机器人辅助下膝关节单髁置换术短期临床疗效

目的评估机器人辅助下膝关节单髁置换术(UKA)的短期临床结果。 方法随访评估2016年9～12月在上海交通大学附属第六人民医院接受机器人辅助下UKA治疗的10例患者,纳入标准：内侧单间隙骨关节炎;不伴严重膝关节内翻畸形;前后交叉韧带完整。其中男2例,女8例,平均年龄(65±6)岁。均采用MAKO RIO机器人手术系统和RESTORIS MCK单髁膝关节假体(STRYKERMAKO Surgical,美国)进行手术。回顾以上10例患者,对其术前及术后影像学资料,日常活动情况,美国膝关节协会评分(KSS)、遗忘关节评分(FJS)等进行记录分析。采用配对样本t检验进行统计学分析。 结果10例患者均获得随访,随访时间平均(22.2±1.5)月。患者KSS的临床评分由术前的(58.8±13.7)分提升至末次随访的(96.0±2.8)分,功能评分由术前的(59.5±19.0)分提升至末次随访的(88.5±15.2)分,膝关节活动度由术前的(90.7±6.1)°提升至末次随访的(127.9±7.2)°(t＝－8.588,P<0.01)。FJS评分为(83±24)分,表示患者对手术膝关节的感受接近本体膝关节。10例患者的影像学评估良好,膝关节内翻畸形角度由术前的(8.8±3.5)°纠正至末次随访时的(4.0±2.0)°(t＝7.294,P<0.01)。患者假体对位对线良好,未见透亮线,未出现假体下沉、假体松动等不良事件,所有患者均未继发外侧间室的骨关节炎,关节间隙正常。 结论机器人辅助下UKA能使假体获得良好的对位对线和软组织平衡,达到功能好、患者主观感受佳的目标,术后短期的临床疗效优异;其远期临床结果及假体生存率需要通过更长期的随访加以证实。     

Preparedness in robotically assisted interventions

For many years, robots have been used in manufacturing to perform a variety of delicate tasks. Their use is now being generalized to other fields, such as biology, domestic applications, and especially medicine, in which they are poised to make a significant contribution. This evolution comes from the progress made in the field of robotics and from recent changes in medical and surgical techniques, namely, developments in medical imaging and a new desire for minimally invasive interventions. This emerging combination of high-precision robotic manipulators, new medical diagnostic techniques, and efficient minimally invasive surgery has not yet been perfected. After a brief discussion of state-of-the-art robotic systems used in urology, this article discusses new challenges presented by robotic minimally invasive surgery. A computer-integrated approach aimed at increasing the efficiency of such interventions through better preparedness is presented. This approach is illustrated by a case study in human nephrectomy and a cardiac animal experiment.     

固定平台内侧单髁膝关节置换的中短期疗效

[目的]研究固定平台单髁假体系统行单髁置换术治疗膝关节内侧单间室骨性关节炎的短期临床疗效。[方法] 2016年7月～2018年5月,79例(91膝)膝内侧室骨性关节炎患者在本科行固定平台单髁膝关节置换术,其中,男32例,女47例,平均年龄(57.39±4.64)岁。[结果]所有患者均顺利完成手术,手术时间(51.25±5.42)min,失血量(86.25±6.32) ml。术中无患者出现神经、血管损伤,1例患者术中胫骨开槽时,出现胫骨内侧平台斜形骨折,术中即行钢板螺钉内固定,术后功能恢复良好。79例中2例失访,其余77例平均随访(14.36±7.58)个月。KSS评分由术前(65.44±5.48)分,显著增加至末次随访时(97.31±1.36)分,差异有统计学意义(P0.05)。膝关节ROM由术前(108.41±2.63)°显著增加至末次随访时(124.22±0.54)°,差异有统计学意义(P0.05)。影像学方面,末次随访时患者股胫角、关节线匹配角和机械轴偏移均较术前显著改善,差异有统计意义(P0.05),未见假体松动、移位,外侧室均无明显退变加重。[结论]应用固定平台单髁假体系统进行单髁关节置换治疗膝关节内侧骨性关节炎可以获得良好的临床效果。     

