and feasibility in this context. The present study explored procedural times, complications, robotic malfunction and limitations, adverse events and pain management outcomes for colorectal procedures, including sigmoid resection, right hemicolectomy and rectal surgery collected in two European centers. Data from 355 colorectal surgeries showed that the median duration of surgery was 147.2 min (IQR: 124.3-183.0), the docking time was reported with a median of 3.4 min (IQR: 2.0-5.4) and the console time was found at a mean of 84.4 min (SD: 33.6). Despite minimal blood loss, pain scores, and robotic malfunction, 2.9% of the cases (10 instances) required conversions to either an open or laparoscopic approach. Further, most robotic limitations were attributed to limited motion (18.9%, 67 cases) and collisions (11.5%, 41 cases). Adverse events (24 cases, 6.8%) were effectively managed, with 23 instances judged completely unrelated to the robotic system. This study underscores the positive outcomes and safety profile of Senhance® Robotic Systems in colorectal surgery, contributing valuable insights for future research and clinical practice.

First pediatric pelvic surgery with the Senhance® robotic surgical system: A case series

The Senhance® robotic system (Senhance [Asensus Surgical Inc., Naderhan, NC, USA]) is a new surgical assistive robot following the da Vinci Surgical System that has been demonstrated to be safe and efficacious. Herein, we report the first case series of pediatric pelvic surgery using Senhance. Two anorectoplasties and one rectal pull-through coloanal anastomosis for rectal stenosis were performed in three children (5-9 months, 7-9 kg) using a 10-mm three-dimensional (3D) 4K camera and 3 and 5 mm forceps operated with Senhance. None of the patients had intraoperative complications or a good postoperative course. Pediatric pelvic surgery with Senhance could be performed precisely and safely with a small body cavity. With its beautiful 3D images, motion of forceps with reduced tremor, and availability of 3-mm forceps, Senhance may be better suited for children compared with other models.

Development of Second Prototype of Twin-Driven Magnetorheological Fluid Actuator for Haptic Device

Magnetorheological fluids (MRFs) are functional fluids that exhibit rapid and reproducible rheological responses to external magnetic fields. An MRF has been utilized to develop a haptic device with precise haptic feedback for teleoperative surgical systems. To achieve this, we developed several types of compact MRF clutches for haptics (H-MRCs) and integrated them into a twin-driven MRF actuator (TD-MRA). The first TD-MRA prototype was successfully used to generate fine haptic feedback for operators. However, undesirable torque ripples were observed due to shaft misalignment and the low rigidity of the structure. Additionally, the detailed torque control performance was not evaluated from both static and dynamic current inputs. The objective of this study is to develop a second prototype to reduce torque ripple by improving the structure and evaluating its static and dynamic torque performance. Torque performance was measured using both constant and stepwise current inputs. The coefficient of variance of the torque was successfully reduced by half due to the structural redesign. Although the time constants of the H-MRC were less than 10 ms, those of the TD-MRA were less than 20 ms under all conditions. To address the slower downward output response, we implemented an improved input method, which successfully halved the response time.

Novel Robotic Platforms for Robot-Assisted Laparoscopic Surgery in Urology: A Narrative Review

Robot-assisted surgery (RAS) has been integrated into clinical practice to overcome several limitations of conventional open or laparoscopic surgery. After the expiration of the long key patent period of Intuitive Surgical, various robotic systems (RSs) have been developed aiming at improving certain characteristics of the first robotic platform, the Da Vinci RS. This narrative review provides an overview of the current RSs used in urology along with the initial results from their application in urologic procedures. Nine robotic platforms are being analyzed regarding their unique characteristics as well as their efficacy, safety, feasibility, and outcomes in urologic, oncological, or non-oncological operations. The main barrier to the wide application of RAS has been the increased cost that refers to both acquisition and maintenance costs. Besides, the health inequality resulting from the lack of expert robotic surgeons and the difficulty of performing robot-assisted procedures in provincial hospitals should be overcome. However, large properly designed comparative studies are required to establish the role of newly introduced RSs. In addition, urologists should keep abreast of new developments and research in robot-assisted urologic procedures.

Comparison of senhance and da vinci robotic radical prostatectomy: short-term outcomes, learning curve, and cost analysis

BACKGROUND

The Senhance® Robotic System is a new laparoscopy-based platform that has been increasingly used in radical prostatectomy (RP) procedures. The purpose of this study is to compare the outcome of Senhance RP (SRP) with da Vinci RP (DRP) cases.

METHODS

From August 2019 to April 2022, we prospectively recruited 63 cases of SRP. We compared the perioperative data, postoperative complication rates, short-term surgical outcomes (3-month postoperative undetectable prostate-specific antigen (PSA) and incontinence rates), learning curves, and cost analysis with data from 63 matched da Vinci Xi RP cases.

