Robotic Colorectal Surgery

Robotic colorectal surgery has gradually been performed more with the help of the technological advantages of the da Vinci® system. Advanced technological advantages of the da Vinci® system compared with standard laparoscopic colorectal surgery have been reported. These are a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, despite these technological advantages, most studies did not report the clinical advantages of robotic colorectal surgery compared to standard laparoscopic colorectal surgery. Only one study recently implies the real benefits of robotic rectal cancer surgery. The purpose of this review article is to outline the early concerns of robotic colorectal surgery using the da Vinci® system, to present early clinical outcomes from the most current series, and to discuss not only the safety and the feasibility but also the real benefits of robotic colorectal surgery. Moreover, this article will comment on the possible future clinical advantages and limitations of the da Vinci® system in robotic colorectal surgery.     

The Role of Robotic Surgery for Rectal Cancer: Overcoming Technical Challenges in Laparoscopic Surgery by Advanced Techniques

The conventional laparoscopic approach to rectal surgery has several limitations, and therefore many colorectal surgeons have great expectations for the robotic surgical system as an alternative modality in overcoming challenges of laparoscopic surgery and thus enhancing oncologic and functional outcomes. This review explores the possibility of robotic surgery as an alternative approach in laparoscopic surgery for rectal cancer. The da Vinci® Surgical System was developed specifically to compensate for the technical limitations of laparoscopic instruments in rectal surgery. The robotic rectal surgery is associated with comparable or better oncologic and pathologic outcomes, as well as low morbidity and mortality. The robotic surgery is generally easier to learn than laparoscopic surgery, improving the probability of autonomic nerve preservation and genitourinary function recovery. Furthermore, in very complex procedures such as intersphincteric dissections and transabdominal transections of the levator muscle, the robotic approach is associated with increased performance and safety compared to laparoscopic surgery. The robotic surgery for rectal cancer is an advanced technique that may resolve the issues associated with laparoscopic surgery. However, high cost of robotic surgery must be addressed before it can become the new standard treatment.

Graphical Abstract

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The <Emphasis Type="Italic">i</Emphasis><Superscript>2</Superscript><Emphasis Type="Italic">Snake</Emphasis> Robotic Platform for Endoscopic Surgery

Endoscopic procedures have transformed minimally invasive surgery as they allow the examination and intervention on a patient’s anatomy through natural orifices, without the need for external incisions. However, the complexity of anatomical pathways and the limited dexterity of existing instruments, limit such procedures mainly to diagnosis and biopsies. This paper proposes a new robotic platform: the Intuitive imaging sensing navigated and kinematically enhanced (\(i^{2}Snake\)) robot that aims to improve the field of endoscopic surgery. The proposed robotic platform includes a snake-like robotic endoscope equipped with a camera, a light-source and two robotic instruments, supported with a robotic arm for global positioning and for insertion of the \(i^{2}Snake,\) and a master interface for master–slave teleoperation. The proposed robotic platform design focuses on ergonomics and intuitive control. The control workflow was first validated in simulation and then implemented on the robotic platform. The results are consistent with the simulation and show the clear clinical potential of the system. Limitations such as tendon backlash and elongation over time will be further investigated by means of combined hardware and software solutions. In conclusion, the proposed system contributes to the field of endoscopic surgical robots and could allow to perform more complex endoscopic surgical procedures while reducing patient trauma and recovery time.     

The first korean experience of telemanipulative robot-assisted laparoscopic cholecystectomy using the da vinci system

With the advancement of laparoscopic instruments and computer sciences, complex surgical procedures are expected to be safely performed by robot assisted telemanipulative laparoscopic surgery. The da Vinci system (Intuitive Surgical, Mountain View, CA, USA) became available at the many surgical fields. The wrist like movements of the instrument's tip, as well as 3-dimensional vision, could be expected to facilitate more complex laparoscopic procedure. Here, we present the first Korean experience of da Vinci robotic assisted laparoscopic cholecystectomy and discuss the introduction and perspectives of this robotic system.     

