Robotics in general surgery: A systematic cost assessment

The rise of the machines: are robots the future of renal artery aneurysm repair? A systematic review

Renal artery aneurysms (RAAs) are a rare vascular condition. Robot-assisted surgery offers a minimally invasive approach for RAA repair, potentially improving surgical outcomes. This review investigates the current evidence on the effectiveness and limitations of this technique. A systematic search following PRISMA guidelines identified relevant studies across five electronic databases. Studies investigating the use of robot-assisted surgery for RAA repair were included. The review identified 11 studies encompassing a total of 23 patients. Procedures included aneurysmectomy, end-to-end anastomosis, prosthetic graft repair, and even coil embolization. All surgeries were successful, with only minor complications reported in four cases. Robot-assisted RAA repair shows promise as a minimally invasive approach with encouraging preliminary outcomes. However, the limited data come from small studies. Future advancements in robotic technology hold the potential to optimize this approach for improved patient care.

Autonomous Robotic Systems in Otolaryngology-Head and Neck Surgery

Robotic surgery is a growing field with increasing applications to patient care. With the rising use of artificial intelligence (AI), a new frontier emerges, allowing semiautonomous robotics. This article reviews the origins of robotic surgery and subsequent trials of automaticity in all fields. It then describes specific nascent robotic and semiautonomous surgical prototypes within the field of otolaryngology. Finally, broader systemic considerations are posited regarding the implementation of AI-driven robotics in surgery.

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.

Determining the learning curve of minimally invasive antireflux surgery: systematic review, meta-analysis, and meta-regression

The rapid uptake of minimally invasive antireflux surgery has led to interest in learning curves for this procedure. This study ascertains the learning curve in laparoscopic and robotic-assisted antireflux surgery. A systematic review of the literature pertaining to learning curves in minimally invasive fundoplication with or without hiatal hernia repair was performed using PubMed, Medline, Embase, Web of Science, and Cochrane Library databases. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase. Twenty-five studies met the eligibility criteria. A meta-regression analysis was performed to quantitatively investigate the trend of number of cases required to achieve surgical proficiency from 1996 to present day. Using a mixed-effects negative binomial regression model, the predicted learning curve for laparoscopic and robotic-assisted antireflux surgery was found to be 24.7 and 31.1 cases, respectively. The meta-analysis determined that surgeons in their learning phase may experience a moderately increased rate of conversion to open procedure (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.28, 4.64), as well as a slightly increased rate of intraoperative complications (OR 1.60; 95% CI 1.08, 2.38), postoperative complications (OR 1.98; 95% CI 1.36, 2.87), and needing reintervention (OR 1.64; 95% CI 1.16, 2.34). This study provides an insight into the expected caseload to be competent in performing antireflux surgery. The discrepancy between outcomes during and after the learning curve for antireflux surgery suggests a need for close proctorship for learning surgeons.

Efficacy and Safety of Robotic Surgery vs. Open Surgery for Hilar Cholangiocarcinoma: A Comprehensive Review

Hilar cholangiocarcinoma, a rare and aggressive bile duct malignancy, presents significant challenges in surgical management. Traditionally treated with open surgery, the emergence of robotic surgery has introduced a new dimension to surgical approaches for this condition. This review aims to systematically compare the efficacy and safety of robotic surgery versus open surgery for hilar cholangiocarcinoma. We conducted a comprehensive review of the literature, including clinical studies, case series, and comparative analyses of robotic and open surgical techniques. Data on oncological outcomes, functional recovery, survival rates, complications, and cost-effectiveness were extracted and analyzed to provide a detailed comparison of the two surgical approaches. Robotic surgery offers several potential advantages over open surgery, including reduced intraoperative blood loss, smaller incisions, and shorter recovery times. However, it requires specialized training and has a higher initial cost. Open surgery, while more established and broadly practiced, remains associated with longer recovery periods and higher complication rates. Oncological outcomes, such as R0 resection rates and survival, appear comparable between the two approaches, though robotic surgery may offer improvements in functional recovery and postoperative quality of life. Both robotic and open surgery have their merits in the treatment of hilar cholangiocarcinoma. Robotic surgery presents promising benefits in terms of reduced invasiveness and improved recovery, while open surgery continues to be a reliable and well-established option. The choice of surgical approach should be guided by patient-specific factors, surgeon expertise, and institutional resources. Further research is needed to refine surgical techniques and establish long-term outcomes, which will aid in optimizing treatment strategies for this challenging malignancy.

Public's Perception and Knowledge of Using Robotics in General Surgery in Eastern Region, Saudi Arabia

BACKGROUND

Robotics in general surgery is a field that involves the use of robotic systems to assist surgeons in performing various types of surgical procedures.

OBJECTIVE

The objective of this study was to evaluate the perception and knowledge of robotic surgery among the Eastern Region's population.

METHODS

This cross-sectional study used an electronic questionnaire that was developed using Google Docs. It included males and females aged above 18 years who lived in the Eastern Province. Participants who were below 18 or above 65 years of age, or non-Saudi, or people who lived in other than the Eastern Region of Saudi Arabia were excluded from the study.

RESULTS

A total of 500 responses were received via the Google Form, and 81 subjects of them were excluded from the study. Approximately half of the participants were aware of the existence of general robotic surgery, while the other half had no prior knowledge about it. When assessing the participants' understanding of how robotic surgery works, a significant proportion provided incorrect responses. In terms of the advantages of general robotic surgery, the most commonly recognized benefit was that it makes the doctor's life easier, followed by more accurate surgical results. However, the participants' understanding of the disadvantages of robotic surgery was not as accurate. A substantial portion of participants were unsure about the disadvantages.

CONCLUSION

The general public of the Eastern Region in Saudi Arabia showed a derated level of knowledge about the use of robotics in general surgery. Furthermore, a major portion of people were unaware of the availability of robotic surgery in Saudi Arabia. Educational programs are warranted to facilitate the implantation of robotic surgery in Saudi Arabia.

Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis

PURPOSE

The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery.

METHODS

A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale.

RESULTS

Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS.

CONCLUSION

This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.

Comparative Analysis of Robotic-Assisted Versus Laparoscopic Appendectomy: A Review

Appendectomy ranks among the most common surgical procedures. Laparoscopic appendectomy has become increasingly popular among certain surgeons. Even laparoscopic appendectomy is considered the gold standard; many surgical subspecialties have adopted robotic surgery in the past 10 years. The robotic system is recognized for enhancing stability, visualization, precision, and spatial flexibility. Surgeons can operate with enhanced dexterity, reduced tremors, three-dimensional visualization, up to 10 times magnification, and control over four arms thanks to improved ergonomics that allow them to sit at a customizable console. The purpose of this study is to evaluate and compare the overall effects, such as intraoperative time, postoperative recovery, feasibility for surgeons, and cost-effectiveness, of robotic-assisted appendectomy and laparoscopic appendectomy through the available literature. It was found that both robotic and laparoscopic surgeries work well for appendectomy, but in some studies, it was found that robotic surgery comes with the perks of shorter hospital stays and quicker recovery, even though it is more expensive, and in some studies, no differences were observed in patient recovery postoperatively. Laparoscopic surgery is still a highly effective and commonly used method, with proven advantages over open appendectomy, despite taking longer for the procedure. We need more studies to fully understand the advantages and disadvantages of robotic surgery, especially when it comes to cost-effectiveness and wider health outcomes.

Role of Robotic-Assisted Surgery in Public Health: Its Advantages and Challenges

The modern hospital setting is closely related to engineering and technology. In a hospital, modern equipment is abundant in every department, including the operating room, intensive care unit, and laboratories. Thus, the quality of treatment provided in hospitals and technology advancements are closely tied. Robotic systems are used to support and improve the accuracy and agility of human surgeons during medical procedures. This surgical approach is commonly referred to as robotic surgery or robotic-assisted surgery (RAS). These systems are not entirely autonomous; they are managed by skilled surgeons who carry out procedures with improved accuracy and minimized invasiveness using a console and specialized instruments. Because RAS offers increased surgical precision, less discomfort after surgery, shorter hospital stays, and faster recovery time, all of which improve patient outcomes and lessen the strain on healthcare resources, it plays a critical role in public health. Its minimally invasive technique benefits patients and the healthcare system by lowering problems, reducing the requirement for blood transfusions, and reducing the danger of infections related to medical care. Furthermore, the possibility of remote surgery via robotic systems can increase access to specialized care, reducing regional differences and advancing fairness in public health. In this review article, we will be covering how RAS has its role in public health.

Robot-assisted surgery in thoracic and visceral indications: an updated systematic review

BACKGROUND

In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery.

METHODS

We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1.

RESULTS

For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting.

CONCLUSION

In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment.

Robotic surgery: public perceptions and current misconceptions

Whilst surgeons and robotic companies are key stakeholders involved in the adoption of robotic assisted surgery (RS), the public's role is overlooked. However, given that patients hold ultimate power over their healthcare decisions, public acceptance of RS is crucial. Therefore, this study aims to identify public understanding, opinions, and misconceptions about RS. An online questionnaire distributed between February and May 2021 ascertained the views of UK adults on RS. The themes of questions included familiarity, experience and comfort with RS, opinions on its ethical implications, and the impact of factual information provided to the participant. The data were evaluated using thematic and statistical analysis, including assessing for statistical differences in age, gender, education level, and presence in the medical field. Overall, 216 responses were analysed. Participants were relatively uninformed about RS, with a median knowledge score of 4.00(2.00-6.00) on a 10-point Likert scale. Fears surrounding increased risk, reduced precision and technological failure were identified, alongside misconceptions about its autonomous nature. However, providing factual information in the survey about RS statistically increased participant comfort (p = < 0.0001). Most (61.8%) participants believed robot manufacturers were responsible for malfunctions, but doctors were held accountable more by older, less educated, and non-medical participants. Our findings suggest that there is limited public understanding of RS. The numerous common misconceptions identified present a major barrier to the widespread acceptance of RS, since inaccurate fears about its nature could discourage potential patients from engaging with robotic procedures.

Robot-assisted vs laparoscopic bariatric procedures in super-obese patients: clinical and economic outcomes

The increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m2) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m2) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m2, primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients.

Robotic Appendicectomy: A review of feasibility

Acute appendicitis is one of the most common abdominal emergencies. There has been an increasing use of robotic abdominal surgery. However, it remains underutilised in emergency settings. This study aimed to systematically review robotic appendicectomy (RA) feasibility. A 20-year systematic review was performed, along with quality assessment. The research protocol was registered with PROSPERO. The search yielded 1,242 citations, including 9 articles. The mean quality score was 10.72 ± 2.56. The endpoints across the studies were rate of conversion to open surgery, length of hospital stay, blood loss and operative time. RA is a safe, feasible technique that can be performed in elective and emergency settings with minimal blood loss. The operative time and hospital stay were within acceptable limits. Robotic surgery's major drawback is its high cost and limited availability. Future studies evaluating RA with a focus on its application during emergencies and its cost-effectiveness are recommended.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Crossover-effects in technical skills between laparoscopy and robot-assisted surgery

INTRODUCTION

Robot-assisted surgery is often performed by experienced laparoscopic surgeons. However, this technique requires a different set of technical skills and surgeons are expected to alternate between these approaches. The aim of this study is to investigate the crossover effects when switching between laparoscopic and robot-assisted surgery.

