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Ingallinella S, Ardito F, Ratti F, Marino R, Catena M, De Rose AM, Razionale F, Rumi F, Cicchetti A, Giuliante F, Aldrighetti L. Evaluation of the economic impact of the robotic approach in major and postero-superior segment liver resections: a multicenter retrospective analysis. Hepatobiliary Surg Nutr 2024; 13:241-257. [PMID: 38617496 PMCID: PMC11007348 DOI: 10.21037/hbsn-23-407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/10/2023] [Indexed: 04/16/2024]
Abstract
Background Economic impact of robotic liver surgery (RLS) is still a debated issue due to the heterogeneity of liver resections considered and the lack of a rigorous methodology. Therefore, the aim of this study is to perform a time-driven activity-based costing (TD-ABC) comparing the costs of RLS, laparoscopic liver surgery (LLS) and open liver surgery (OLS) in the context of complex liver resections and to compare short term perioperative outcomes. Methods The institutional databases of two Italian high volume hepatobiliary centres were retrospectively reviewed from February 2021 to April 2022. Patients submitted to major hepatectomies or postero-superior liver resections were selected and divided into three groups according to the approach scheduled (RLS, LLS and OLS) and compared. Major contributors of perioperative expenses were calculated using the TD-ABC model and accurately quantifying each unit resource consumed per patient and the time spent performing each activity. A primary intention-to-treat analysis (ITT-A) including conversions in the RLS and LLS groups was performed. Results Forty-seven RLS, 101 LLS and 124 OLS were collected. LLS and RLS showed reduced blood loss, morbidity, mortality and hospital stay compared with open. A trend towards reduced conversion rate in RLS compared to LLS was registered. Total costs associated with RLS were estimated at €10,637 vs. €9,543 for LLS and vs. €13,960 for OLS. The higher intraoperative costs associated with RLS (+153.3% vs. OLS and +148.2% vs. LLS, P<0.001), primarily related to surgical equipment expenses, were slightly offset by the postoperative savings (-56.0% vs. OLS and -29.4% vs. LLS, P<0.001) resulting from significantly reduced hospital stays. Conclusions RLS offers economic advantages over OLS, as initial higher costs are offset by better perioperative outcomes. The evolving robotic marketplace is expected to drive down RLS costs, promoting widespread adoption in minimally invasive procedures. Despite its higher costs than LLS, RLS's ability to enhance minimally invasive feasibility makes it a preferred choice for complex cases, reducing the need for conversions.
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Affiliation(s)
- Sara Ingallinella
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Foundation “Policlinico Universitario A. Gemelli”, IRCCS, Catholic University, Rome, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
| | - Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, Foundation “Policlinico Universitario A. Gemelli”, IRCCS, Catholic University, Rome, Italy
| | - Francesco Razionale
- Hepatobiliary Surgery Unit, Foundation “Policlinico Universitario A. Gemelli”, IRCCS, Catholic University, Rome, Italy
| | - Filippo Rumi
- Graduate School of Health Economics and Management, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Americo Cicchetti
- Graduate School of Health Economics and Management, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Foundation “Policlinico Universitario A. Gemelli”, IRCCS, Catholic University, Rome, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Faculty of Medicine, University Vita-Salute San Raffaele, Milan, Italy
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Sucandy I, Marques HP, Lippert T, Magistri P, Coelho JS, Ross SB, Chumbinho B, Di Sandro S, DiBenedetto F. Clinical Outcomes of Robotic Resection for Perihilar Cholangiocarcinoma: A First, Multicenter, Trans-Atlantic, Expert-Center, Collaborative Study. Ann Surg Oncol 2024; 31:81-89. [PMID: 37718337 DOI: 10.1245/s10434-023-14307-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/01/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Perihilar cholangiocarcinoma is a difficult cancer to treat with frequent vascular invasion, local recurrence, and poor survival. Due to the need for biliary anastomosis and potential vascular resection, the standard approach is an open operation. Suboptimal outcomes after laparoscopic resection had been sporadically reported by high-volume centers. In this first, Trans-Atlantic, multicenter study, we report our outcomes of robotic resection for perihilar cholangiocarcinoma. This is the largest study of its kind in the Western hemisphere. METHODS Between 2016 and 2023, we prospectively followed patients undergoing robotic resection for perihilar cholangiocarcinoma at three, high-volume, robotic, liver-surgery centers. RESULTS Thirty-eight patients underwent perihilar cholangiocarcinoma utilizing the robotic technique; Klatskin type-3 was the most common. The median age was 72 years, and 82% of the patients underwent preoperative biliary drainage. Median operative time was 481 minutes with a median estimated blood loss of 200 mL. The number of harvested lymph nodes was seven, and 11 (28%) patients yielded positive lymph nodes. Three patients required vascular reconstruction; 18% of patients had >1 biliary anastomosis. R0 resection margins were achieved in 82% of patients. Clavien-Dindo Grade ≥3 complications were seen in 16% of patients. The length of stay was 6 days. Five patients had an unplanned readmission within 30 days. One patient died within 30 days. With a median follow-up of 15 months, 68% of patients are alive without disease, 13% recurred, and 19% died. CONCLUSIONS Application of the robotic platform for perihilar cholangiocarcinoma is safe and feasible with acceptable short-term clinical and oncological outcomes.
