Robotic endovascular surgery: current and future practice

Minimally invasive techniques have been at the forefront of surgical progress, and the evolution of endovascular robotic technologies has seen a paradigm shift in the focus of future innovation. Endovascular robotic technology may help overcome many of the challenges associated with traditional endovascular techniques by enabling greater control, stability, and precision of target navigation and treatment, while simultaneously reducing operator learning curves and improving safety. Several robotic systems have been developed to perform a broad range of endovascular procedures, but none have been used at scale or widely in routine practice, and the evidence for their safety, effectiveness, and efficiency remains limited. High cost and device complexity, lack of haptic feedback, and limited integration and interoperability with existing equipment and devices are the principal technology, cost, and sustainability barriers to the scalability and widespread adoption in day-to-day practice. In order to fully realize its potential, future robotic innovation must ensure compatibility with a range of off-the-shelf equipment that can be tracked and exchanged quickly during a procedure and come together with developments in navigation, tracking, and imaging. Reducing cost and complexity and supporting sustainability of the technology is key. In parallel, new technologies must be evaluated by clear and transparent standardized outcomes and be accompanied by robust clinical training. Key to the successful future development and dissemination of robotic technology is open collaboration among industry, clinicians, and patients in order to fully understand and address current challenges and enable the technology to realize its full potential.     

Robotic bariatric surgery: A general review of the current status

Background

While conventional laparoscopy is the gold standard for almost all bariatric procedures, robotic assistance holds promise for facilitating complex surgeries and improving clinical outcomes. Since the report of the first robotic‐assisted bariatric procedure in 1999, numerous publications, including those reporting comparative trials and meta‐analyses across bariatric procedures with a focus on robotic assistance, can be found.

Purpose

This article reviews the current literature and portrays the perspectives of robotic bariatric surgery.

Conclusions

While there are substantial reports on robotic bariatric surgery currently in publication, most studies suffer from low levels of evidence. As such, although robotics technology is without a doubt superior to conventional laparoscopy, the precise role of robotics in bariatric surgery is not yet clear.     

Robotic bariatric surgery: a systematic review

BackgroundObesity is a nationwide epidemic, and the only evidence-based, durable treatment of this disease is bariatric surgery. This field has evolved drastically during the past decade. One of the latest advances has been the increased use of robotics within this field. The goal of our study was to perform a systematic review of the recent data to determine the safety and efficacy of robotic bariatric surgery. The setting was the University Hospitals Case Medical Center (Cleveland, OH).MethodsA PubMed search was performed for robotic bariatric surgery from 2005 to 2011. The inclusion criteria were English language, original research, human, and bariatric surgical procedures. Perioperative data were then collected from each study and recorded.ResultsA total of 18 studies were included in our review. The results of our systematic review showed that bariatric surgery, when performed with the use of robotics, had similar or lower complication rates compared with traditional laparoscopy. Two studies showed shorter operative times using the robot for Roux-en-Y gastric bypass, but 4 studies showed longer operative times in the robotic arm. In addition, the learning curve appears to be shorter when robotic gastric bypass is compared with the traditional laparoscopic approach. Most investigators agreed that robotic laparoscopic surgery provides superior imaging and freedom of movement compared with traditional laparoscopy.ConclusionThe application of robotics appears to be a safe option within the realm of bariatric surgery. Prospective randomized trials comparing robotic and laparoscopic outcomes are needed to further define the role of robotics within the field of bariatric surgery. Longer follow-up times would also help elucidate any long-term outcomes differences with the use of robotics versus traditional laparoscopy.     

Robotic hypospadias surgery: a new evolution

The dictum that “there is nothing new in surgery not previously described,” is quoted regularly and is particularly true of hypospadias. There is an ongoing search for solutions to many troublesome issues concerning surgical treatment of hypospadias, such as what age is the most appropriate to apply surgery, or in how many stages surgery should be performed. We present a case report of the first robotic hypospadias surgery to propose a departure from the standard practice, in the hope of expanding medical expertise and teaching globally. The use of a robot for reconstructive surgery is not novel; its use for extracorporeal surgery is, but we contend that there is no difference in the surgical steps to carry out a hypospadias repair. In addition, we envision that the benefits of applying robotic surgery for extracorporeal reconstructive procedures will greatly impact the current paradigm of surgery and surgical education. For those surgeons who already possess comfort with robotic skills, reconstructive procedures outside of a major cavity are feasible, and time will provide safety and efficacy data. Our hope is that others will join in the advancement of telesurgery and its applications and appreciate the potential expansion of surgical knowledge that will be afforded by this change in how we teach and operate.     