METHODS

An international multicentre crossover study was conducted. Trainees with distinctly different levels of experience were divided into three groups (novice, intermediate, expert). Each trainee performed six trials of a standardized suturing task using a laparoscopic box trainer and six trials using the da Vinci surgical robot. Both systems were equipped with the ForceSense system, measuring five force-based parameters for objective assessment of tissue handling skills. Statistical comparison was done between the sixth and seventh trial to identify transition effects. Unexpected changes in parameter outcomes after the seventh trial were further investigated.

RESULTS

A total of 720 trials, performed by 60 participants, were analysed. The expert group increased their tissue handling forces with 46% (maximum impulse 11.5 N/s to 16.8 N/s, p = 0.05), when switching from robot-assisted surgery to laparoscopy. When switching from laparoscopy to robot-assisted surgery, intermediates and experts significantly decreased in motion efficiency (time (sec), resp. 68 vs. 100, p = 0.05, and 44 vs. 84, p = 0.05). Further investigation between the seventh and ninth trial showed that the intermediate group increased their force exertion with 78% (5.1 N vs. 9.1 N, p = 0.04), when switching to robot-assisted surgery.

CONCLUSION

The crossover effects in technical skills between laparoscopic and robot-assisted surgery are highly depended on the prior experience with laparoscopic surgery. Where experts can alternate between approaches without impairment of technical skills, novices and intermediates should be aware of decay in efficiency of movement and tissue handling skills that could impact patient safety. Therefore, additional simulation training is advised to prevent from undesired events.

Qualitative Study on the Information Needs of Patients Undergoing Da Vinci Robotic Surgery

To explore the information needs and experiences of patients who underwent Da Vinci robotic surgery and to establish a reference for providing information support to these patients. Semi-structured interviews were conducted with 11 patients who underwent robotic surgery. Thematic analysis was subsequently executed on the data obtained from the interviews to identify the themes. Thematic analysis generated two main themes with six supporting sub-themes. The main themes were (1) surgical information acquisition experience and (2) the need for personalization to obtain satisfactory information. Patients who received Da Vinci robotic surgery had insufficient understanding of the surgical methods and possessed high demand for surgical-related information. Although patients' understanding of robotic surgery might be improved through multi-channel information support, due to the differences in patient access to information, personalized experiences would occur during this process. Professional information support could effectively enhance their positive psychological experiences with surgery.

Robotic-assisted versus laparoscopic living donor nephrectomy for renal transplantation: a systematic review and meta-analysis

INTRODUCTION

Renal transplantation remains the definitive treatment for end-stage renal disease. Currently employed minimally invasive techniques include robotic-assisted laparoscopy and laparoscopy. This study aims to determine whether either method provides an advantage.

METHODS

Following PRISMA guidelines, a systematic review was conducted. Data were analysed using Review Manager 5.3.

RESULTS

A total of 12 studies were included. Operative time and operative bleeding were similar between both approaches, with a mean difference (MD) of 16min (95% confidence interval (CI) -4.06, 37.38; p = 0.11) and 10.44ml (95% CI -43.89, 64.78; p = 0.71), respectively. Robotics had longer warm ischemia time (MD 1.14min; 95% CI 0.65, 1.63; p = 0.00001) but reduced length of stay (LOS) (MD -0.23days; 95% CI -0.45, -0.01; p = 0.04) and pain (MD -1.26 VAS; 95% CI -1.77, 0.75). Similar complication and conversion rates were seen among groups.

CONCLUSIONS

Robotic approaches provide a viable alternative to laparoscopic surgery. Operative time, bleeding volumes, complications and conversion rates are similar between both techniques; apparent robotic advantages on LOS and Pain need to be better analysed by future studies.

Role of 5G Networks in Healthcare Management System

The present-day healthcare system operates on a 4G network, where the data rate needed for many IoT devices is impossible. Also, the latency involved in the network does not support the use of many devices in the network. The 5G-based cellular technology promises an effective healthcare management system with high speed and low latency. The 5G communication technology will replace the 4G technology to satisfy the increasing demand for high data rates. It incorporates higher frequency bands of around 100 MHz using millimetre waves and broadband modulation schemes. It is aimed at providing low latency while supporting real-time machine-to-machine communication. It requires a more significant number of antennas, with an average base station density three times higher than 4G. However, the rise in circuit and processing power for multiple antennas and transceivers deteriorates energy efficiency. Also, the data transmission power for 5G is three times higher than for 4G technology. One of the advanced processors used in today's mobile equipment is NVIDIA Tegra, which has a multicore system on chip (SoC) architecture with two ARM Cortex CPU cores to handle audio, images, and video. The state-of-the-art software coding using JAVA or Python has achieved smooth data transmission from mobile equipment, desktop or laptop through the internet with the support of 5G communication technology. This paper discusses some key areas related to 5G-based healthcare systems such as the architecture, antenna designs, power consumption, file protocols, security, and health implications of 5G networks.

Robotic Cholecystectomies: What Are They Good for? - A Retrospective Study - Robotic versus Conventional Cases

INTRODUCTION

Robot-assisted cholecystectomies are often criticized as expensive with uncertain benefit to patients. Characterization of robotic surgery benefits, as well as specific factors that drive cost, has the potential to shape the current debate.

METHODS

The surgical cost and outcomes among patients who underwent robotic (n = 283) or non-robotic (n = 1438) laparoscopic cholecystectomies between 2012 and 2018 at a single academic institution were examined retrospectively. All cholecystectomies were primary surgical procedures with no secondary procedures. We also examined the subset of robotic (n = 277) and non-robotic (n = 1108) outpatient procedures.

RESULTS

Robotic cholecystectomies were associated with higher median total cost compared to conventional procedures, largely attributable to variable costs and surgical costs. Patients who underwent conventional cholecystectomy had longer mean lengths of stays (1.7 versus 1.1 days) compared to robotic procedures-with over 10 times as many requiring hospital admission.