Chip-on-tip endoscope incorporating a soft robotic pneumatic bending microactuator

In the ever advancing field of minimally invasive surgery, flexible instruments with local degrees of freedom are needed to navigate through the intricate topologies of the human body. Although cable or concentric tube driven solutions have proven their merits in this field, they are inadequate for realizing small bending radii and suffer from friction, which is detrimental when automation is envisioned. Soft robotic actuators with locally actuated degrees of freedom are foreseen to fill in this void, where elastic inflatable actuators are very promising due to their S3-principle, being Small, Soft and Safe. This paper reports on the characterization of a chip-on-tip endoscope, consisting out of a soft robotic pneumatic bending microactuator equipped with a 1.1?×?1.1 mm² CMOS camera. As such, the total diameter of the endoscope measures 1.66 mm. To show the feasibility of using this system in a surgical environment, a preliminary test on an eye mock-up is conducted.     

交互式微创手术机器人系统研究进展

微创手术相对于传统的开刀手术,创口面积较小,可以很大程度减小对人体的伤害,提高医疗器械的利用率.然而,微创手术也存在灵活性和操作特性受限等缺点.交互式微创手术机器人系统不仅改善了微创手术的稳定性、安全性和准确性,还在控制手术机器人时引进了力反馈,是微创手术领域新的发展方向.本文综述了交互式微创手术机器人系统的发展现状和实现人机交互的关键技术,最后对其发展做出展望和总结.     

Comparative Survival Outcome of Robot-Assisted Staging Surgery Using Three Robotic Arms versus Open Surgery for Endometrial Cancer

PurposeThere is lack of data on direct comparison of survival outcomes between open surgery and robot-assisted staging surgery (RSS) using three robotic arms for endometrial cancer. The purpose of this study was to compare the overall survival (OS) and disease-free survival (DFS) between open surgery and RSS using three robotic arms for endometrial cancer.Materials and MethodsConsecutive women with endometrial cancer who underwent surgery between May 2006 and May 2018 were identified. Robotic procedures were performed using the da Vinci robotic system, and the robotic approach consisted of three robotic arms including a camera arm. Propensity score matching, as well as univariate and multivariate Cox regression of OS and DFS were performed according to clinicopathologic data and surgical method.ResultsThe study cohort included 423 unselected patients with endometrial cancer, of whom 218 underwent open surgery and 205 underwent RSS using three robotic arms. Propensity score-matched cohorts of 146 women in each surgical group showed no significant differences in survival: 5-year OS of 91% vs. 92% and DFS of 86% vs. 89% in the open and robotic cohorts, respectively (hazard ratio, 1.02; 95% confidence interval, 0.82–1.67). In the univariate analysis with OS as the endpoint, surgical method, age, stage, type II histology, grade, and lymph node metastasis were independently associated with survival. Surgical stage, grade, and type II histology were found to be significant independent predictors for OS in the multivariate analysis.ConclusionRSS using three robotic arms and laparotomy for endometrial carcinoma had comparable survival outcomes.     

Toward a Flexible Variable Stiffness Endoport for Single-Site Partial Nephrectomy

Laparoscopic partial nephrectomy for localized renal tumors is an upcoming standard minimally invasive surgical procedure. However, a single-site laparoscopic approach would be even more preferable in terms of invasiveness. While the manual approach offers rigid curved tools, robotic single-site systems provide high degrees of freedom manipulators. However, they either provide only a straight deployment port, lack of instrument integration, or cannot be reconfigured. Therefore, the current main shortcomings of single-site surgery approaches include limited tool dexterity, visualization, and intuitive use by the surgeons. For partial nephrectomy in particular, the accessibility of the tumors remains limited and requires invasive kidney mobilization (separation of the kidney from the surrounding tissue), resulting in patient stress and prolonged surgery. We address these limitations by introducing a flexible, robotic, variable stiffness port with several working channels, which consists of a two-segment tendon-driven continuum robot with integrated granular and layer jamming for stabilizing the pose and shape. We investigate biocompatible granules for granular jamming and demonstrate the stiffening capabilities in terms of pose and shape accuracy with experimental evaluations. Additionally, we conduct in vitro experiments on a phantom and prove that the visualization of tumors at various sites is increased up to 38% in comparison to straight endoscopes.     

数据手套控制的微创手术机械臂抓钳系统设计

设计了一种实时控制腹腔镜手术机械臂的数据手套.利用惯性测量单元和摇杆电位器采集手部姿态信息,基于逆运动学法建立人手到手术机械臂关节的映射关系,控制手术机械臂抓钳的动作,实现常规手术操作.实验结果表明,该系统操作简单、实时性好,响应时间530 ms,对数据手套控制手术机械臂的研发具有参考价值.     