RESULTS

There was no difference in BL (180 versus 180 ml, p = 0.86) and postoperative surgical complication rate (Clavient -Dindo grade I-IV, 25.3 versus 22.2%, p = 0.21) between the SRP cases and the DRP. Regarding the oncologic and continence function, there was no difference between positive margin rate (36.5% versus 41.3%, p = 0.58), rate of undetectable PSA level at postoperative 3 months (68.3 versus 66.7%, p = 0.85), and incontinence rate (14.3 versus 15.9%, p = 1.0) at postoperative 3 months between the two cohorts. The learning curve showed a quick downward slope for laparoscopic experienced surgeons. The median pocket cost for SRP patients in our hospital was $4170, which was lower than $7675 for the DRP patients.

CONCLUSIONS

Safety and short-term outcomes are comparable between SRP and DRP. For experienced LRP surgeons, using the Senhance system to perform RP is straightforward. With a more affordable price as its biggest advantage, the Senhance system may serve as a safe and effective alternative for robotic RP.

First experience with the Hugo™ robot-assisted surgery system for endometriosis: A descriptive study

INTRODUCTION

The Medtronic Hugo™ Robot-assisted Surgery (RAS) system was recently approved for clinical use. We explored the safety and feasibility of this system for endometriosis surgery. The primary outcome was safe case completion without major surgical complications (Clavien-Dindo grade ≤2) and no conversion to open surgery or laparoscopy.

MATERIAL AND METHODS

Surgeries for endometriosis performed at the Department of Gynecology, Rigshospitalet, on the Medtronic Hugo™ RAS system were included. Two experienced robotic surgeons performed all surgeries with their usual robotic team. The variables included were patient demographics, peri- and postoperative data, complications and 30-day readmission rate. We used the IDEAL framework 1/2a for surgical innovation in this descriptive study.

RESULTS

The first 12 patients were included. All cases were completed without intraoperative complications or conversion. Four patients experienced Clavien-Dindo grade 1 postoperative complications. No patients were re-admitted within 30 days. Median docking time (17 minutes), console time (87.5 minutes), blood loss (40 mL) and length of hospital stay (1 day) were acceptable compared with previous literature.

CONCLUSIONS

In this pilot study, we found the Medtronic Hugo™ RAS system safe and feasible for robot-assisted surgery for endometriosis. The advent of new robotic systems is welcomed to accelerate the development of technology that will advance surgical care for patients across the globe.

Learning curves and procedural times in Senhance®-robotic assisted fundoplication: results from 237 consecutive patients undergoing robotic fundoplication in a single center as part of the European TRUST Robotic Surgery Registry Study

BACKGROUND

Gastroesophageal reflux disease requiring an operative solution is common. Minimally invasive surgery to generate an anti-reflux barrier at the distal esophagus following the principle of the "floppy Nissen" technique has become the gold standard. Advanced robotic-assisted systems may deliver more consisted outcomes.

METHODS

This registry study analyzed safety and efficacy of the Senhance® surgical system in the surgical treatment of reflux disease and procedural proficiency. Data from 237 consecutive patients operated in a single center were evaluated. Historic standard laparoscopies from the same center were analyzed to compare robotic surgery learning curve effects.

RESULTS

Using the Senhance® Surgical System, during the first 50 patients there was a significant decrease in surgery time which was maintained over the duration of study, pointing to the surgical staff's system-specific learning. After this phase, procedural times were comparable between the robotic-assisted and traditional laparoscopic surgery. The effect of learning was greater than for standard laparoscopy. For 237 patients, there were four conversions to laparoscopic surgery. Two serious adverse events were recorded, both cardiac in nature and not related to the use of the robot.

CONCLUSIONS

Robotic fundoplication was swiftly implemented in a non-university hospital with 65 surgical beds. The operating time was no longer than in standard laparoscopy, the procedure was more standardized than open or laparoscopic surgery and hospitalization times may have been sustainably shortened. The autonomy at the system's digital platform (cockpit) to conduct robotic fundoplications is a big step forward in surgery.

The Availability, Cost, Limitations, Learning Curve and Future of Robotic Systems in Urology and Prostate Cancer Surgery

Robot-assisted surgical systems (RASS) have revolutionised the management of many urological conditions over the last two decades with robot-assisted radical prostatectomy (RARP) now being considered by many to be the preferred surgical approach. Intuitive Surgical has dominated the market during this time period with successive iterations of the da Vinci model. The expiration of patents has opened the RASS market and several new contenders have become available or are currently in development. This comprehensive narrative review aims to explore the merits of each robotic system as well as the evidence and barriers to their use. The newly developed RASS have increased the versality of robotic surgical systems to a wider range of settings through advancement in technology. The increased competition may result in an overall reduction in cost, broadening the accessibility of RASS. Learning curves and training remain a barrier to their use, but the situation appears to be improving through dedicated training programmes. Outcomes for RARP have been well investigated and tend to support improved early functional outcomes. Overall, the rapid developments in the field of robot-assisted surgery indicate the beginning of a promising new era to further enhance urological surgery.