CONCLUSIONS

At present, robotic cholecystectomies have a little value to patients and institutions outside of surgical training. Prior to narrowing the analysis to outpatient cases, difference in total cost between procedures was less pronounced due to more frequent inpatient management following conventional procedures. Future optimization of robotic consumables and free market competition among system manufacturers may increase financial feasibility by decreasing variable costs associated with robotic surgery.

Robotic Foregut Surgery in the Veterans Health Administration: Increasing Prevalence, Decreasing Operative Time, and Improving Outcomes

BACKGROUND

Historically, robotic surgery incurs longer operative times, higher costs, and nonsuperior outcomes compared with laparoscopic surgery. However, in areas of limited visibility and decreased accessibility such as the gastroesophageal junction, robotic platforms may improve visualization and facilitate dissection. This study compares 30-day outcomes between robotic-assisted foregut surgery (RAF) and laparoscopic-assisted foregut surgery in the Veterans Health Administration.

STUDY DESIGN

This is a retrospective review of the Veterans Affairs Quality Improvement Program database. Patients undergoing laparoscopic-assisted foregut surgery and RAF were identified using CPT codes 43280, 43281, 43282, and robotic modifier S2900. Multivariable logistic regression and multivariable generalized linear models were used to analyze the independent association between surgical approach and outcomes of interest.

RESULTS

A total of 9,355 veterans underwent minimally invasive fundoplication from 2008 to 2019. RAF was used in 5,392 cases (57.6%): 1.63% of cases in 2008 to 83.41% of cases in 2019. After adjusting for confounding covariates, relative to laparoscopic-assisted foregut surgery, RAF was significantly associated with decreased adjusted odds of pulmonary complications (adjusted odds ratio [aOR] 0.44, p < 0.001), acute renal failure (aOR 0.14, p = 0.046), venous thromboembolism (aOR 0.44, p = 0.009) and increased odds of infectious complications (aOR 1.60, p = 0.017). RAF was associated with an adjusted mean ± SD of 29 ± 2-minute shorter operative time (332 minutes vs 361 minutes; p < 0.001).

CONCLUSIONS

Veterans undergoing RAF ascertained shorter operative times and reduced complications vs laparoscopy. As surgeons use the robotic platform, clinical outcomes and operative times continue to improve, particularly in operations where extra articulation in confined spaces is required.

Robotic versus Laparoscopic Gastrectomy for Gastric Cancer: An Updated Systematic Review

Background and Objectives: Gastrectomy with D2 lymphadenectomy is the standard surgical treatment with curative intent for patients with gastric cancer (GC). Over the last three decades, surgeons have been increasingly adopting laparoscopic surgery for GC, due to its better short-term outcomes. In particular, laparoscopic gastrectomy (LG) has been routinely used for early gastric cancer (EGC) treatment. However, LG suffers from technical limitations and drawbacks, such as a two-dimensional surgical field of view, limited movement of laparoscopic tools, unavoidable physiological tremors and discomfort for operating surgeon. Therefore, robotic surgery has been developed to address such limitations. Materials and Methods: We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines in order to investigate the benefits and harms of robotic gastrectomy (RG) compared to the LG. PubMed/MEDLINE, Scopus, Cochrane Library (Cochrane Database of Systematic Re-views, Cochrane Central Register of Controlled Trials-CENTRAL) and Web of Science (Science and Social Science Citation Index) databases were used to search all related literature. Results: The 7 included meta-analyses covered an approximately 20 years-study period (2000-2020). Almost all studies included in the meta-analyses were retrospective ones and originated from Asian countries (China and Korea, in particular). Examined overall population ranged from 3176 to 17,712 patients. If compared to LG, RG showed both operative advantages (operative time, estimated blood loss, number of retrieved lymph nodes) and perioperative ones (time to first flatus, time to restart oral intake, length of hospitalization, overall complications, Clavien-Dindo (CD) ≥ III complications, pancreatic complications), in the absence of clear differences of oncological outcomes. However, costs of robotic approach appear significant. Conclusions: It is impossible to make strong recommendations, due to the statistical weakness of the included studies. Further randomized, possibly multicenter trials are strongly recommended, if we want to have our results confirmed.

A systematic review of robotic surgery: From supervised paradigms to fully autonomous robotic approaches

BACKGROUND

From traditional open surgery to laparoscopic surgery and robot-assisted surgery, advances in robotics, machine learning, and imaging are pushing the surgical approach to-wards better clinical outcomes. Pre-clinical and clinical evidence suggests that automation may standardise techniques, increase efficiency, and reduce clinical complications.

METHODS

A PRISMA-guided search was conducted across PubMed and OVID.

RESULTS

Of the 89 screened articles, 51 met the inclusion criteria, with 10 included in the final review. Automatic data segmentation, trajectory planning, intra-operative registration, trajectory drilling, and soft tissue robotic surgery were discussed.

CONCLUSION

Although automated surgical systems remain conceptual, several research groups have developed supervised autonomous robotic surgical systems with increasing consideration for ethico-legal issues for automation. Automation paves the way for precision surgery and improved safety and opens new possibilities for deploying more robust artificial intelligence models, better imaging modalities and robotics to improve clinical outcomes.

Single-port versus multiport robotic-assisted radical prostatectomy: A systematic review and meta-analysis on the da Vinci SP platform

CONTEXT

Prostate cancer is the most common cancer in men; robotic prostatectomy has cemented itself as part of the standard of care. Since its approval by the Food and Drug Administration in 2018, the SP console's application has been increasingly studied and compared with the multiport (MP) robotic approach.

METHODS

Following PRISMA guidelines and PROSPERO registration CRD42021228744, a systematic review was performed in April 2021 on single-port robotic-assisted radical prostatectomies (SP-RARPs) compared to MP. Outcomes of interest were operative time, bleeding, complications, analgesic use, and postoperative continence, and erectile function. Data were analyzed with Review Manager 5.3.