Surgical Outcomes of Robotic Radical Hysterectomy Using Three Robotic Arms versus Conventional Multiport Laparoscopy in Patients with Cervical Cancer

Purpose

To compare surgical outcomes of robotic radical hysterectomy (RRH) using 3 robotic arms with those of conventional laparoscopy in patients with early cervical cancer.

Materials and Methods

A retrospective cohort study included 102 patients with stage 1A1-IIA2 cervical carcinoma, of whom 60 underwent robotic and 42 underwent laparoscopic radical hysterectomy (LRH) with pelvic lymph node dissection performed between December 2009 and May 2013. Perioperative outcomes were compared between two surgical groups.

Results

Robotic approach consisted of 3 robotic arms including the camera arm and 1 conventional assistant port. Laparoscopic approach consisted of four trocar insertions with conventional instruments. There were no conversions to laparotomy. Mean age, body mass index, tumor size, cell type, and clinical stage were not significantly different between two cohorts. RRH showed favorable outcomes over LRH in terms of estimated blood loss (100 mL vs. 145 mL, p=0.037), early postoperative complication rates (16.7% vs. 30.9%, p=0.028), and postoperative complications necessitating intervention by Clavien-Dindo classification. Total operative time (200.5±61.1 minutes vs. 215.6±83.1 minutes, p=0.319), mean number of lymph node yield (23.3±9.3 vs. 21.7±9.8, p=0.248), and median length of postoperative hospital stay (11 days vs. 10 days, p=0.129) were comparable between robotic and laparoscopic group, respectively. The median follow-up time was 44 months with 2 recurrences in the robotic and 3 in the laparoscopic cohort.

Conclusion

Surgical outcomes of RRH and pelvic lymphadenectomy were comparable to that of laparoscopic approach, with significantly less blood loss and early postoperative complications.     

Robotic Surgery Improves Technical Performance and Enhances Prefrontal Activation During High Temporal Demand

Robotic surgery may improve technical performance and reduce mental demands compared to laparoscopic surgery. However, no studies have directly compared the impact of robotic and laparoscopic techniques on surgeons’ brain function. This study aimed to assess the effect of the operative platform (robotic surgery or conventional laparoscopy) on prefrontal cortical activation during a suturing task performed under temporal demand. Eight surgeons (mean age?±?SD?=?34.5?±?2.9 years, male:female ratio?=?7:1) performed an intracorporeal suturing task in a self-paced manner and under a 2 min time restriction using conventional laparoscopic and robotic techniques. Prefrontal activation was assessed using near-infrared spectroscopy, subjective workload was captured using SURG-TLX questionnaires, and a continuous heart rate monitor measured systemic stress responses. Task progression scores (au), error scores (au), leak volumes (mL) and knot tensile strengths (N) provided objective assessment of technical performance. Under time pressure, robotic suturing led to improved technical performance (median task progression score: laparoscopic suturing?=?4.5 vs. robotic suturing?=?5.0; z?=???2.107, p?=?0.035; median error score: laparoscopic suturing?=?3.0 mm vs. robotic suturing?=?2.1 mm; z?=???2.488, p?=?0.013). Compared to laparoscopic suturing, greater prefrontal activation was identified in seven channels located primarily in lateral prefrontal regions. These results suggest that robotic surgery improves performance during high workload conditions and is associated with enhanced activation in regions of attention, concentration and task engagement.     

Changes in Patterns of Radical Prostatectomy due to Diffusion of Robotic Surgical System: A Nationwide Study Using Health Insurance Claims Data