Improvement of Haptic Interface for Teleoperation Endoscopic Surgery Simulators Using Magnetorheological Fluid Devices

A magnetorheological (MR) fluid is a composite material comprising ferromagnetic particles, medium oils, and several types of additives. We developed an MR fluid clutch for haptics (H-MRC) and installed it in a haptic interface that simulates teleoperation endoscopic surgery (ES). To enhance its operability, we redesigned the H-MRC to reduce its weight and improve its control system. We reduced the weight of the H-MRC and haptic gripper by 77.0 g and 137.0 g, respectively. To evaluate the influence of the improvement and force feedback functions on remote operation skills, we conducted pick-and-place tests with a remotely controlled system. In the tests, we subjectively evaluated the NASA-TLX and quantitatively evaluated the success rate of the task. The results of the subjective assessment showed significant reductions in mental stress during the teleoperation task. In addition, the results of the quantitative evaluation showed that the force feedback function was effective against the teleoperation skills of the operators.

SENHANCE ROBOTIC RADICAL PROSTATECTOMY

Since its introduction 20 years ago, robotic radical prostatectomy has become a standard of care in the treatment of localized prostate cancer in many Centers. Until recently, they have all been performed by the only available robotic platform. Senhance is a novel robotic platform that was approved for clinical use. The term Senhance was used to systematically search PubMed and Scopus databases for relevant articles that were afterward filtered for appropriate designs and data reports. There were two reports that met all of the criteria and were included in the review. Both studies were designed as prospective case series with a total of 234 patients where the data including operative data and oncological outcomes were reported. The average operative time ranged between 180 and 195 min, with estimated blood loss between 250 and 300 mL. There was 3 Clavien - Dindo grade III, and 1 Clavien - DIndo grade IV complication reported. One of the studies compared it with laparoscopy, but no significant difference in operative time and blood loss was found. Both studies concluded that the Senhance is a feasible and safe robotic platform for radical prostatectomy.

Robotics in laparoscopic surgery - A review

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

Robotic colorectal surgery using the Senhance® robotic system: a single center experience

BACKGROUND

The aim of this study was to evaluate the initial experience of a single robotic center with the Senhance^® robotic systems (TransEnterix Surgical Inc, Morrisville, NC, USA) in colorectal surgery.

METHODS

We performed a retrospective analysis of prospectively collected data of patients who underwent colorectal surgery using the Senhance^® robotic systems, from November 2018 to November 2020. Perioperative, intraoperative, and short-term postoperative data were assessed.

RESULTS

There were 57 patients (28 women and 29 men, mean age 61.7 ± 6.2 years [range 23-84 years]). Forty-eight (84.2%) patients underwent surgery for colorectal cancer (22 colon cancer and 26 rectal cancer) and 9 (15.8%) for benign conditions. Mean operating time was 194 min ± 57.8 min (range 90-380 min). In total, 27(47.4%) operations were performed on the colon and 30 (52.6%) on the rectum; mean length of postoperative hospital stay was 8 ± 6.2 days (range 3-48 days). There were 2 (3.4%) conversions to open surgery. No intraoperative complications occurred. Seven patients (12.3%) had postoperative complications 3 (5.3%) of whom had to be treated under general anesthesia. There was no mortality. In 48 patients operated on for colorectal cancer, the mean lymph-node harvest was 18 ± 7.9 (range 7-38 lymph nodes). In the rectal cancer group of 26 patients, the distal resection margin was 3.3 ± 1.8 cm.

CONCLUSIONS

In our experience, surgery using the new Senhance^® robotic system was safe and feasible in surgery of the colon and rectum. Randomized controlled trials comparing this type of colorectal surgery with laparoscopic and/or other types of robotic surgery are needed.

First Pediatric Pyeloplasty Using the Senhance® Robotic System—A Case Report

A pediatric robotic pyeloplasty has been performed with the Senhance^® robotic system for the first time in January 2021 on a 1.5-year-old girl with symptomatic ureteropelvic junction stenosis. A Senhance^® robotic system (Asensus Surgical^® Inc., Durham, NC, USA) with three arms and 5 mm instruments was used, providing infrared eye tracking of the 5 mm camera and haptic feedback for the surgeon, facilitating suturing of the anastomosis and double-J stent insertion. The robotic surgery lasted 4.5 h, was uneventful and successful, without recurrence of the ureteropelvic junction obstruction after six months, and with normal development of the patient’s growth and organ function. The use of the robotic system was shown to be safe and feasible; long term follow-up will be conducted subsequently in pediatric surgery.

Surgical assistant manipulator with diagonal joints and multi-stage telescopic screws for laparoscopic solo surgery

PURPOSE

A surgeon in a sterilized area can perform robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot for view stabilization and a forceps robot for pulling organs. At present, no locally operated surgical assistant manipulator with a mechanical remote center of motion (RCM) is available to operate within a small space while providing a wide range of movement. The present study describes a new locally operated detachable end-effector manipulator (LODEM) with diagonal joints and multi-stage telescopic screws.

