Renal surgery in the new millennium

In the not too distant future, the minimally invasive renal surgeon will be able to practice an operation on a difficult case on a three-dimensional virtual reality simulator, providing all attributes of the real procedure. The patient's imaging studies will be imported into the simulator to better mimic particular anatomy. When confident enough of his or her skills, the surgeon will start operating on the patient using the same virtual reality simulator/telepresence surgery console system, which will permit the live surgery to be conducted by robots hundreds of miles away. The robots will manipulate miniature endoscopes or control minimally or noninvasive ablative technologies. Endoscopic/laparoscopic footage of the surgical procedure will be stored digitally in optical disks to be used later in telementoring of a surgery resident. All this and more will be possible in the not so distant third millennium.     

Augmented reality in open surgery

Augmented reality (AR) has been successfully providing surgeons an extensive visual information of surgical anatomy to assist them throughout the procedure. AR allows surgeons to view surgical field through the superimposed 3D virtual model of anatomical details. However, open surgery presents new challenges. This study provides a comprehensive overview of the available literature regarding the use of AR in open surgery, both in clinical and simulated settings. In this way, we aim to analyze the current trends and solutions to help developers and end/users discuss and understand benefits and shortcomings of these systems in open surgery. We performed a PubMed search of the available literature updated to January 2018 using the terms (1) “augmented reality” AND “open surgery”, (2) “augmented reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”, (3) “mixed reality” AND “open surgery”, (4) “mixed reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”. The aspects evaluated were the following: real data source, virtual data source, visualization processing modality, tracking modality, registration technique, and AR display type. The initial search yielded 502 studies. After removing the duplicates and by reading abstracts, a total of 13 relevant studies were chosen. In 1 out of 13 studies, in vitro experiments were performed, while the rest of the studies were carried out in a clinical setting including pancreatic, hepatobiliary, and urogenital surgeries. AR system in open surgery appears as a versatile and reliable tool in the operating room. However, some technological limitations need to be addressed before implementing it into the routine practice.     

Imaging-assisted endoscopic surgery: Cleveland Clinic experience

BACKGROUND AND PURPOSE: Our initial experience in using computer-aided image assistance in minimally invasive urology was reported. MATERIALS AND METHODS: The system consisted of a computer and a localizer allowing spatial localization of the position of the various surgical instruments, using a magnetic sensor as well as an optical sensor. Available imaging modality included real-time ultrasound as well as preoperative computed tomography (CT) or magnetic resonance imaging (MRI). RESULTS: We first clinically applied the fusion system of real-time US with preoperative CT or MRI for percutanous radiofrequency/cryoablation for renal tumor. We also clinically applied an augmented reality visualization system that helps the laparoscopic surgeon to understand three-dimensional (3D) anatomies beyond the surgical view. Augmented reality was feasible and useful to facilitate the surgeon's direct interpretation of 3D anatomies of cancer or vital anatomies beyond the surgical view, using preoperative CT data during laparoscopic partial nephrectomy and intraoperative transrectal US during laparoscopic radical prostatectomy. To our knowledge, we report the first clinical use of augmented reality technology in urology. CONCLUSIONS: Imaging assistance beyond the endoscopic surgical view could increase the precision for and confidence of the surgeon, providing preoperative oncological data and understanding of the surrounding vital anatomies. Novel computer-based emerging techniques with 3D imaging technologies potentially indicate the ideal dissection plane to achieve better oncological outcomes as well as to maximize functional preservation.     

Bildfusion,virtuelle Realität,Robotik und Navigation Einfluss auf die chirurgische Praxis

In the new minimally invasive surgical era, virtual reality, robotics, and image merging have become topics on their own, offering the potential to revolutionize current surgical treatment and assessment. Improved patient care in the digital age seems to be the primary impetus for continued efforts in the field of telesurgery. The progress in endoscopic surgery with regard to telesurgery is manifested by digitization of the pre-, intra-, and postoperative interaction with the patients' surgical disease via computer system integration: so-called Computer Assisted Surgery (CAS). The preoperative assessment can be improved by 3D organ reconstruction, as in virtual colonoscopy or cholangiography, and by planning and practicing surgery using virtual or simulated organs. When integrating all of the data recorded during this preoperative stage, an enhanced reality can be made possible to improve intra-operative patient interactions. CAS allows for increased three-dimensional accuracy, improved precision and the reproducibility of procedures. The ability to store the actions of the surgeon as digitized information also allows for universal, rapid distribution: i.e., the surgeon's activity can be transmitted to the other side of the operating room or to a remote site via high-speed communications links, as was recently demonstrated by our own team during the Lindbergh operation. Furthermore, the surgeon will be able to share his expertise and skill through teleconsultation and telemanipulation, bringing the patient closer to the expert surgical team through electronic means and opening the way to advanced and continuous surgical learning. Finally, for postoperative interaction, virtual reality and simulation can provide us with 4 dimensional images, time being the fourth dimension. This should allow physicians to have a better idea of the disease process in evolution, and treatment modifications based on this view can be anticipated. We are presently determining the accuracy and efficacy of 4 dimensional imaging compared to conventional evaluations.     

