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

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

Next-generation robotic surgery - from the aspect of surgical robots developed by industry

At present, much of the research conducted worldwide focuses on extending the ability of surgical robots. One approach is to extend robotic dexterity. For instance, accessibility and dexterity of the surgical instruments remains the largest issue for reduced port surgery such as single port surgery or natural orifice surgery. To solve this problem, a great deal of research is currently conducted in the field of robotics. Enhancing the surgeon’s perception is an approach that uses advanced sensor technology. The real-time data acquired through the robotic system combined with the data stored in the robot (such as the robot’s location) provide a major advantage. This paper aims at introducing state-of-the-art products and pre-market products in this technological advancement, namely the robotic challenge in extending dexterity and hopefully providing the path to robotic surgery in the near future.     

Robot-assisted low anterior resection for a rectal cancer patient with ileal conduit: A case report

Surgery for rectal cancer patients with an ileal conduit after total cystectomy is difficult because adhesions in the pelvis and around the ileal conduit are expected. In the present case, we performed robot-assisted low anterior resection of the rectum in a 69-year-old male patient with rectal cancer who underwent ileal conduit diversion after total cystectomy. In this procedure, the port was inserted into the left upper abdomen as a first step, and two additional ports were added on the left side. Low anterior resection was performed using two left hands to create more space in the abdominal cavity for the ileal conduit. We present this minimally invasive robotic procedure that is extremely useful for dissection of adhesions in a narrow pelvic cavity.     

Concept design of robotic modules for needlescopic surgery

Background: Many minimally invasive surgical procedures and assisting robotic systems have been developed to further minimize the number and size of incisions in the body surface. This paper presents a new idea combining the advantages of modular robotic surgery, single incision laparoscopic surgery and needlescopic surgery.

Material and methods: In the proposed concept, modules carrying therapeutic or diagnostic tools are inserted in the abdominal cavity from the navel as in single incision laparoscopic surgery and assembled to 3-mm needle shafts penetrating the abdominal wall.

Results: A three degree-of-freedom robotic module measuring 16?mm in diameter and 51?mm in length was designed and prototyped. The performance of the three connected robotic modules was evaluated.

Conclusion: A new idea of modular robotic surgery was proposed, and demonstrated by prototyping a 3-DOF robotic module. The performance of the connected robotic modules was evaluated, and the challenges and future work were summarized.     

Laparoendoscopic single-site surgery for urachal remnants

INTRODUCTION: Urachal remnants are relatively rare but may potentially cause various symptoms and an increased risk for developing adenocarcinoma. Open or laparoscopic surgery is usually used for their resection. Laparoendoscopic single-site surgery has been recently applied in several surgical procedures. This report describes two cases of vesicourachal diverticulum treated by resection using laparoendoscopic single-site surgery. MATERIALS AND SURGICAL TECHNIQUE: In each case, laparoendoscopic single-site surgery was performed transperitoneally via one port at a subumbilical semicircular incision. Except for a flexible camera and SILS Port, traditional, non-flexible laparoscopic instruments were used. After the induction of general anesthesia, the patient was placed in a supine position (or lithotomy position). A 2.0-cm incision was made semicircumferentially following the natural subumbilical folds. After the umbilical ligament was cut under direct vision, a SILS Port was placed at the incision. The urachus was liberated distally down to the roof of the urinary bladder using 0° 5-mm flexible camera. Vesicourachal diverticulum with a bladder cuff was completely excised under the supporting view of cystoscopy. Both patients' perioperative days were uneventful. DISCUSSION: Our findings suggest that the laparoendoscopic single-site surgery procedure is safe, minimally invasive and cosmetically acceptable. Therefore, this procedure is an excellent option for the radical resection of urachal remnants.     

Single‐port laparoscopic splenectomy: The first three cases

In the past two decades, laparoscopic surgery has replaced open surgery in most abdominal surgeries, including splenectomies for which it has become the standard. Single‐port laparoscopic surgery is a newly emerging surgical technique that decreases postoperative scarring and parietal trauma. Herein we report on three cases of splenectomy in which single‐port laparoscopic surgery technique was applied. Between October 2008 and January 2009, a 13‐year‐old male suffering from grade‐III splenic trauma and two females, aged 33 and 61, respectively, and both diagnosed with immune thrombocytopenic purpura, underwent single‐port laparoscopic splenectomies. Preoperative and postoperative management, including vaccination, was performed in a routine manner. A 3.5 cm transverse incision at the anterior axillary line at umbilicus level was used as a single‐port entry point. The entire procedure took 195, 125 and 133 minutes, respectively. All patients recovered and were discharged without any complications.     

