Electromagnetic navigation improves minimally invasive robot-assisted lung brachytherapy.

OBJECTIVE: Recent advances in minimally invasive thoracic surgery have renewed an interest in the role of interstitial brachytherapy for lung cancer. Our previous work has demonstrated that a minimally invasive robot-assisted (MIRA) lung brachytherapy system produced results that were equal to or better than those obtained with standard video-assisted thoracic surgery (VATS) and comparable to results with open surgery. The purpose of this project was to evaluate the performance of an integrated system for MIRA lung brachytherapy that incorporated modified electromagnetic navigation and ultrasound image guidance with robotic assistance. METHODS: The experimental test-bed consisted of a VATS box, ZEUS and AESOP surgical robotic arms, a seed injector, an ultrasound machine, video monitors, a computer, and an endoscope. Our previous custom-designed electromagnetic navigational software and the robotic controller were modified and incorporated into the MIRA III system to become the next-generation MIRA IV. Inactive brachytherapy seeds were injected as close as possible to a small metal ball target embedded in an opaque agar cube. The completion time, the number of attempts, and the accuracy of seed deployment were compared for manual placement, standard VATS, MIRA III, and the new MIRA IV system. RESULTS: The MIRA IV system significantly reduced the median procedure time by 61% (104 s to 41 s), tissue trauma by 75% (4 attempts to 1 attempt), and mean seed placement error by 64% (2.5 mm to 0.9 mm) when compared to a standard VATS. MIRA IV also reduced the mean procedure time by 48% (85 s to 44 s) and the seed placement error by 68% (2.8 mm to 0.9 mm) compared to the MIRA III system. CONCLUSIONS: A modified integrated system for performing minimally invasive robot-assisted lung brachytherapy was developed that incorporated electromagnetic navigation and an improved robotic controller. The MIRA IV system performed significantly better than standard VATS and better than MIRA III.     

Comparison of skill training with robotic systems and traditional endoscopy: implications on training and adoption

BACKGROUND: Robotic systems are being used by an increasing number of surgeons. This environment is markedly different from that of traditional surgery and involves videoscopic guidance, remote surgical control, and the loss of haptic feedback. Defining how surgeons learn with these systems is necessary to establish training protocols for this technology. This study compared the learning curve for a robotic surgical system with that of traditional endoscopy in the performance of two standardized skill drills. MATERIALS AND METHODS: Twenty participants (average age 27 +/- 4 years, six females) repeated two standardized endoscopic dexterity and depth perception drills for 15 repetitions with the ZEUS robotic surgical system and manual endoscopic instruments (MAN). A score combining time and precision was given for each repetition. The learning curves and overall performance with and without robotic assistance were compared. RESULTS: For both MAN and ZEUS, improvements in performance were significantly greatest during the first five repetitions (P < 0.01, for both). Participants reached the training curve plateau faster with ZEUS than with conventional instruments (8th versus 10th for both drills). Using robotic assistance, dominant and non-dominant hand performance were statistically similar. The number of errors committed with ZEUS were significantly fewer for drill two (0.09 errors/repetition versus 0.24 errors/repetition, P = 0.002) compared to manual technique. CONCLUSIONS: This study demonstrated that training curves for conventional and robotic-assisted systems are remarkably similar. This should prove useful in the training and education of this new technology. This study further suggested that robotics may increase ambidexterity by improving non-dominant hand performance.     

