机器人微创心脏手术的应用现状

微创是心脏外科的发展方向之一.随着自动机械和计算机技术的进步,机器人微创外科手术已成为现实.机器人微创心脏手术具有创伤小、操作精细等优点,是微创心脏外科的前沿技术之一.作为一种革新的手术方式,机器人辅助下微创心脏手术得到了极大的关注,本文就机器人心脏手术的临床应用及手术效果作一综述.     

Totally robotic left colectomy

Laparoscopic colectomy has been a challenge for surgeons due to steep learning curves, limited dexterity of instruments and non-depth perception with visualization. Robotics for left colectomy has been described in the past years using mostly single docking or hybrid techniques. With the advantages of the robotic technology including the use of 3D visualization, increase dexterity with 360-degree motion of the instruments, surgeons may see an increase in the adoption of minimally invasive surgery for colectomies. Surgeons know that multi-quadrant dissection can be difficult at best with the current platforms available due to the approach of the angles with the robotic arms and collisions. The use of a single docking technique can be challenging especially for the dissection of the splenic flexure especially in obese patients. We describe a double docking technique for the approach of the left colectomy that may help surgeons in the approach of multi-quadrant colorectal surgery.     

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.     

Miniature in vivo robot for laparoendoscopic single-site surgery

Background  

The aim of this study was to develop a multidexterous robot capable of generating the required forces and speeds to perform surgical tasks intra-abdominally. Current laparoscopic surgical robots are expensive, bulky, and fundamentally constrained by a small entry incision. A new approach to minimally invasive surgery places the robot completely within the patient. Miniature in vivo robots may allow surgeons to overcome current laparoscopic constraints such as dexterity, orientation, and visualization.     

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??A rational evaluation of open surgery in the era of minimally invasive surgery GU Jin. Department of Gastrointestinal Oncology, Peking University Cancer Hospital; Pediatric Surgery, Shougang Hospital, Peking University,Beijing100042,China
Abstract Nowadays, laparoscopic resection of colorectal cancer is widely used. Robust evidence to conclude that laparoscopic surgery and open surgery have similar outcomes in colorectal cancer. Undeniably, we have entered an era of minimally invasive surgery, and our traditional open surgery is being replaced by minimally invasive surgery in recent decades owing to favorable short-term outcomes, such as less pain, reduced blood loss, and improved recovery time. Surgeons should be soberly aware that there is a serious tendency for young surgeons in the field of surgery to simply pursue technology. They no longer pay attention to traditional open surgery, but are keen on the latest minimally invasive technology to make and show a beautiful surgery.In this era of minimally invasive surgery, Surgeons must realize that open surgery still plays an important role in tumor treatment.     

A comprehensive review of anti-reflux procedures completed by computer-assisted tele-surgery

Gastro-esophageal reflux disease (GERD) is the most common esophageal disorder. Although GERD is an illness primarily treated by medical management, patients refractory to, or those unwilling to endure long-term medical therapy often undergo anti-reflux surgery. Laparoscopic surgery made the surgeon's task technically more challenging. While laparoscopy provides a good field of vision, all depth perception is lost. Furthermore, the movements of the chopstick-like instruments are counter-intuitive with limited degrees of freedom, diminished tactile feedback, and disassociated movement. Now that advanced minimally invasive surgeons have acquired the necessary skills to overcome these hurdles, technology has developed a way to make laparoscopic surgery easier. The latest advance in laparoscopic surgery is computer-assisted telesurgery (CATS) which allows the surgeon to be seamlessly submerged into the surgical field while being seated at a distance from the patient. The technological advances afforded by CATS make minimally-invasive surgery easier by adding stereoscopic vision, which provides depth perception, and the endo-wrist, which provides wrist-like dexterity within the abdominal cavity. The advantages of CATS are: the ergonomic positioning of the surgeon thus decreasing fatigue; stereoscopic vision with possibility of 10x magnification; wrist-like manual dexterity with intuitive motion; motion-scaling and tremor elimination all of which enhance precision and accuracy. A small yet growing body of evidence has provided information which suggests that the use of CATS for anti-reflux surgery is equivalent to the current gold standard, unassisted laparoscopy.     

