Virtual reality training in laparoscopic surgery: a preliminary assessment of minimally invasive surgical trainer virtual reality (MIST VR).

BACKGROUND: The "fulcrum effect" of the body wall on surgical instrument manipulation is a major hurdle for novice endoscopic surgeons. Virtual reality training has not previously been evaluated as a means to overcome this problem. MATERIALS AND METHODS: 16 participants with no experience of endoscopy were required to make multiple defined incisions under laparoscopic laboratory conditions within 2-minute periods. Half of the subjects were randomized to receive initial training on the Minimally Invasive Surgical Trainer, Virtual Reality (MIST VR) computer programme. RESULTS: Participants with MIST VR training made significantly more correct incisions (P = 0.0001) than the control group on test trial 1, and even after extended practice by both groups (P = 0.0001). They were also significantly more likely to actively use both hands to perform the endoscopic evaluation task (P = 0.01). CONCLUSIONS: Virtual reality training represents a potential, viable solution for junior endoscopists, for overcoming the "fulcrum effect", in a replicable, safe learning environment which allows objective and reliable quantification of skill levels by trainers.     

Image-based electrode array tracking for epicardial electrophysiological mapping in minimally invasive arrhythmia surgery

Purpose

Electrophysiological mapping is effective in realizing a precise minimally invasive arrhythmia surgery. Recently, an epicardial electrophysiological mapping system for minimally invasive arrhythmia surgery was reported. The system requires a small electrode array, a tracking system and a global mapping algorithm. The optical tracking system employed in the research requires line of sight and complicated configuration. This paper proposes a new tracking method for locating an electrode array.

Methods

We developed a small electrode array and optical markers. Center points of respective optical markers and the electrode array are tracked via an endoscopic stream and calculated in image space. The orientation of the electrode array is calculated using the dot product between the vector joining two center points of two upper optical markers and the vector joining two end points of the longest edge of the electrode array.

Results

Mean tracking errors of position and orientation of the electrode array were 0.51?mm and 0.64??, respectively. And the processing time was constant at 46?ms per frame. Our method could successfully track the electrode array on the epicardium during in vivo experiment and a global epicardial electrophysiological map was reconstructed from separately measured epicardial electrograms by the small electrode array.

Conclusions

An image-based tracking method for locating an electrode array was proposed. Tracking accuracy, processing time and applicability to surgical environment of our method proved to be acceptable. Consequently, our method enables the electrode array tracking system to be simplified with no separate tracking system.     

Future trends in minimally invasive surgery

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HEALTH CARE COSTS in the United States are climbing annually at a staggering rate. Technology often is blamed for rising health care costs; however, some medical advances, such as minimally invasive surgery (MIS), are critical to improving health care efficiency, enhancing the quality of care provided, and decreasing overall expenses.

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SAVINGS OR PROFITS relating to technology may be difficult to measure quantitatively, but when surgeons and perioperative personnel have reached the peak of the learning curve for performing MIS procedures, complication rates drop significantly.

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PATIENTS ARE EXPERIENCING the benefits of MIS (eg, decreased postoperative pain, shorter hospital stays and often no need for an overnight stay, ability to return to work sooner), all of which encourage technologically savvy consumers to seek MIS options. AORN J 82 (December 2005) 1006-1018.

     

Training in minimally invasive surgery: An Asian perspective

Minimally invasive surgery, which requires a different approach than used in the past, has created a revolution not only in surgical practice but also in surgical education. To overcome the challenges and difficulties of minimally invasive surgery, training needs to be done outside the operating room and away from the patient. New educational tools have emerged in the form of surgical simulators, including trainer boxes, virtual reality simulators and hybrid simulators. Many studies have confirmed the effectiveness of both box trainers and virtual reality simulators for surgical education. The integration of simulators into a structured laparoscopic skills curriculum creates an ideal training ground for acquiring the necessary skills for minimally invasive surgery. It has also been proven that this training model is effective for transferring acquired skills into the clinical setting.     

