手术机器人在腹部外科应用现状与展望

近年来兴起的手术机器人技术在微创的基础上,依靠其前所未有的技术优越性将手术的精准度和可行性提升到了一个全新的高度,引起人们的广泛关注,并已在腹部外科逐步应用[1-3]。     

Proof‐of‐concept of a laser mounted endoscope for touch‐less navigated procedures

Background and Objectives

During navigated procedures a tracked pointing device is used to define target structures in the patient to visualize its position in a registered radiologic data set. When working with endoscopes in minimal invasive procedures, the target region is often difficult to reach and changing instruments is disturbing in a challenging, crucial moment of the procedure. We developed a device for touch less navigation during navigated endoscopic procedures.

Materials and Methods

A laser beam is delivered to the tip of a tracked endoscope angled to its axis. Thereby the position of the laser spot in the video‐endoscopic images changes according to the distance between the tip of the endoscope and the target structure. A mathematical function is defined by a calibration process and is used to calculate the distance between the tip of the endoscope and the target. The tracked tip of the endoscope and the calculated distance is used to visualize the laser spot in the registered radiologic data set.

Results

In comparison to the tracked instrument, the touch less target definition with the laser spot yielded in an over and above error of 0.12 mm. The overall application error in this experimental setup with a plastic head was 0.61 ± 0.97 mm (95% CI ?1.3 to +2.5 mm).

Conclusion

Integrating a laser in an endoscope and then calculating the distance to a target structure by image processing of the video endoscopic images is accurate. This technology eliminates the need for tracked probes intraoperatively and therefore allows navigation to be integrated seamlessly in clinical routine. However, it is an additional chain link in the sequence of computer‐assisted surgery thus influencing the application error. Lasers Surg. Med. 45:377–382, 2013. © 2013 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals, Inc.

     

Content validation of a novel robotic surgical simulator

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

? To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System.

PATIENTS AND METHODS

? Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool.

RESULTS

? Forty‐two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. ? Eighty per cent of the entire cohort had an average of 4 years of experience with robot‐assisted surgery. ? Eleven (26%) novices lacked independent robot‐assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160–2200) robot‐assisted cases. Experts rated the ‘clutch control’ virtual simulation task as a good (71%) or excellent (29%) teaching tool. ? Seventy‐eight per cent rated the ‘ball place’ task as good or excellent but 22% rated it as poor. ? Twenty‐seven per cent rated the ‘needle removal’ task as an excellent teaching tool, 60% rated it good and 13% rated it poor. ? Ninety‐one per cent rated the ‘fourth arm tissue removal’ task as good or excellent. ? Ninety‐four per cent responded that RoSS would be useful for training purposes. ? Eighty‐eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. ? Seventy‐nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery.

CONCLUSION

? Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity.     

微创外科——不断发展的技术与理念

自1991年国内开展第1例腹腔镜胆囊切除术以来,在外科的每一个领域,微创外科手术无论是技术还是理论都取得迅速和广泛的发展。腹腔镜肝切除术已不再是梦想,且已成为现实,国外已报告2804例腹腔镜肝切除术。腹腔镜切除术已成为胰腺良性肿瘤的一种治疗方式,更是用于重症急性坏死性胰腺炎及平时危重疾病控制损伤的处理。目前自然腔道外科（NOTES）和机器人手术获得了越来越多的关注。影像学?内镜?腹腔镜?机器人?N0TES的“结盟”,将给传统的外科学带来极大的震撼。外科的明天可能会越来越数字化。     

腹腔镜技术的现状与展望

腹腔镜技术在普外科手术中的应用在经历了20年的发展历程之后,已从最初的单纯胆囊切除手术逐步发展到今日涉及胃肠、肝胆、胰腺、甲状腺、乳腺和腹壁外科等普外科几乎所有手术。目前,腹腔镜正处于专科化,规范化和进一步微创化的时代,随着手术技术、手术器械的不断发展与创新,腹腔镜技术将会获得更进一步的发展。     

微创技术治疗胸腰椎骨折

目的研究微创技术治疗脊柱骨折的适应证和疗效。方法选择10例单纯胸腰椎骨折、损伤平面以下无神经功能损害、无需进行椎板减压的患者，在C臂X线机下定位病椎椎弓根根部，做4个1.5cm长的切口，固定与复位均在这4个小切口内完成。结果所有患者均恢复惟体高度并矫正后凸畸形。手术时间约1．5h，出血量约50ml。结论微创技术治疗脊柱骨折适用于单纯胸腰椎骨折、损伤平面以下无神经功能损害、无需进行椎板减压的患者，优点是创伤小、术后康复快。     