Sirolimus: a current perspective

Sirolimus, a macrocyclic lactone that displays a novel mechanism of immunosuppressive action, is a critical-dose drug requiring therapeutic drug monitoring for optimal outcomes. The compound was documented in two multicenter, blinded clinical trials to reduce the incidence of acute rejection episodes when used in combination with cyclosporine and steroids vs. azathioprine or placebo comparators. Furthermore, studies utilizing cyclosporine withdrawal documented a long-term benefit on renal function of chronic sirolimus therapy, albeit with a modestly enhanced incidence of acute rejection episodes. Although this application may be useful in selected cases, we believe that minimal initial cyclosporine exposures de novo mitigate the need for eventual withdrawal for chronic nephropathy, while preserving the immunosuppressive synergy during the maintenance phase. Recipients treated de novo with a sirolimus-cyclosporine combination tolerate steroid withdrawal at 1 month after living-donor or at 3 to 6 months after cadaveric kidney transplantation with only a 5% risk of acute rejection episodes and 6% incidence of chronic reactions within 3 years. However, sirolimus exacerbates the hypertriglyceridemic and hypercholesterolemic proclivities of transplant recipients, as well as exerts myelosuppressive effects, which are augmented by concomitant therapy with azathioprine or, particularly, with mycophenolate mofetil. Due to its apparent lack of nephrotoxicity, sirolimus has been employed for induction therapy in a calcineurin antagonist-free regimen in combination with either basiliximab or rabbit antilymphocyte sera for weak or strong immune responders, respectively, followed by introduction of a calcineurin antagonist upon resolution of the ischemia-reperfusion injury. Therefore, sirolimus proffers a potent and unique platform for new immunosuppressive strategies in organ transplantation.     

Robotic surgery

The industrial revolution demonstrated the capability of robotic systems to facilitate and improve manufacturing. As a result, robotics extended to various other domains, including the delivery of health care. Hence, robots have been developed to assist hospital staff, to facilitate laboratory analyses, to augment patient rehabilitation, and even to advance surgical performance. As robotics lead usefulness and gain wider acceptance among the surgical community, the urologist should become familiar with this new interdisciplinary field and its “URobotics” subset: robotics applied to urology. This article reviews the current applications and experience, issues and debates in surgical robotics, and highlights future directions in the field.     

Robotic surgery

This article discusses the developments that led up to robotic surgical systems as well as what is on the horizon for new robotic technology. Topics include how robotics is enabling new types of procedures, including natural orifice endoscopic translumenal surgery in which one cannot reach by hand under any circumstances, and how these developments will drive the next generation of robots.     

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).     

Robotic renal surgery: pyeloplasty

The treatment of ureteropyelic junction (UPJ) obstruction offers a perfect sketch of the parallel evolution of the availability of technology and changes in surgical proceedings. From the open Anderson-Hynes pyeloplasty, passing through percutaneous or retrograde endopyelothomy with various instruments, to the laparoscopic approach, technology and human talent have found a field for development in this reconstructive procedure. Robotic surgery is young and starts to define its role in urology surgery. There are established procedures such as radical prostatectomy; it remains to be established what operations will benefit from the robotic technology, so results are under continuous evaluation. The non stopping advance of computer technology guarantees future achievements of robotic technology. The objective is to achieve that surgeons could perform difficult surgical procedures with a level of accuracy and clinical results that would be difficult to achieve with conventional methods. We analyze the technical features, results and comparative studies of the robotic pyeloplasty from the medical literature. Robotic surgery has demonstrated its usefulness in the performance of pyeloplasties, with good results in primary and secondary UPJ stenosis in children and adults, in various aetiologies. Robotics enables to diminish the difficulties of intracorporeal suture and the learning curve for surgeons without laparoscopic experience. Nevertheless, although initial clinical experience with robotic pyeloplasty is favourable, continuous evaluation of results is necessary to determine if the surgical procedure is as effective in the long-term as laparoscopic and open pyeloplasty.     

Robotic surgery: an update

Minimally invasive surgery techniques have revolutionized surgery. Robotic surgery may be the next revolution in surgical technology. Robotics coupled with minimally invasive surgery and microscopic surgery provides the potential to do more complex and more precise tasks. Robotic surgery offers tremor filtration, motion scaling, indexed movements, additional degrees of freedom, and improved ergonomics. We explore robotic history, the present surgical technology, the current clinical cases and research, and the future of robotics. We will look specifically at the birth and progress of our own problem.