Technical assessment of porcine enteroenterostomy performed with ZEUS robotic technology

BACKGROUND/PURPOSE: Limitations of minimally invasive pediatric surgery include the inability to perform precise anastomoses of 2 to 15 mm. Robotic technology facilitates the performance of endoscopic microsurgical procedures. This study examined the technical feasibility of performing an enteroenterostomy in piglets utilizing ZEUS robotic technology. METHODS: Ten piglets (6.5 to 8.5 kg) underwent enteroenterostomy. Standard laparoscopic techniques were used in the control group (n = 5), and ZEUS robotic technology was used in the experimental group (n = 5). AESOP controlled the camera in both groups. Anesthesia time; surgery time; robotic set-up time; and anastomotic time, patency, diameter, and integrity were compared. RESULTS: No statistical difference existed between the means of the control and experimental groups for anesthesia time (176.0 v 154.0 minute; P =.63), surgery time (143.0 v 139.2 minute; P =.92), anastomosis time (109.4 v 93.0 minutes; P =.56), AESOP set-up time (4.2 v 7.0 minutes; P =.51), and anastomotic diameter (7.062 v 7.362 mm; P =.62). All anastomoses were patent without narrowing. The ZEUS cases averaged 14 minutes faster than the standard laparoscopic cases, even with the ZEUS set-up time included. CONCLUSIONS: These data supports the hypothesis that robotic-assisted enteroenterostomy is technically feasible. ZEUS robotic technology will potentially play an important role in expanding the applications of minimally invasive pediatric surgery.     

Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting.

OBJECTIVE: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. METHODS: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. PHASE I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. PHASE II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. PHASE III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. RESULTS: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. CONCLUSIONS: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.     

Post-brachytherapy transurethral resection of the prostate in patients with localized prostate cancer

PURPOSE: We assessed the rate and results of transurethral resection of the prostate (TURP) in patients previously treated with brachytherapy as monotherapy for localized prostate cancer. MATERIALS AND METHODS: From May 1998 to May 2003, 600 patients with localized prostate cancer were treated with brachytherapy at our institution. Brachytherapy was performed as monotherapy with curative intent for clinically localized prostate cancer without adjuvant treatment in patients with clinical stages T1c (68.4%) or T2a (31.6%) disease. -Iodine and palladium implants were used in 583 and 7 patients, respectively. A real-time interactive implantation technique was used in all but the first 17 patients, who were treated using a preplanned technique. RESULTS: Of the 600 patients 19 (3.1%) underwent TURP after brachytherapy. Among the patients with acute urinary retention the median interval between prostate brachytherapy and urinary retention was 2 months (range 0.5 to 32). No TURP was done within 6 months after implant. The median interval between prostate brachytherapy and TURP was 7 months (range 6 to 41) and median prostate specific antigen (PSA) before TURP was 0.5 ng/ml (range 0.04 to 3.4). In the 19 patients the median weight of resected prostatic tissue was 8 gm (range 2 to 19) and 1 to 11 seeds were removed (median 5). The perioperative and postoperative courses were uneventful. There was no TURP related incontinence. With a median followup of 28 months after brachytherapy (range 7 to 48) no patient had clinical or biochemical evidence of disease progression, and for the group of 19 patients who underwent TURP median serum PSA at the end of followup was 0.38 ng/ml (range 0.03 to 3.4). CONCLUSIONS: After brachytherapy as monotherapy, TURP can be done safely if indicated. In our experience the resection of prostatic tissue along with a limited number of seeds at least 6 months after implantation did not impair PSA based biological and clinical results of brachy-therapy.     

Robotic percutaneous access to the kidney: comparison with standard manual access