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Affiliation(s)
| | - Hugo P Marques
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Trenton Lippert
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Joao Santos Coelho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | | | - Beatriz Chumbinho
- Hepato-Biliary-Pancreatic and Transplantation Center, Lisbon Central Hospitals and University Center/NOVA Medical School, Lisbon, Portugal
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio DiBenedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University Hospital of Modena "Policlinico", University of Modena and Reggio Emilia, Modena, Italy
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Falls SJ, Maxwell CM, Kaye DJ, Dighe SG, Schiffman SC, Bartlett DL, Wagner PL, Allen CJ. Minimally Invasive Hepatopancreatobiliary Surgery at a Large Regional Health System: Assessing the Safety of Program Expansion. Am Surg 2024; 90:85-91. [PMID: 37578387 DOI: 10.1177/00031348231192073] [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] [Indexed: 08/15/2023]
Abstract
BACKGROUND Complex, minimally invasive hepatopancreatobiliary surgery (MIS HPB) is safe at high-volume centers, yet outcomes during early implementation are unknown. We describe our experience during period of rapid growth in an MIS HPB program at a large regional health system. METHODS During an increase in MIS HPB (60% greater from preceding year), hospital records of patients who underwent HPB surgery between 1/1/2019 and 12/31/2020 were reviewed. Operative time, estimated blood loss (EBL), conversion rates, length of stay (LOS), and perioperative outcomes were assessed. RESULTS 267 patients' cases were reviewed. The population was 62 ± 13 years, 50% female, 90% white. MIS was more frequently performed for hepatic than pancreatic resections (59% vs 21%, P < .001). Open cases were more frequently performed for invasive malignancy in both pancreatic (70% vs 40%, P < .018) and hepatic (87% vs 70%, P = .046) resections. There was no difference in operative time between MIS and open surgery (293[218-355]min vs 296[199-399]min, P = .893). When compared to open, there was a shorter LOS (4[2-6]d vs 7[6-10]d, P < .001) and lower readmission rate (21% vs 37%, P = .005) following MIS. Estimated blood loss was lower in MIS liver resections, particularly when performed for benign disease (200[63-500]mL vs 600[200-1200]mL, P = .041). Overall 30-day mortality was similar between MIS and open surgery (1.0% vs 1.8%, P = 1.000). DISCUSSION During a surgical expansion phase within our regional health system, MIS HPB offered improved perioperative outcomes when compared to open surgery. These data support the safety of implementation even during intervals of rapid programmatic growth.