METHODS

A forceps manipulator attached to commercial surgical forceps was developed. This manipulator uses RCM diagonal joints for the yaw and pitch axes, providing an intuitive pivot point and free rotation, and telescopic nested screws with multiple sliders clamp the commercial forceps for the axis of insertion. The manipulator placed above the abdominal wall using a fixed arm connected to a bed rail is motor controlled by a handheld interface with button switches for precise traction and is controlled manually for easy rough positioning.

RESULTS

Positional accuracy at the tip with a load of 5 N was under 0.5 mm. Mechanical deflection was under 2.1 mm. The manually controlled force was under 4.4 N. Successful simulated laparoscopic cholecystectomy using the prototype manipulator to handle the target and maintain stability was performed on a surgically realistic gallbladder model.

CONCLUSIONS

A LODEM with diagonal joints and multi-stage telescopic screws was developed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a surgeon working near the patient. This electric motor-controlled laparoscopic instrument holder by the surgeon in the surgical field could be used for such applications.

Kinematic and Workspace Analysis of the Master Robot in the Sinaflex Robotic Telesurgery System

Robotic telesurgery systems, including master and slave robots, have emerged in recent years to provide benefits for both surgeons and patients. Surgeons use the master manipulator to navigate the slave robot. The Sina_flex telesurgery system introduced recently by Sina Robotics and Medical Innovators Co., Ltd. consists of two main subsystems: master robotic surgery console and slave surgery robots. As the surgeon use the master robot's handles to control the slave surgery robots, it is important for the master robot to provide the ergonomic postures for the surgeon and also providing a large enough workspace and good manipulability for the surgeon to control it. So in this paper, workspace, manipulability and isotropy of each handle at the master robot of the Sinaflex telesurgery system are analyzed. To this end, the kinematic of the master manipulator is derived, and its Jacobian is calculated. Using the simulation environment, the workspace of the master handle is obtained and drawn. The manipulability of the robot for each points of the workspace is computed. According to the results attained from the simulation study, the most manipulability values lie between 0.1 and 0.9 where it is greater than 0.44 for more than 50% of the whole workspace points of the end effector, which is as large as 574×484×560 mm.

Potential Contenders for the Leadership in Robotic Surgery

Purpose: To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. Materials and Methods: A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci^® system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Results: Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I^®, Versius^®, and Senhance^® are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. Conclusions: The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.

First experience using the Senhance surgical system in laparoscopic local gastrectomy for gastrointestinal stromal tumor

Various innovative robotic systems have been developed to improve surgery precision. The Senhance Surgical System (SSS) is a digital laparoscopic system offering eye tracking and haptic feedback. Several reports have described application of the SSS to general surgeries, including cholecystectomy and colectomy. However, use of the SSS for gastric tumor has not been reported. We experienced a case of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) with the SSS. A 74-year-old man diagnosed with GIST underwent LLG with the SSS. Operation, docking, and console times were 117, 11, and 59 minutes, respectively. No perioperative complications were encountered. This study is the first to report LLG for GIST with the SSS. LLG with the SSS was safe and feasible. The SSS can use reusable forceps and contribute to reducing medical costs. The development of instruments is also progressing, and various kinds of surgery are likely to be indicated.

Inguinal hernia TAPP repair using Senhance® robotic platform: first multicenter report from the TRUST registry

PURPOSE

The purpose of this article was to provide feasibility and safety results of robotic transabdominal preperitoneal inguinal hernia repair (Robotic TAPP).

METHODS

We included 271 cases of robotic inguinal hernia TAPP repair using the Senhance^® robotic platform from four different centers between March 2017 and March 2020. Key data points were intraoperative and postoperative complication rate, operating time, length of hospital stay, postoperative pain score and time required to get back to a daily routine that were inserted in the TransEnterix European Patient Registry for Robotic assisted Laparoscopic Procedures in Urology, Abdominal Surgery, Thoracic and Gynecologic Surgery (TRUST).

RESULTS

We report 203 cases of unilateral and 68 cases of bilateral inguinal hernia repairs. Mean operative time was 74 ± 35 min (range 32-265 min), postoperative complications occurred in five (1.85%) cases, the intraoperative complication rate was five (1.85%). The average subjective patient-related pain score after the procedure was 3 ± 1.9 (range 1-9), length of hospital stay was 39 ± 28 h (range 4-288 h), and recovery time was 9.65 ± 8 days (range 1-36 days).

CONCLUSION

Robotic inguinal hernia TAPP repair shows inspiring results. It is a safe and doable procedure. However, cost analysis should be performed in future to show the superiority over other techniques.

Robotic-assisted radical prostatectomy with the Senhance® robotic platform: single center experience

OBJECTIVE

To describe our institution's initial experience with robot-assisted radical prostatectomy (RARP) using the Senhance^® robotic system.

PATIENTS AND METHODS

A prospective analysis of 127 robot-assisted radical prostatectomies was performed. Patient demographics, preoperative and intraoperative parameters, histopathological examination results, intraoperative and early postoperative complications were obtained and analyzed.