Novel procedure, SILSOID colectomy, is a bridge between conventional and single-incisional laparoscopic colectomy

Introduction: Laparoscopic colectomy (LC) is a widely accepted treatment for various diseases of the colon. Transumbilical single‐incisional laparoscopic surgery (SILS) offers excellent cosmetic results compared with standard multi‐port laparoscopic surgery. We describe a new hybrid laparoscopic procedure, SILSOID colectomy, which combines conventional LC with SILS. Methods: We performed SILSOID colectomy to treat four patients with colorectal disease. Three ports were inserted through the single transumbilical incision, and an additional port was inserted in the flank at a site that depended on the location of the lesion. Division and anastomosis of the colon were performed extracorporeally. Results: SILSOID colectomy was carried out uneventfully in all four cases. The median operation time was 220 minutes (range, 179–320 min), and the median blood loss was negligible (range, negligible–285 mL), respectively. Although one patient experienced a postoperative wound infection, no other postoperative complications occurred. Conclusion: SILSOID colectomy is safe and feasible and it can be used as an alternative to conventional LC. We consider this procedure to be a bridge between conventional LC and more advanced laparoscopic procedures, such as SILS.     

运用X-cone单孔器械行经脐单孔腹腔镜胆囊切除术

目的:探讨运用X-cone单孔器械完全经脐单孔腹腔镜胆囊切除术的方法和可行性.方法:回顾性分析我院2011年4月至2011年11月期间54例经脐单孔胆囊切除患者的临床资料.结果:本组54例均运用X-cone单孔腹腔镜器械经脐行单孔腹腔镜胆囊切除术,2例因胆囊炎症严重,解剖不清,改为二孔法腹腔镜手术,其他均手术成功,成功率96.3％.本组病例手术时间平均(30±14) (20 ～ 58) min,出血5 ～50 mL,平均10.6 mL.术后次日恢复流汁饮食,住院时间3～4 d.随访至今,1例患者切口液化,无其他术中、术后并发症.术后患者无瘢痕效果十分满意.结论:运用X-cone单孔腹腔镜器械经脐单孔腹腔镜胆囊切除术具有同样的手术安全性,更具有突出的切口美容效果,术后疼痛轻、康复快、住院时间短,同时患者住院费用低,值得在临床广泛推广.     

机器人辅助根治性膀胱前列腺切除术＋原位双U形回肠代膀胱术

目的探讨da-Vinci机器人辅助腹腔镜下行根治性膀胱前列腺切除术的可行性和疗效。方法患者男性,64岁,膀胱镜检膀胱内多发性占位,CT检查无远处转移。手术采用3臂2辅助孔,da-Vinci机器人辅助腹腔镜下全膀胱切除＋前列腺切除,盆腔淋巴结清扫,体外开放手术下取出切除的膀胱、前列腺,原位双U形回肠代膀胱术。观察手术时间、术中失血量、术后肠道功能恢复、术后并发症及手术效果。结果手术时间330min（包括体位摆放及da-Vinci机器人到位30min）,其中全膀胱切除180min,原位膀胱术120min。手术失血量800ml,输红细胞600ml,血浆300ml。术后病理：膀胱尿路上皮癌。术后第10天拔除双侧输尿导管,术后3周拔除导尿管,未发生手术并发症及术后并发症,尿控良好。结论 da-Vinci机器人辅助腹腔镜下根治性膀胱前列腺切除术可以明显减少术中出血,恢复快,缩短住院时间。机器人将复杂的盆腔腹腔镜手术变得简单易行,提高了手术的精细度和灵巧性。     

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.     

Robot-integrated intraoperative ultrasound: Initial experience with hepatic malignancies

Purpose: A new robotic surgery tool allows intraoperative ultrasound to be performed using a fully robotic technique. Herein, we evaluate the feasibility and reliability of robotically integrated ultrasound to guide resection of malignant hepatic tumors. Material and methods: A consecutive series of ultrasound-guided robotic resections of primary and secondary hepatic malignancies was analyzed in terms of perioperative data and specimen evaluation, focusing on the reliability of the new robot-integrated ultrasound probe. Results: Ten consecutive patients underwent 15 robotic liver resections. Two patients were resected to excise primary hepatocellular cancers and eight underwent resections of liver metastases. R0 resections were achieved for all lesions. The median operative time was 247 min, and blood loss was limited. No mortality occurred. Conclusions: Our present analysis confirmed the reliability of fully robotic liver resection guided via robotically integrated ultrasonic assessment. Robotic surgery, particularly hepatic resection, may benefit greatly from better manageability, and the fact that the surgeon can directly manage both the operative and the diagnostic parts of the procedure.     