RESULTS

Seven studies were included, of which six studies met the inclusion criteria for quantitative synthesis, totalling 1068 patients, out of which 324 underwent SP-RARP and 744 underwent MP-RARP. No differences were found in baseline characteristics such as age, body mass index, prostatic-specific antigen, or stage. No differences in blood loss-15.77 mL [-42.44, 10.89], p = 0.25, operative time 3.93 min [-4.12, 11.98], p = 0.34, or positive surgical margins, with an odds ratio (OR) of 0.78 [0.55, 1.10], p = 0.15-were found. Length of stay was significantly shorter in SP -0.94 days [-1.56, -0.33], p = 0.003, with no differences in complication rates, with an OR of 1.29 [0.78, 2.14], p = 0.32, continence rates, with an OR of 1.29 [0.90, 1.83], p = 0.16, erectile function, with an OR of 0.86 [0.52, 1.40], p = 0.54, or biochemical recurrence. Qualitative evidence suggests decreased opioid consumption.

CONCLUSION

SP-RARPs are feasible alternatives to the traditional MP with possible benefits in pain management and length of stay. Future high-quality studies are needed to confirm these findings.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

Evaluating the Cost for Robotic vs "Non-Robotic" Transhiatal Esophagectomy

INTRODUCTION

This study was undertaken to analyze and compare the cost of robotic transhiatal esophagectomy (THE) to "non-robotic" THE (ie, "open" and laparoscopic).

METHODS

With IRB approval, we prospectively followed 82 patients who underwent THE. We analyzed clinical outcomes and perioperative charges and costs associated with THE. To compare profitability, the robotic approach was analyzed against "non-robotic" approaches of THE using F-test, Mann-Whitney U test/Student's t-test, and Fisher's exact test. Statistical significance was reported as P ≤0.05. Data are presented as median (mean ± SD).

RESULTS

67 patients underwent the robotic approach, and 15 patients underwent "non-robotic" approach; 4 were "open" and 11 were laparoscopic. 79 patients had adenocarcinoma. Operative duration for robotic THE was 327 (331 ± 82.8) vs 213 (225 ± 62.0) minutes (P = 0.0001) and estimated blood loss was 150 (184 ± 136.1) vs 300 (476 ± 708.7) mL (P = 0.0001). Length of stay was 7 (11 ± 11.8) vs 8 (12 ± 10.6) days (P = 0.76). 16 patients had post-operative complications with a Clavien-Dindo score of three or more. Hospital charges for robotic THE were $197,405 ($259,936 ± 203,630.8) vs "non-robotic" THE $159,588 ($201,565 ± $185,763.5) (P = 0.31). Cost of care for robotic THE was $34,822 ($48,844 ± $45,832.8) vs "non-robotic" THE was $23,939 ($39,386 ± $44,827.2) (P = 0.47). Payment received for robotic THE was $14,365 ($30,003 ± $40,874.7) vs "non-robotic" THE was $28,080 ($41,087 ± $44,509.1) (P = 0.41). 15% of robotic operations were profitable vs 13% of "non-robotic" operations.

CONCLUSIONS

Patients were predominantly older overweight men who had adenocarcinoma of the esophagus. The robotic approach had increased operative time and minimal blood loss. More than a fourth of operations included concomitant procedures. Patients were discharged approximately one week after THE. Overall, the robotic approach has no apparent significant differences in charges, cost, or profitability.

Predictors and Consequences of Unplanned Conversion to Open During Robotic Colectomy: An ACS-NSQIP Database Analysis

Robotic-assisted surgery has become a desired modality for performing colectomy; however, unplanned conversion to an open procedure may be associated with worse outcomes. The purpose of this study is to examine predictors and consequences of unplanned conversion to open in a large, high fidelity data set. A retrospective analysis of 11 061 robotic colectomies was conducted using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) 2012-2017 database. Predictors of conversion and the effect of conversion on outcomes were analyzed by multivariate logistic regression resulting in risk-adjusted odds ratios of conversion and morbidity/mortality. Overall, 10 372 (93.8%) patients underwent successful robotic colectomy, and 689 (6.2%) had an unplanned conversion. Predictors of conversion included age ≥ 65 years, male gender, obesity, functional status not independent, American Society of Anesthesia (ASA) classification IV-V, non-oncologic indication, emergency case, smoking, recent weight loss, bleeding disorder, and preoperative organ space infection. Conversion is an independent risk factor for mortality, overall morbidity, cardiac morbidity, pulmonary morbidity, renal morbidity, venous thromboembolism morbidity, wound morbidity, sepsis, bleeding, readmission, return to the operating room, and extended length of stay (LOS). Unplanned conversion to open during robotic colectomy is an independent predictor of morbidity and mortality.

Robotic versus laparoscopic anterior resections for rectal and rectosigmoid cancer: an institutional experience

INTRODUCTION

Colorectal surgery has evolved with the advent of laparoscopic techniques and now robotic-assisted surgery. There is significant literature supporting the use of laparoscopic techniques over open surgery with evidence of enhanced post-operative recovery, reduced use of opioids, smaller incisions and equivalent oncological outcomes. Robotic minimally invasive surgery addresses some of the limitations of laparoscopic surgery, providing surgical precision and improvements in perception and dexterity with a resulting decrease in tissue damage.

METHODS

We retrospectively reviewed the medical records of patients who underwent robotic-assisted anterior resection for cancer of the rectum or rectosigmoid junction in our institution since our robotic programme began in 2017. Patient demographics were identified via electronic databases and patient charts. A matched cohort of laparoscopic cases was identified.

RESULTS

A total of 51 consecutive robotic-assisted anterior resections were identified and case matched with laparoscopic resections for comparison. Robotic-assisted surgery was associated with a shorter length of stay (p = 0.04), reduced initial post-operative analgesia requirements (p < 0.01) and no significant difference in time to bowel movement or stoma functioning (p = 0.84). All patients had an R0 resection, and there was no statistical difference in lymph node yield between the groups (p = 0.14). Robotic surgery was associated with a longer operative duration (p < 0.001).