PURPOSE: To evaluate the efficiency, accuracy, and safety of robotic percutaneous access to the kidney (PAKY) for percutaneous nephrolithotomy in comparison with conventional manual techniques. MATERIALS AND METHODS: We compared the intraoperative access variables (number of access attempts, time to successful access, estimated blood loss, complications) of 23 patients who underwent robotic PAKY with the remote center of motion device (PAKY-RCM) with the same data from a contemporaneous series of 23 patients who underwent conventional manual percutaneous access to the kidney. The PAKY-RCM incorporates a robotic arm and a friction transmission with axial loading system to accurately position and insert a standard 18-gauge needle percutaneously into the kidney. The blood loss during percutaneous access was estimated on a four-point scale (1 = minimal to 4 = large). The color of effluent urine was graded on a four-point scale (1 = clear to 4 = red). RESULTS: The mean target calix width was 13.5 +/- 9.2 mm in the robotic group and 12.2 +/- 4.5 mm in the manual group (P = 0.57). When comparing PAKY-RCM with standard manual techniques, the mean number of attempts was 2.2 +/- 1.6 v 3.2 +/- 2.5 (P = 0.14), time to access was 10.4 +/- 6.5 minutes v 15.1 +/- 8.8 minutes (P = 0.06), estimated blood loss score was 1.3 +/- 0.49 v 1.7 +/- 0.66 (P = 0.14), and color of effluent urine following access was 2.0 +/- 0.90 v 2.1 +/- 0.7 (P = 0.82). The PAKY-RCM was successful in obtaining access in 87% (20 of 23) of cases. The other three patients (13%) required conversion to manual techniques. There were no major intraoperative complications in either group. CONCLUSIONS: Robotic PAKY is a feasible, safe, and efficacious method of obtaining renal access for nephrolithotomy. The number of attempts and time to access were comparable to those of standard manual percutaneous access techniques. These findings provide the groundwork for the development of a completely automated robot-assisted percutaneous renal access device.     

Open,Video- and Robot-Assisted Thoracoscopic Lobectomy for Stage II-IIIA Non-Small Cell Lung Cancer

BackgroundThis study compares the short- and long-term outcomes of open vs robotic vs video-assisted thoracoscopic surgery (VATS) lobectomy for stage II-IIIA non-small-cell lung cancer (NSCLC).MethodsOutcomes of patients with stage II-IIIA NSCLC (excluding T4 tumors) who received open and minimally invasive surgery (MIS) lobectomy in the National Cancer Database from 2010 to 2017 were assessed using propensity score-matched analysis.ResultsA propensity score-matched analysis of 4652 open and 4652 MIS patients demonstrated a decreased median length of stay associated with MIS compared with open lobectomy (5 vs 6 days; P < .001). There were no significant differences in 30-day mortality, 30-day readmission, or overall survival between the open and MIS groups. A propensity score-matched analysis of 1186 VATS and 1186 robotic patients showed that compared with VATS, the robotic approach was associated with no significant differences in 30-day mortality, 30-day readmission, and overall survival. However, the robotic group had a decreased median length of stay compared with VATS (4 vs 5 days; P < .001). The conversion rate was also significantly lower for robotic compared with VATS lobectomy (8.9% vs 15.9%, P < .001).ConclusionsNo significant differences were found in long-term survival between open and MIS lobectomy and between VATS and robotic lobectomy for stage II-IIIA NSCLC. However, the MIS approach was associated with a decreased length of stay compared with the open approach. The robotic approach was associated with decreased length of stay and decreased conversion rate compared with the VATS approach.     

4D Brachytherapy, a novel real-time prostate brachytherapy technique using stranded and loose seeds

What's known on the subject? and What does the study add? There are a number of techniques used successfully to perform brachytherapy, including 2-stage procedures and realtime techniques using loose seeds. This study demonstrates a one-stage realtime brachytherapy technique using stranded seeds with improved time efficiency and clinical outcome: 4D Brachytherapy. This paper reviews the development of a new one-stage prostate brachytherapy technique (4D Brachytherapy) using a combination of stranded and loose seeds. This novel technique utilizes a nomogram constructed from over 1000 procedures to calculate the seed requirement in advance of the implant. This allows stranded seeds to be pre-ordered and loaded prior to the procedure rather than per-operatively, resulting in a more efficient use of operating room time. The use of both stranded and loose seeds may reduce the risk of migration from peripherally placed seeds via the venous plexus, whilst maintaining the flexibility to optimize the dose within the prostate and especially at the apex of the gland. Prospectively collected data show significantly improved dosimetry: median D(90) 143 and 153?Gy (P < 0.005) and median V(100) 88% and 93% (P < 0.005) for the Seattle technique and 4D Brachytherapy implant technique, respectively. Also there was a reduced short-term urinary morbidity as assessed by the change in International Prostate Symptom Score (IPSS) at 3 months and 1 year compared with the Seattle technique. Mean (sd) change in IPSS from baseline at 1 year was 2.73 (5.92) and 0.97 (5.10) for the Seattle and 4D Brachytherapy series, respectively (P < 0.049).     