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Affiliation(s)
- Samantha J Falls
- Surgical Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Conor M Maxwell
- Surgical Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Dylan J Kaye
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Shruti G Dighe
- Surgical Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Suzanne C Schiffman
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - David L Bartlett
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Patrick L Wagner
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Casey J Allen
- Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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Deyrat J, Tzedakis S. Feasibility, safety and limits of robotic approach for lymphadenectomy in biliary tumours. Hepatobiliary Surg Nutr 2023; 12:404-406. [PMID: 37351125 PMCID: PMC10282671 DOI: 10.21037/hbsn-23-149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/26/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Julie Deyrat
- AP-HP, Centre Université de Paris, Groupe Hospitalier Cochin Port Royal, DMU Cancérologie et spécialités médico-chirurgicales, Service de chirurgie hépatobiliaire, digestive et endocrinienne, Paris, France
| | - Stylianos Tzedakis
- AP-HP, Centre Université de Paris, Groupe Hospitalier Cochin Port Royal, DMU Cancérologie et spécialités médico-chirurgicales, Service de chirurgie hépatobiliaire, digestive et endocrinienne, Paris, France
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Chang J, Yu L, Li Q, Wang B, Yang L, Cheng M, Wang F, Zhang L, Chen L, Li K, Liang L, Zhou W, Cai W, Ren Y, Hu Z, Huang Z, Sui T, Fan J, Wang J, Li B, Cao X, Yin G. Development and Clinical Trial of a New Orthopedic Surgical Robot for Positioning and Navigation. J Clin Med 2022; 11:jcm11237091. [PMID: 36498666 PMCID: PMC9738984 DOI: 10.3390/jcm11237091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 12/02/2022] Open
Abstract
Robot-assisted orthopedic surgery has great application prospects, and the accuracy of the robot is the key to its overall performance. The aim of this study was to develop a new orthopedic surgical robot to assist in spinal surgeries and to compare its feasibility and accuracy with the existing orthopedic robot. A new type of high-precision orthopedic surgical robot (Tuoshou) was developed. A multicenter, randomized controlled trial was carried out to compare the Tuoshou with the TiRobot (TINAVI Medical Technologies Co., Ltd., Beijing) to evaluate the accuracy and safety of their navigation and positioning. A total of 112 patients were randomized, and 108 patients completed the study. The position deviation of the Kirschner wire placement in the Tuoshou group was smaller than that in the TiRobot group (p = 0.014). The Tuoshou group was better than the TiRobot group in terms of the pedicle screw insertion accuracy (p = 0.016) and entry point deviation (p < 0.001). No differences were observed in endpoint deviation (p = 0.170), axial deviation (p = 0.170), sagittal deviation (p = 0.324), and spatial deviation (p = 0.299). There was no difference in security indicators. The new orthopedic surgical robot was highly accurate and optimized for clinical practice, making it suitable for clinical application.
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Affiliation(s)
- Jie Chang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Lipeng Yu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Qingqing Li
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Boyao Wang
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210003, China
| | - Lei Yang
- Department of Orthopedics, The Affiliated Taizhou People’s Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Taizhou 225300, China
| | - Min Cheng
- Nanjing Tuodao Medical Technology Co., Ltd., Nanjing 210012, China
| | - Feng Wang
- Nanjing Tuodao Medical Technology Co., Ltd., Nanjing 210012, China
| | - Long Zhang
- Nanjing Tuodao Medical Technology Co., Ltd., Nanjing 210012, China
| | - Lei Chen
- Nanjing Tuodao Medical Technology Co., Ltd., Nanjing 210012, China
| | - Kun Li
- Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Liang Liang
- Guizhou Provincial People’s Hospital, Guiyang 550002, China
| | - Wei Zhou
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Weihua Cai
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yongxin Ren
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhiyi Hu
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Zhenfei Huang
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Tao Sui
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Jin Fan
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Junwen Wang
- Wuhan Fourth Hospital, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
- Correspondence: (J.W.); (B.L.); (X.C.); (G.Y.)
| | - Bo Li
- Guizhou Provincial People’s Hospital, Guiyang 550002, China
- Correspondence: (J.W.); (B.L.); (X.C.); (G.Y.)
| | - Xiaojian Cao
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Correspondence: (J.W.); (B.L.); (X.C.); (G.Y.)
| | - Guoyong Yin
- The First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
- Correspondence: (J.W.); (B.L.); (X.C.); (G.Y.)
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Lu H, Han T, Li F, Yang J, Hou Z. Global trends and hotspots in research of robotic surgery in oncology: A bibliometric and visual analysis from 2002 to 2021. Front Oncol 2022; 12:1055118. [PMID: 36439475 PMCID: PMC9691977 DOI: 10.3389/fonc.2022.1055118] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 10/28/2022] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND With the development of robotic surgery in the field of oncology, an increasing number of relevant research papers have been published. In order to explore the research hotspots and trends in this field, a bibliometric and visual analysis was performed for the first time. METHODS The literature records related to oncology robotic surgery were obtained from the Web of Science Core Collection database and imported into the software VOSviewer 1.6.18, CiteSpace 6.1.R3, and the Bibliometric Online Analysis Platform for analysis. RESULTS A total of 6,964 publications, including 5,635 articles and 1,329 reviews, were included in this study. Over the past 20 years, annual publications and citations have experienced rapid growth, particularly in the last two years. The United States was the country with the most publications, while Yonsei University in South Korea was the most productive institution. The Journal of Robotic Surgery and the Journal of Urology were the journals with the most publications and citations, respectively. Mottrie A from Belgium and Ficarra V from Italy were the authors with the highest number of publications and citations, respectively. The keywords "robotic surgical procedure", "laparoscopic surgery", "prostate cancer", "colorectal cancer", "gastric cancer", "resection", "complications classification", "open surgery", "transoral robotic surgery", "pathological outcomes", and "robot-assisted surgery" reflect the research hotspots and trends of oncology robotic surgery. CONCLUSION The therapeutic advantages of robotic surgery in oncology are not yet prominent, and further randomized controlled trials with multicenter and large samples are needed to evaluate the advantages of robotic surgery compared with laparoscopic surgery and open surgery in the treatment of tumors from multiple outcome indicators.
