Robotic surgery for the upper gastrointestinal tract: Current status and future perspectives

More than 4000 da Vinci Surgical Systems have been installed worldwide. Robotic surgery using the da Vinci Surgical System has been increasingly performed in the last decade, especially in urology and gynecology. The da Vinci Surgical System has not become standard in surgery of the upper gastrointestinal tract because of a lack of clear benefits in comparison with conventional minimally invasive surgery. We initiated robotic gastrectomy and esophagectomy for patients with upper gastrointestinal cancer in 2009, and we have demonstrated the potential advantages of the da Vinci Surgical System in reducing postoperative local complications after gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. However, robotic surgery has the disadvantages of a longer operative time and higher costs than the conventional approach. In this review article, we present the current status of robotic surgery for gastric and esophageal cancer, as well as future perspectives on this approach, based on our experience and a review of the literature.     

Impact of stent design on clinical outcome after coronary stent implantation

Abstract

Robotic surgery using the da Vinci Surgical System promises to extend the capabilities of minimally invasive surgery and many surgical specialties are applying this new technology. With the progress of robotic surgery, we have many opportunities to perform intracorporeal anastomosis and knotting. In these procedures, we use needle drivers, and we sometimes experience collapse of sutures after grasping them due to the lack of tactile feedback. In this study, we evaluated the relationship between the decrease of durability and robotic manipulation and whether a difference in endurance can be observed using different types of robotic instruments or needle drivers for conventional laparoscopic surgery. We held 4-0 mono-filament sutures with three types of EndoWrist: Large Needle Driver (LND), Cadiere Forceps (CF) and Debaky Forceps (DF) of the da Vinci surgical system once or three times and measured the decrease of durability of the suture. The mean tensions of the suture were significantly decreased after robotic manipulation with LND. The mean tension after holding three times with LND was significantly less than that with the CF. During intracorporeal anastomosis and knotting in robotic surgery, it is important to decrease the necessity to hold the suture directly with EndoWrist. If needed, the best EndoWrist to use is CF or DF, but not LND.     

Ovarian cystectomy for a dermoid cyst with the new single-port robotic system

We report a 27 year-old patient with a dermoid cyst who underwent robotic single port transumbilical ovarian cystectomy. She was operated through a 2 cm long single midline umbilical incision using a new platform from Intuitive Surgical. The operative time was 45 minutes and the docking time was 15 minutes. Ovarian cystectomy using the da Vinci single-port system is feasible and effective. This new semi-rigid robotic surgery platform may increase access to the potential advantages of single-site surgery. Robotic systems designed specifically for single port approach have the potential of alleviating several of the limitations associated with traditional laparoscopic single-site surgery.     

Robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy

The utility of robotic surgery for remnant gastric cancer remains unclear. We report a case of a robotic gastrectomy for remnant gastric cancer after pancreaticoduodenectomy and Child reconstruction with Braun enteroenterostomy. Adhesiolysis, lymphadenectomy, and gastrectomy were robotically performed. Indocyanine green fluorescence imaging confirmed the tissue perfusion of the reconstructive tract. The patient's postoperative course was uneventful. Robotic surgery facilitates safety for gastrectomy after pancreaticoduodenectomy because of its precise manipulation; its advantages can be further exploited by maximizing usage of the assistant's forceps. Indocyanine green fluorescence imaging capability of the da Vinci Xi Surgical System allows timely evaluation of tissue perfusion at the site of interest, leading to a more reliable procedure.     

Underwater robotic suturing

Background Laparoscopic and robotic surgeries have become popular, and this popularity is increasing. However, the environment in which such surgeries are performed is rarely discussed. Similar to arthrosurgery performed in water, artificial ascites could be a new environment for laparoscopic surgery. This study was performed to determine whether robotic surgery is applicable to complicated suturing underwater. Material and methods A da Vinci Surgical System S was used. A weighted fabric sheet was placed at the bottom of a tank. Identical sets were made for each environment: One tank was dry, and the other was filled with water. The suturing task involved placement of a running silk suture around the perimeter of a small circle. The task was performed eight times in each environment. The task time and integrity score were determined. The integrity score was calculated by evaluating accuracy, tightness, thread damage, and uniformity; each factor was evaluated using a five-point scale. Results Although statistically significant differences were not shown in either task time or integrity score between the underwater and air environments, robotic suturing underwater is not inferior to performance in air. Conclusions The feasibility of robotic suturing underwater was confirmed under the herein-described experimental conditions.     