Four years' experience with the minimally invasive surgical approach in cochlear implant surgery

This is a prospective study on 808 profoundly or totally deaf patients who underwent either unilateral or bilateral cochlear implantation, involving a minimally invasive surgical approach, at the Medical University of Hannover's Department of Otolaryngology between May 2001 and May 2005. Advanced Bionics, Cochlear and MED‐EL devices were used, the latter having been in use at our department since the beginning of 2003.

The aim of our investigation was to determine the optimal surgical technique, evaluate safety aspects and gauge patient satisfaction with this minimally invasive surgical approach during cochlear implantation. Surgical technique is analysed. Complications such as skin flap problems did not occur. The use of this minimally invasive surgical technique did not increase the surgical risk. This procedure proved both cosmetically and psychologically beneficial for patients, especially for children and their parents.     

Artificial tactile sensing in minimally invasive surgery - a new technical approach.

The loss of tactile sensation is a commonly known drawback of minimally invasive surgery (MIS). Since the advent of MIS, research activities in providing tactile information to the surgeon are still ongoing, in order to improve patient safety and to extend the indications for MIS.We have designed a tactile sensor system comprising a tactile laparoscopic grasper for surgical palpation. For this purpose, we developed a novel tactile sensor technology which allows the manufacturing of an integrated sensor array within an acceptable price range. The array was integrated into the jaws of a 10mm laparoscopic grasper. The tactile data are transferred wirelessly via Bluetooth and are presented visually to the surgeon. The goal was to be able to obtain information about the shape and consistency of tissue structures by gently compressing the tissue between the jaws of the tactile instrument and thus to be able to recognize and assess anatomical or pathological structures, even if they are hidden in the tissue. With a prototype of the tactile sensor system we have conducted bench-tests as well as in-vitro and in-vivo experiments. The system proved feasibility in an experimental environment, it was easy to use, and the novel tactile sensor array was applicable for both palpation and grasping manoeuvres with forces of up to 60N. The tactile data turned out to be a useful supplement to the minimal amount of haptic feedback that is provided by current endoscopic instruments and the endoscopic image under certain conditions.     

Four years' experience with the minimally invasive surgical approach in cochlear implant surgery.

This is a prospective study on 808 profoundly or totally deaf patients who underwent either unilateral or bilateral cochlear implantation, involving a minimally invasive surgical approach, at the Medical University of Hannover's Department of Otolaryngology between May 2001 and May 2005. Advanced Bionics, Cochlear and MED-EL devices were used, the latter having been in use at our department since the beginning of 2003.The aim of our investigation was to determine the optimal surgical technique, evaluate safety aspects and gauge patient satisfaction with this minimally invasive surgical approach during cochlear implantation. Surgical technique is analysed. Complications such as skin flap problems did not occur. The use of this minimally invasive surgical technique did not increase the surgical risk. This procedure proved both cosmetically and psychologically beneficial for patients, especially for children and their parents.     

微创心脏外科的现状

微创外科(minimallyinvasivesurgery,MIS)概念的提出是外科学的一场革命,它深刻地影响了外科学的根本理念,并渗透于外科学的各个具体专业,由此出现的微创心脏外科(minimallyinvasivecardiacsurgery,MICS)也极大地推动了传统心脏外科学的发展。1997年5月,国际上成立了国际微创心?..     

Innovative handles for use in minimally invasive surgery

Summary

Most of the handles available for laparoscopic surgery are not ergonomically designed. Based on anatomic, physiologic and ergonomic principles, new criteria for handles for laparoscopic surgery have been developed. In minimally invasive surgery, handles have to be adjustable for various hand sizes. The functional elements need to be operated by the sensitive parts of the fingers, without causing pressure areas. Rotation movements have to be transmitted directly to the effector; the instrumen?s shaft represents an immediate extension of the lower arm rotation axis. Taking these factors into account, new concepts for handles were developed. The multi-functional handle ‘MFEHG Schafreuter’ is shaped to fit either the right or left hand. Manipulation of the various functional elements is carried out using the first three fingers, while the handle rests in the half-closed hand. The vario-handle ‘VG Hirschberg’ is shaped to fit either hand and can be held in various grip positions for precise dissection, or for strenuous work. Both handles fulfil ergonomic criteria and support a bimanual and more ergonomical laparoscopic surgery.     

