Launching a successful robotic surgery program

Robotic-assisted laparoscopic prostatectomy is rapidly becoming the most commonly performed surgical approach to treat clinically localized prostate cancer. The establishment of a robotic surgery program at any institution requires a structured plan and certain key elements to be in place to allow successful development. At least five essential phases are necessary for successful implementation of a robotics program. A thorough initial design and implementation lead to the execution of clinical services that meet previously established goals. Once the execution phase is established, the next step is to focus on maintenance and growth to maximize the benefits of the program. In this paper, we discuss the necessary phases for creating a successful robotic program, paying special attention to the aspects that allowed our facility to create a profitable robotic-assisted laparoscopic prostatectomy program in year 1.     

Image-guided robotic surgery

Medical image processing leads to an improvement in patient care by guiding the surgical gesture. Three-dimensional models of patients that are generated from computed tomographic scans or magnetic resonance imaging allow improved surgical planning and surgical simulation that offers the opportunity for a surgeon to train the surgical gesture before performing it for real. These two preoperative steps can be used intra-operatively because of the development of augmented reality, which consists of superimposing the preoperative three-dimensional model of the patient onto the real intraoperative view. Augmented reality provides the surgeon with a view of the patient in transparency and can also guide the surgeon, thanks to the real-time tracking of surgical tools during the procedure. When adapted to robotic surgery, this tool tracking enables visual serving with the ability to automatically position and control surgical robotic arms in three dimensions. It is also now possible to filter physiologic movements such as breathing or the heart beat. In the future, by combining augmented reality and robotics, these image-guided robotic systems will enable automation of the surgical procedure, which will be the next revolution in surgery.     

Teaching robotic surgery: a stepwise approach

Background After an initial institutional experience with 50 robot-assisted laparoscopic Roux-en-Y gastric bypass procedures, a curriculum was developed for fellowship training in robotic surgery. Methods Thirty consecutive robotic gastric bypasses were performed using the Zeus robotic surgical system to fashion a two-layer gastrojejunostomy. For teaching purposes, performance of the anastomosis was divided into three discrete tasks. Robotic suturing tasks were assigned to the trainee in cumulative order in ten-case increments. Our patient population averaged 44 years of age and 47 kg/m² in BMI. Patients were predominantly female (87%). Results The robotic training experience of the fellow defines the increases in surgical responsibility over the series of cases. Statistical analysis revealed no significant differences in task times or total robotic operative time as participation of the trainee in performing the gastrojejunostomy increased. No adverse robotic events or surgical complications occurred throughout this series. The learning curve of the fellow compared favorably with the initial experience of the institution. Conclusion Robotic surgery training may be safely implemented in a minimally invasive surgery training program. A gradual introduction of robotic technique appears to maximize the learning experience and minimize the potential for adverse outcomes. Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) April 13–16, 2005 in Fort Lauderdale, Florida, USA.     

Trends in robotic surgery

Robotic surgery began as a technology-driven innovation but is now becoming a genuine method of improving healthcare effectiveness worldwide. This comprehensive review introduces the current trends, using examples of specific systems to distinguish the various types of robotic surgical devices, from remote handling machines to those performing delicate local interventions. We end by commenting on how to extend existing systems and provide an account of the rapid developments in minimally invasive robotic surgery.     

Computer-assisted robotic antireflux surgery

Antireflux surgery has evolved significantly since its inception 50 years ago. The current standard is laparoscopic fundoplication. The computer-assisted telemanipulator, a new device recently approved for use in laparoscopy, reduces some of the shortcomings of the laparoscopic approach. This review specifically discusses the role of this novel surgical tool in antireflux surgery.     

Dual-console robotic surgery: a new teaching paradigm

Robotic surgery has emerged as an alternative option in minimally invasive gynecologic surgery. The development of the dual-console da Vinci Si Surgical System^® has enabled modification of the training atmosphere. We sought to investigate operative times and surgical outcomes while operating with the dual-console model in a training environment for our first fifty cases. We identified the first fifty patients who underwent robot-assisted total hysterectomy (TRH), with or without bilateral salpingo-oophorectomy (BSO), with or without pelvic and para-aortic lymph node dissection (PPALND), by use of the dual-console robotic system. Records were reviewed for patient demographics and surgical details. All surgery was conducted using the dual-console system and performed by staff physicians and fellows. Operative time was calculated from robotic docking until completion of the procedure. Cases were identified from November 2009 through July 2010. Mean age was 56.2 years (SD 13.35, 95 % CI 52.46–59.86). Mean BMI was 29.5 (SD 7.67, 95 % CI 27.35–31.61). Seventy-eight percent of these patients were considered overweight, including 12 defined as obese (BMI 30–34.9) and 10 patients classified as morbidly obese (BMI ≥ 35). Surgery completed included PPALND alone (n = 1); radical hysterectomy (n = 1); TRH only (n = 3); TRH/BSO (n = 25); and TRH/BSO/PPALND (n = 20). Mean total operating room time was 188.8 min (SD 55.31, 95 % CI 173.45–204.11). Mean total surgical time for all cases was 118.1 min (SD 44.28, 95 % CI 105.87–130.41). Two vascular injuries were encountered, with one requiring conversion to laparotomy. These results compare favorably with historically reported outcomes from single-console systems. Utilizing the dual-console enables use of an integrated teaching and supervising environment without compromising operative times or patient outcomes.     