Guest Editorial II: New endoscopic procedures in urology – the impact of laparoscopic radical prostatectomy

Abstract

Epiphrenic diverticula are rare protrusions of the distal esophagus attributed to esophageal motility disorders or obstructive diseases. In presence of a relevant symptomatology, surgery is mandatory. Although many reports confirm the feasibility of the laparoscopic transhiatal approach, the mobilization of the esophagus and the myotomy appear challenging. The intrinsic characteristics of the da Vinci Robotic System could facilitate the approach to the esophagogastric junction and an extended mobilization of the esophagus. We describe a robotic transhiatal surgical treatment of an epiphrenic diverticulum with a Dor antireflux procedure. Robotic-assisted diverticulectomy appears feasible and safe with a low risk of esophageal perforation and pleura damage.     

Robotic assisted retroperitoneoscopic nephroureterectomy -- first experience and the hybrid port technique

Robot-assisted renal surgery is usually performed transperitoneally due to more available space for excursion of the robotic arms. To our knowledge, we report the first experience with robotic retroperitoneoscopic nephroureterectomy using the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) and a hybrid port technique. Robotic retroperitoneal nephroureterectomy was performed on two male patients. One 37-year-old patient had a painful non-functioning hydronephrotic left kidney and megaureter; the other aged 76 had a muscle invasive lower left ureteric tumour. Both the procedures were successfully completed with the robot without conversion. Mean operative time was 182.5 min and estimated blood loss 75 ml. Histological examination confirmed the preoperative diagnoses; margins were clear in the patient with tumour. Postoperative recovery was uneventful. We report the technical feasibility of robotic retroperitoneoscopic nephroureterectomy. However, as with all new technology, the benefits need to be further evaluated and proven before this technique can be widely accepted.     

Performances on simulator and da Vinci robot on subjects with and without surgical background

Abstract

Objective: To assess whether previous training in surgery influences performance on da Vinci Skills Simulator and da Vinci robot.

Material and methods: In this prospective study, thirty-seven participants (11 medical students, 17 residents, and 9 attending surgeons) without previous experience in laparoscopy and robotic surgery performed 26 exercises at da Vinci Skills Simulator. Thirty-five then executed a suture using a da Vinci robot.

Results: The overall scores on the exercises at the da Vinci Skills Simulator show a similar performance among the groups with no statistically significant pair-wise differences (p?<?.05). The quality of the suturing based on the unedited videos of the test run was similar for the intermediate (7 (4, 10)) and expert group (6.5 (4.5, 10)), and poor for the untrained groups (5 (3.5, 9)), without statistically significant difference (p?<?.05).

Conclusion: This study showed, for subjects new to laparoscopy and robotic surgery, insignificant differences in the scores at the da Vinci Skills Simulator and at the da Vinci robot on inanimate models.     

Robotics in laparoscopic urology.

Following the successful application of the da Vinci robot in minimally invasive radical prostatectomy, several surgeries are now being performed with the assistance of the robot. These include both upper tract and lower tract surgeries such as nephrectomy, pyeloplasty and sacrocolpopexy and both ablative and reconstructive procedures. This article attempts to put into perspective the current role of the da Vinci Surgical system in urologic surgery and discusses in brief new developments in robotic technology that are on the horizon. A MEDLINE search was performed and published data on robot-assisted urologic procedures were reviewed. Abstracts presented at major international conferences in the last two years were also reviewed. Studies presenting operative and functional data for more than five patients were used in the review. There has been an explosive increase in the number of urologic procedures being attempted using Da Vinci assistance. Many, such as partial nephrectomy, donor nephrectomy, cystoprostatectomy, ureteral reimplantation and vasovasostomy are in the phase of feasibility studies, however others such as radical prostatectomy and pyeloplasty have one year functional results available which are comparable to those of other minimally invasive approaches. We believe that robotic technology represents the future of minimally invasive surgery and applications for the robot will expand as more centers report their results.     

