Robot-assisted surgery

Computer-enhanced surgical systems are becoming common worldwide. Currently, 331 da Vinci surgical systems have been installed. Robotic surgery was successfully performed on more than 20,000 patients in 2004. Intuitive Surgical has received FDA clearance for laparoscopic and thoracoscopic procedures, including hysterectomy or prostatectomy, as well as cardiac revascularization. The Japanese "Future Project" team has developed a prototype of a smaller surgical robotic system and successfully performed telesurgery on animals between Tokyo and Fujinomiya on August 8, 2002, and between Fukuoka and Seoul on March 2, 2005. Robotic surgery will lead to dramatic progress in medicine with the development of surgical navigation systems, simulation systems, and telementoring systems.     

Robot-assisted orthopedic surgery

The main advantages of robot-assisted orthopedic surgery over conventional orthopedic techniques are improved accuracy and precision in the preparation of bone surfaces, more reliable and reproducible outcomes, and greater spatial accuracy. Orthopedic surgery is ideally suited for the application of robotic systems. The ability to isolate and rigidly fix bones in known positions allows robotic devices to be securely fixed to the bone. As such, the bone is treated as a fixed object, simplifying the computer control of the robotic system. Commercially available robotic systems can be categorized as either passive or active devices, or can be categorized as positioning or milling/cutting devices. Computer assisted orthopedic surgery is a related area of technological development in orthopedics; however, robot-assisted orthopedic surgery can achieve levels of accuracy, precision, and safety not capable with computer assisted orthopedic surgery. Applications of robot-assisted orthopedic surgery currently under investigation include total hip and knee replacement, tunnel placement for reconstruction of knee ligaments, and trauma and spinal procedures. Several short-term studies demonstrate the feasibility of robotic applications in orthopedics, however, there are no published long-term data defining the efficacy of robot-assisted orthopedic surgery. Issues of cost, training, and safety must be addressed before robot-assisted orthopedic surgery becomes widely available. Robot-assisted orthopedic surgery is still very much in its infancy but it has the potential to transform the way orthopedic procedures are done in the future.     

Robot-assisted cardiac surgery

The use of robotics is evolving in cardiac surgery. Robots allow minimally invasive techniques to be applied to ischemic heart and valve disease. Notably, this frees the patient from sternotomy, allowing a quick recovery while preserving the most critical aspects of the surgical procedure. The increasing use of stents for revascularization is significant. For best results to the patient, the graft of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is a mainstay of symptom-free survival. Stenting and robotic LIMA-to-LAD grafting in a one-staged or two-staged approach may be an attractive combined specialty treatment. This would offer best practices to the patient, along with the best technologies available. In this chapter, the most common techniques in cardiac robotic surgery are outlined. Procedural steps are described, and their expanding indications for use discussed. Additionally, a focus on combining technologies for new treatments is considered.     

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.     

Robot-assisted gastric surgery

In conclusion, robot-assisted gastric surgery is now considered to be feasible in patients with Stage IA (T1N0) and Stage IB (T1N1, T2N0) early gastric cancer. The optimal treatment modalities have yet to be identified, however, and therefore clinical trials are called for. The authors believe that this new technology will markedly increase the survival rate of such patients all over the world in the near future, while also helping to significantly decrease the complication rates and hospital stay of the patients, which will thus result in a major beneficial socioeconomic impact.     

Robot-assisted abdominal surgery

BACKGROUND: Robotic assistance or telemanipulation is the latest technological advance in minimally invasive surgery. Its future implementation will depend on the advantages that it can provide over standard laparoscopy or open surgery. METHODS: All Medline-cited papers (from case reports to reviews) about telemanipulators used in visceral surgery were assessed. The data in each paper were analysed to enable an up-to-date review of robot-assisted abdominal surgery by the most advanced telemanipulator (da Vinci). RESULTS: Most papers presented case series demonstrating the feasibility of robotic technology in performing a specific procedure. Comparative studies of robot-assisted surgery versus standard laparoscopic or open surgery were usually matched cohort studies. They generally showed an increased operating time for robot-assisted procedures but with similar rates of conversion, intraoperative and postoperative complications, and mortality in comparison to those of laparoscopic surgery. Consistent long-term follow-up data were missing and only one randomized clinical trial was conducted. CONCLUSION: Robot-assisted surgery appears safe and feasible for certain standard surgical procedures. However, at its current level of development, it offers no clear, significant advantage over standard laparoscopic techniques.     

Robot-assisted surgery: training and re-training surgeons

A renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller incisions with enhanced technological assistance. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci telemanipulation system, which has recently gained FDA-approval. Initial results are reported. Despite procedural success, implementation of new technology requires restructuring training programs and re-training senior surgeons. Ultimately, our desire for improved and less traumatic patient care will continue to drive this new technology into the future.     

