Neurosurgical robotics: a review of brain and spine applications

Neurosurgery has traditionally been at the forefront of advancing technologies, adapting new techniques and devices successfully in an effort to increase the safety and efficacy of brain and spine surgery. Among these adaptations are surgical robotics. This paper reviews some of the more promising systems in neurosurgical robotics, including brain and spine applications in use and in development. The purpose of the discussion is twofold—to discuss the most promising models for neurosurgical applications, and to discuss some of the pitfalls of robotic neurosurgery given the unique anatomy of the brain and spine.     

Robotic spine surgery: Ushering in a new era

The endeavour to make spine surgery safe with reproducible, consistent outcomes has led to growing interest and research in the field of intraoperative imaging, navigation and robotics. The advent of surgical robot systems in spine surgery is relatively recent – with only a few systems approved for commercial use. At present, pedicle screw insertion remains the primary application of robotic systems in spine surgery. The purported advantages of robot-assisted pedicle screw insertion over other conventional techniques are its increased accuracy, reproducible consistency and reduced radiation exposure. Many of these claims have been supported or refuted by individual studies – and high quality evidence for the same is lacking. Robotic spine surgery also has its share of limitations which include increased operative time, considerable learning curve and technical pitfalls unique to the robotic systems. The applications of robotic spine surgery are evolving and expanding to spinal deformity, spine oncology and needle-based interventional treatments. This review provides an overview of the evolution and current status of robotic spine surgery along with an evidence-based discussion of its current applications in spine surgery.     

机器人手术系统在肝脏外科中的应用

机器人手术系统具有稳定、清晰及放大的3D视野,可滤过术者手部震颤,具有多个自由度的灵活稳定操作,克服了传统腹腔镜的不足。尽管机器人手术系统在泌尿外科、妇产科等外科领域得到广泛应用,但在肝脏外科中的作用仍未得到充分认识。笔者综合国内外相关文献,结合团队经验,针对机器人手术系统在肝脏外科应用中的适应证、机器人手术系统肝切除...     

手术机器人在微创外科的应用进展

微创外科是二十世纪医学科学发展的伟大成就之一,以切口小、创伤轻、痛苦少、恢复快等优点迅速在外科各专业领域得以推广应用。手术机器人的出现,使微创外科的发展进入新的一页。目前手术机器人的临床应用已扩展到外科领域的各个分支,极大地拓展了传统的腹腔镜微创外科,将掀起微创外科的又一次新技术革命浪潮。     

The Safety and Efficacy of Approaches to Liver Resection: A Meta-Analysis

Background:The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.Database:Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).Conclusion:Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.     

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.     

机器人胰十二指肠切除术临床应用的初步探索

目的初步探究机器人辅助腹腔镜胰十二指肠切除术临床应用价值。方法回顾性分析解放军总医院自2012年2月至2015年9月行机器人辅助腹腔镜胰十二指肠切除术13例病人的临床资料。结果 13例病人均顺利完成手术,全部手术均为完全切除,手术时间为(548±124)min,术中出血量为(200±127)ml,术后住院时间为(23±11)d,所有病人均康复出院,无死亡病人。结论机器人辅助腹腔镜胰十二指肠切除术安全、可行,具有一定的临床应用价值。     

Current Status of Robotic Surgery

Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms “robotic surgery, telesurgery, and laparoscopy.” A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.     

国产机器人妙手S系统远程手术实验研究

目的验证国产手术机器人妙手S系统远程手术的安全性和稳定性。方法将国产手术机器人妙手S系统的主从手分开,主手放置在天津大学机械工程学院机器人实验室,从手放置在北京第二炮兵总医院(现火箭军总医院)机器人外科实验室。在天津操作手术机器人主手,通过因特网远程控制北京的机器人臂(从手)进行远程猪胆囊切除、胃穿孔修补、肝脏楔形切除术。检测机器人远程进行切除、缝合、打结、止血等操作的安全性和稳定性。天津至北京距离118 km。结果本次动物(猪)实验完成远程胆囊切除、胃穿孔修补、肝脏楔形切除术,为国内首次动物腹部外科远程手术成功案例。胆囊切除手术时间为50 min,出血5 nl;胃穿孔修补手术时间为20 min,出血0 ml;肝脏楔形切除手术为30 min,出血15 ml。顺行法切除胆囊,先解剖胆囊三角,显露出胆囊管、胆囊动脉和胆总管,离断胆囊管后,顺行剥离胆囊浆膜,注意避免损伤肝脏及右肝管、右肝动脉。胃穿孔修补采用2-0慕丝线行全层间断缝合术,共缝合3针。肝脏楔形切除肝叶边缘大小约2 cm×1cm肝组织。术中无周围脏器损伤等并发症。手术过程有延时效应,延时平均小于250 ms,机器人手术系统无明显抖动等不良状况,实验顺利完成。结论国产手术机器人妙手S系统具有良好的安全性和稳定性,可顺利完成腹部外科远程手术。     

Renal vein varix and UPJ obstruction: a case report and techniques for robotic management

The use of minimally invasive techniques to manage an ureteropelvic junction obstruction (UPJO) has been well described. In this case report, we describe the management of an UPJO and a large renal vein varix discovered at the time of robotic pyeloplasty. The control and precision of robotic assistance was key to the effective management of this intra-operative finding.     