Robotics in laparoscopic urology

Following the successful application of the da Vinci robot in minimally invasive radical prostatectomy, several surgeries are now being performed with the assistance of the robot. These include both upper tract and lower tract surgeries such as nephrectomy, pyeloplasty and sacrocolpopexy and both ablative and reconstructive procedures. This article attempts to put into perspective the current role of the da Vinci Surgical system in urologic surgery and discusses in brief new developments in robotic technology that are on the horizon. A MEDLINE search was performed and published data on robot‐assisted urologic procedures were reviewed. Abstracts presented at major international conferences in the last two years were also reviewed. Studies presenting operative and functional data for more than five patients were used in the review. There has been an explosive increase in the number of urologic procedures being attempted using Da Vinci assistance. Many, such as partial nephrectomy, donor nephrectomy, cystoprostatectomy, ureteral reimplantation and vasovasostomy are in the phase of feasibility studies, however others such as radical prostatectomy and pyeloplasty have one year functional results available which are comparable to those of other minimally invasive approaches.

We believe that robotic technology represents the future of minimally invasive surgery and applications for the robot will expand as more centers report their results.     

Ablative and reconstructive robotic-assisted laparoscopic renal surgery

Introduction: The increasing role of robotic technology to facilitate surgical procedures has attracted much attention from surgeons and patients alike. In particular, the dramatic increase in the number of laparoscopic radical prostatectomies performed using the da Vinci^TM surgical system has led to interest in using this technology for other procedures. We have evaluated our own experience performing ablative and reconstructive laparoscopic renal surgery using the da Vinci^TM system to determine its potential role. Aims: To review our experience of robotic‐assisted laparoscopic procedures of the upper urinary tract. Materials and methods: Our da Vinci^TM system was installed in June 2004. A prospective database has been maintained concerning all patients and procedures performed from that time. Procedures involving the upper urinary tract were identified and the data was examined. This included patient demographics, operative time, blood loss, hospital stay and patient outcomes. Results: Twenty‐six robotic procedures involved the upper urinary tract. Of these, two had to be converted to conventional laparoscopic surgery because of da Vinci^TM mechanical failure. Robotic‐assisted procedures included pyeloplasty (n = 15), simple nephrectomy (n = 2), radical nephrectomy (n = 1), nephroureterectomy (n = 2), and live donor nephrectomy (n = 4). The mean operative time was 215 min. The anastomotic time for the pyeloplasties averaged 47 min. The mean blood loss was 75 ml. There were no conversions to open surgery. The complication rate was 8.7%. Postoperative stay averaged 2.9 days. Conclusion: The da Vinci^TM surgical system may be safely used to assist in the performance of laparoscopic renal surgery.     

Laparoscopic colorectal cancer surgery: Japanese experience

In Japan, laparoscopic colectomy for cancer started in 1992. A national survey has revealed that, since that time, the number of cases that have undergone this procedure has steadily increased, and by 2007, there were over 9000 cases. This figure includes an increase in the percentage of more advanced cases, which has occurred due to technical improvements in lymph node dissection. A Japanese randomized controlled trial comparing laparoscopic to open surgery started in November 2004, with enrollment ending in April 2009 with 1050 cases. For this study, preoperative stage T3 and T4 cases were selected for inclusion, and D3 dissection was required. To assess the technical skill of surgeons, the Japan Society of Endoscopic Surgery established the Endoscopic Surgical Skill Qualification System to encourage high‐level surgical techniques. Assessment is conducted by reviewing unedited videos. The success rate for colon and rectal surgeries has ranged between 37%–40%. The Endoscopic Surgical Skill Qualification System has contributed to the establishment of standard technical skills in laparoscopic surgery, the development of an educational system for laparoscopic surgeons, and a reduction in the number complications. Technical difficulties still exist in laparoscopic rectal cancer surgery, but with the technical progress in laparoscopic colorectal surgery, the number of laparoscopic rectal cancer surgeries has been gradually increasing in number. A multicentric phase II study on the feasibility and long‐term outcome for stage I and II rectal cancer started in 2008. In this study, the short‐term outcomes including anastomotic leakage rate and long‐term survival, will be clarified. Combined with continuously improved technologies, training techniques and surgical standards, laparoscopic colorectal surgery is steadily progressing in Japan.     