Novel dynamic information integration during da Vinci robotic partial nephrectomy and radical nephrectomy

With the increasing discovery of small renal neoplasms, minimally invasive excisional approaches have become more popular. Robotic partial nephrectomy is an emerging procedure. During robotic renal surgery, the console surgeon often has a need to view images or other data during the surgical dissection. Herein, we describe the preliminary use of integrative surgical imaging in the console surgical view during 20 cases of robotic partial and radical nephrectomy. Integration of this technology, termed Tilepro, allows the surgeon to view data within the robotic console and thus prevents disengagement. The success rate of transmission was 95% and the usefulness of the transmission was 89%. Complications included delayed transmission and cabling issues. This technology is useful in robotic renal surgery and may have benefits in telepresence or other surgical fields. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Incorporating robotics into an open-heart program

The above described clinical series show that after a careful and thorough training program and stepwise introduction of surgical telemanipulation systems, application of telemanipulations is safe and shows acceptable results. Still, OR times are longer than for conventional procedures, and the operation is demanding, and expensive. The main shortcoming is that the procedure is only suitable for a highly selected patient population. However, despite all the clinical experience gathered in various centers, this technique is still evolving and in its beginning. There are some very promising developments that will improve the benefit of telemanipulators. For the first time, the separation of the surgeon from the surgical field facilitates training of surgeons on simulators. This might lead to a higher standard of surgical performance. Progress in sensor technology will make tactile-force feedback available, and new 3 D-visualization systems are designed to provide a better depth perception and higher resolution of the endoscopic image. Virtual stabilizing systems will enable robotic systems to operate on a virtual arrested heart without the need for CPB or mechanical stabilizers. These and other research topics summarized under the term augmented reality will enhance the natural senses and abilities of the surgeon. More and more, automatization will find its way into the OR. Preoperatively collected data about the patient's anatomy will be used to create safety margins, the robotic system will allow for the surgeon's movements, and instruments will be able to find their way to the surgical site without remote control. Because a stepwise approach has led to the clinical results that we and others have now achieved, it is the basis for further step-by-step development of the application of telemanipulation systems in coronary artery bypass grafting, and possibly other endoscopic procedures in cardiac surgery.     

Equipment and technology in surgical robotics

Contemporary medical robotic systems used in urologic surgery usually consist of a computer and a mechanical device to carry out the designated task with an image acquisition module. These systems are typically from one of the two categories: offline or online robots. Offline robots, also known as fixed path robots, are completely automated with pre-programmed motion planning based on pre-operative imaging studies where precise movements within set confines are carried out. Online robotic systems rely on continuous input from the surgeons and change their movements and actions according to the input in real time. This class of robots is further divided into endoscopic manipulators and master–slave robotic systems. Current robotic surgical systems have resulted in a paradigm shift in the minimally invasive approach to complex laparoscopic urological procedures. Future developments will focus on refining haptic feedback, system miniaturization and improved augmented reality and telesurgical capabilities.     

Tele-surgery simulation with a patient organ model for robotic surgery training

Robotic systems are increasingly being incorporated into general laparoscopic and thoracoscopic surgery to perform procedures such as cholecystectomy and prostatectomy. Robotic assisted surgery allows the surgeon to conduct minimally invasive surgery with increased accuracy and with potential benefits for patients. However, current robotic systems have their limitations. These include the narrow operative field of view, which can make instrument manipulation difficult. Current robotic applications are also tailored to specific surgical procedures. For these reasons, there is an increasing demand on surgeons to master the skills of instrument manipulation and their surgical application within a controlled environment. This study describes the development of a surgical simulator for training and mastering procedures performed with the da Vinci surgical system. The development of a tele-surgery simulator and the construction of a training center are also described, which will enable surgeons to simulate surgery from or in remote places, to collaborate over long distances, and for off-site expert assistance.     