RESULTS

The median patient age was 61.0 ± 6.36 (from 37 to 73) years, with a mean body mass index of 26.2 ± 3.79 kg/m². Of 127 patients, 16.5% (n = 21) underwent a pelvic lymph node dissection, 29.1% (n = 37) underwent one sided or bilateral nerve sparing. Post-operative extracapsular invasion (≥ pT3) was found in 15% (n = 19) of the cases and a Gleason score ≥ 7 in 74.8% of all patients. Our median operative time was 180 ± 41.98 min [interquartile range (IQR) 150-215], and median blood loss was 250 ± 236 (IQR 175-430) ml. Of 127 patients, 33.9% (n = 43) had positive margins, of them 28.7% in pT2 and 57.9% in pT3. Fifteen patients (11.8%) experienced complications, of them only three had Clavien-Dindo ≥ 3. Operation time decreased by about 60 min and estimated blood loss decreased by about 200 ml from the initial experience of each surgeon.

CONCLUSIONS

Robotic prostatectomy using a Senhance^® robotic system is feasible, and warrants further study to determine whether it can improve patient outcomes.

Upper urinary tract surgery and radical prostatectomy with Senhance® robotic system: Single center experience-First 100 cases

BACKGROUND

The Senhance^® robotic surgery system is a novel robotic platform used in several European and World centres. We present our experience in urologic surgery using this platform.

PATIENTS AND METHODS

From May 2019 to December 2020, we performed 30 operations of upper urinary tract (UUT) and 70 extraperitoneal radical robotic prostatectomies (RRP). Relevant data were prospectively collected for key outcomes.

RESULTS

The median age for UUT was 51, and for RRP 65 years. The average estimated blood loss for UUT was 30, and for RRP 200 ml. The average operating time for UUT was 160, and for RRP 200 min. In-hospital stay for UUT was on average 4, and for RRP 5 days. In UUT group, one patient had Clavien-Dindo complication grade II and one had IIIb. In RRP, three patients had grade I complications and three patients had grade II complications. Catheter was removed on average 8 days after RRP.

CONCLUSION

The Senhance^® robotic system is a safe and feasible approach to urological surge.

Initial experience of laparoscopic radical nephrectomy using the Senhance® robotic system for renal cell carcinoma

The Senhance^® robotic system (TransEnterix, Morrisville, NC, USA), previously called the TELELAP Alf-X system, is a novel robotic system with a telesurgical concept. We herein describe our initial experience of Senhance^® assisted laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) with detailed figures and videos. Case 1: A left renal tumor was incidentally detected in a 52-year-old female on ultrasonography. Case 2: A right renal tumor was detected in a 67-year-old male with epigastric pain on computed tomography. They were referred for further examination and diagnosed with RCC (clinical T1bN0M0 and clinical T2aN0M0, respectively). Senhance^® assisted LRN was completed without conversion to conventional LRN or open surgery in both cases. The pneumoperitoneum time, console time and estimated blood loss in case 1 and case 2 were 173 min, 143 min and 3 mL, and 154 min, 122 min and 50 mL, respectively. The postoperative course was uneventful. Senhance^® assisted LRN for RCC was safely and precisely performed. Furthermore, the operator was comfortable during the surgery. Although further surgical experience and long-term follow-up are required to assess surgical and oncological outcomes, Senhance^® assisted LRN for RCC may be a promising procedure.

Supplementary information

The online version contains supplementary material available at 10.1007/s13691-021-00487-x.

Locally operated assistant manipulators with selectable connection system for robotically assisted laparoscopic solo surgery

PURPOSE

By integrating locally operated surgical assistant robots in a sterilized area, a surgeon can perform safe robotically assisted laparoscopic solo surgery while controlling a laparoscope-holding robot and a forceps robot. At present, there is no leader-follower control system with switchable connection for the leader device in which each assistant follower robot can provide the manipulation intuitively and easily. In the present study, a new locally operated leader-follower selectable control system has been developed.

METHODS

The leader-follower system was developed to connect one leader operating device and one of two selectable follower assistant manipulator devices with different numbers of axes, kinematics models, sensors, and actuators for view stabilization and pulling organs. The system is constructed using the middleware of the ORiN-based medical robot architecture MRLink. The system is regulated by the robot integrator application with unilateral leader-follower PTP using the relative displacement between the leader device and the selected follower device through providers of device interface including the information and control commands.

RESULTS

The execution cycle for updating the position was 50 ms, and the time delay to catch up with the same position was 100 ms. Two assistant manipulators controlled by the leader-follower selectable system could successfully produce the desired view and handle the target organ model for 17 min in a simulated laparoscopic cholecystectomy.

CONCLUSIONS

A locally operated leader-follower selectable control system was constructed to facilitate minimally invasive, robotically assisted laparoscopic solo surgery by a doctor working near the patient. This system could be used for such applications.

Robot-assisted surgery with Senhance robotic system for colon cancer: our original single-incision plus 2-port procedure and a review of the literature

BACKGROUND

The Senhance robotic system provides such advantages as an eye-tracking camera control system, haptic feedback, operator comfort, and reusable endoscopic instruments. The aim of this small study was to assess the feasibility and safety of performing a reduced-port robot-assisted colectomy for colon cancer with the use of a novel robotic system.

