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

Evaluation status of current and emerging minimally invasive robotic surgical platforms

BACKGROUND

The rapid adoption of robotics within minimally invasive surgical specialties has also seen an explosion of new technology including multi- and single port, natural orifice transluminal endoscopic surgery (NOTES), endoluminal and "on-demand" platforms. This review aims to evaluate the validation status of current and emerging MIS robotic platforms, using the IDEAL Framework.

METHODS

A scoping review exploring robotic minimally invasive surgical devices, technology and systems in use or being developed was performed, including general surgery, gynaecology, urology and cardiothoracics. Systems operating purely outside the abdomen or thorax and endoluminal or natural orifice platforms were excluded. PubMed, Google Scholar, journal reports and information from the public domain were collected. Each company was approached via email for a virtual interview to discover more about the systems and to quality check data. The IDEAL Framework is an internationally accepted tool to evaluate novel surgical technology, consisting of four stages: idea, development/exploration, assessment, and surveillance. An IDEAL stage, synonymous with validation status in this review, was assigned by reviewing the published literature.

RESULTS

21 companies with 23 different robotic platforms were identified for data collection, 13 with national and/or international regulatory approval. Of the 17 multiport systems, 1 is fully evaluated at stage 4, 2 are stage 3, 6 stage 2b, 2 at stage 2a, 2 stage 1, and 4 at the pre-IDEAL stage 0. Of the 6 single-port systems none have been fully evaluated with 1 at stage 3, 3 at stage 1 and 2 at stage 0.

CONCLUSIONS

The majority of existing robotic platforms are currently at the preclinical to developmental and exploratory stage of evaluation. Using the IDEAL framework will ensure that emerging robotic platforms are fully evaluated with long-term data, to inform the surgical workforce and ensure patient safety.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

[The first clinical experience of using the new Senhance remote-controlled robotic system in general surgery in Russia]

Until recently, clinical studies in the field of robotic-assisted surgery have been conducted in Russia only on the basis of the DaVinci system. The advent of a new robotic system separated the concept of «robotic surgery» from DaVinci. An increase in the number of alternative surgical robots will expand the possibilities of studying the functionality of these systems, differences in their operation, safety and efficiency for patients, and convenience for surgeons.

OBJECTIVE

Evaluation of own initial experience of using Senhance robotic surgical system in the work of the general surgery department.

MATERIAL AND METHODS

A prospective collection of data on the surgical treatment of patients with various pathologies using the Senhance robotic system was carried out, followed by its analysis in relation to the duration of the operation, the incidence of intraoperative complications and the need for conversion, as well as the volume of blood loss and early postoperative complications.

RESULTS AND DISCUSSION

Now, only perioperative, and early postoperative data are available for analysis. While accumulating our own experience with the Senhance system, we concluded that, since the transition from robotic to manual laparoscopic surgery and vice versa does not require changing of access points and is performed quickly, it is practically expedient to perform some stages of the operation manually, and others using surgical robot. For example, with the help of manual laparoscopy, it is more ergonomic to perform wide tractions and movements of organs and tissues. At the same time, robotic surgery has undeniable advantages when performing lymph node dissection, performing manual sutures, including anastomoses, which does not lead to an increase in the duration of the intervention.

CONCLUSION

Presented experience of using the Senhance system has shown that it meets the declared indicators of convenience, efficiency and safety of operations in general surgery.

Single-Port versus Multiple-Port Robot-Assisted Radical Prostatectomy: A Systematic Review and Meta-Analysis

Background: Single-port robotic-assisted radical prostatectomy has been reported as a safe and feasible technique. However, recent studies comparing single-port versus multiple-port robotic radical prostatectomy have displayed conflicting results. Objectives: To investigate the benefit of single-port robotic radical prostatectomy and the impact on outcome compared to multiple-port robotic radical prostatectomy. Methods: Based on PRISMA and AMSTAR criteria, a systematic review and meta-analysis were carried out. Finally, we considered the controlled studies with two cohorts (one cohort for single-port RARP and the other cohort for multiple-port RARP). For statistical analysis, Review Manager (RevMan) software version 5.4 was used. The Newcastle-Ottawa Scale was employed to assess the risk of bias. Results: Five non-randomized controlled studies with 666 patients were included. Single-port robotic radical prostatectomy was associated with shorter hospital stays. Only 60.6% of single-port patients (109/180) required analgesia compared to 90% (224/249) of multiple-port patients (Z = 3.50; p = 0.0005; 95% CI 0.07:0.47). Opioid administration was also significantly lower in single-port patients, 26.2% (34/130) vs. 56.6% (77/136) (Z = 4.90; p < 0.00001; 95% CI 0.15:–0.44) There was no significant difference in operative time, blood loss, complication rate, positive surgical margin rate, or continence at day 90. Conclusion: The available data on single-port robotic radical prostatectomy is very limited. However, it seems comparable to the multiple-port platform in terms of short-term outcomes when performed with expert surgeons. Single-port prostatectomies might provide a shorter hospital stay and a lower requirement for opioids; however, randomized trials with long-term follow-up are mandatory for valid comparisons.

Robotic donor hepatectomy: Are we there yet?

In living donor liver transplantation (LDLT) the safety of the live donor (LD) is of paramount importance. Despite all efforts, the morbidity rates approach 25%-40% with conventional open donor hepatectomy (DH) operations. However, most of these complications are related to the operative wound and despite increased self- esteem and satisfaction in various quality of life analyses on LD, the most common grievance is that of the scar. Performing safe and precise DH through a conventional laparoscopic approach is a formidable task with a precipitous learning curve for the whole team. Due to the ramifications the donor operation carries for the donor, the recipient, the transplant team and for the LDLT program in general, the development and acceptance of minimally invasive DH (MIDH) has been slow. The robotic surgical system overcomes the reduced visualization, restricted range of motion and physiological tremor associated with laparoscopic surgery and allows for a comparatively easier transition from technical feasibility to reproducibility. However, many questions especially with regards to standardization of surgical technique, comparison of outcomes, understanding of the learning curve, etc. remain unanswered. The aim of this review is to provide insights into the evolution of MIDH and highlight the current status of robotic DH, appreciating the existing challenges and its future role.

Current Robotic Platforms in Surgery and the Road Ahead

Minimally invasive surgery has rapidly evolved from the once novel laparoscopic approach to advanced robotic surgery. In the past few decades alone, robotic systems have gone from systems which were significantly limited to full-fledged platforms featuring 3D vision, articulated instruments, integrated ultrasound and fluorescence capabilities, and even the latest wireless connectivity, as is now standard. In this review, we aimed to summarize features of currently commercialized and utilized robotic surgical systems as well as currently unfolding platforms. The pros and cons of different robotic surgical systems were discussed. In addition, we discussed the future perspectives of robotic platforms used in general surgery. In this regard, we emphasized that the market, once dominated by Intuitive Surgical Inc., has become occupied by several worthy competitors with new technological giants such as Google. Eventually, the question facing hospital systems will not be of whether or not to invest in robotic surgery, but instead of how they will strike balance between price, features, and availability when choosing robots from the growing market to best equip their surgeons.