Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting.

OBJECTIVE: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. METHODS: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. PHASE I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. PHASE II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. PHASE III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. RESULTS: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. CONCLUSIONS: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.     

Minimally invasive mitral valve surgery using three-dimensional video and robotic assistance.

Different techniques have been developed for the common goal to minimize surgical trauma for mitral valve surgery. This article focuses on Port-Access (Heartport, Inc, Redwood City, CA) mitral valve replacement or repair (PAMVR) with emphasis on three-dimensional video and robotic assistance. PAMVR was undertaken using a small right anterior minithoracotomy using an endovascular cardiopulmonary bypass (CPB) system. A three-dimensional minicamera allowed visualization of the mitral valve apparatus during this limited access surgery. The three-dimensional (3D) image was displayed inside a helmet just above the real surgical image (VISTA system [Vista, Inc, Westborough, MA]). In addition, the camera was attached to a robotic arm (AESOP [Computer Motion, Inc, Goleta, CA]) that allows stabilization and voice-activated movement of the camera. Fifty patients (16 men, 34 women), aged 36 to 77 years (median, 61.5 years) underwent PAMVR. The underlying diseases were mitral valve insufficiency (n = 36) and combined mitral valve disease (n = 14). With optimal visualization, mitral valve repair was performed in 26 patients with quadrangular resection of the posterior leaflet (n = 26) and repair of the anterior leaflet (n = 3) together with insertion of a posterior or complete anuloplasty ring. The valve was replaced in 24 patients with a mechanical valve prosthesis. Intraoperative and postoperative mortality was 0%. One patient (2%) needed reoperation after a failed repair of an anterior leaflet prolaps. Three-month follow-up was complete in 40 patients, with 34 patients (85%) in New York Heart Association (NYHA) class I and 6 patients in class II. In conclusion, using 3D video and robotic assistance, it was possible to minimize the length of skin incision but at the same time to optimally visualize the whole mitral valve apparatus to perform true Port-Access mitral valve surgery, including complex repair techniques.     

Technique of closed chest coronary artery surgery on the beating heart.

OBJECTIVE: The application of an endoscopic stabilizer (Intuitive Surgical, Mountain View, CA, USA) enables closed chest off-pump coronary artery bypass via a four-point stab incision avoiding sternotomy and minithoracotomy. METHODS: Between May 1999 and January 2001 we operated upon a total of 37 patients (five female, 32 male, median age 62+/-9 years) suffering from coronary artery disease using totally endoscopic coronary artery bypass (TECAB), whereas an initial series of eight TECAB patients was operated upon using an endovascular bypass system (Heartport). The da Vinci surgical system was used in order to perform left internal mammary artery (LIMA) or right internal mammary artery (RIMA) harvesting and anastomoses on a beating heart in 29 patients (four female, 25 male, median age 64+/-9.8 years). Altogether 26 patients suffering from single-vessel coronary artery disease (SVCAD) were revascularized applying LIMA to the left anterior descending artery (LAD) and three patients with two diseased coronary vessels received bilateral internal mammary artery grafting (BIMA), respectively. RESULTS: In this series we had a 100% survival rate. Conversion rate to a median sternotomy was 3.4%. Patients were operated upon via four 1-cm chest incisions using the da Vinci robot for LIMA or BIMA harvesting and for performance of anastomoses on the beating heart. In the overall series of 56 patients intended to be treated by TECAB, 19 (33.9%) were converted to a minimally invasive direct coronary artery bypass procedure. CONCLUSION: This new robotic-enhanced surgical technique promotes an optimistic way of thinking about the further development of this procedure and its application in patients suffering from single-vessel CAD.     

Alteration of the Traditional Extracorporeal Bypass Circuit to Accommodate Port-Access Minimally Invasive Cardiac Procedures Using Endovascular Based Cardiopulmonary Bypass

Port-Access minimally invasive cardiac surgery systems (Heartport, Inc., Redwood City, CA, U.S.A.) enable surgeons to perform many procedures including valve surgery and complete coronary artery revascularization of all surfaces of the heart through small anterior thoracotomies. The endovascular based EndoCPB (Heartport, Inc.) cardiopulmonary bypass system uses a modified extracorporeal circuit to afford the same level of myocardial protection through cardioplegic cardiac arrest and bypass as is provided in traditional open chest surgery. We describe the changes required to convert a conventional CPB pump circuit to perform Port-Access procedures and make recommendations based on clinical experience to facilitate establishing a Port-Access surgical team and interpreting EndoCPB pressure and flow data. Specific emphasis is placed on the expanded role of the perfusionist in these cases.     