计算机辅助导航骨科手术及医用机器人技术在创伤骨科的应用

本文介绍了计算机辅助导航骨科手术(CAOS)及医用机器人技术在创伤骨科应用中的主要进展、当前在临床应用中存在的主要问题和相关对策,并对其未来的发展趋势进行了预测,同时简要介绍了北京积水潭医院创伤骨科在计算机辅助导航骨科手术及医用机器人技术方面的研究进展。当前骨科手术导航定位所应用的医学图象导引系统已经由使用单一的C型臂、CT等传统影像设备向应用三维C型臂、多模态图像处理系统等新型影像设备转变,基于多模态图像的导航系统将有可能成为导航手术的主流。医用机器人已经在自动化程度和人机交互模式方面,有了长足进展,摆脱了原有工业机器人的结构模式。医学图像后处理技术及其它相关信息技术极大地丰富了导航和机器人外科,只有在不断完善光学定位技术的同时,加大对其它定位方法的研究,才能够提高定位精度;要对相关设备进行开放式结构设计,使不同导航系统的注册软件能够互相兼容,手术器械能够通用,降低设备成本。骨科医生要正确认识计算机辅助导航骨科手术及医用机器人技术,在充分了解CAOS的技术特点、基本原理、操作程序的基础上,对要实施的手术具有深刻的理解,才能开展CAOS手术。目前,迫切需要建立CAOS技术标准、临床适应证和手术操作规范,进行CAOS产品之间的技术比较和评估,便于医生选择合适的CAOS产品。伴随快速发展的信息技术,数字化手术室、智能化微创导航手术系统、医用机器人辅助的远程医疗将有可能成为未来CAOS技术的主要组成部分。     

达芬奇手术机器人：结直肠外科的新挑战

精准化微创手术已成为结直肠外科医疗水平的象征。达芬奇手术机器人系统的应运而生,开启了精准化微创手术的新纪元。该系统的优势在于:可提供高清稳定的立体视觉、精准化的直觉式动作控制、滤除的手部震颤、缩短的手术曲线以及可远程控制性。但其局限性在于:触觉反馈缺失,手术时间延长和价格昂贵等。笔者就达芬奇手术机器人系统的构成、发展史及其在结直肠外科手术中的应用现状进行阐述,并对这一先进智能技术的前景进行了些许思索。     

肝脏肿瘤的微创治疗——从腹腔镜到机器人

目的探讨完全腹腔镜、手助式腹腔镜及机器人三种微创手术方式在肝脏切除术中的可行性、安全性及适用范围。方法回顾性分析上海交通大学医学院附属瑞金医院普外科自2004年9月至20l2年1月期间完成的微创肝脏切除术(minimally invasive liver resection,MILR)128例患者的临床资料,根据手术方式分为完全腹腔镜肝脏切除术(pure laparoscopic resection,PLR)组、手助式腹腔镜肝脏切除术(hand-assisted laparoscopicresection,HALR)组及机器人辅助肝脏切除术(robotic liver resection,RLR)组,分别观察3组患者术中与术后恢复情况并进行对比分析。结果 PLR组82例,中转开腹3例,手术时间为(145.4±54.4)min(40～290 min)、术中出血量为(249.3±255.7)ml(30～1 500 ml),术后并发腹腔感染3例,胆瘘5例,经保守治疗后痊愈,无围手术期死亡,术后住院时间为(7.1±3.8)d(2～34 d)。HALR组35例,中转开腹3例,手术时间为(182.7±59.2)min(60～300 min)、术中出血量为(754.3±785.2)ml(50～3 000 ml),术后并发腹腔感染1例,胆瘘2例,切口感染2例,经保守治疗后痊愈,无二次手术,术后住院时间为(15.4±3.7)d(12～30 d)。RLR组11例,中转开腹2例,手术时间为(129.5±33.5)min(120～200 min)、术中出血量为(424.5±657.5)ml(50～5 000 ml),术后并发腹腔感染1例,胆瘘1例,经保守治疗后痊愈,术后住院时间为(6.4±1.6)d(5～9 d)。3组中,RLR组手术时间最短(P=0.001),术后住院时间最短(P=0.000),PLR组术中出血量最少(P=0.000),其差异均有统计学意义。结论肝脏肿瘤微创切除术安全、可行,临床工作中,需要根据不同的病例选择不同的手术方式。机器人辅助肝脏切除术为肝脏肿瘤的微创治疗带来了新的突破。     

Trends of robotic-assisted surgery for thyroid,colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation

BackgroundThe current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.MethodsData on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.ResultsThe odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93–0.97; OR: 0.90, 95% CI: 0.88–0.92; and OR: 0.71, 95% CI: 0.65–0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25–1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).ConclusionsThe use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.     