The Kirby view: A radiographic view for flatfoot evaluation

The Kirby view allows the surgeon to have tangible pretreatment evidence of the calcaneal relationship to the tibiotalar joint. It also allows the surgeon to construct preoperative templates to determine how far medially the calcaneus needs to be moved to achieve a good alignment with the tibiotalar joint, rather than just guessing at the time of surgery. This view also allows the surgeon to better evaluate the results of the surgical procedure postoperatively (2, 3 and 4). We believe that this view can easily be taken and will provide the practitioner with excellent information on the position of the calcaneus when evaluating any flatfoot deformity. We now have it made it a routine radiograph view taken on all flatfoot deformities.     

Microvascular decompression surgery for trigeminal neuralgia: technical review based on surgical anatomy

To perform secure microvascular decompression for trigeminal neuralgia, it is important to perform each surgical procedure based on detailed anatomical knowledge. As for microsurgical procedure, there are two major approaches; the supracerebellar approach and the trans-horizontal fissure approach. This article reviews the advantages of each surgical approach and describes points to pay attention to, with figures which will help the surgeon to perform this surgery. The importance of real decompression or transposition of the offending vessels is stressed. The significance of preoperative imaging as well as perioperative management including the patients' positioning is also described.     

Prevalence of haptic feedback in robot-mediated surgery: a systematic review of literature

With the successful uptake and inclusion of robotic systems in minimally invasive surgery and with the increasing application of robotic surgery (RS) in numerous surgical specialities worldwide, there is now a need to develop and enhance the technology further. One such improvement is the implementation and amalgamation of haptic feedback technology into RS which will permit the operating surgeon on the console to receive haptic information on the type of tissue being operated on. The main advantage of using this is to allow the operating surgeon to feel and control the amount of force applied to different tissues during surgery thus minimising the risk of tissue damage due to both the direct and indirect effects of excessive tissue force or tension being applied during RS. We performed a two-rater systematic review to identify the latest developments and potential avenues of improving technology in the application and implementation of haptic feedback technology to the operating surgeon on the console during RS. This review provides a summary of technological enhancements in RS, considering different stages of work, from proof of concept to cadaver tissue testing, surgery in animals, and finally real implementation in surgical practice. We identify that at the time of this review, while there is a unanimous agreement regarding need for haptic and tactile feedback, there are no solutions or products available that address this need. There is a scope and need for new developments in haptic augmentation for robot-mediated surgery with the aim of improving patient care and robotic surgical technology further.     

Robotic renal surgery

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.     

Real-time 3D image reconstruction guidance in liver resection surgery

Background

Minimally invasive surgery represents one of the main evolutions of surgical techniques. However, minimally invasive surgery adds difficulty that can be reduced through computer technology.

Methods

From a patient’s medical image [US, computed tomography (CT) or MRI], we have developed an Augmented Reality (AR) system that increases the surgeon’s intraoperative vision by providing a virtual transparency of the patient. AR is based on two major processes: 3D modeling and visualization of anatomical or pathological structures appearing in the medical image, and the registration of this visualization onto the real patient. We have thus developed a new online service, named Visible Patient, providing efficient 3D modeling of patients. We have then developed several 3D visualization and surgical planning software tools to combine direct volume rendering and surface rendering. Finally, we have developed two registration techniques, one interactive and one automatic providing intraoperative augmented reality view.

Results

From January 2009 to June 2013, 769 clinical cases have been modeled by the Visible Patient service. Moreover, three clinical validations have been realized demonstrating the accuracy of 3D models and their great benefit, potentially increasing surgical eligibility in liver surgery (20% of cases). From these 3D models, more than 50 interactive AR-assisted surgical procedures have been realized illustrating the potential clinical benefit of such assistance to gain safety, but also current limits that automatic augmented reality will overcome.

Conclusions

Virtual patient modeling should be mandatory for certain interventions that have now to be defined, such as liver surgery. Augmented reality is clearly the next step of the new surgical instrumentation but remains currently limited due to the complexity of organ deformations during surgery. Intraoperative medical imaging used in new generation of automated augmented reality should solve this issue thanks to the development of Hybrid OR.     