Perioperative outcomes of three-port robotically assisted hysterectomy: a continuous series of 53 cases

This study evaluated the feasibility and safety of 3-port robotically assisted laparoscopic hysterectomy (RALH), using a consecutive series of women who underwent 3-port RALH in a university hospital. From November 2010 until June 2013 we operated on 53 women, whose mean age was 48.4 ± 7.7 years (range 35–68 years), and mean body mass index was 27.1 ± 5.1 kg/m² (range 19.5–42.9 kg/m²). The indications for hysterectomy were myoma in 31 (58.5 %), adenomyosis in 10 (18.9 %), cervical dysplasia in 4 (7.5 %), neoplasia in 4 (7.5 %), and recurrent polyps or postmenopausal bleeding in the remaining 4 women (7.5 %). We performed total RALH in 50 cases (94.3 %) and subtotal in the others. The median duration of total intervention was 169 min (interquartile range 147.5–206.5 min). The mean weight of the uterus was 209.8 ± 166.6 g (range 36–790 g) and mean estimated blood loss was 72.3 ± 75.9 ml (range 0–300 ml). There were no perioperative complications, in particular no blood transfusions nor conversions to laparotomy. The median hospital stay was 4 days (interquartile range 3–4 days). One patient was reoperated 1 month later for vaginal vault hematoma and another was readmitted 3 weeks post-operatively due to vaginal vault dehiscence after premature intercourse, but did not require reoperation. Three-port RALH is feasible and safe for simple hysterectomy. We believe this experience using minimum ports to be useful to prepare for robotically assisted single-port hysterectomy.     

Intravesical robotically assisted bilateral ureteral reimplantation

An efficient laparoendoscopic technique for bilateral intravesical ureteral reimplantation would offer the certainty of cure provided by open surgery with the reduced morbidity of laparoscopy. We have assessed the clinical utility of robotically assisted intravesical bilateral ureteral reimplantation in children. Ports are placed in the dome of the bladder, and the procedure is performed in a fashion identical to that used for open transtrigonal reimplantation. A catheter is left in place for 1 or 2 days. With modifications in port placement using the VersaStep radially dilating sheath system, we have not had any port-site leakage. One patient has unilateral persisting low-grade reflux. This technique may be a useful option for antireflux surgery and should be further refined.     

Early experience with robotically assisted laparoscopic donor nephrectomy

The da Vinci robotic system became available at our institution in late August 2000. We decided to use this system to perform robotically assisted laparoscopic donor nephrectomies. A prospective study was conducted of 10 consecutive patients who underwent robotically assisted laparoscopic donor nephrectomy between January and May 2001. The mean operative time was 166 minutes. The mean hospital stay was 1.8 days. The need for parenteral pain medication was limited to the first postoperative day. All kidneys were transplanted successfully; no rejections occurred. This early experience suggests that the results of robotically assisted laparoscopic donor nephrectomy are similar to those of laparoscopic donor nephrectomy. We believe that robotic surgery, which enables regaining of the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, allows us to perform the donor nephrectomy with greater precision, confidence, and comfort.     

Early experience with robotically assisted internal thoracic artery harvest

We sought to determine the efficacy of using robotic assistance to facilitate endoscopic harvesting of internal thoracic arteries (ITAs). A total of 104 patients had ITAs harvested endoscopically with use of both the AESOP 3000 system (Computer Motion, Goleta, CA, U.S.A.) and Zeus robotic telesurgical system (Computer Motion). All ITAs were harvested with a harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH, U.S.A.). With the left lung collapsed, ITAs were harvested with CO2 insufflation through three 5-mm ports in the left chest. All patients tolerated insufflation without hemodynamic compromise. Average ITA harvest time was 61.3 +/- 20.9 minutes. Intraoperative graft flows averaged 36.3 +/- 22.4 mL/min. There were three distal ITA injuries; all other vessels were patent after harvesting and demonstrated no angiographic evidence of injury. This article demonstrates a technique by which ITA can be safely harvested totally endoscopically with use of computer-enhanced robotic systems and a harmonic scalpel, allowing complete pedicle dissection through 5-mm ports with minimal ITA manipulation.     