METHODS

This was a single-center retrospective study of eight patients with colon cancer who underwent single-incision plus 2-port robot-assisted colectomy with the Senhance robotic system (SILS+2-S) between December 2019 and March 2020 at our hospital. Data on perioperative outcomes, which included operative time, operative blood loss, length of hospitalization, postoperative complications, and histopathological results, were collected prospectively.

RESULTS

The mean patient age was 70.9 years and the mean body mass index was 24.4 kg/m². One patient was converted to laparoscopy due to a damaged scope holder. The mean operative and console times were 229.1 and 139.1 min, respectively. The mean intraoperative blood loss was 49.4 ml. The mean length of the umbilical incision was 3.0 cm. The mean number of harvested lymph nodes was 18.3. The surgical margins were negative in all eight patients. There was neither morbidity nor mortality associated with the procedure, and no Clavien-Dindo classification Grade II-IV complications occurred.

CONCLUSIONS

SILS+2-S is a safe and feasible approach for patients with colon cancer. Further studies are needed to validate the advantages of SILS+2-S and to evaluate the long-term oncological outcomes.

The TransEnterix European Patient Registry for Robotic-Assisted Laparoscopic Procedures in Urology, Abdominal, Thoracic, and Gynecologic Surgery ("TRUST")

INTRODUCTION

Robotic surgery was first introduced in the mid-1980s, and at the end of the '90s, the da Vinci® System (Intuitive Surgical Inc., Sunnyvale, California) was introduced in Europe and held a monopoly for years afterward. In 2016, Senhance™ digital laparoscopic platform (TransEnterix Inc., Morrisville, North Carolina) came to the market. This new platform is based on laparoscopic movements and is designed for laparoscopic surgeons. This study shows the surgical outcomes of patients after different visceral, colorectal, gynecological, and urological surgical procedures done with the Senhance™ digital laparoscopic platform with a focus on safety.

MATERIALS AND METHODS

The study population consists of 871 patients who underwent robotic surgery with the Senhance™ platform. The most common procedures were hernia repairs (unilateral and bilateral), cholecystectomies, and prostatectomies. The procedures were performed in five centers in Europe between February 2017 and July 2020 by experienced laparoscopic surgeons.

RESULTS

220 (25.3 %) out of 871 patients had a unilateral hernia repair, 70 (8.0%) a bilateral hernia repair, 159 (18.3%) underwent a cholecystectomy, and 168 (19.3%) a prostatectomy. The other procedures included visceral, colorectal, and gynecological surgery procedures. The median docking time was 7.46 minutes for the four most common procedures. The duration of surgery varied from 32 to 313 minutes, the average time was 114.31 minutes. Adverse events were rare overall. There were 48 (5.5 %) adverse events out of 871 patients, 24 of them (2.8 % of all cases) were severe. Out of all 24 severe adverse events, five events (20.8%) were likely related to the robot, 17 events (70.8%) were unlikely related to the robot, and two events (8.3%) could not be categorized. Regarding complications following unilateral hernia repairs, data from 212 patients was available. Thirteen (6.1%) complications occurred, and six of those (2.8%) were serious. Out of 68 patients with a bilateral hernia repair, six patients (8.8%) developed complications, three of which were severe (4.4%). The complication rate was 2.8% in the patients following a cholecystectomy (4/144); two of them serious. After prostatectomy, six out of 141 patients (4.3 %) had complications; one serious (0.7%) No mortality was observed. Data about unplanned conversions to laparoscopic surgery could be collected from 761 patients which is a rate of 3.7%. There were 12 conversions out of 760 procedures to open surgery (1.6%).

CONCLUSIONS

Our series shows these procedures are safe and reproducible. The findings suggest that the surgical results after robotic surgery with the Senhance™ system are promising. Long-term data regarding complication rates should be the subject of future studies.

Single-incision plus two-port robotic surgery for sigmoid colon cancer using the Senhance robotic system

Informed by our experiences with reduced-port surgery for colorectal cancer, we performed the first single-incision plus two-port robotic sigmoidectomy for cancer with the Senhance robotic system. A 70-year-old woman presented to our department for the treatment of sigmoid colon cancer. We performed single-incision two-port robotic sigmoidectomy. A wound protector was inserted through a 3.0-cm transumbilical incision, a multiport access device was mounted on top of it, and then a camera port and a 5-mm assistant's port were placed in the multiport access device. Two extra ports were placed on the central line of the abdomen. Lymph node dissection around the inferior mesenteric artery and mobilization of the left-sided colon were completed without any perioperative complications. The total operative time was 204 minutes, and the console time was 113 minutes. The estimated blood loss was 75 mL. The patient was discharged on postoperative day 8 without any complications.

An early experience with the Senhance surgical robotic system in colorectal surgery: a single-institute study

BACKGROUND

We present our initial single-centre experience with Senhance surgical robot-assisted colorectal surgery and examine its safety and feasibility.