Geschichte und Entwicklung der computerassistierten Chirurgie in der Orthopädie

Computer assisted orthopaedic surgery (CAOS) was developed to improve the accuracy of surgical procedures. It has improved dramatically over the last years, being transformed from an experimental, laboratory procedure into a routine procedure theoretically available to every orthopaedic surgeon.The first field of application of computer assistance was neurosurgery. After the application of computer guided spinal surgery, the navigation of total hip and knee joints became available. Currently, several applications for computer assisted surgery are available. At the beginning of navigation, a preoperative CT-scan or several fluoroscopic images were necessary. The imageless systems allow the surgeon to digitize patient anatomy at the beginning of surgery without any preoperative imaging. The future of CAOS remains unknown, but there is no doubt that its importance will grow in the next 10 years, and that this technology will probably modify the conventional practice of orthopaedic surgery.     

Use of a robotic system as surgical first assistant in advanced laparoscopic surgery

BACKGROUND: To date, the use of robotic systems has concentrated on enhancing the dexterity of the individual surgeon performing advanced laparoscopic surgery. Surgical assistants must still be present. We present a clinical experience using a robotic system as a surgical first assistant, enabling the performance of solo surgery in increasingly complex procedures. Laparoscopic fundoplication was selected as an advanced laparoscopic procedure that has routinely required a human assistant. STUDY DESIGN: Between January and April 2001, 10 patients with gastroesophageal reflux disease underwent laparoscopic antireflux surgery. The Zeus Robotic Surgical System (Computer Motion) was used to perform all functions typically handled by surgical assistants. The system was manipulated solely by the surgeon at all times with controls draped within the sterile field. This control console remained at the surgeon's side and at no time did the surgeon leave the sterile field. The presence of the robotic system did not interfere with access to the patient. RESULTS: Among 10 operations, 8 were performed completely without the need or use of any human assistance. Set-up of the robotic system averaged 28 minutes per patient, including sterile draping. Operative times ranged from 68 to 155 minutes. There were no adverse events noted in the perioperative period. All patients were discharged the day after the procedure without any complications. CONCLUSIONS: Robotic assistance to facilitate solo surgery in advanced laparoscopic procedures appears to be a feasible and safe technique. More importantly, this experience seems to demonstrate a potential for the Zeus robotic system for telementoring applications. Given a real-time communication system, a distant mentor could manipulate the robotic arms and guide a local, novice laparoscopic surgeon through an advanced procedure. Additional instrumentation must be available and more study is needed to quantify the clinical usefulness, safety, and efficacy of this new tool.     

Pelvic floor reconstruction: state-of-the-art and beyond

Reconstructive surgery for pelvic-floor dysfunction is challenging and complex. It requires an extensive familiarity with pelvic anatomy and a wide armamentarium of surgical procedures to offer patients with various structural defects. Not every patient is suited for every procedure and the surgeon must be able to individualize the approach. Each technique has indications and benefits: vaginal repairs are relatively simple and cause less morbidity than abdominal repairs, which are generally more durable. Laparoscopic repairs provide excellent visualization with decreased morbidity, but operative times are longer, there is greater cost, and learning curves are steep. Techniques and principles described for vaginal and abdominal approaches can be applied to laparoscopic and robotic surgery, but comparative outcomes are not available. Robotic assistance with the laparoscopic approach may bring this method to the mainstream by helping surgeons who are not trained formally in laparoscopy to perform advanced skills. Advances in technology and surgical skills will support the application of laparoscopic and robotic approaches, and the development of better synthetic and biologic materials likely will improve vaginal repairs. Future studies will determine the utility of the approach.     

International survey study of attitudes towards robotic surgery

The field of robotic surgery is rapidly advancing both in terms of the surgical procedures performed and the potential applications of this technology. This survey study attempts to evaluate the opinions of the public regarding a number of issues in robotic surgery. A web-based survey study was constructed using the web-based software ??Kwiksurveys??. This survey was then advertised and distributed over the Internet to gain responders from a wide range of socio-economic groups and in a number of countries. Responses were collected over a six-month period. One-hundred and fifty-five participants took part in this survey study. The mean age of participants was 35.5?±?3.4?years. The majority of participants (52%) were either comfortable or totally comfortable with the current version of robotic surgery during which a surgeon in the same room controls instruments inside the patient. Sixty-eight percent of responders reported they would be very uncomfortable with the idea of not seeing the operating surgeon in person before or after surgery. Forty-five percent of participants reported they would consider the idea of an internal robot operating internally with little or no external scarring. This survey study has demonstrated that currently the public seem to be comfortable with the current version of robotic surgery, with the operating surgeon in the same room as the patient. The results of this survey study show that even with technical advances in robotic surgery, patients will still want to have contact with their operating surgeon.     