Human reliability and training in minimally invasive surgery

Effective training is essential to decrease the number of errors during surgery, especially during minimally invasive surgery. To develop effective training methods, it should be realized that different types of errors exist. Errors can be divided into slips, lapses and mistakes. The type of error very much depends on the complexity of the task performed. Therefore, these error types can be roughly classified to the level of surgeon's behavior which can be modelled using Rasmussen's model of human behavior that distinguishes between skill, rule and knowledge-based behavior. To avoid errors, training methods for the different levels of behavior are needed, having their own objectives, means and needs. To date, training objectives, means and needs are not standardized.     

MicroHip: a minimally invasive procedure for total hip replacement surgery using a modified Smith-Peterson approach

This article presents an anterior, minimally invasive surgical approach to the hip joint, aligned along an inter-nervous plane. Positioning in lateral decubitus position on a regular operation table obviates the need for a special orthopedic or fracture table. Traction is not applied. Most of the instruments used for this procedure are standard instruments for reaming of the acetabulum and positioning of the cup; specific, angulated instruments are recommended at least for obese patients. Using an incision of < 6-8 cm, this MI approach provides a perfect view of the acetabulum and proximal femur,including natural landmarks for proper implant positioning. The approach follows the gap between the tensor muscle and the gluteus medius muscle, using part of the anterior ilo-femoral Smith-Peterson approach. No tendons or muscles are cut or detached. The joint capsule is split and left in place. The hip joint is not dislocated; we perform the osteotomy of the femoral neck in situ. To date we have performed several hundred MicroHip operations, with no nerve lesions or trochanter fractures. Definitive results are not yet available, but our experience to date shows that this method can be used with virtually any patient, while such factors as hospitalization time, pain, blood loss and work incapacity can be cut almost in half. The MicroHip technique, used by an increasing number of clinics around the world, can be successfully applied by good surgeons after suitable training.     

虚拟微创心脏手术中力觉信息的采集

利用等强度梁和步进电机模拟真实手术中的穿透过程,针对心脏瓣膜微创手术进行了不同穿透速度的力采集实验,获得了虚拟手术中力反馈的真实信息,也为建立虚拟人手术专家系统提供了有效的数据.实验记录了穿透曲线,发现当穿透力高于10 mm/s时心脏瓣膜的穿透力出现了峰谷交替出现的曲线;而低于这个速度时候并无明显的峰谷区别.还有一个明显的现象,穿透力随着穿透速度的增加而增加.实验数据为力反馈设备提供了实际的反馈曲线,并可以用于计算试验软组织对象的材料特性,为计算机仿真模拟提供材料参数.     

腹腔镜微创技术在急诊普外手术中的应用效果

目的评价腹腔镜微创技术在急诊普外手术中的临床价值。方法选取2016年9月-2018年1月该院急诊普外科收治的手术患者80例作为研究对象,按照随机数字表法分为对照组(n=40)和治疗组(n=40),对照组采取开腹手术治疗,治疗组采取腔镜微创技术治疗,观察并比较两组手术情况、术后并发症及疼痛情况的差异。结果治疗组手术时间、排气时间和住院时间分别为(69.6±12.5)min、(25.8±2.8)h和(4.9±1.0)d,明显短于对照组,差异均有统计学意义(t=2.45、11.21和5.27,P0.05);治疗组术中出血量为(29.7±11.1)ml,明显少于对照组,差异有统计学意义(t=14.94,P0.05);治疗组患者术后并发症发生率为7.5%,明显低于对照组患者的25.0%,差异有统计学意义(χ2=4.50,P0.05);两组均无无痛病例,治疗组轻度疼痛率高于对照组,重度疼痛率低于对照组,差异均有统计学意义(χ2=6.55,5.16,P0.05);中度疼痛率两组比较,差异无统计学意义(P0.05)。结论腹腔镜微创技术应用于急诊普外科手术中,具有效果良好、创伤小、恢复快、疼痛程度轻和并发症发生率低等优点,值得在临床中进一步普及和推广。     