Clinical characteristics and feasibility of thoracoscopic approach for congenital cystic adenomatoid malformation in adults.

OBJECTIVE: Congenital cystic adenomatoid malformation (CCAM) in adults is very rare, and surgical resection is the treatment of choice. We evaluated the clinical characteristics and feasibility and safety of video-assisted thoracic surgery (VATS) in adult patients with CCAM. METHODS: Retrospective analysis of nine consecutive adult patients with CCAM treated surgically between January 1995 and April 2006 at a single center. The clinical characteristics and surgical outcome were evaluated retrospectively. RESULTS: The records of five men and four women were examined. The median age at diagnosis was 30.5 years (range 16-44 years). The most frequent symptoms were cough (n=4) and hemoptysis (n=2). Three patients had recurrent respiratory infections. Chest computed tomography (CT) was reviewed in all cases. The lesions were on the right side in six patients and on the left in three. All patients had lesions in a single lobe, except one patient who had multi-lobar lesions. The CCAM appeared as thin-walled multi-septated cystic lesions in six patients and as parenchymal consolidations in three patients. Four patients underwent VATS lobectomy and four underwent lobectomy through a conventional open thoracotomy. One patient had open pneumonectomy. The median operating time (160 min in VATS lobectomy and 165 min in open lobectomy), median duration of chest tube drainage (4 days in VATS lobectomy and 6.5 days in open lobectomy), and postoperative complications (one patient in each treatment group) were similar between the VATS and open lobectomy groups. The hospital stay was shorter in the VATS lobectomy group (median 5 days) than in the open lobectomy group (median 7.5 days). No postoperative or procedure-related mortality occurred. CONCLUSIONS: CCAM is rare in adults. Patients usually present with recurrent respiratory infections and thin-walled multi-septated cystic lesions. VATS is a feasible and safe technique to treat adult patients with CCAM.     

Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy

The financial impact of employing minimally invasive techniques for lobectomy compared with traditional open thoracotomy was assessed. A retrospective review was conducted using ICD9 codes for thoracotomy, video-assisted thoracic surgery (VATS), and robotic VATS lobectomy to determine total average costs associated with the resultant hospital stay. The difference in total average costs was calculated for each group. Robotic VATS lobectomy had higher associated costs than VATS only, primarily attributed to increased costs of the first hospital day, but was still less costly than thoracotomy. The average cost of VATS is substantially less than thoracotomy primarily because of a decreased length of stay. The cost of robotic assistance for VATS is still less than thoracotomy, but greater than VATS alone.     

Video-assisted thoracoscopic introduction of talc in the treatment of recurrent spontaneous pneumothorax.

OBJECTIVE: To present our experience of using a video-assisted thoracic surgical (VATS) technique to treat spontaneous pneumothorax. DESIGN: Retrospective study. SETTING: Teaching hospital, The Netherlands. SUBJECT: 34 patients with recurrent spontaneous pneumothoraces. INTERVENTION: Combined bullectomy, parietal pleural abrasion, and spraying with talc using the Tissuecol (Immuno) spray device using a VATS technique. Measurement of pain by visual analogue scale (VAS) and analgesic requirements. MAIN OUTCOME MEASURES: Duration of drainage and hospital stay, pain, and morbidity. RESULTS: Patients were followed up after 4 weeks and 1 year. Median drainage time postoperatively was 2 days (range 1-3) and duration of hospital stay 3 days (range 2-5). One pneumothorax recurred and one wound became infected. Patients scored a median of 4 (range 1-9) on the VAS for pain at 4 weeks, and 2 (range 0-6) at 1 year. CONCLUSION: Bullectomy combined with pleural abrasion and the introduction of talc using a VATS technique is safe and effective, and requires only a short hospital stay.     