理性看待微创外科时代的开放手术——从《新英格兰医学杂志》的一篇文章谈起

当今,腹腔镜微创技术已经广泛应用于临床。大量证据表明,微创手术在结直肠癌的治疗中具有有创伤小、失血少、恢复快、疼痛轻的优势,而且短期和远期疗效表现出与开放手术相当的结果。在过去的几十年中,微创手术正在取代开放手术。但也应该看到,当前青年外科医师单纯追求技术的倾向十分严重,他们对传统的开放手术不再关注,热衷于最新的微创技术,做漂亮的手术。在这个微创外科全面到来的时代,必须认识到,开放手术经过100多年的历史积淀,仍在肿瘤治疗中发挥着重要作用。     

微创胃肠外科现状的反思

自1987年Mouret进行世界首例LC以来,以腹腔镜为基本技术的微创外科得到了迅猛的发展,成为外科发展史的一个里程碑。20年来,胃肠外科微创手术完成了从良性疾病向恶性肿瘤的过渡;微创理念深入人心,推广、普及非常迅猛,我国的胃肠微创手术水平跻身国际前列;微创胃肠手术已从精准化进入了功能化时代。然而,在遇到巨大发展机遇的同时我们也面临巨大的挑战,未来如何发展很大程度上取决于我们今天对微创胃肠外科现状的反思以及对未来的评估。     

Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.     

State of the Art in Robotic Hepatobiliary Surgery

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon’s movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.     

Use of operative laparoscopes in single-port surgery: The forgotten tool

Single-port surgery is an emerging advancement in the field of minimally invasive surgery. Several different techniques and tools have been developed to decrease the invasiveness of various operations. Amongst these new developments, many general surgeons have overlooked an important tool, the operative laparoscope. These telescopes reduce the number of ports placed during minimally invasive operations by providing both visualization and operative channels to accommodate instruments. We have described several simple techniques that employ the operative laparoscope to reduce the number of incisions in laparoscopic surgery with good outcomes. Single-port surgery has been shown to be safe and effective and may someday replace traditional laparoscopy in the performance of minimally invasive operations.     

Special problems in laparoscopic surgery. Previous abdominal surgery, obesity, and pregnancy

Previous surgery, obesity, and pregnancy should no longer be considered contraindications to laparoscopic surgery. Surgeons should exercise good judgement in patient selection, use meticulous surgical techniques, and prepare thoroughly for the planned procedure. Patients and surgeons should be aware of increased conversion rates. With these caveats in mind, these patients can still experience the advantages of minimally invasive surgery without increased risks.     

Laparoscopic truncal vagotomy, antrectomy with Billroth-II reconstruction for complicated duodenal ulcer (Case report and literature review)

Today surgeons are performing fewer elective ulcer surgeries, as H2 receptor blockers and the eradication of Helicobacter pylori represent a major step in treatment of this disease. Nevertheless, patients with complications and those resistant to medical therapy should be offered surgical options. The laparoscopic management of these complications is an alternative to open surgery, if applied with appropriate patient selection. The authors report a case with repeated bleeding and duodenal narrowing due to a duodenal ulcer. The patient was treated by totally intraabdominal laparoscopic truncal vagotomy, antrectomy and Billroth-II reconstruction--this probably being the first performed and publicized operation in Hungarian literature. The technique this operation and common perioperative problems based on existing literature are reviewed. The benefits of the minimally invasive approach were clearly evident. The authors believe that minimally invasive approaches will renew the interest in definitive surgery for the treatment of ulcer disease.     

Laparoscopic pancreatoduodenectomy: How far have we come and where are we headed?