Laparoscopic principles of robotic surgery

The evolution of surgical therapy has been vertiginous, from the classical principles of open surgery to laparoscopy and currently to robotic surgery, in which the principles of robotic engineering have been successfully applied to the surgeon's daily work. The development of minimally invasive surgery, initially led by conventional laparoscopy, was a fertile field for the development of surgical techniques with the robot. The use of automatized systems for surgery is not as new as one could think, but the robots today participating in the main operative rooms worldwide are an example of the newest and most advanced available technology. Urology has become the leading surgical speciality in the application of technologies for diagnosis and treatment of its diseases, and robotic surgery is not an exception. We present our vision about the state of the art in automatized surgery, in the setting of its close relationship with conventional laparoscopic surgery, which originated it.     

Application of a robotic telemanipulation system in stereotactic surgery

To assess the clinical usefulness, accuracy, and safety of telemanipulation for frameless stereotactic surgery using the CAS-BH5 robot system, we prospectively evaluated 10 patients (age: 5-79 years; mean: 44 years) who underwent telemanipulation frameless stereotactic operations from September to December 2005. The CAS-BH5 robot system consists of three main parts: a planning subsystem, a surgical localization subsystem, and a telemanipulation subsystem. Specifically, CAS-BH5 is capable of network communication, video transmission, graphic simulation and human-machine interaction, and thus facilitates remote planning and transmission of neuronavigation data, monitoring and manipulating. Telemanipulation was performed via a digital data network with a speed of 2,000 kilobytes per second by a neurosurgeon in Beijing while the patients were located in Yan'an, 1,300 km away. Remote fiducial registration was performed with a mean accuracy of 1.05 mm and the standard difference between the planned and actual trajectory was 0.13 mm. The mean time from fiducial registration to closure was 30.2 +/- 1.66 min. At 12-month follow-up, 90% of patients had improved neurologically. There were no complications. This preliminary data indicates that telemanipulation in frameless stereotactic surgeries is feasible, reliable and safe. In the future, we believe that telemanipulation will facilitate collaboration between surgeons, enhance training, allow for sharing of resources, and have wide applications in the field of neurosurgery.     

机器人手术系统在心脏外科手术中的应用

随着外科手术微创化的发展,达芬奇机器人手术系统已被应用于多种心脏外科手术.该系统融合了人工智能的研究成果,具有3D高清术野、动作缩放、机械臂灵活、震颤过滤、操作稳定、创伤小等优点,且能缓解医护人员疲劳.外科手术机器人为心脏外科手术的快速化、精准化、微创化提供了新的思路和途径,代表了微创心脏外科的发展方向.但达芬奇机器人手术系统作为通用型腔镜手术机器人,在心外科的应用也面临系统复杂、操作时间长、缺乏触觉反馈、总体费用昂贵等不足和挑战.本文主要阐述了达芬奇机器人手术系统在心脏外科领域应用的优势、安全性、有效性及在推广、应用过程中存在的问题,并对其未来的发展前景进行了展望,期望可以为机器人手术系统在心脏外科的应用提供帮助.     

Outcomes in robotic cardiac surgery

The specialty of cardiac surgery has evolved substantially over the last 50 years, and surgical procedures that seemed impossible then are now commonly encountered in hospitals throughout the world. The latest development in this ever-evolving field is minimally invasive and robot-assisted procedures. In this article we will review the surgical outcomes reported for different series of procedures in cardiac surgery.     

Updates in robotic colorectal surgery

Since the introduction of master-slave manipulators (otherwise known as telemanipulators) in 1990, minimally invasive surgery paved the way for the development of the first robotic surgical systems to overcome the limitations of laparoscopic surgery. The robotic system over the last decade has rapidly gained acceptance and popularity among surgeons, especially colorectal surgeons around the world. Advantages of robotic surgical systems includes superior instrumentation and stable field of vision which enable precise dissection in confined spaces such as the pelvis. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior perioperative and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe and USA has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skills. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.     

Updates in robotic colorectal surgery

Since the introduction of master-slave manipulators (otherwise known as telemanipulators) in 1990, minimally invasive surgery paved way for the development of the first robotic surgical systems to overcome the limitations of laparoscopic surgery. Over the last decade, the robotic system has rapidly gained acceptance and popularity among surgeons, especially colorectal surgeons around the world. Advantages of robotic surgical systems includes superior instrumentation and stable field of vision which enable precise dissection in confined spaces such as the pelvis. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior perioperative and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe and USA has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skills. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.