Minimally invasive port-access coronary artery bypass grafting.

The Port-Access endovascular cardiopulmonary bypass system (Heartport, Inc., Redwood City, CA, USA), a recent technological innovation in minimally invasive cardiac surgery, was conducted successfully in coronary artery bypass grafting on a 69-year-old woman. The left internal thoracic artery was harvested through a limited left anterior thoracotomy and anastomosed to the left anterior descending coronary artery on a protected and arrested heart. Intraoperative coronary angiography confirmed good graft patency. The patient was discharged from the hospital in good condition 7 days after the operation. This was the first successful minimally invasive Port-Access coronary artery bypass grafting in Japan.     

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.     

Clinical experience in thoracoscopic left internal mammary artery harvesting with voice activated robotic assistance]

Between September 1998 to February 2000, 45 consecutive patients underwent robotic-assisted, video-enhanced coronary artery bypass grafting. All IMA's were harvested using the voice-activated robotic assistant (AESOP 3000, Computer Motion Inc, Santa Barbara, CA) and the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Left IMA's were successfully harvested in all patients. Harvested IMA's were anastomosed to LAD's under direct vision through limited left anterior thoracotomy. The IMA harvest time was 57.8 +/- 23.2 min, intraoperative graft flow was 34.3 +/- 20.5 ml/min, postoperative hospital stay was 3.9 +/- 1.5 days. The early postoperative angiogram showed that all grafts were patent. There was no mortality, no significant morbidity. The robotic assisted, video enhanced CABG provides safe and complete LIMA dissection with minimal manipulation and assures sufficient LITA length for tension free anastomosis.     

Robot-assisted general surgery

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.     

体外循环与非体外循环冠状动脉旁路移植术患者桥血流的对比研究

目的比较非体外循环和体外循环下冠状动脉旁路移植术(CABG)的左乳内动脉(LIMA)和大隐静脉(SV)桥血流的变化。方法将547例行CABG患者分为非体外循(OPCAB)组(403例)和体外循环(CCABG)组(144例)。常规用LIMA与左前降支(LAD)吻合,其余靶血管使用SV吻合。于全部吻合口吻合完毕血流动力学稳定情况下,用即时血流测量仪(TTFM)直接测量并记录桥血流各项参数。结果搏动指数(PI值)、无效血流率及舒张期峰流量,LIMA桥OPCAB组分别为2.7±1.8,(2.2±4.3)%,(46.8±2.7)m l/m in,CCABG组分别为2.8±2.0,(3.4±3.1)%,(52.8±3.7)m l/m in;SV桥,OPCAB组分别为2.8±0.1,(1.8±0.3)%,(85.8±3.2)m l/m in,CCABG组分别为2.6±0.2,(1.3±0.2)%,(93.9±5.6)m l/m in,两组比较差异均无统计学意义(P均>0.05);平均流量及收缩期峰流量,CCABG组[SV桥(62.9±3.9)与(106.9±7.3)m l/m in,LIMA桥(32.5±23.5)与(41.6±4.4)m l/m in]均大于OPCAB组[SV桥(47.2±1.7)与(58.0±2.7)m l/m in,LIMA桥(26.5±19.9)与(27.0±1.6)m l/m in],差异有统计学意义(t=6.61,6.77,5.16,5.96,P均<0.01);CCABG组血管阻力LIMA桥与SV桥分别为(3.6±0.3)与(1.6±0.2)mm Hg.m l-1.m in-1,小于OPCAB组的(4.7±0.2)与(2.7±0.1)mm Hg.m l-1.m in-1,两者比较差异有统计学意义(t=4.32,P均<0.01)。结论CCABG组与OPCAB组对比,桥血管的通畅率无显著性差别。     