METHODS

From June 2019 to December 2019, patients who underwent Senhance surgical robot-assisted colorectal surgery in our hospital were retrospectively analysed. We focused on the short-term outcomes.

RESULTS

In total, 46 patients were enrolled in the study. Colorectal cancer was the most common indication for surgery (39 patients). The median total operation time was 283 min, and the median blood loss was 50 cc. Meanwhile, the median number of harvested lymph nodes was 20. Elderly age, advanced American Society of Anaesthesiologists stage, and right-sided colon surgery were associated with the occurrence of complications greater than grade III.

CONCLUSION

Our findings demonstrate the feasibility and safety of the Senhance surgical robotic system in colorectal surgery. Care should be taken regarding the indications and patient selection.

Right hemicolectomy with D3 lymph node dissection for right-sided transverse colon cancer using the Senhance robotic system: a case report

Background

The evolution of remote systems and artificial intelligence technology has led to increase in robotic surgeries. One system used in this case report is the Senhance robotic system. The most important premise for using robotic surgery in cancer therapeutics is to ensure oncological safety. Similar to conventional laparoscopic surgery, robotic surgery needs to be a reliable and secure surgical procedure, such as complete mesocolic excisions with central vascular ligations in Western countries or D3 lymph node dissections (dissection of the lymph nodes that locates from the origin to the terminal branch of the main feeding artery of cancer) in Japan.

Case presentation

A 76-year-old man underwent clinical examination for severe anemia. He was diagnosed with transverse colon cancer of tumor (T)3, node (N)1a, metastasis (M)0 cancer stage IIIA. A right hemicolectomy with D3 lymph node dissection using the Senhance surgical system was performed. The operative time was 313 min and the estimated blood loss was 5 ml. He was discharged from our hospital 12 days after the surgery without any complications. What is the remarkable of this report, not only mobilization of right colon but also D3 lymph node dissection and vascular ligation were performed intraperitoneally by using Senhance robotic system as conventional laparoscopic surgery. We tried using fourth robotic arm to accomplish lymphadenectomies and middle colic artery dissection. A right hemicolectomy with D3 dissection using the Da Vinci surgical system was reported. Another report of a right hemicolectomy performed with the Senhance robotic system was identified; however, in that study, lymph node dissections were not performed intraperitoneally.

Conclusions

Therefore, to our knowledge, this is the first report using the Senhance robotic system for right hemicolectomy with D3 dissection. We hope that our case report will assist in the establishment of this robotic procedure in surgical practice.

Next-generation robotics in gastrointestinal surgery

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

A first case of ileocecal resection using a Senhance Surgical System in Japan

BACKGROUND

Several manufacturers are in the process of developing various innovative systems and expect more options in the robot market. One of the latest systems, the Senhance® platform (TransEnterix Surgical Inc, Morrisville, NC, USA), has already been introduced in Europe and has also been approved for clinical use in Japan. We report the first case of colorectal resection using Senhance in Japan.

CASE PRESENTATION

The patient was a 79-year-old Japanese man who visited a previous physician for positive fecal occult blood. Upon close inspection, the preoperative diagnosis was cT2N0M0 stage I. We performed surgery using Senhance. The operation time was 198 min, and the estimated amount of bleeding was 10 g. He was discharged after surgery without any major complications. However, it is also true that the operability of the conventional port arrangement was poor during the surgical operation.

CONCLUSION

We report the first Senhance-assisted ileocecal resection for colorectal cancer in Japan. In the future, we would like to find more ways to use it by accumulating more cases.

A roadmap for robotic-assisted sigmoid resection in diverticular disease using a Senhance™ Surgical Robotic System: results and technical aspects

Since the turn of the century, robotic-assisted colorectal surgery has been synonymous with the da Vinci® robotic surgical system. We report in this study our first results in robotic-assisted sigmoid resection for diverticular disease using the Senhance™ Surgical Robotic System, while introducing a standardized roadmap for engaging the robotic arms. 12 patients underwent a sigmoid resection using the Senhance™ Surgical Robotic System. All four arms of the robotic system were engaged during all procedures according to a previously devised roadmap. A 4-trocar technique was used in all patients. Perioperative data, including those regarding technical difficulties, were collected and analyzed. Two procedures were converted into standard laparoscopy. There were no conversions to open surgery. The mean age of the patients was 62.5 years (47-79). One third of the patients were males. The mean BMI was 27 kg/m2 (19-38). The mean operative time, the mean console time and the mean docking time were 219 min (204-305), 149 min (124-205) and 10 min (6-15), respectively. The mean length of stay was 9 days (6-15). There was one major complication (8.3%, Clavien-Dindo IIIb). There were no mortalities. No other complications were observed. No patients were readmitted after discharge. The Senhance™ Surgical Robotic System can be used safely in sigmoid resection for diverticular disease after adequate training and systematic planning of the different steps of the procedure. Further experience is needed to judge the benefit for patient and surgeon, as well as the cost and time effectiveness.