Minimal invasive surgery for hip replacement: a new technique using the NILNAV hip system

Background: Minimal invasive surgical techniques are used for cruciate ligament reconstructions, unicondylar knee replacements and, more recently, for fixation of fractures. This is a report of the first instrumented technique for hip replacement using a 5‐cm incision without the need for a navigation system or X‐rays. Methods: It uses the C.F.P stem (LINK) but is universal. It includes jigs for the osteotomy of the neck, a right‐angled reamer and spacers (lollipops) to orientate the acetabular cup to the femoral stem. A case series of 14 patients using this new hip replacement technique (called NILNAV Hip System) is reported. Results: The procedure was successfully performed on all seven patients, with reduced postoperative pain and stiffness, and increased quality of life and functional status. All patients were discharged on postoperative Days 1 and 2 with minimal pain and blood loss. Conclusions: This new minimal access total hip replacement technique was successfully performed on seven patients. There are several advantages of using this system compared with the more traditional techniques. Such a technique should help reduce morbidity and mortality rates for those patients undergoing a total hip replacement.     

Laparoscopic ligation of the median sacral artery before resection of a sacrococcygeal teratoma

To minimize the risk of exsanguinating hemorrhage, the authors describe a technique of laparoscopic ligation of the median sacral artery before posterior sagittal resection of type I sacrococcygeal teratoma (SCT). Two female infants with antenatally diagnosed SCT underwent postnatal evaluation and preoperative imaging and were taken to the operating room. In both patients, pneumoperitoneum was established via an epigastic 5-mm trocar. Two additional trocars were inserted in the right and left lower quadrants. The peritoneal reflection was opened to the right of the sigmoid colon, and the presacral space was explored. A large median sacral artery was identified easily, isolated, and divided. The children then were placed in a prone position, and the tumors underwent en bloc resection via a Chevron incision with minimal blood loss. The laparoscopic portion of the procedure was performed in an average of 15 minutes. This is the first report of laparoscopic ligation of the median sacral artery before posterior resection of a sacrococcygeal tumor in an infant. This technique can be performed easily with minimal morbidity. Division of this artery is a logical preventative measure and may reduce the risk of hemorrhage during operative resection.     

微创外科近20年进展及未来发展趋势

腹腔镜微创外科经历了3个发展阶段,即从“要不要做？”到“如何规范做？”,再到“做什么？”。回首过去20年,微创手术已从最初的单纯胆囊切除拓展到胃肠、肝胆胰、减重代谢、疝与腹壁外科等领域,手术量和手术复杂度逐步提高。展望未来,微创外科将更多地结合疾病本身治疗的进步而发展,人工智能、虚拟现实、下一代移动通信传输、肿瘤靶向治疗等技术将助力微创外科的进一步创新。微创外科也将秉承“绿色”理念,实现可持续发展。     

腹腔镜与内镜相结合——微创外科发展方向

腹腔镜技术是外科发展史上具有革命性意义的重大进步,更重要的是使微创观念植根于外科医生心中.同时,内镜技术的发展同样日新月异,双操作孔道内镜和"子母镜"的出现,大大拓展了内镜下诊断治疗的适应证.     

Microsurgical management of the lumbar intervertebral disc-disease

One hundred consecutive patients operated on for sciatica pain using microsurgical techniques between April 1984 and February 1985 were evaluated retrospectively. This paper gives preoperative clinical data, end-result of surgery, rate of complications and true recurrent herniations.On the basis of the results, both soon after operation and at later follow-up (between three and five years) we fell encouraged to continue using this mode of operation. Complete or significant pain relief was achieved in 92% of patients; 93% were able to return to their preoperative normal physical activities. The frequency of complications was low.     

NOTES: new dimension of minimally invasive surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery. NOTES eliminates abdominal incisions and incision‐related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Since the first NOTES was reported by Kalloo et al. in 2004, significant achievements in the laboratory have occurred. Clinical use in humans has been limited, but several cases and one small clinical trial were published recently. As a further technical revolution in minimally invasive surgery, NOTES has the promising potential to be safer, less invasive, provide better cosmesis and possibly be more cost‐effective. The purpose of the present article was to review the development and current status of NOTES and highlight important advances associated with this innovative approach.