Single-port versus needlescopic versus conventional laparoscopic cholecystectomy: a comparative study

Introduction: Single‐port laparoscopic cholecystectomy (LC) has been recently introduced to achieve clinical benefits over standard LC. However, surgical outcomes of this operation have been poorly described compared with current techniques. The purpose of this study is to evaluate the surgical outcomes of single‐port LC compared with needlescopic and conventional LC. Methods: We reviewed the surgical outcomes of consecutive patients with symptomatic gallbladder stone disease who underwent single‐port LC (31 cases), needlescopic LC (26 cases) and conventional LC (32 cases) from March 2009 to January 2010. Operation time, hospital stay, conversion, complications, and postoperative pain using visual analog scale were analyzed. In addition, patients were interviewed for overall satisfaction and cosmetic results. Results: BMI in the single‐port group was significantly lower than in the conventional group (26.0 ± 4.0 vs 30.8 ± 7.3 kg/m², P=0.0017). Operation time in the single‐port group was significantly longer than in the conventional group (65.1 ± 20.1 minutes vs 52.2 ± 19.6 minutes, P=0.012). There was one conversion in the single‐port group. In nine cases in the single‐port group (29%), a Kirschner wire or a suture retractor helped visualization. There was one complication in the single‐port group (wound infection) and one in the needlescopic group (bile leak, requiring laparoscopy). Hospital stay, visual analog scale scores, and overall satisfaction did not vary among these groups. Greater cosmetic satisfaction was shown in the single‐port group compared with the conventional group (P=0.039). Conclusion: Single‐port LC is feasible and secure, with better cosmetic results than conventional LC. Further prospective randomized studies are still required to show its superiority over current LC techniques.     

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.     

Vaginal NOTES surgery in patients with prior hysterectomy: A first case series

This is a first feasibility on vaginal natural orifice transluminal endoscopic surgery (vNOTES) in patients with prior hysterectomy. Our aim was to gain initial experience on performing vNOTES surgery on prior hysterectomy cases, whereby the main concern is that pelvic adhesions may impede safe transvaginal access. Between January 2017 and February 2020, a single surgeon (J.B.) performed vNOTES surgery on nine patients with a history of hysterectomy. Conventional laparoscopic instruments were inserted transvaginally through a vNOTES port. No abdominal incisions were made. Patient data and perioperative data were analyzed. Mean operating time was 38 minutes and there were no operative complications. Postoperative pain scores were low. The mean size of the adnexal cysts that were removed was 26 mm. In this study, vNOTES surgery was successfully performed in nine patients with prior hysterectomy. Following the IDEAL principles, it is important to report on our initial findings of this IDEAL stage 1 study. The results warrant further investigation in IDEAL stage 2 studies but do not validate the widespread use of this approach.     

Laparoendoscopic single-site compared with conventional laparoscopic surgery for gynaecological acute abdomen in pregnant women

ObjectiveTo estimate the safety and feasibility of laparoendoscopic single-site surgery (LESS) in pregnant patients with acute abdomen.MethodsBaseline characteristics, surgical results, and obstetric and neonatal outcomes were retrospectively compared between single and multiport procedures in patients who underwent laparoscopic surgery during pregnancy between 2017 and 2021.ResultsFifty-four pregnant patients were included: 26 who underwent LESS (salpingectomy, 11 cases/cystectomy, 15 cases) and 28 who underwent conventional laparoscopic surgeries (salpingectomy, 12 cases/cystectomy, 16 cases) during pregnancy. One patient in the single-port group required additional ports. No patients converted to laparotomy. In patients undergoing salpingectomy, the single-port group showed lower 8- and 24-h postoperative pain scores, shorter hospital stays, and lower Self-rating Anxiety Scale scores prior to discharge versus conventional laparoscopy. One patient experienced postoperative vaginal bleeding and a missed abortion during follow-up. In patients receiving cystectomy, 8- and 24-h pain scores, postoperative hospital stay, and anxiety scores were lower in the single-port versus multiport group. Other outcomes were comparable between the groups.ConclusionThe feasibility and efficacy of laparoscopic surgery during pregnancy is similar between single- or multiport routes, however, the single-port route may be associated with less postoperative pain, shorter hospital stay, and lower anxiety.     

Is the bipolar vessel sealer device an effective tool in robotic surgery? A retrospective analysis of our experience and a meta-analysis of the literature about different robotic procedures by investigating operative data and post-operative course

Background: The latest robotic bipolar vessel sealing tools have been described to be effective allowing to perform procedures with reduced blood loss and shorter operative times. The aim of this study was to assess the efficacy and reliability of these devices applied in different robotic procedures.