Use of the Zeus robotic surgical system for cardiac surgery

The development of closed chest cardiopulmonary bypass systems has opened the door for totally endoscopic cardiac surgery. We used the robotic surgical system ZEUS for closure of the atrial septal defect (ASD) in three patients. Under one-lung ventilation, Port-Access cardiopulmonary bypass system of the drainage from the right internal jugular vein and the the right femoral vein and the return to the right femoral artery was started after port placement at the forth intercostal space of the right thoracic wall. ASD direct closure was achieved by using robotic surgical system ZEUS under cardiac arrest. The three patients were discharged in 7 days after the operation uneventfully. The robotic surgical system ZEUS can make cardiac surgeries less invasive than ever.     

Computer-enhanced thoracoscopic thymectomy with the Zeus telemanipulation surgical system

Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.     

Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass?

Background  

The aim of this retrospective study was to evaluate the clinical outcome of three different minimally invasive surgical techniques for left anterior descending (LAD) coronary artery bypass grafting (CABG): Port-Access surgery (PA-CABG), minimally invasive direct CABG (MIDCAB) and off-pump totally endoscopic CABG (TECAB).     

Port-Access Bilateral Internal Mammary Artery Grafting for Left Main Coronary Artery Disease: Canine Feasibility Study

A bstract Background : To extend the applications of minimal access cardiac surgery, an endovascular cardiopulmonary bypass (CPB) system that allows cardioplegia delivery and cardiac venting was used to perform bilateral internal mammary artery (IMA) bypass grafting in six dogs. Methods : The left IMA (LIMA) was taken down thoracoscopically from three left lateral chest ports, followed by the right IMA (RIMA) from the right side. One left-sided port was extended medially 5 cm with or without rib resection, to expose the pericardium. Both IMAs were divided and exteriorized through the left anterior mediastinotomy. Flow and pedicle length were satisfactory in all cases. Femoral-femoral bypass was used and the heart arrested with antegrade delivery of cardioplegic solution via the central lumen of a balloon catheter inflated to occlude the ascending aorta. All anastomoses were made through the mediastinotomy under direct vision. In five studies the RIMA was attached to the left anterior descending artery (LAD) and the LIMA to the circumflex, and in one study the RIMA was tunneled through the transverse sinus to the circumflex and the LIMA was anastomosed to the LAD. All animals were weaned from CPB in sinus rhythm without inotropes. CPB duration was 108 ± 27 minutes (mean ± SD) and the clamp duration was 54 ± 10 minutes. Results : Preoperative and postoperative cardiac outputs were 2.9 ± 0.71/min and 2.4 ± 0.31/min, respectively (p = NS), and corresponding pulmonary artery occlusion pressures were 6 ± 3 mmHg and 7 ± 2 mmHg, respectively (p = NS). All 12 grafts were demonstrated to be fully patent. Postmortem examination revealed well aligned pedicles and correctly grafted target vessels. Conclusion : This canine model demonstrates the potential for a less invasive approach to the surgical management of left main coronary artery disease in humans.     

Internal thoracic artery to left anterior descending anastomosis performed on the beating heart by endoscopic robot assistance using a new distal connector.

BACKGROUND: Automated distal connecting devices have been recently introduced to facilitate coronary anastomosis. This could have a large impact on the capacity of robotic systems to perform completely endoscopic off-pump bypass, where the quality of anastomosis and the prolonged operative time for the performance of the anastomosis have until now been cause for concern. Our group tried to determine the feasibility and efficacy of the JoMed distal graft connector using the ZEUS robotic system. METHODS: Six swine, with a mean weight of 25.8 (standard deviation [SD] 2.2) kg, underwent endoscopic off-pump internal thoracic artery-left anterior descending (ITA-LAD) anastomosis with a special stabilizing system using ZEUS robotic assistance. The anastomosis was performed with the JoMed distal connector. RESULTS: The connector was employed successfully in 4 of 6 cases using a special delivery instrument. Two animals fibrillated within 2 minutes after the application of proximal occluding snares and were excluded from the analysis. The total device deployment time was 2 minutes 4 seconds (SD 50 s) in 4 of 6 survivors, which remained hemodynamically stable and in sinus rhythm until euthanasia. Coronary angiography and transonic flow measurements were used to verify patency. CONCLUSION: The JoMed distal graft connector may facilitate the use of robot-assisted endoscopic bypass on a beating heart. Long-term patency issues will need to be assessed.     

Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1-year follow-up

OBJECTIVE: To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses. SUMMARY BACKGROUND DATA: Recently there has been an interest in using robotics and computers to enhance the surgeon's ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery. METHODS: Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA-LAD anastomosis. All other required grafts were completed by conventional techniques. RESULTS: Seventeen LITA-LAD grafts (89%) had adequate intraoperative flow. The mean LITA-LAD graft flow was 38.5 +/- 5 mL/min. At 8 weeks, LITA-LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 +/- 4.2 months, all patients were NYHA class I and there were no adverse cardiac events. CONCLUSIONS: The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses.     

Robotic surgery: urologic implications

Current medical robots have nothing in common with the anthropomorphic robots in science fiction classics. They are in fact, manipulators, working on a master-slave principle. Robots can be defined as "automatically controlled multitask manipulators, which are freely programmable in three or more spaces." The success of robots in surgery is based on their precision, lack of fatigue, and speed of action. This review describes the theory, advantages, disadvantages, and clinical utilization of mechanical and robotic arm systems to replace the second assistant and provide camera direction and stability during laparoscopic surgery. The Robotrac system (Aesculap, Burlingame, CA), the First Assistant (Leonard Medical Inc, Huntingdon Valley, PA), AESOP (Computer Motion, Goleta, CA), ZEUS (Computer Motion), and the da Vinci (Intuitive Surgical, Mountain View, CA) system are reviewed, as are simple mechanical-assist systems such as Omnitract (Minnesota Scientific, St. Paul, MN), Iron Intern (Automated Medical Products Corp., New York, NY), the Bookwalter retraction system (Codman , Somerville, NJ), the Surgassistant trade mark (Solos Endoscopy, Irvine, CA), the Trocar Sleeve Stabilizer (Richard Wolf Medical Instruments Corp., Rosemont, IL), and the Endoholder (Codman, Somerville, NJ).     

Intraoperative color Doppler ultrasound assessment of LIMA-to-LAD anastomoses in off-pump coronary artery bypass grafting

BACKGROUND: Although techniques for off-pump coronary artery bypass grafting (CABG) are continually being refined, angiographic follow-up studies have indicated a higher rate of anastomoses-related stenoses than expected after traditional on-pump CABG. This study was performed to evaluate the use of intraoperative epicardial color Doppler ultrasound to quality-assess left internal mammary artery (LIMA) to left anterior descending coronary artery (LAD) anastomoses performed on the beating heart. METHODS: Twenty-four LIMA-to-LAD anastomoses were evaluated with real-time epicardial ultrasound imaging using an ultrasound transducer positioned between the paddles of the stabilizer during off-pump procedures. The length of the anastomosis (D(A)), diameters of LIMA (D(M)), LAD at the toe of the anastomosis (D1), and 5 mm distally to the anastomosis (D2) were measured, and the ratios between these variables were calculated. The flow velocity through the anastomoses was visualized by color Doppler coding, and flow was assessed with transit-time flowmetry. RESULTS: The epicardial color Doppler ultrasound allowed accurate assessment of the anastomoses. Twenty-three (96%) of the primary anastomoses were confirmed as patent. Mean ratios of D1/D2, D(A)/D2, and D(M)/D2 were 0.89 +/- 0.13, 3.01 +/- 1.04 and 1.32 +/- 0.32, respectively. One anastomosis had a stenosis more than 50% detected by color Doppler ultrasound. After surgical revision, transit-time flow increased from 22 to 40 ml/min. CONCLUSIONS: Intraoperative color Doppler ultrasound allowed adequate imaging for quality assessment of LIMA-to-LAD anastomoses performed on the beating heart. One anastomosis was revised due to a technical error detected by epicardial color Doppler imaging. Epicardial ultrasound scanning is a valuable tool for intraoperative assessment of LIMA-to-LAD anastomoses during off-pump coronary surgery.     