CONCLUSION

In this early experience, robotic surgery has proven feasible and safe and is comparable to laparoscopic surgery in terms of completeness of resection and recovery. As costs and operating times decline and as technology progresses, robotic surgery may one day replace traditional laparoscopic techniques.

Operating costs, fiscal impact, value analysis and guidance for the routine use of robotic technology in abdominal surgical procedures

BACKGROUND

This study was designed to define the value, cost, and fiscal impact of robotic-assisted procedures in abdominal surgery and provide clinical guidance for its routine use.

METHODS

34,984 patients who underwent an elective cholecystectomy, colectomy, inguinal hernia repair, hysterectomy, or appendectomy over a 24-month period were analyzed by age, BMI, risk class, operating time, LOS and readmission rate. Average Direct and Total Cost per Case (ADC, TCC) and Net Margin per Case (NM) were produced for each surgical technique, i.e., open, laparoscopic, and robotic assisted (RA).

RESULTS

All techniques were shown to have similar clinical outcomes. 9412 inguinal herniorrhaphy were performed (48% open with $2138 ADC, 29% laparoscopy with $3468 ADC, 23% RA with $6880 ADC); 8316 cholecystectomies (94% laparoscopy with $2846 ADC, 4.4% RA with a $7139 ADC, 16% open with a $3931 ADC); 3432 colectomies (42% open with a $12,849 ADC, 38% laparoscopy with a $10,714, 20% RA with a $15,133); 12,614 hysterectomies [42% RA with a $8213 Outpatient (OP) ADC, 39% laparoscopy $5181 OP ADC, 19% open $4894 OP ADC]. Average Global NM is - 1% for RA procedures and only positive with commercial payors.

CONCLUSION

RA techniques do not produce significant clinical enhancements than similar surgical techniques with identical outcomes while their costs are much higher. The produced value analysis does not support the routine use of RA techniques for inguinal hernia repair and cholecystectomy. RA techniques for hysterectomies and colectomies are also performed at much higher cost than open and laparoscopic techniques, should only be routinely used with appropriate clinical justification and by cost efficient surgical providers.

How can robot-assisted surgery provide value for money?

Objectives

To develop an interactive tool that estimates what potential benefits are needed for the robot to provide value for money when compared with endoscopic or open surgical interventions.

Design

A generic online interactive tool was developed to analyze the (health) effects needed to compensate for the additional costs of using a surgical robotic system from a healthcare perspective. The application of the tool is illustrated with a hypothetical new surgical robotic platform. A synthesis of evidence from different sources was used combined with interviews with surgeons.

Setting

Flexible tool that can be adapted to flexible settings.

Participants

Any hospital patient group for which robotic, endoscopic or open surgical procedures may be considered as appropriate treatment alternatives (eg, urology, gynecology, and so on).

Intervention

Robotically assisted surgical interventions.

Comparator

Endoscopic or open surgical interventions.

Main outcome measures

Thresholds of how much (health) effect is needed for robot-assisted surgery to provide value for money and to become cost-effective.

Results

The utilization rate of the surgical robotic system and a reduction in complications appeared to be important aspects in determining the value for money. To become cost-effective, it was deemed important for new surgical robotic systems to have added clinical benefit and become less costly than the current system.

Conclusions

This paper and its assisting interactive tool can be used by clinicians, researchers, and policymakers to gain insight in the benefit needed to provide value for money when using a (new) surgical robotic system or, when the effects are known or can be estimated, to assess the value for money for a specific indication. For robotic surgery to provide most value for money, we recommend assessing for each indication whether the necessary effects seem achievable.

Changes in UK renal oncological surgical practice from 2008 to 2017: implications for cancer service provision and surgical training

OBJECTIVE

To determine and analyse the temporal changes in oncological nephrectomy practice and training opportunities using data obtained from the UK British Association of Urological Surgeons nephrectomy register from 2008 to 2017.

PATIENT AND METHODS

All nephrectomies within the dataset for this time period were analysed (n = 54 251). Cases were divided into radical nephrectomy (RN), partial nephrectomy (PN) and nephroureterectomy (NU). Simple nephrectomy, donor nephrectomy and benign PN were excluded. The annual frequencies for each oncological nephrectomy method, surgical approach, grade of surgeon, hospital caseload numbers and short-term surgical outcomes were determined.

RESULTS

Reported annual nephrectomy numbers increased by 2.5-fold in the 9-year time period. The number of hospitals performing nephrectomies decreased by 22%, however, more than 40% of centres performed more than 70 cases a year. There was a trend towards a decrease in overall length of hospital stay (9 vs 5 days; P < 0.01) and decreased transfusion rates. The proportion of minimally invasive procedures increased from 57% to 75%, with nephron-sparing rates increasing from 8.9% overall to 24.8%. With regard to surgical technique, robot-assisted surgery saw a mean annual increase of 222%. Overall, there was a 10% decrease in the proportion of PNs performed by trainee surgeons.

CONCLUSIONS

Renal surgery has changed considerably with regard to volume and also surgical approach, with rates of nephron-sparing surgery and minimally invasive surgery significantly increasing. Increasing hospital centralization and institutional experience, and a shift to robot-assisted surgery appear to have contributed to the observed improved patient outcomes. The increasing utilization of robot-assisted surgery has potential implications and challenges for the training of future urology surgeons.