Endoscopes with latest technology and concept

Endoscopic imaging systems that perform as the "eye" of the operator during endoscopic surgical procedures have developed rapidly due to various technological developments. In addition, since the most recent turn of the century robotic surgery has increased its scope through the utilization of systems such as Intuitive Surgical's da Vinci System. To optimize the imaging required for precise robotic surgery, a unique endoscope has been developed, consisting of both a two dimensional (2D) image optical system for wider observation of the entire surgical field, and a three dimensional (3D) image optical system for observation of the more precise details at the operative site. Additionally, a "near infrared radiation" endoscopic system is under development to detect the sentinel lymph node more readily. Such progress in the area of endoscopic imaging is expected to enhance the surgical procedure from both the patient's and the surgeon's point of view.     

Successful cholecystectomy during robotic gastrectomy

Abstract

Background: Surgeons have successfully combined various laparoscopic procedures with increasing technical ease. However, few reports exist regarding the feasibility of combined robotic operations. We present our institution's successful concomitant robotic surgery for early gastric cancer and coexisting gallbladder disease. Material and methods: From our prospectively collected database, seven patients who received robotic cholecystectomies during their robotic gastric cancer operations were retrospectively compared to 247 patients who underwent robotic gastrectomies alone. Preoperative patient characteristics, operative factors, postoperative length of stay, and complications were evaluated. Results: The preoperative patient characteristics and operative factors did not differ between the two groups. All robotic cholecystectomies were performed with the same ports and instruments used during robotic gastrectomies without open conversion, robot redocking or patient repositioning. Mean time to perform robotic cholecystectomies was 15.1 + 3.2 minutes. The combined group had no mortality, one wound infection, and one intraabdominal fluid collection at the gastric resection bed, which were comparable to the gastrectomy alone group. The mean postoperative length of hospital stay was unaltered by the addition of the cholecystectomy. Conclusions: Robotic cholecystectomies can safely and efficiently be combined with robotic gastric cancer surgery, yielding several benefits. Improving robotic technology and experience may allow surgeons to efficiently combine more complicated procedures.     

Modifiable Factors to Decrease the Cost of Robotic-Assisted Procedures

In 2000, the US Food and Drug Administration approved the da Vinci Surgical System® for use in the United States. Since that time, the number of surgical robotic systems throughout the United States has continued to grow. The costs for using the system include the initial purchase ($1 million to $2.3 million) plus annual maintenance fees ($100,000 to $150,000) and the cost of limited-use or disposable instruments. Increasing the number of procedures that are performed using the robotic system can decrease the per-procedure costs. Two modifiable factors that contribute to increasing the annual caseload are increasing the number of surgeons capable of using the system and having a properly educated perioperative nursing team. An educated surgical team decreases turnover time, facilitates proper flow of each surgical procedure, and is able to actively and passively solve intraoperative problems.     

Robotic-assisted surgery for pediatric choledochal cyst: Case report and literature review

Our paper describes the key surgical points of pediatric choledochocystectomy performed completely by Da Vinci robotic system. A choledochocystectomy was safely carried out for a girl at our hospital, and without any complication. Then systematic literature review was done to discuss the methods of intestine surgery and intestinal anastomosis, the use of 3^rd robotic arm, the surgical safety and advantages comparing open and laparoscopic surgery. We systematically reviewed choledochocystectomy for children performed by robotic surgery. We included a total of eight domestic and foreign reports and included a total of 86 patients, whose average age was 6.3 (0.3-15.9) years; the male-to-female ratio was 1:3.5 (19:67). Seven patients experienced conversion to open surgery, and the surgery success rate was 91.9% (79/86). The average total operation time was 426 (180-520) min, the operation time on the machine was 302 (120-418) min, 11 cases used the number 3 arm, and the remaining mainly used the hitch-stitch technique to suspend the stomach wall and liver. Forty-seven patients underwent pull-through intestine and intestinal anastomosis, and 39 patients underwent complete robotic intestine surgery and intestinal anastomosis. The hospitalization time of robotic-assisted choledochocystectomy was 8.8 d. Eight patients had biliary fistula and were all cured by conservative treatment and continuous observation. One patient had anastomotic stenosis, and one patient had wound dehiscence, both cured by surgery. Choledochocystectomy for children performed by completely robotic surgery and Roux-en-Y hepaticojejunostomy is safe and feasible. The initial experience shows that this surgical approach has a clearer field than the traditional endoscopy, and its operation is more flexible, the surgery is more accurate, and the injury is smaller. With the advancement of technology and the accumulation of surgeons’ experience, robotic surgery may become a new trend in this surgical procedure.     