The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience

Background This study investigated the use of robotics to perform extended esophageal resection in a series of patients. Methods A total of 14 patients with a median age of 64 years underwent esophagectomy using the da Vinci robot. At presentation, there were 12 cases of cancer, staged at T2N1 (n = 2), T3N0 (n = 2), T3N1 (n = 6), T4N1 (n = 1), and M1a (n = 1); 2 cases of high-grade dysplasia; 8 cases of adenocarcinoma; and 4 cases of squamous cell cancer; as well as 2 middle third, 9 lower third, and one gastroesophageal junction tumor. Nine patients had undergone preoperative chemoradiotherapy, and six had undergone prior abdominal surgery. The patients were categorized into three chronological groups according to the procedure performed. Group 1 consisted of the first three patients in the series, whose surgery was thoracic only (robotically assisted esophagectomy). Group 2, the next three patients, had robotically assisted thoracic esophagectomy plus thoracic duct ligation using a laparoscopic gastric conduit. Group 3, the last eight patients, underwent completely robotic esophagectomy. Results For Group 3, the total operating room time was 11.1 ± 0.8 h (range, 11.3–13.2 h), with a console time of 5.0 ± 0.5 h (range, 4.8–5.8 h). The estimated blood loss was 400 ± 300 ml (range, 200–950 ml). One patient in group 1 had a thoracic duct leak. In groups 2 and 3, thoracic duct ligation resulted in no further leaks. Other postoperative complications included severe pneumonia (1 case), atrial fibrillation (5 cases), cervical anastomotic leak (2 cases), wound infection (1 case), and bilateral vocal cord paresis requiring tracheostomy (1 case). In seven of the cases, no intensive care unit time was required. There was one death from pneumonia 72 days after the procedure. The rate of disease-free survival was 87%. Conclusion The robotic approach facilitates an extended three-field esophagolymphadenectomy even after induction therapy and abdominal surgery. Larger scale trials are needed to define the role of this technique.     

Ergonomics and human factors in endoscopic surgery: a comparison of manual vs telerobotic simulation systems

Background Minimally invasive surgical techniques expose surgeons to a variety of occupational hazards that may promote musculoskeletal disorders. Telerobotic systems for minimally invasive surgery may help to reduce these stressors. The objective of this study was to compare manual and telerobotic endoscopic surgery in terms of postural and mental stress. Methods Thirteen participants with no experience as primary surgeons in endoscopic surgery performed a set of simulated surgical tasks using two different techniques — a telerobotic master — slave system and a manual endoscopic surgery system. The tasks consisted of passing a soft spherical object through a series of parallel rings, suturing along a line 5 -cm long, running a 32-in ribbon, and cannulation. The Job Strain Index (JSI) and Rapid Upper Limb Assessment (RULA) were used to quantify upper extremity exposure to postural and force risk factors. Task duration was quantified in seconds. A questionnaire provided measures of the participants' intuitiveness and mental stress. Results The JSI and RULA scores for all four tasks were significantly lower for the telerobotic technique than for the manual one. Task duration was significantly longer for telerobotic than for manual tasks. Participants reported that the telerobotic technique was as intuitive as, and no more stressful than, the manual technique. Conclusions Given identical tasks, the time to completion is longer using the telerobotic technique than its manual counterpart. For the given simulated tasks in the laboratory setting, the better scores for the upper extremity postural analysis indicate that telerobotic surgery provides a more comfortable environment for the surgeon without any additional mental stress. The view expressed in this article are those of the authors and do not reflect the official policy or position of the US Air Force, the Department of Defense, or the US government.     

Robotic surgery versus laparoscopy; a comparison between two robotic systems and laparoscopy

Laparoscopy has found a role in standard urologic practice, and with training programs continuing to increase emphasis on its use, the division between skill sets of established non-laparoscopic urologic practitioners and urology trainees continues to widen. At the other end of the spectrum, as technology progresses apace, advanced laparoscopists continue to question the role of surgical robotics in urologic practice, citing a lack of significant advantage to this modality over conventional laparoscopy. We seek to compare two robotic systems (Zeus and DaVinci) versus conventional laparoscopy in surgical training modules in the drylab environment in the context of varying levels of surgical expertise. A total of 12 volunteers were recruited to the study: four staff, four postgraduate trainees, and four medical student interns. Each volunteer performed repeated time trials of standardized tasks consisting of suturing and knot tying using each of the three platforms: DaVinci, Zeus and conventional laparoscopy. Task times and numbers of errors were recorded for each task. Following each platform trial, a standardized subjective ten-point Likert score questionnaire was distributed to the volunteer regarding various operating parameters experienced including: visualization, fluidity, efficacy, precision, dexterity, tremor, tactile feedback, and coordination. Task translation from laparoscopy to Zeus robotics appeared to be difficult as both suture times and knot-tying times increased in pairwise comparisons across skill levels.