Material and methods: All robotic operations, between 2014 and 2016, were performed using the EndoWrist One VesselSealer (EWO, Intuitive Surgical, Sunnyvale, CA), a bipolar fully wristed device. Data, including age, gender, body mass index (BMI), were collected. Robot docking time, intraoperative blood loss, robot malfunctioning and overall operative time were analyzed. A meta-analysis of the literature was carried out to point the attention to three different parameters (mean blood loss, operating time and hospital stay) trying to identify how different coagulation devices may affect them.

Results: In 73 robotic procedures, the mean operative time was 118.2?minutes (75–125?minutes). Mean hospital stay was four days (2–10 days). There were two post-operative complications (2.74%).

Conclusions: The bipolar vessel sealer offers the efficacy of bipolar diathermy and the advantages of a fully wristed instrument. It does not require any change of instruments for coagulation or involvement of the bedside assistant surgeon. These characteristics lead to a reduction in operative time.     

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.     

自制套管单孔腹膜后镜肾上腺切除术初步经验总结

[目的]探讨采用自制套管进行单孔腹膜后镜肾上腺切除术的可行性和初步经验.[方法]2010年6月至2011年8月北京大学第一医院共有9例患者行单孔腹膜后镜肾上腺切除术.患者平均年龄59岁(32 ～80岁),男5例,女4例,平均BMI为24.1 kg/m2.所有手术均为腹膜后入路,选择腋中线与腋后线之间髂嵴上方3cm处斜行切口,切口长度3～4 cm.先以气囊扩张建立腹膜后腔,然后置入以手套自制单孔多通道套管建立手术入路,采用前端可弯曲腹腔镜器械联合常规腹腔镜器械完成手术,在术毕从切口取出标本.[结果]肿瘤长径平均3.3 cm(1.5～5.5 cm),左侧3例,右侧6例.平均手术时间62min(40～127 min),术中平均出血量为50 ml(0 ～200ml).9例手术均顺利完成,无中转开放手术或增加附加套管,无术中、术后并发症发生.平均术后住院时间为5 d(3 ～7 d).[结论]对于选择合适的病例,采用自制套管行单孔腹膜后镜肾上腺切除术是安全可行的,具有一定的美观效果,但远期疗效尚待观察,手术器械及手术技术尚待完善.     

Current experiences with robotic surgery at Severance Hospital,Yonsei University in Korea

We started performing laparoscopic cholecystectomies in 1991. Since that time, many surgeons have been trained in laparoscopic and minimally invasive surgery, and laparoscopic surgery has been used in numerous procedures, with patients benefitting as a result. We performed the first automated surgery in Korea using Automated Endoscopic System for Optimal Positioning in June 1996. Inspired by Inbae Yoon and assisted by his generous donation, our hospital started the IB Yoon Multi‐Specialty Endoscopic Research & Training Center in 1998. Subsequently in March 2005, we started the Severance Robotic and Minimally Invasive Surgery Center. The establishment of these centers has enabled us to widen the use of laparoscopic surgery and to teach many surgeons the principles of and the techniques involved in laparoscopic and robotic surgery. We performed our first robotic surgery using the da Vinci Surgical System in July 2005. In the 4 years since introducing the da Vinci Surgical System, we have successfully performed more than 2600 robotic surgical procedures. As the collaboration between medicine and robotic engineering produces more technically advanced results, we hopefully can develop our own version of the robotic system in the near future.     

Five millimetre-instruments in paediatric robotic surgery: Advantages and shortcomings

Purpose: The study was designed to assess the utility and controversies surrounding the usage of 5-mm instruments in paediatric robotic surgery. Adequate, delicate instruments for surgery in very narrow spaces are still lacking. Material and methods: Thirty children underwent elective abdominal robotic surgery. Working sites, assembly and operative time, hospital stay, advantages, complications and shortcomings are reported. Results: Interventions were performed in the following anatomical sites: 11 upper abdominal, nine pelvic, ten renal procedures. The majority of procedures required two operative trocars. A 2–3 mm accessory port was necessary for operations in the renal area and upper abdomen. The ports had to be placed at least 3 cm from the costal margins and superior iliac spines and at an angle of at least 130° with respect to the camera trocar. This configuration allowed intra-corporal knotting, vessel ligation and dissection with instruments in the inverted position. Operative times and hospital stays were similar to those reported for 8 mm-instruments. Conclusion: The use of 5-mm instruments was advantageous in renal and pelvic sites. The benefits in upper abdominal surgery need further evaluation, particularly in patients weighing <10 kg. Smaller sized instruments with high endowrist dexterity would resolve the problems encountered in paediatric robotic-assisted surgery using 5-mm instruments.