Robotic-like suturing with FlexDex Surgical System® for difficult laparoscopic suture

The field of laparoscopic surgery has experienced an exponential growth in recent years. Despite great progress in this field, standard laparoscopic tools have not been optimally developed and still has some deficiencies when it comes to mobility and ergonomics. Robotic surgery has attempted to solve these problems by improving the articulation of surgical instruments. However, it presents a series of disadvantages, among which are its high cost, low availability and the need of a specific training, which conditions its profitability and hinders a widespread use. We present the results of a prospective clinical series of 20 cases in which the safety, efficacy and ergonomics of FlexDex® have been tested for performing laparoscopic intracorporeal sutures. The result is a safe and functional tool that offers both control and precision in its handling, while improves the ergonomics of the surgeon. This device represents an alternative that combines the precision and range of movements of robotic surgery with the greater availability of conventional laparoscopy.

Evolving experience of operating theatre staff with the implementation of robotic-assisted surgery in the public sector

Objectives The use of robotic-assisted surgery (RAS) remains predominantly in the private sector. In the public sector, the effect of the implementation of RAS on theatre staff is unknown. The aim of this study was to examine the knowledge and attitudes of theatre staff before and after implementation of RAS in the public sector. Methods In all, 250 theatre staff, including nursing, medical and support staff, were invited to participate in the study. A survey investigating the benefits of RAS for patients and staff, concerns towards the workplace environment and facilitators towards the implementation of new technology was administered before (June 2016) and after (February 2019) the implementation of a comprehensive RAS program. Results The survey was completed by 164 (65.6%) staff before and 200 (80.0%) staff after the implementation of RAS. With time, most nursing (P=0.002) and medical staff (P=0.003) indicated that RAS may benefit patients by reducing intraoperative complications, whereas support staff remained uncertain about this benefit (P=0.594). Before the implementation, most medical staff indicated that RAS would benefit staff, although after they were unsure about this benefit. Overall, before RAS implementation, theatre staff were mostly concerned about workplace safety, but this concern was significantly reduced after RAS implementation (P<0.010). Conclusions With time, operating theatre staff considered their RAS program to be associated with enhanced benefits to patients, and their concerns regarding workplace safety were significantly reduced. Conversely, theatre staff were unsure about the benefits of RAS to themselves. It is important for organisations to consider the evolving impact of new technology on their staff and to refine ongoing education and training programs in line with these changes. What is known about the topic? The implementation of RAS is rapidly evolving in major hospitals. Therefore, it is important to investigate the knowledge, attitudes and experiences of operating theatre staff before and after the implementation of RAS, especially in the public sector. What does this paper add? This study found that with time theatre staff considered RAS to be beneficial to patients, and their initial concerns about the effect on workplace safety were significantly reduced. What are the implications for practitioners? It is important for organisations to consider the evolving impact of the implementation of new technology on operating theatre staff and to refine ongoing education and training programs as required.

Making the Jump: A Qualitative Analysis on the Transition From Bedside Assistant to Console Surgeon in Robotic Surgery Training

OBJECTIVE

To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training.

DESIGN

Qualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019.

SETTING

An urban, academic, multihospital general surgery residency program with a robust robotic surgery program.

PARTICIPANTS

Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews.

RESULTS

Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console.

CONCLUSIONS

Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

Achieving robotic program best practice performance and cost versus laparoscopy: Two case studies define a framework for optimization

BACKGROUND

Robotic surgery is seen by many hospital administrators and surgeons as slower and more expensive than laparoscopic surgery despite the implementation of commonly held robotic best practices. Multiple factors, including surgeon learning curves and program governance, are often overlooked, precluding optimal robotic program performance.

METHODS

An assessment of several leading robotic surgery publications is presented followed by real-world case studies from two US hospitals: an existing robotic program in a mid-sized, regional hospital system and a small, rural hospital that launched a new program.

RESULTS

Improvements in robotic surgery costs/program efficiency were seen at the hospital system vs baseline at 18 months post-implementation; and high-performance robotic efficiency and cost benchmarks were matched or surpassed at the rural hospital at 1 year post-launch.

DISCUSSION

When best practices are utilized in robotic programs, surgical case times, costs, and efficiency performance metrics equaling or exceeding laparoscopy can be achieved.

Searching for the Least Invasive Management of Pelvi-Ureteric Junction Obstruction in Children: A Critical Literature Review of Comparative Outcomes

Introduction: To review the published evidence on the minimally invasive pyeloplasty techniques available currently with particular emphasis on the comparative data about the various minimally invasive alternatives to treat pelvi-ureteric junction obstruction and gauge if one should be favored under certain circumstances. Materials and Methods: Non-systematic review of literature on open and minimally invasive pyeloplasty including various kinds of laparoscopic procedures, the robotic-assisted laparoscopic pyeloplasty, and endourological procedures. Results: Any particular minimally invasive pyeloplasty procedure seems feasible in experienced hands, irrespective of age including infants. Comparative data suggest that the robotic-assisted procedure has gained wider acceptance mainly because it is ergonomically more suited to surgeon well-being and facilitates advanced skills with dexterity thanks to 7 degrees of freedom. However, costs remain the major drawback of robotic surgery. In young children and infants, instead, open surgery can be performed via a relatively small incision and quicker time frame. Conclusions: The best approach for pyeloplasty is still a matter of debate. The robotic approach has gained increasing acceptance over the last years with major advantages of the surgeon well-being and ergonomics and the ease of suturing. Evidence, however, may favor the use of open surgery in infancy.

Integrating Robotic Technology Into Resident Training: Challenges and Recommendations From the Front Lines

PURPOSE

To develop recommendations for improving the integration of robotic technology into today's apprentice-based resident training.

METHOD

During a national meeting in 2017, 24 robotic surgeons were interviewed about their experiences integrating robotic technology into resident training. Qualitative thematic analysis of interview notes and recordings revealed themes related to challenges and recommendations.