Accuracy study of computer-assisted drilling: the effect of bone density, drill bit characteristics, and use of a mechanical guide

OBJECTIVE: This study was designed to determine the clinical relevant accuracy of CT-based navigation for drilling. DESIGN: Experimental model. SETTING: Laboratory. METHODS: Twelve drills of varying lengths and diameters were tested with 2 different set-ups. Group 1 used free-hand navigated drilling technique with foam blocks equipped with titanium target points. Group 2 (control) used a newly developed 3-dimensional measurement device equipped with titanium target points with a fixed entry for the navigated drill to minimize bending forces. One examiner performed 690 navigated drillings using solely the monitor screen for control in both groups. The difference between the planned and the actual starting and target point (up to 150 mm distance) was measured (mm). STATISTICS: Levene test and a nonpaired t test. Significance level was set as P < 0.05. RESULTS: The core accuracy of the navigation system measured with the 3-dimensional device was 0.5 mm. The mean distance from planned to actual entry points in group 1 was 1.3 (range, 0.6-3.4 mm). The mean distance between planned and actual target point was 3.4 (range, 1.7-5.8 mm). Free-hand navigated drilling showed an increased difference with increased length of the drill bits as well as with increased drilling channel for drill bits 2.5 and 3.2 mm and not for 3.5 and 4.5 mm (P < 0.05). CONCLUSIONS: The core accuracy of the navigation system is high. Compared with the navigated free-hand technique, the results suggest that drill bit deflection interferes directly with the precision. The precision is decreased when using small diameter and longer drill bits.     

Laparoscopic splenectomy with the da Vinci robot

BACKGROUND: We report our first series of minimally invasive splenectomies with a robotic surgical system. METHODS: From August 2001 to October 2003, laparoscopic splenectomies with the da Vinci operating robot were performed in 7 patients (five females and two males, ages 20 to 74 years). RESULTS: Indications for splenectomy were hematologic disorders in four patients and hypersplenism in three patients. Median dimensions of the resected spleens were 140 +/- 34 mm x 80 +/- 11 mm x 50 +/- 17 mm and median weight was 307 +/- 193 g. Median total operative time was 147 +/- 58 minutes including 107 +/- 49 minutes for the robotic act. There were no intraoperative complications and no conversions to open surgery. The median postoperative hospital stay was 7 days. CONCLUSION: This first series suggests that robotic splenectomy with the da Vinci surgical system is technically feasible and safe. It provides an alternative to the conventional laparoscopic procedure. Nevertheless, justification for this new technique will require a larger prospective series and longer follow-up.     

Performance measurements in endolaparoscopic infrarenal aortic graft implantation using computer-enhanced instrumentation: a laboratory model for training.

BACKGROUND: Performance measurements in an endolaparoscopic aortic animal laboratory model have been reported since Dion's work (1995). The purpose of this paper is to report performance measurements using computer-enhanced surgical instrumentation in a porcine model. METHODS: From February 2000 to December 2002, training in robotic instrumentation consisted of implantation of infrarenal aortic grafts in 3 groups of 5 animals each. The time frame to complete all 15 procedures reflects 2 major difficulties: the need to schedule procedures based on the surgeon's time off from his solo practice and the availability of laboratory sites to complete the procedures. A full endolaparoscopic technique was used to perform 2 end-to-end anastomoses through an intraperitoneal approach. A different method of computer-enhanced instrumentation was used for each group of animals as follows: (1) AESOP robotic arm and HERMES integrated voice control instrumentation, (2) AESOP-HERMES-ZEUS robotic systems, (3) da Vinci robotic system. The aortic clamp time, total operative time, and blood loss were recorded for each procedure. Secondary endpoints included spinal cord ischemia, graft thrombosis, and bleeding. RESULTS: All animals tolerated the procedure. All grafts were patent and suture anastomoses intact. Two instances of bleeding, both of which were controlled laparoscopically, occurred. Aortic clamping time was significantly improved in Group 3 compared with that in Group 2 (P=0.008). CONCLUSION: The results of the first group reflect previous experience with the AESOP-HERMES instrumentation. However, the times of the ZEUS group and da Vinci group reflect initial exposure to the technology. The remote position of the surgeon at the console did not appear to affect the performance as shown in the last group. The da Vinci group provides an advantage compared with the ZEUS group. Both systems showed adaptability and versatility in controlling adverse bleeding encounters.     