Prospective study comparing standard and robotically assisted laparoscopic cholecystectomy

Background and aims Laparoscopic surgery has become the treatment of choice for cholecystectomy. Many studies showed that while this approach benefits the patient, the surgeon faces such distinct disadvantages as a poor ergonomic situation and limited degrees of freedom with limited motion as a consequence. Robots have the potential to overcome these problems. To evaluate the efficiency and feasibility of robotically assisted surgery (RAC), we designed a prospective study to compare it with standard laparoscopic cholecystectomy (SLC).Materials and methods Between 2001 and 2003, 26 patients underwent SLC and 20 patients underwent RAC using the ZEUS system. The feasibility, safety, and possible advantages were evaluated. To assess the efficacy, the total time in the operating room was divided into preoperative, operative, and postoperative time frames.Results For RAC in comparison with SLC, the preoperative phase including equipment setup was significantly longer. In the intraoperative phase, the cut-closure time and camera and trocar insertion times were significantly longer. It is interesting to note that the net dissection time for the cystic artery, duct, and the gall bladder was not different from SLC.Conclusions The study demonstrates the feasibility of robotically assisted cholecystectomy without system-specific morbidity. There is time loss in several phases of robotic surgery due to equipment setup and deinstallation and therefore, presents no benefit in using the robot in laparoscopic cholecystectomy.     

The use of robotically assisted surgery for treating urachal anomalies

OBJECTIVE: To report the management of urachal anomalies using a robotically assisted approach. PATIENTS AND METHODS: Between January 2005 and February 2006, five patients (mean age 51 years, range 24-68) were diagnosed with urachal anomalies. Two basic robot-assisted surgical approaches were used for excising the urachal anomalies: excision of the urachal remnant via partial cystectomy, and radical cystectomy for excision of urachal adenocarcinoma. RESULTS: All five cases were successful and the excised specimens were assessed histologically. The short-term oncological outcome in the three patients with histologically confirmed moderately differentiated adenocarcinoma showed no evidence of recurrent disease within a median interval of 8 months. Surveillance follow-up cystoscopy in the patients who had a partial cystectomy showed a well-healed bladder mucosa with no evidence of recurrence. CONCLUSIONS: Radical excision of the urachal tract with partial cystectomy or radical cystectomy using the da Vinci robot is safe, effective and technically feasible.     

金属对金属全髋关节表面置换治疗髋关节色素沉着绒毛结节性滑膜炎早期临床效果观察

目的探讨金属对金属全髋关节表面置换术治疗髋关节色素沉着绒毛结节性滑膜炎(PVNS)的可行性及早期临床效果。方法对7例经影像学检查及病理检查确诊的PVNS实施了滑膜切除+全髋关节表面置换术,术后康复锻炼。手术前后行Harris髋关节功能评分。结果7例均获随访,时间12～20(14.6±2.4)个月。患者假体位置良好,无松动、股骨颈骨折及明显骨溶解等并发症,关节活动度90°～130°,可从事日常生活,未出现复发症状。Harris髋关节功能评分由术前(45.2±7.8)分改善至术后(95.8±2.6)分。结论全髋关节表面置换术结合滑膜切除术早期能有效改善髋关节PVNS患者的临床症状、提高生活质量。     

Optimal port placement and enhanced guidance in robotically assisted cardiac surgery

Background Optimal port placement and enhanced guidance in robotically assisted cardiac surgery is required to improve preoperative planning and intraoperative navigation. Methods Offline optimal port placement is planned on a three-dimensional virtual reconstruction of the patient’s computed tomography scan. Using this data, an accurate in vivo port placement can be performed, which is achieved by augmented reality techniques superimposing virtual models of the thorax and the teleoperator arms on top of the real worldview. Results A new system incorporating both port placement planning and intraoperative navigation in robotically assisted minimally invasive heart surgery was established to aid the operative workflow. A significant reduction of operation time by improved planning and intraoperative support is anticipated. Conclusions The enhanced intraoperative orientation possibilities may lead to further decrease in operation time and have the continuing ability to improve quality.     