RESULTS

Four themes emerged, each corresponding to a general recommendation for integrating robotic technology into training. The first, surgical techniques versus tools, contrasts faculty's sequential mastery-surgical techniques first, then the robotic tool-with residents' simultaneous learning. The recommendation is to create separate learning opportunities for focused skill acquisition. The second theme, timing of exposure to the robotic tool, describes trainees' initial focus on tool use for basic surgical steps. The recommendation is to increase access to basic robotic cases. The third theme covers the relationship of laparoscopic and robotic surgery. The recommendation is to emphasize similar and dissimilar features during all minimally invasive surgical cases. The fourth theme, use of the dual console (which enables two consoles to operate the robot, the primary determines the secondary's functionality), highlights the unique teaching opportunities this console creates. The recommendation is for surgeons to give verbal guidance so residents completely understand surgical techniques.

CONCLUSIONS

Surgical educators should consider technique versus tool, timing of exposure to the tool, overlapping and varying features of robotic and laparoscopic surgery, and use of the dual console as they develop curricula to ensure thorough acquisition and synthesis of all elements of robotic surgery.

The MicroHand S robotic-assisted versus Da Vinci robotic-assisted radical resection for patients with sigmoid colon cancer: a single-center retrospective study

BACKGROUND

Sigmoid colon cancer is a lethal disease and has a strong indication for surgery. Robotic-assisted surgery is one of the promising alternative treatment for this disease. Nowadays, the MicroHand S surgical system and the Da Vinci surgical system have been assembled in China. However, there is still no report to study the therapeutic effects of the two robotic-assisted surgical systems. Thus, the purpose of this study was to compare clinical and economic outcomes of patients with sigmoid colon cancer undergoing robot-assisted radical surgery via The MicroHand S or Da Vinci surgical system.

METHODS

The clinical data of 45 patients with sigmoid colon cancer undergoing the MicroHand S or Da Vinci robotic-assisted surgery at The Third Xiangya Hospital of Central South University from January 2017 to January 2019 were retrospectively analyzed.

RESULTS

Twenty-one patients received MicroHand S robotic-assisted radical surgery and 24 patients received Da Vinci robot-assisted radical surgery. No significant differences were observed in terms of operation time, number of lymph node harvested, blood loss, intestinal exhaust time, time of oral feeding resumption, volume of abdominal cavity 24-h drainage, hospital stay, complication and rate of conversion, removal time of drainage tube and catheter between MicroHand S and Da Vinci group. However, the MicroHand S group had significantly lower hospitalization costs (P = 0.002) and shorter time to get out of bed after surgery (P = 0.04). In addition, no recurrence and metastases were observed in both groups during the follow-up.

CONCLUSIONS

In patients with sigmoid colon cancer, the Da Vinci surgical system did not show obvious clinical advantages compared to the MicroHand S surgical system in surgical outcomes. However, the MicroHand S surgical platform showed advantages in terms of the hospitalization costs and length of postoperative bedtime. The outcome of this study will probably result in a shift to the MicroHand S surgical system as treatment preference in China.

Short-term outcomes of robotic-assisted right colectomy compared with laparoscopic surgery: A systematic review and meta-analysis

To assess the clinical efficacy and safety of robotic-assisted right colectomy (RRC) with conventional laparoscopic right colectomy (LRC) by performing a systematic review and meta-analysis of the published studies. All published literature for comparative studies reporting preoperative outcomes of RRC and LRC were searched. We searched the databases included Cochrane Library of Clinical Comparative Trials, MEDLINE, Embase, Web of Science and Chinese Biomedical Database (CBM) from 1973 to 2018. The censor date was up to January 2018. Operative time, estimated blood loss, length of hospital stay, conversion rates to open surgery, postoperative complications, and related outcomes were evaluated. All calculations and statistical tests were performed using Stata 12.0 software. A total of 7769 patients with colon cancer enrolled in 13 trials were divided into a study group (n = 674) and a control group (n = 7095). Meta-analysis suggested significantly greater length of hospital stay in the LRC group [MD = -0.85; 95% CI: -1.07 to -0.63; P < 0.00001]. Robotic surgery was also associated with a significantly lower complication rate [OR = 0.73; 95% CI: 0.52 to 1.01; P = 0.05]. There were statistically significant differences between the groups in estimated blood loss [MD = -16.89; 95% CI: -24.80 to -8.98; P < 0.00001] and the rate of intraoperative conversion to open surgery [OR = 0.34, 95% CI: 0.15 to 0.75; P = 0.008)], but these differences were not clinically relevant. The recovery of bowel function in two groups is no significant differences [MD = -0.58, 95% CI: -0.96 to -0.20, P = 0.0008]. However, operation times [MD = 43.61, 95% CI: 39.11 to 48.10, P < 0.00001] were longer for RRC than for LRC. Compared to LRC, RRC was associated with reduced estimated blood loss, reduced postoperative complications, longer operation times. Recovery of bowel function and other perioperative outcomes were equivalent between the two surgeries.

A Cost-Effectiveness Analysis of the Integration of Robotic Spine Technology in Spine Surgery

OBJECTIVE

We investigate the cost-effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice.

METHODS

The time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue.

RESULTS

A total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases.

CONCLUSION

Application of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery.

A Novel Intuitively Controlled Articulating Instrument for Reoperative Foregut Surgery: A Case Report

The field of laparoscopic surgery has continued to grow exponentially over the years, prompting new innovative technologies. Despite substantial advancements, standard laparoscopic tools have undergone little design changes and fail to optimize mobility in limited spaces. Advancements in robotics have attempted to address this, allowing for increasing degrees of freedom and articulation of instruments. Even so, this system has proven to be cumbersome with questionable cost-effectiveness. In this study, we present the first use of a solely mechanical intuitively controlled articulating laparoscopic needle driver. The ability to naturally articulate allowed for ease during suturing and knot tying during the critical portions of the operation. The FlexDex surgical instrument demonstrates promise in the field of foregut surgery in addition to other areas of minimally invasive specialties.