PurposeThis study analyzed the changes in the number of surgeries and surgical patterns due to the adoption and diffusion of new medical technology while focusing on radical prostatectomy.Materials and MethodsMedical equipment status report data and the National Health Insurance claims data from 2007 to 2019 were used. A total of 62798 radical prostatectomies from 135 medical facilities were analyzed. Radical prostatectomy was classified into open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and robot-assisted laparoscopic radical prostatectomy (RARP) using the fee schedule codes. A linear mixed model was used to determine whether the adoption of a robotic surgical system had an effect on the number of surgeries and surgical patterns after adjusting for medical characteristics.ResultsThe number of radical prostatectomies performed in Korea increased from 1756 in 2007 to 8475 in 2019. During this period, the proportion of RARP in total surgery increased from 17.5% to 74.3%. The mean number of surgeries at medical facilities adopting the robotic surgical system was 128.3, which was higher compared to 18.5 cases in medical facilities that did not adopt it. The adoption of a robotic surgical system increased the number of radical prostatectomy surgeries by 12.1 cases and the RARP share by 47.2% in a linear mixed model.ConclusionThe adoption and diffusion of robotic surgical systems in Korea increased the number of surgeries as well as the share of robotic surgery. It is necessary to manage a technology that is widely used in a state where its clinical effectiveness is uncertain.     

Use of a new venous cannula for minimally invasive cardiac surgery

Interest in minimally invasive cardiac surgery (MICS) for cardiac disease continues to increase, because it causes less surgical trauma and produces a better cosmetic appearance. We introduced the transxiphoid approach without sternotomy for correction of congenital heart defects. To improve exposure of the cardiac lesion during MICS, we developed a new venous cannula that is made of wire reinforced silicone, with an inflatable balloon attached at the tip. The advantages of this cannula are its extreme flexibility and that a tape does not need to be placed around the vena cava. During a period of 12 months, eight children underwent closure of atrial septal defects. The approach consisted of a 4 to 5 cm low midline incision with division of the xiphoid only. The new venous cannula was used as the superior vena cava cannula, all the patients survived the operation. This new venous cannula provided better exposure during cardiac surgery through a limited incision and is beneficial for minimally invasive cardiac surgery.     

The application of digital surgical diagnosis and treatment technology: a promising strategy for surgical reconstruction of craniomaxillofacial defect and deformity

The craniomaxillofacial defect and deformity always leads to serious dysfunction in mastication and facial contour damage, significantly reducing patients’ quality of life. However, surgical reconstruction of a craniomaxillofacial hard tissue defect or deformity is extremely complex and often does not result in desired facial morphology. Improving the result for patients with craniomaxillofacial defect and deformity remains a challenge for surgeons. Using digital technology for surgical diagnosis and treatment may help solve this problem. Computer-assisted surgical technology and surgical navigation technology are included in the accurate digital diagnosis and treatment system we propose. These technologies will increase the accuracy of the design of the operation plan. In addition, the intraoperative real-time navigating location system controlling the robotic arm or advanced intelligent robot will provide accurate, individualized surgical treatment for patients. Here we propose the hypothesis that a digital surgical diagnosis and treatment technology may provide a new approach for precise surgical reconstruction of complicated craniomaxillofacial defect and deformity. Our hypothesis involves modern digital surgery, a three-dimensional navigation surgery system and modern digital imaging technology, and our key aim is to establish a technological platform for customized digital surgical design and surgical navigation for craniomaxillofacial defect and deformity. If the hypothesis is proven practical, this novel therapeutic approach could improve the result of surgical reconstruction for craniomaxillofacial defect and deformity for many patients.     

The rabbit nephrectomy model for training in laparoscopic surgery

BACKGROUND: Laparoscopic surgical training is generally done with the teacher-student model using complex exercises. This study was performed to evaluate a new training model that emphasizes the repetition of simple procedures. METHODS: Laparoscopic surgery was performed in rabbits (n=200) using conventional instruments. Gynaecologists (n=10) and medical students (n=10) performed a series of exercises during 20 full days training. Nephrectomy was chosen to evaluate and score laparoscopic skills, i.e. duration of surgery and complication rate, since it mimics the surgical challenge and involves dissection of major vessels. Each surgeon performed 20 nephrectomies, alternating left and right sides. RESULTS: Duration of surgery and complications decreased with training. For duration of surgery, a two-phase exponential decay learning curve, with different decays for gynaecologists and students, was observed. Gynaecologists achieved shorter operating times than students for real and calculated times in the first procedure (P<0.0001 and P<0.0001) and for calculated time in the last procedure (P=0.001). Severe complications were more frequent in students than in gynaecologists (P=0.0003). CONCLUSION: The rabbit nephrectomy model is suitable for training in laparoscopic surgery. Since it implies the repetition of short and well-defined exercises, progression is easier to monitor and the necessity for continuous supervision is less, making training less expensive.     