Robotic surgery for simultaneous gastric and rectal cancers

The number of patients with multiple primary malignancies is increasing due to the improvements in diagnostic techniques, which increases the necessity of simultaneous resection. Meanwhile, minimally invasive robotic surgery is becoming popular in Japan, and its use in multiple cancer resection will increase. We present our experience with the settings and ports placement when using the da Vinci Xi system for simultaneous resection of rectal and gastric cancer.     

Current status of endoscopic surgery in Japan: The 14th National Survey of Endoscopic Surgery by the Japan Society for Endoscopic Surgery

In Japan, the first endoscopic surgery, a laparoscopic cholecystectomy, was performed in 1990. Since then, operative procedures have been standardized, and the safety and efficacy of endoscopic surgery have been evaluated. In accordance with the social acceptance of endoscopic surgery as a less invasive type of surgery, the number of endoscopic procedures performed has increased in all surgical domains. The Japan Society for Endoscopic Surgery (JSES) has played an important role in the development of endoscopic surgery in Japan. Notably, a technical skills certification system for surgeons was established by the JSES to train instructors on how to teach safe endoscopic surgery. Furthermore, the JSES has conducted a national survey every two years to evaluate the status of endoscopic surgery over time. In 2017, 248 743 patients underwent endoscopic surgery in all surgical domains, such as abdominal, thoracic, mammary and thyroid gland, cardiovascular, obstetrics and gynecology, urologic, orthopedic, and plastic surgery. The 14th National Survey of Endoscopic Surgery conducted by the JSES demonstrated the status of laparoscopic surgery in Japan in 2016‐2017.     

Under-table mounting for AESOP robot for laparoscopic flank surgery

Summary. Background and objectives: A new method of mounting the AESOP (Automated Endoscopic System for Optimal Positioning-Computer Motion Inc., Goleta, CA) robotic arm for use in laparoscopic flank procedures is described. Methods: The AESOP robotic arm was mounted on a specially developed bracket to allow under-table positioning of the device on a specially-designed radiolucent laparoscopic urology table (Orthopedic Systems Inc., Union City, CA). With the AESOP device controlling the laparoscope, laparoscopic right total nephrectomy was performed in a patient with renal failure and a lower pole renal mass. Results: The operative time was 315 min. The robotic arm was able to control the camera with the patient in the flank position, providing a stable, clear view during the procedure. Conclusions: The use of a robotic arm to manipulate the laparoscope can significantly assist laparoscopic surgery. The AESOP device, intended for attachment to a standard operating table to provide for robotic control of the laparoscope with the patient in the supine position, can be used for renal and/or ureteral laparoscopic surgery with the patient in the flank position using a new under-table mounting adapter.     

达芬奇机器人辅助下经双侧腋窝和乳晕入路甲状腺手术体位的护理体会(附83例报告)

目的：探讨达芬奇机器人经双侧腋窝和乳晕途径(bilateral axillo-breast approach, BABA)入路实施甲状腺手术时体位的摆放护理,以保障手术顺利进行。方法：2015 年5 月至2016 年12月我院运用达芬奇机器人手术系统完成机器人BABA 入路甲状腺手术共83例。本研究总结分析了病人手术体位的安置、术后并发症发生及相关护理因素。83例患者均采取头高脚低仰卧位(与地面约呈15-30°),肩部略垫高,患者乳房下方安置一条弹力绑带,固定于手术床旁,将患者双侧乳房向上推高,最大限度地减小术者的手术盲区,扩大手术视野。结果：83例均顺利完成达芬奇机器人BABA 入路甲状腺手术,无一例出现因体位不当、护理失误而引起的并发症。患者满意度为100%。结论：达芬奇机器人BABA入路甲状腺手术术中合理放置体位可保障手术安全顺利进行,并可有效预防术后并发症的发生。