New technologies and future applications of surgical lasers. The right tool for the right job.

The real future of surgical lasers, and indeed of surgery itself, will depend on the integration of the surgeon into a system incorporating real-time tissue sensors, computer-directed robotic manipulation, and laser-tissue interactions that are customized to the clinical task. The human surgeon will operate as the central judgmental element in this mechanized and semiautomated laser surgical system. Only then will we really be able to make use of the subtle and varied laser-tissue effects now being discovered.     

Initial experience with the four-arm computer-enhanced telesurgery device in foregut surgery

BACKGROUND: The da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) has been used effectively and with good results. Previously, the surgeon could manipulate three arms on the robot: one camera port and two working ports. This configuration required a second surgeon for most general surgical procedures. Recently, the robotic device has been modified to include a fourth arm, adding another computer-assisted instrument that the surgeon can manipulate. In this report, we describe our experience with the da Vinci robot with a fourth arm modification for the performance of selected surgical procedures. MATERIALS AND METHODS: A total of six patients were prospectively enrolled and underwent surgery using the modified da Vinci robot. Their average age was 56 years. Five patients underwent Nissen fundoplication, and one patient underwent Heller myotomy. Operative time, defined as the time from skin incision to completed skin closure, as well as robotic time, defined as the time during which the robot was being used, were recorded. Intra-operative and perioperative complications were also recorded. RESULTS: Average operative and robotic times for Nissen fundoplication were 134 and 80 minutes, respectively. Operative and robotic times for the Heller myotomy were 118 and 70 minutes. All patients tolerated the procedure well and experienced no perioperative complications. CONCLUSIONS: The da Vinci robot with the addition of the fourth arm results in a efficient and safe operation and allows the surgeon to perform additional maneuvers without the use of a surgical assistant.     

Reprints of: Robotic colorectal surgery: Evolution and future

The introduction of laparoscopic cholecystectomy changed the approach to abdominal surgery revealing the patient-specific advantages of minimally invasive approaches to gastrointestinal diseases. Unfortunately, inherent limitations of laparoscopy impeded widespread utilization of laparoscopic surgery in advanced procedures such as laparoscopic colectomy. Even as prospective and randomized trials demonstrated outcomes advantages for the patient, few surgeons introduced laparoscopic colectomy into their practice. Robotic surgery has offered solutions to these inherent limitations of laparoscopic surgery. Yulan Wang and Computer Motion introduced the first FDA approved robotic surgery assistant, AESOP. This robot responded to foot controls and subsequently oral commands providing tremor free reliable video-laparoscopic camera control. As video-laparoscopic colorectal surgery evolved, Colorectal Surgeons were plagued with the intrinsic limitations of laparoscopic surgery, such as motion reversal and motion amplification of the surgical instruments caused by the fulcrum effect of the abdominal wall trocar. Using Department of Defense grants and venture capital funding, two surgical technology companies, Computer Motion and Intuitive Surgery developed robotic surgical systems to overcome these limitations, Zeus and da Vinci, respectively. Although these robotic surgical systems were intended to perform remote battle-field surgery with the surgeon stationed on an aircraft carrier or remote MASH Hospital, state licensing issues and malpractice concerns prompted both companies to focus on surgery with the patient, surgeon and robot in the same operating room. Zeus gained FDA approval first and Da Vinci followed shortly after. Eventually patent conundrums proved only solvable by Intuitive buying out Computer Motion leading to a consolidation of the technology from both companies into the subsequent generations of Da Vinci. More recently, as Intuitive׳s patents begin to expire, new robotic surgery companies are entering the market with surgical robots targeting specific niches in the future robotic surgery market. In particular, MedRobotics, for example, will soon introduce a surgical robot given FDA approval for transanal resections of neoplastic lesions. Similarly, Titan will enter the market with a surgical robot at a substantially lower price-point that the da Vinci. Clearly, surgical robotic options for colorectal patients will continue to expand in the near future. The long-term use of these technologies, of course, will require a long period of prospective and randomized clinical trials.