Selective retrograde venous revascularization of the myocardium when PCI or CABG is impossible: investigation in a porcine model

We investigated the possibility of nourishing the myocardium through selective retrograde coronary venous bypass grafting (CVBG) with an off-pump technique and evaluated various methods of monitoring the physiological effects of this procedure. In a porcine model, the left internal mammary artery (LIMA) was anastomosed to the left anterior descending coronary vein (LAD vein) in an off-pump procedure. The LAD vein was ligated proximal to the anastomosis. The LAD artery was ligated proximally. The physiological effects were monitored using microdialysis, tissue oxygen tension, blood flow in LIMA, blood samples, and hemodynamic and histological analyses. As controls, 5 pigs underwent surgery involving only LAD artery ligation without CVBG. CVBG with LAD ligation was performed in 16 pigs; 12 survived CVBG and were monitored for 2-2.5 hours while in sinus rhythm, a 75% salvage rate after an otherwise lethal LAD artery occlusion. Immediately after LAD artery ligation, the anterior wall of the left ventricle became cyanotic and hypokinetic. Over time it regained color and contractility as flow in the LIMA increased. Microdialysis showed a significant increase in lactate. Initially tissue oxygen tension decreased, but with time some recovery was seen. Cardiac troponin T was elevated. Histological analysis showed ischemic changes. In control pigs, microdialysis was performed for 1.5 hours up to LAD artery ligation, after which all pigs died in ventricular fibrillation arrest. No increase in lactate was observed. These results indicate that after LAD artery occlusion, CVBG can nourish the myocardium to a certain extent and prevent death in the majority of cases, although varying degrees of ischemia remain.     

Applications of robotic surgery in pediatric patients

Minimally invasive surgery is increasingly becoming the standard approach to treatment for pediatric patients. Infants present a technical challenge due to the small size of structures and the small workspace available. Master-slave robotic surgical telemanipulators help overcome this challenge by facilitating microsurgery in a confined workspace. The Zeus Robotic Surgical System (Computer Motion, Inc., Goleta, CA, U.S.A.) was used to develop the robotic approach and to evaluate the technical feasibility of performing four technically challenging procedures that are typically performed in infants. Robotic enteroenterostomy, hepaticojejunostomy, portoenterostomy, and esophagoesophagostomy were performed in piglets and compared with the same procedures performed by standard minimally invasive techniques. Enteroenterostomy, hepaticojejunostomy, and esophagoesophagostomy procedures were successfully developed and are technically feasible. The portoenterostomy procedure needs further study to validate data from the second set of experiments, showing a lower complication rate in the robotic group. Survivor studies are needed to fully elucidate the advantages that may be provided by the robotic approach.     

Robotically assisted laparoscopic cholecystectomy: a pilot study

HYPOTHESIS: Since the advent of laparoscopic surgery in 1987 and the introduction of robotics into medicine in 1991, medical technology has advanced to robotic applications in performing surgery. In our study, we investigated the feasibility of performing simple laparoscopic maneuvers and laparoscopic cholecystectomy using a robotic surgical system. DESIGN: The study used a ZEUS robotic system (Computer Motion Inc, Goleta, Calif), consisting of 3 interactive robotic arms fixed at the operating table and remotely controlled by the surgeon. After initial training, using a bench model and 3 isolated porcine livers to perform cholecystectomy, 7 female pigs underwent robotically assisted laparoscopic cholecystectomy. The surgeon, seated at the console, manipulated the 3-mm laparoscopic instruments and performed the surgery. RESULTS: Robotically assisted laparoscopic cholecystectomy was accomplished in all 7 pigs, with a mean operative time of 46 minutes (range, 30-62 minutes). There were no complications. The mean time to setup of the robotic system decreased from 30 minutes to 14 minutes. All the robotic maneuvers were performed without any particular difficulties, and the movements were stable, accurate, and reliable, with good control. CONCLUSIONS: Our preliminary experimental study showed that robotically reproduced laparoscopic maneuvers, such as tying, suturing, dissection, clipping, and cautery, seemed to be as accurate and as fast as maneuvers made without robotics. We conclude that our initial experimental and animal study confirmed the feasibility of robotically assisted laparoscopic cholecystectomy. Further reports are needed to show that robotics can be used for clinical applications in surgery.