Robot-assisted Laparoscopic Aortobifemoral Bypass for Aortoiliac Occlusive Disease: Early Clinical Experience

BACKGROUND: Robotic technology may facilitate laparoscopic aortic reconstruction. We present our early clinical experience with laparoscopic aortobifemoral bypass, aided by two different robotic surgical systems. METHODS: Between February 2002 and April 2004, we performed eight robot-assisted laparoscopic aorto-bifemoral bypasses for aortoiliac occlusive disease. All patients were male; median age was 55 years (range: 36-64). Dissection was performed laparoscopically and the robotic system was used to construct the aortic anastomosis. RESULTS: A robot-assisted anastomosis was successfully performed in seven patients. Median operative time was 405 min (range: 260-589), with a median clamp-time of 111 min (range: 85-205). Median blood loss was 900 ml (range: 200-5800). Median anastomosis time was 74 min (range 40-110). In two patients conversion was necessary, one due to bleeding of an earlier clipped lumbar artery after completion of the anastomosis, the other because of difficulties with the laparoscopic exposure of the aorta. On post-operative day 3 one patient died unexpectedly as a result of a massive myocardial infarction. Median hospital stay was 7.5 days (range: 3-57). CONCLUSION: Our initial experience with robotic assisted laparoscopic surgery (RALS) shows it is a feasible technique for aortoiliac bypass surgery. However, laparoscopic aortoiliac surgery demands considerable experience and operative times need to be reduced before this technique can be widely implemented.     

Efficiency of manual versus robotical (Zeus) assisted laparoscopic surgery in the performance of standardized tasks

Background: The objective of this study was to compare the efficiency of manual and robotically assisted laparoscopic surgery. Methods: To evaluate the surgical efficiency in a set of basic endoscopic movements, 20 medical students without any surgical experience were selected to perform at random a set of laparoscopic tasks either manually or robotic assisted (Zeus). This task consisted of dropping beads into receptacles, running a 25-cm rope, capping a hypodermic needle, suturing, and performing a laparoscopic cholecystectomy on a cadaver liver of a pig. A quantitative time–action analysis was performed to evaluate the efficacy and skill performance in terms of time and the number of actions. Results: The dropping beads exercise and the laparoscopic cholecystectomy required more time when performed with robotic assistance, as compared with manual performance (respectively, median, 78.5 s; range, 63 – 122 s vs median, 144.5 s; range, 100 – 169 s; p <0.01 and median, 34.0 min; range 11–44 min vs median, 46.5 s; range, 21 – 79 min; p = 0.05). A tendency toward fewer total actions in all the robotically assisted exercises was observed. However, significance was shown only in the rope-passing task (median, 71; range, 59 – 87 vs median, 62; range, 57–80; p = 0.05). Grasping the beads, the rope, and either the needle or the cap were tasks that required fewer actions to complete when performed with robotically assistance (respectively, median, 11; range, 10 – 14 vs median, 12.5; range, 11 – 15; p <0.01; median, 56; range, 55 – 60 vs median, 60.5 min; range, 55 – 65; p = 0.03, and median, 6; range, 4 – 21 vs median, 10.5; range, 6 – 38; p = 0.02). As compared with the robotically assisted rope-passing exercise, more failures were made in the manually performed procedure (p = 0.03), mainly caused by unintentional dropping of the rope (p = 0.02). Conclusions: Robotically assisted laparoscopic surgery by participants without any surgical experience might require more time, but actions can be performed equally or more precisely as compared with manual laparoscopic surgery.     