机器人辅助外科达芬奇手术系统Nissen在胃底折叠治疗中的Meta分析

背景：与传统腹腔镜技术相比,机器人辅助外科特别是达芬奇手术系统可以提供良好的三维成像技术、更好的人体生物工程学设计及更加精细的操作。 目的：通过Meta分析评价机器人辅助外科达芬奇手术系统Nissen胃底折叠在治疗胃食管反流性疾病中的安全性及可行性。 方法：运用计算机检索Embase、OVID及PubMed等数据库有关达芬奇系统辅助Nissen胃底折叠治疗胃食管反流性疾病的论文。根据数据类型不同,统计方法分别采用倒方差法和M-H法,并根据异质性分析结果分别采用随机效应模型和固定效应模型。 结果与结论：共纳入5篇文献,累计160例患者。Meta分析结果显示,除术中及术后并发症外,传统腹腔镜组与机器人Nissen胃底折叠组总手术时间、有效手术时间、术后吞咽困难发生率、中转开腹或中转为传统腹腔镜手术率、再手术率、住院时间及住院费用差异均无显著性意义(P > 0.05)。说明机器人Nissen胃底折叠在治疗胃食管反流行疾病时并不优于传统腹腔镜手术,因此应谨慎选择适应证。     

Robot-assisted resection of paraspinal Schwannoma

Resection of retroperitoneal tumors is usually perfomed using the anterior retroperitoneal approach. Our report presents an innovative method utilizing a robotic surgical system. A 50-yr-old male patient visited our hospital due to a known paravertebral mass. Magnetic resonance imaging showed a well-encapsulated mass slightly abutting the abdominal aorta and left psoas muscle at the L4-L5 level. The tumor seemed to be originated from the prevertebral sympathetic plexus or lumbosacral trunk and contained traversing vessels around the tumor capsule. A full-time robotic transperitoneal tumor resection was performed. Three trocars were used for the robotic camera and working arms. The da Vinci Surgical System® provided delicate dissection in the small space and the tumor was completely removed without damage to the surrounding organs and great vessels. This case demonstrates the feasibility of robotic resection in retroperitoneal space. Robotic surgery offered less invasiveness in contrast to conventional open surgery.     

Robotic Surgery in Gynecologic Field

Operative laparoscopy was initially developed in the field of gynecology earlier on and the advent of laparoscopic surgery led to advances in general surgery as well. In the last few years, a number of articles have been published on the performance of surgical procedures using the robot-assisted laparoscopy. The shortcomings of conventional laparoscopy have led to the development of robotic surgical system and future of telerobotic surgery is not far away, enabling a surgeon to operate at a distance from the operating table. The complete loss of tactile sensation is often quoted as a big disadvantage of working with robotic systems. Although the first generation da Vinci robotic surgical system provides improved imaging and instrumentation, the absence of tactile feedback and the high cost of the technology remain as limitations. New generations of the robotic surgical systems have been developed, allowing visualization of preoperative imaging during the operation. Though the introduction of robotics is very recent, the potential for robotics in several specialties is significant. However, the benefit to patients must be carefully evaluated and proven before this technology can become widely accepted in the gynecologic surgery.     

Compact tracking of surgical instruments through structured markers

Virtual and augmented reality surgery calls for reliable and efficient tracking of the surgical instruments in the virtual or real operating theatre. The most diffused approach uses three or more not aligned markers, attached to each instrument and surveyed by a set of cameras. However, the structure required to carry the markers does modify the instrument’s mass distribution and can interfere with surgeon movements. To overcome these problems, we propose here a new methodology, based on structured markers, to compute the six degrees of freedom of a surgical instrument. Two markers are attached on the instrument axis and one of them has a stripe painted over its surface. We also introduce a procedure to compute with high accuracy the markers center on the cameras image, even when partially occluded by the instrument’s axis or by other structures. Experimental results demonstrate the reliability and accuracy of the proposed approach. The introduction of structured passive markers can open new possibilities to accurate tracking, combining markers detection with real-time image processing.     

Robotic Surgery for Cervical Cancer

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being perfomred under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required. Conclusion: Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.