Replacement of the patello-femoral joint with the total condylar knee arthroplasty

Summary We have studied 241 total condylar knee arthroplasties with replacement of the articular surface of the patella in 206 patients. The average age was 65 years.The technique of replacement of the patellofemoral joint emphasises realignment of the quadriceps mechanism, minimal excision of the patella to preserve subchondral bone, preservation of soft tissue attachments including the infrapatellar fat pad, and closure of the quadriceps without tension.The results of replacement have been good to excellent in 95 per cent of patients followed for two years or more. There were no subluxations, dislocations or fractures. Loosening was noted in one case associated with anterior knee pain. Discomfort was also noted with eccentric placement of the prosthesis where bone was left uncovered.We consider that routine replacement of the patello-femoral joint is advisable with total condylar knee arthroplasty.

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Résumé Etude de 241 arthroplasties totales du genou avec remplacement de la surface articulaire rotulienne, pratiquées sur 206 malades dont l'âge moyen était de 65 ans.En ce qui concerne la technique du remplacement rotulien, il faut insister sur le réalignement du tendon quadricipital, sur une résection limitée de la rotule afin de conserver l'os sous-chondral, sur la préservation des parties molles péri-rotuliennes y compris le ligament adipeux et sur la suture sans tension du quadriceps.Les résultats du remplacement rotulien ont été excellents ou bons chez 95% des opérés, suivis deux ans ou plus. Il n'y a eu ni subluxations, ni luxations, ni fractures. Un seul cas de descellement a été observé, s'accompagnant de douleurs à la face antérieure du genou. Une gêne a également été notée lorsque la prothèse a été placée en position excentrique, là où l'os était resté découvert.On peut donc recommander l'utilisation systématique de la prothèse rotulienne au cours de l'arthroplastie du genou par prothèse «total condylar».

     

The radiological outcomes of total knee arthroplasty using computer assisted navigation ORTHOPILOT.

Comprehensive radiographic analysis of total knee arthroplasty performed traditionally and with the use of Computer Assisted Navigation (CAN) is presented. The aim of this study was to compare the precision of implant alignment considering two operating techniques. The analyzed material consisted of 100 radiograms of patients operated on traditional way and 100 knee joint radiograms of patients operated on with a use of CAN. Assessment of postoperative radiograms was carried out in order to analyze coronal mechanical axis and sagittal orientation of both femoral and tibial components. Measurements were taken precisely up to 1 degrees and therefore results were classified as good (0-2 degrees deviation due to mechanical axis), satisfactory (2-4 degrees) and poor (over 4 degrees). The radiological outcome allows to present the following conclusions: CAN allows to minimize the risk of incorrect prosthesis alignment and therefore significantly improves the radiological outcome of total knee arthroplasty. This improvement can lead to better long time "survival" of implant components. The only price one pays for this improvement is 15-20 minute surgery delay, however it needs further studies to determine other possible disadvantages.     

System for robotically assisted percutaneous procedures with computed tomography guidance.

We present the prototype of an image-guided robotic system for accurate and consistent placement of percutaneous needles in soft-tissue targets under CT guidance inside the gantry of a CT scanner. The couch-mounted system consists of a seven-degrees-of-freedom passive mounting arm, a remote center-of-motion robot, and a motorized needle-insertion device. Single-image-based coregistration of the robot and image space is achieved by stereotactic localization using a miniature version of the BRW head frame built into the radiolucent needle driver. The surgeon plans and controls the intervention in the scanner room on a desktop computer that receives DICOM images from the scanner. The system does not need calibration, employs pure image-based registration, and does not utilize any vendor-specific hardware or software features. In the open air, where there is no needle-tissue interaction, we systematically achieved an accuracy better than 1 mm in hitting targets at 5-8 cm from the fulcrum point. In the phantom, the orientation accuracy was 0.6 degrees, and the distance between the needle tip and the target was 1.04 mm. Experiments indicated that this robotic system is suitable for a variety of percutaneous clinical applications.