Minimally invasive pancreatoduodenectomy is currently a feasible option in selected patients at high volume centers with available expertise. Although the procedure has been described two decades ago, laparoscopic surgeons have been reluctant to perform it since it is technically demanding. Currently there is no standardized training process for minimally invasive pancreatoduodenectomy and this is required to ensure the safety of the procedure. Even the open pancreatoduodenectomy can be a challenging procedure where the outcome depends much upon the patient volume and surgeon’s experience. In the minimally invasive setting, all the current evidence comes from retrospective data with inherent selection bias. Although the proposed benefits have been reported in many series, a randomized trial comparing with the open approach is highly unlikely to happen, given the complexity of pancreatic cancer and patient selection for complex surgery. Rather, in a disease for which cure is an utopian statement, perhaps the ultimate aim of minimally invasive pancreatoduodenectomy can be the improvement in the quality of life. Also further studies are needed to assess the immunologic role affecting the oncologic outcomes in patients undergoing minimally invasive pancreatoduodenectomy. The robotic platforms have got easily accepted since they can overcome some of the limitations of the laparoscopic platforms such as limited range of motion, two dimensional visualization and poor ergonomics. The main limitations of robotic procedures are related to the high costs associated with the system and disposable equipment. Currently evidence is lacking regarding the cost effectiveness of the procedure and also the push from the industry is on rise. All these minimally invasive techniques have a long learning curve and prior extensive experience in hepatopancreatobiliary surgery is mandatory for surgeons embarking on these endeavours.     

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.     

腹腔镜手术治疗胰腺肿瘤的现状

Laparoscopic pancreatic surgery represents one of the most advanced applications for laparoscopic surgery currently in use.In the past,minimally invasive techniques in pancreatic surgery were only used for diagnostic laparoscopy,staging of pancreatic cancer and palliative procedures for unresectable pancreatic cancer.A growing number of case series and multi-institutional reports on safety and efficacy of minimally invasive pancreatic resection have been published.Current knowledge on minimally invasive pancreatic resection is based mainly on short-term outcomes from a small number of centers with cohorts too small to make strong arguments for or against its use.In carefully selected patients,minimally invasive pancreatic resection is safe and feasible.However,the procedure should only be attempted by surgeons who are experienced in open pancreatic surgery and in laparoscopic surgery.The role and oncologic safety of minimally invasive approach for pancreatic resection for pancreatic cancer remain unknown.     

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手术切除是惟一有希望治愈结直肠癌肝转移的手段。随着微创技术的不断进步,腹腔镜和机器人技术越来越多地应用于结直肠癌肝转移的手术治疗中,并取得了较好的疗效。腹腔镜和机器人技术的应用,只有在结直肠癌肝转移外科治疗的总体原则框架下,严格把握手术指征,合理选择手术时机,才能充分发挥微创技术的优势,以更小的创伤、更小的打击和更小的风险使结直肠癌肝转移病人得到合理的治疗。临床上,在充分考虑每个病人的整体情况后,经过多学科综合治疗协作组讨论,合理应用腹腔镜及机器人等手术方式,将扩大微创手术治疗的优势,给更多的结直肠癌肝转移病人带来更佳的近期和远期疗效。     

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??Current status and future perspective: robot-assisted laparoscopic techniques ZHOU Ning-xin, LIU Quan-da. The PLA Secondary Artillery General Hospital, Beijing, 100088, China
Corresponding author??ZHOU Ning-xin, E-mail: zhounx301@163.com
Abstract With the widespread of conventional laparoscopic techniques, modern surgery has evolved into a minimally invasive era. However, the limitations of conventional laparoscopic equipments confine its further expanding applications. The advent of robot-assisted laparoscopic techniques (surgical robot), with advantages of improved 3D visualization of the operative field and increased dexterity allowing more precise and complicated procedures, overcomes above limitations. Thus, there has been an unprecedented explosion in the use of surgical robotics in all surgical subspecialties, which heralds the coming of a new minimally invasive era.     

Minimally invasive esophagectomy for caustic esophageal stricture in children

Esophageal stricture after lye ingestion in children is the most frequent indication for esophagectomy in children, but this operation entails significant risks for complications. With continuing advances in minimally invasive technology, complex procedures such as esophagectomy can be performed using small incisions, with the aim of reducing morbidity and mortality. Experience with minimally invasive esophagectomy is limited and has involved thoracoscopic dissection with the addition of laparotomy for gastric mobilization. The authors report a case of intractable caustic esophageal stricture in a child treated by a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. In adult patients, this procedure has been associated with decreased hospital stay and more rapid return to normal activities, and we believe similar benefits will be obtained in children. Until further studies are done to show the advantage over the standard open technique, this procedure should be performed only in centers with experience in open esophageal surgery in children as well as by surgeons with advanced thoracoscopic and laparoscopic skills.