经食管超声心动图在机器人辅助心脏手术中的应用价值

目的应用经食管超声心动图（TEE）监测、指导机器人辅助心脏手术，在微创环境下，使手术完美成功。方法8例机器人辅助心脏手术患者均在手术切口前将探头插人食管内，待机器人辅助手术开始，整个手术过程中与机器人的监视器同步进行TEE监测、指导机器人辅助手术。结果4例房间隔缺损修补、3例房间隔缺损封堵和1例二尖瓣置换术均获得成功，术后即刻TEE检查均未见残余分流、瓣周漏及瓣膜反流。结论机器人辅助心脏手术，在TEE监测和指导下机械手能准确、无误地到位缝合、修补，释放封堵器，同时可观察有无残余分流、瓣周漏及瓣膜反流，一旦缝合、修补不足可及时纠治，确保手术成功。     

A robot-guided minimally invasive approach for cochlear implant surgery: preliminary results of a temporal bone study

Purpose  The aim of this study was to create an access canal to the inner ear, by drilling, and perform the cochleostomy for cochlear implant surgery using robot guidance. Methods  A robot, a surgical drill and an Image-Guided Surgery (IGS) system were combined in a closed-loop setup. Ten temporal bones were scanned at the planning stages of the procedure. The robot guided the drill along the preplanned trajectory and created the approach. Postoperative scans were obtained. Results  The cochleostomy was performed completely in nine out of ten cases. This did not prove possible for one of the specimens, the target site selected being in too superficial a location in relation to the round window. No violation of the facial nerve took place, although the chorda tympani nerve was violated in one case and the stapes in two. It was obvious during preoperative planning that these structures would be violated, but this was accepted in order to maintain a safety margin from the facial nerve. No other unforeseen damage occurred. Conclusions  This preliminary study suggests that robot-guided drilling of a minimally invasive approach to the cochlea might be feasible, but further improvements are necessary before any clinical application becomes possible. Where the width of the facial recess is less than 2.5 mm, the chorda tympani nerve and the ossicles are at risk. Source of financial support or funding: Deutsche Forschungsgemeinschaft (DFG-German Research Foundation), Priority Program 1124 (Medical Robotics).     

微创手术在疼痛治疗中的应用

本文阐述了疼痛临床常用微创手术,如:针刀疗法、胶原酶溶盘术、射频疗法、椎间盘减压术、脊髓刺激术、硬膜外腔镜的适应证、禁忌证、疗效及并发症,并重点介绍微创手术实施过程中的原则、关键技术和注意事项等.     

A multimedia electronic patient record (ePR) system for image-assisted minimally invasive spinal surgery

Purpose

This paper presents the concept of bridging the gap between diagnostic images and image-assisted surgical treatment through the development of a one-stop multimedia electronic patient record (ePR) system that manages and distributes the real-time multimodality imaging and informatics data that assists the surgeon during all clinical phases of the operation from planning Intra-Op to post-care follow-up. We present the concept of this multimedia ePR for surgery by first focusing on image-assisted minimally invasive spinal surgery as a clinical application.

Methods

Three clinical phases of minimally invasive spinal surgery workflow in Pre-Op, Intra-Op, and Post-Op are discussed. The ePR architecture was developed based on the three-phased workflow, which includes the Pre-Op, Intra-Op, and Post-Op modules and four components comprising of the input integration unit, fault-tolerant gateway server, fault-tolerant ePR server, and the visualization and display. A prototype was built and deployed to a minimally invasive spinal surgery clinical site with user training and support for daily use.

Summary

A step-by-step approach was introduced to develop a multimedia ePR system for imaging-assisted minimally invasive spinal surgery that includes images, clinical forms, waveforms, and textual data for planning the surgery, two real-time imaging techniques (digital fluoroscopic, DF) and endoscope video images (Endo), and more than half a dozen live vital signs of the patient during surgery. Clinical implementation experiences and challenges were also discussed.