Supervised Autonomous Electrosurgery via Biocompatible Near-Infrared Tissue Tracking Techniques

Autonomous robotic surgery systems aim to improve patient outcomes by leveraging the repeatability and consistency of automation and also reducing human induced errors. However, intraoperative autonomous soft tissue tracking and robot control still remains a challenge due to the lack of structure, and high deformability of such tissues. In this paper, we take advantage of biocompatible Near-Infrared (NIR) marking methods and develop a supervised autonomous 3D path planning, filtering, and control strategy for our Smart Tissue Autonomous Robot (STAR) to enable precise and consistent incisions on complex 3D soft tissues. Our experimental results on cadaver porcine tongue samples indicate that the proposed strategy reduces surface incision error and depth incision error by 40.03% and 51.5%, respectively, compared to a teleoperation strategy via da Vinci. Furthermore, compared to an autonomous path planning method with linear interpolation between the NIR markers, the proposed strategy reduces the incision depth error by 48.58% by taking advantage of 3D tissue surface information.

Robotic surgery using Senhance® robotic platform: single center experience with first 100 cases

Until recently, robotic surgery has been associated only with the da Vinci robotic system. A novel Senhance^® robotic system (TransEnterix Surgical Inc., Morrisville, NC, USA) was introduced almost 5 years ago. Published reports on experience using this robotic platform are very limited. We present a prospective analysis of the first 100 robotic surgeries in abdominal surgery, gynecology, and urology in Klaipeda University Hospital, Klaipeda, Lithuania. Out of 100 operated patients during the mentioned period, 49 were female and 51 men, age range 27-79 years, on an average 55 years. 39 underwent robotic abdominal surgical procedures, 31-urological, and 30 gynecological surgeries. Duration of surgery varied from 30 min to 6 h and 5 min, on an average 2 h 25 min. Almost half 49 (49%) were operated on for malignant diseases: prostate cancer-27, renal cell carcinoma-1, endometrial cancer-7, ovarian cancer-1, colorectal cancer-13 (7 colon and 6 rectum). In-hospital stay was on an average 4 days, range 1-15 days. There were 3 (3%) conversions: two to laparoscopy (both undergoing robotic radical prostatectomy) and one to open (undergoing total hysterectomy). 6 (6%) complications occurred during 30 postoperative days, 2 demanding surgery. According to the Clavien-Dido classification, they were grade II in 3, grade III a in 1 and grade III b in 2 cases. There was no mortality in this patient population. Our experience with different types of robotic surgeries allows us to state that the Senhance^® robotic system is feasible and safe in general surgery, gynecology, and urology, and wider implementation of this system worldwide is simply a question of time.

Autonomous Laparoscopic Robotic Suturing with a Novel Actuated Suturing Tool and 3D Endoscope

Compared to open surgical techniques, laparoscopic surgical methods aim to reduce the collateral tissue damage and hence decrease the patient recovery time. However, constraints imposed by the laparoscopic surgery, i.e. the operation of surgical tools in limited spaces, turn simple surgical tasks such as suturing into time-consuming and inconsistent tasks for surgeons. In this paper, we develop an autonomous laparoscopic robotic suturing system. More specific, we expand our smart tissue anastomosis robot (STAR) by developing i) a new 3D imaging endoscope, ii) a novel actuated laparoscopic suturing tool, and iii) a suture planning strategy for the autonomous suturing. We experimentally test the accuracy and consistency of our developed system and compare it to sutures performed manually by surgeons. Our test results on suture pads indicate that STAR can reach 2.9 times better consistency in suture spacing compared to manual method and also eliminate suture repositioning and adjustments. Moreover, the consistency of suture bite sizes obtained by STAR matches with those obtained by manual suturing.

[Robotics and augmented reality : Current state of development and future perspectives]

BACKGROUND

Digitalization in surgery is gaining attention in the surgical community, with robotics and augmented reality as key issues.

ROBOTICS

The term surgical robot is basically not adequate to describe currently available telesupport and manipulation systems. These are passive tools which have to be activated by the surgeon and only provide relatively low levels of active support. Accordingly, justification of use is currently difficult with respect to the cost-benefit relationship. A real breakthrough will be achieved by upgrading them into genuine intelligent and collaborative support systems and justify the term as the true meaning of robotics.

AUGMENTED REALITY (AR)

Augmented or enriched reality improves or facilitates normal sensory perception by the integration of additional information of a different nature. Intuitive perception of the surgical site would have the potential to revolutionize surgery, but prior to clinical use, the matching of the real and the virtual world still has to be optimized (referencing); however, AR is now already a valuable tool for training and simulation as well as workflow support in the operating room (OR).

CRITICAL COMMENT AND PERSPECTIVES

The promising new technological development towards the future cooperative surgical OR environment, including both robotic and AR modules, will have a significant impact on surgery, even in the mid-term. Decisive for this is that surgeons actively take part in the evaluation of this process to ensure that future "intelligent" tools will remain mere assistant or supporting systems.