Video-assisted thoracoscopic surgery for spontaneous pneumothorax--a 7-year learning experience

OBJECTIVES: To determine the effect of increasing experience of video-assisted thoracoscopic surgery (VATS) in the treatment of spontaneous pneumothorax (SP) on clinical efficacy and surgical practice. PATIENTS AND METHODS: A prospective study of 180 consecutive operations in 173 patients who underwent VATS for SP by a single surgeon during a 7 year period. RESULTS: 118 patients, mean age 32.1 years (range 13-63 years), were treated for primary spontaneous pneumothorax (PSP) while 55 patients, mean age 65.9 years (range 28-92 years), were treated for secondary spontaneous pneumothorax (SSP). All patients had VAT parietal pleurectomy combined in 162 (90%) patients with stapled bullectomy. At a current median experience of 2.0 years (range 0.4-6.8 years), 12 (6.6%) patients required reoperation for treatment failures within 12 months of surgery--9 patients within 30 days of VATS and 3 for late recurrent pneumothorax. Two patients (both with SSP) died within 30 days of surgery. When compared with PSP, VATS in SSP is characterized by an elderly, male predominance, a longer postoperative stay, a higher mortality rate and a lower rate of late recurrence. With increasing experience of the technique, there has been a significant decrease in treatment failures. In the treatment of PSP, both operating time and postoperative stay have decreased significantly with experience whilst the use of staple cartridges per patient has increased significantly with experience in both PSP and SSP. CONCLUSION: There is a demonstrable 'learning curve' effect on the clinical efficacy and surgical practice of video assisted thoracoscopic surgery for spontaneous pneumothorax.     

Minimally invasive approaches for lung lobectomy – from VATS to robotic and back!

BACKGROUND: Recently, minimally invasive approaches for pulmonary lobectomy have gained increasing interest and acceptance. Besides, the "conventional" video-assisted thoracoscopic (VATS) approach, the robotic technique with the da Vinci™ surgical system has been evaluated by different groups. METHODS: An appraisal of both approaches is given based on profound personal experiences and with reflexion of the current literature. RESULTS: Both techniques have been proven to be feasible and safe. Operating times and costs are higher with the robotic approach, without proven advantages over conventional VATS. Long-term follow-up data support the oncologic accuracy of the VATS approach but are still lacking for the robotic approach. CONCLUSIONS: The robotic approach provides no proven benefits over the conventional thoracoscopic approach and is thus not recommended for pulmonary lobectomy.     

Fluoroscopy-aided thoracoscopic resection of pulmonary nodule localized with contrast media

BACKGROUND: The pulmonary nodules have become the major indication of video-assisted thoracic surgery (VATS). Recently, several preoperative or intraoperative techniques for identifying small or deeply seated pulmonary nodules have facilitated thoracoscopic resection. We describe the new technique for detecting difficult lesions. METHODS: Preoperatively, we marked the visceral pleura near the pulmonary nodules with dye, simultaneously injected contrast media (1 water-soluble Optiray [Mallinckrodt Medical Inc, Quebec, Canada], 18 barium sulfate, 11 Lipiodol [Laboratoire Guerbet, Aulnay-sous-Bois, France]) into or around the nodule under computed tomography (CT) guidance. During VATS, we were able to easily and accurately detect and resect all the nodules localized with contrast media, of which the radiopacity was visualized on the portable fluoroscopic monitor. RESULTS: Between February 1996 and December 1998, we thoracoscopically resected 30 nodules in 28 patients (13 were women; age, 53 +/- 14 years). The resected nodules were 17 +/- 7.6 mm (range; 4 to 32 mm) in size, and 8.9 +/- 8 mm (range, 2 to 34 mm) in depth. The pathologic diagnosis of the nodules was benign in 20 and malignant in 10 (six primary cancers of lung and four metastatic cancers). There were only minor complications related CT localization. CONCLUSIONS: This new technique can help the surgeons detect and resect the difficult lesions with safety and rapidity by VATS without thoracotomy.