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Affiliation(s)
- Hua Lu
- Department of Orthopedics and Traumatology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Tingliang Han
- Department of Orthopedics and Traumatology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Fangcun Li
- Department of Rehabilitation Medicine, Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin, China
| | - Jiali Yang
- Department of Orthopedics and Traumatology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Zhaomeng Hou
- Department of Orthopedics and Traumatology, Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
- Faculty of Orthopedics and Traumatology, Guangxi University of Chinese Medicine, Nanning, China
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FINOTTI M, D’AMICO F, TESTA G. The current and future role of robotic surgery in liver surgery and transplantation. Minerva Surg 2022; 77:380-390. [DOI: 10.23736/s2724-5691.22.09629-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bijlstra OD, Broersen A, Oosterveer TTM, Faber RA, Achterberg FB, Hurks R, Burgmans MC, Dijkstra J, Mieog JSD, Vahrmeijer AL, Swijnenburg RJ. Integration of Three-Dimensional Liver Models in a Multimodal Image-Guided Robotic Liver Surgery Cockpit. Life (Basel) 2022; 12:life12050667. [PMID: 35629335 PMCID: PMC9144252 DOI: 10.3390/life12050667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Robotic liver surgery represents the most recent evolution in the field of minimally-invasive liver surgery. For planning and guidance of liver resections, surgeons currently rely on preoperative 2-dimensional (2D) CT and/or MR imaging and intraoperative ultrasonography. Translating 2D images into digital 3-dimensional (3D) models may improve both preoperative planning and surgical guidance. The da Vinci® robotic surgical system is a platform suitable for the integration of multiple imaging modalities into one single view. In this study, we describe multimodal imaging options and introduce the Robotic Liver Surgery Cockpit; Methods: in-house developed software was used and validated for segmentation and registration to create a virtual reality 3D model of the liver based on preoperative imaging. The accuracy of the 3D models in the clinical setting was objectively assessed in 15 patients by measuring tumor diameters and subjectively with a postoperative conducted questionnaire; Results: Implementation and applicability of the 3D model in the surgical cockpit was feasible in all patients and the quality of the 3D reconstructions was high in 14 (93%) of cases. Tumor diameters measured on CT and/or MR imaging were comparable to automated measurements using the segmentation software and 3D models; Conclusions: the 3D model was successfully incorporated in the robotic surgery console as part of a multimodality imaging platform and aided the surgeon in planning and guidance of the resection. Future studies should focus on further automation of 3D rendering and progress into augmented reality.
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Affiliation(s)
- Okker D. Bijlstra
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
- Department of Surgery, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
- Correspondence:
| | - Alexander Broersen
- Section of Image Processing, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.B.); (J.D.)
| | - Timo T. M. Oosterveer
- Section of Interventional Radiology, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (T.T.M.O.); (M.C.B.)
| | - Robin A. Faber
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Friso B. Achterberg
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Rob Hurks
- Department of Radiology, Amsterdam University Medical Center, 1081 HV Amsterdam, The Netherlands;
| | - Mark C. Burgmans
- Section of Interventional Radiology, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (T.T.M.O.); (M.C.B.)
| | - Jouke Dijkstra
- Section of Image Processing, Department of Radiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (A.B.); (J.D.)
| | - J. Sven D. Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Alexander L. Vahrmeijer
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands; (R.A.F.); (F.B.A.); (J.S.D.M.); (A.L.V.)
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam University Medical Center, Cancer Center Amsterdam, University of Amsterdam, 1081 HV Amsterdam, The Netherlands;
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