Robot-assisted remote telepresence surgery

A potential application of robotic surgical systems is to act as the hands and eyes of a surgeon operating from a considerable distance, enabling the surgeon to offer a variety of surgical services through gaining true telepresence by the interface of the telecommunication link and a surgical robotic system. The limited use of robot-assisted remote telepresence surgery to date has demonstrated not only that this is technologically feasible and safe but also that the patients are willing to accept its limitations when it is used in an environment where significant value from its use is realized. This chapter will discuss some of the lessons learned, the potential future applications, and the necessary next steps for its safe and widespread adoption.     

Robot-assisted laparoscopic colorectal surgery

Colorectal surgery can be difficult at open and laparoscopic surgery. This is particularly the case for rectal surgery deep in the pelvis. In obese males distal rectal dissection can be challenging because of instrument and visual limitations. Robot-assisted laparoscopic colorectal operations do not differ significantly from the standard laparoscopic approach but it has certainly been shown that it is feasible to perform the same operation using robotic assistance for the dissection. This allows the surgeon to benefit from vastly enhanced vision and dexterity, which may ultimately translate into benefit for the patient in terms of reduced operating time, and better preservation of pelvic nerves and other structures.     

Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience

Background  

Use of robotic surgery has gained increasing acceptance over the last few years. There are few reports, however, on advanced pancreatic robotic surgery. In fact, the indication for robotic surgery in pancreatic disease has been controversial. This paper retrospectively reviews one surgeon’s experience with robotic surgery to treat pancreatic disease, and analyzes its indications and outcomes, as well as the controversy that exists.     

Robot-assisted thoracoscopic surgery: current status and prospects

The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.     

Monitoring of somatosensory evoked potentials in carotid surgery: Results,usefulness and limitations of the method

We have monitored cortical somatosensory evoked potentials (SEP) during 177 carotid operations (167 carotid endarterectomies). An intraluminal shunt was always used for endarterectomy of the internal carotid artery (CEA). SEP was not readable in 21 operations. During 126 carotid operations, no alteration of SEP occurred. However, three patients had an immediate postoperative neurologic deficit while the SEP remained normal. Abnormal SEP occurred in 30 patients. In two cases irreversible loss of SEP was seen. Both patients awoke with a new neurologic deficit after the operation. We found reversible abnormal SEP in 28 cases. In 63 cases with contralateral stenosis, abnormal SEP caused by carotid clamping was observed in 15 (24%). The diagnostic sensitivity of intraoperative SEP monitoring in predicting neurologic outcome following carotid operation was 100% with a specificity of 40%. Monitoring of SEP during carotid surgery is a reliable and useful method to detect incipient cerebral ischemia and to determine the need for shunting. The prognostic value of SEP monitoring to predict postoperative neurologic deficits is limited by the low specificity of the method.     

机器人手术在小儿外科中的发展现状及展望

2000年达芬奇机器人手术系统通过美国食品药品监督管理局认证,并作为现阶段微创外科领域最先进的技术逐渐应用在普外科、泌尿外科、胸心外科、妇科、小儿外科等领域.目前,小儿外科机器人手术的临床应用还处于学习成长阶段,存在很多的挑战及障碍.本文通过对国内外相关文献进行综合及分析,介绍了小儿机器人手术的发展现状及争议,并进一步展望机器人手术系统在小儿外科的发展前景.     

Robot-assisted endoscopic surgery: a four-year single-center experience

BACKGROUND: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. METHODS: Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vincitrade mark robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). RESULTS: The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45-420) and the median blood loss was 30 ml (0-800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%). CONCLUSION: During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems.     

机器人手术在小儿泌尿外科的应用现状与展望

在过去的数十年间,腹腔镜的出现导致了外科手术一次真正的革命,代表着外科手术思维模式的变迁,而机器人手术进一步推动了这种模式进入更高的层次.虽然机器人手术已经安全、成功地运用于成人泌尿外科的多种手术,但是它在小儿泌尿外科的应用相对较少.机器人手术系统具有良好的3D可视化视野、精细的运动控制操作系统和震颤过滤性能等优点,其在小儿泌尿外科实践中的潜在价值是巨大的.成人泌尿外科机器人手术技术不能照搬到小儿泌尿外科,因此充分了解机器人手术技术在小儿泌尿外科领域应用的现状及存在的问题很有必要.本文对机器人手术在小儿泌尿外科的应用现状进行总结.     

Meta-analysis in surgery: methods and limitations

The growth of new knowledge continues to advance the surgical disciplines, and several types of literature reviews attempt to consolidate this expansion of information. Meta-analysis is one such method that integrates findings on the same subject from different studies. Within surgery, there is a wealth of literature on a given topic, which needs to be considered collectively. As such, meta-analyses have been performed to address issues like the use of bowel preparation for colorectal surgery and comparisons of outcomes for laparoscopic vs open surgical approaches. A basic understanding of the groundwork required for meta-analysis is fundamental toward interpreting and critiquing its results. This review provides an overview of the principles, application, and limitations of meta-analysis in the context of surgery.