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.     

Anesthesia management of totally endoscopic atrial septal defect repair with a robotic surgical system

Study Objective

To investigate anesthetic techniques for robot-assisted endoscopic atrial septal defect (ASD) repair.

Design

Clinical observational study.

Setting

Operating room of a general military hospital.

Patients

56 adult, ASA physical status 1 and 2 patients undergoing elective general anesthesia.

Interventions

After induction of general anesthesia, a left-sided, double-lumen endotracheal tube was positioned to allow single left-lung ventilation and contralateral CO₂ pneumothorax (capnothorax). With ultrasound guidance, peripheral cardiopulmonary bypass (CPB) catheters were placed.

Measurements and Main Results

All patients tolerated single left-lung ventilation before CPB; however, hypoxia (oxygen saturation < 90%) occurred in 11 (19.6%) patients post-CPB, which required treatment with continuous positive airway pressure. Fifteen (26.8%) patients had hypotension secondary to capnothorax, which was treated with transfusion and vasopressors. Aortic cross-clamp time was 43.6 ± 11.2 minutes, and CPB time was 106.7 ± 12.4 minutes. The median intensive care unit stay was 21 hours and postoperative hospital stay was 4 to 7 days.

Conclusions

The key issue for anesthetic management of robot-assisted totally endoscopic ASD repair is maintaining stable hemodynamics and oxygenation, especially during one-lung ventilation and capnothorax.     

Mediastinal neurogenic tumours. Early and late results of surgical treatment

Early and late results of surgery for neurogenic mediastinal tumour were evaluated in 66 cases with a mean follow-up of 12 years. The series comprised 48 neurilemmomas, 8 neurofibromas, 7 ganglioneuromas, and neurinoma, neurofibrosarcoma and ganglioneuroblastoma each in one case. There were two early deaths (3%), one due to peroperative bleeding from the left subclavian artery and the other to acute myocardial infarction. Operative complications arose in 12 cases (18%), the most common being wound infection (3 cases). There were 17 late deaths (26.6%). In the neurilemmoma group, 3 of the 13 late deaths were related to the tumour or its treatment, and both deaths in the neurofibroma group were related to malignant transformation. Recurrence of tumour appeared in 3 of the 48 patients with neurilemmoma and also in the single patient with neurinoma as tumour classification. One neurilemmoma was a dumb-bell tumour, and operation in this case resulted in paraplegia. Malignant transformation appeared in 2 of the 8 neurofibromas 5 and 13 years postoperatively. Because of the risks of malignant degeneration and of recurrence, patients operated on for neurogenic mediastinal tumour should be carefully followed up for many years.     

A newly designed SIPC device for management of lymphoedema

Purpose  

Using (Sequential) intermittent pneumatic compression (SIPC) is one of the most appropriate nonsurgical treatments for lymphoedema. In this study, we introduce a new mode for SIPC and evaluate its clinical results with higher pressures.     

Laparoscopic transperitoneal adrenalectomy using a remote-controlled robotic surgical system

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors. Although laparoscopic surgery provides clear patient benefit, laparoscopic adrenalectomy using conventional instrumentation is complex. Our objective was to evaluate whether the da Vinci trade mark Surgical System, a comprehensive robotic endoscopic surgical device, could be used effectively to perform laparoscopic adrenalectomy. PATIENTS AND METHODS: Through a transperitoneal approach, three right and one left adrenal tumors were removed in four patients using this method. RESULTS: There were no complications, and the clinical results were excellent. CONCLUSION: We demonstrate the feasibility of performing laparoscopic adrenalectomy exclusively by using robotic telepresent technology from a remote workstation. The da Vinci System enables conventionally trained urologic surgeons to perform complex minimally invasive procedures with ease and precision. Therefore, we are convinced that the system helps the urologist to adapt the whole spectrum of laparoscopic procedure in this field.     

机器人在直肠癌治疗中的应用

世界范围内机器人手术系统具有三维图像清晰和操作稳定灵活的优势,已广泛应用于直肠癌外科手术。此文在介绍机器人手术系统特点及应用变迁的基础上,对机器人直肠癌手术应用现状进行回顾,并简述我国的应用现状。目前,机器人直肠癌手术的安全性和有效性已得到肯定。与腹腔镜手术比较,机器人直肠癌手术在短期结局和长期生存方面暂无明显优势。随着器械不断进步和大样本研究的开展,机器人手术系统将在直肠癌手术中发挥更重要的作用。     

The first clinical application of a "hands-on" robotic knee surgery system.

The performance of a novel "hands-on" robotic system for total knee replacement (TKR) surgery is evaluated. An integrated robotic system for accurately machining the bone surfaces in TKR surgery is described. Details of the system, comprising an "active constraint" robot, called Acrobot, a "gross positioning" robot, and patient clamps, are provided. The intraoperative protocol and the preoperative, CT-based, planning system are also described. A number of anatomical registration and cutting trials, using plastic bones, are described, followed by results from two preliminary clinical trials, which demonstrate the accuracy achieved in the anatomical registration. Finally, the first clinical trial is described, in which the results of the anatomical registration and bone cutting are seen to be of high quality. The Acrobot system has been successfully used to accurately register and cut the knee bones in TKR surgery. This demonstrates the great potential of a "hands-on" robot for improving accuracy and increasing safety in surgery.     

Early clinical results of endorectal surgery using a newly designed rectal tube with a side window

Background: Transanal endoscopic microsurgery (TEM) using the original Buess devices requires the use of a completely closed system for positive pressure gas insufflation. To simplify the setup of the system and expose the target lesion in the rectum without gas insufflation, we have developed a new operating rectal tube with a side window. Methods: The new rectal tube is a transparent cylinder measuring 40 mm in diameter with its forward end closed and a 40-mm opening on its side. When a rectal tumor is captured within the opening, it can be clearly visualized without positive gas insufflation. Under endoscopic control, the lesion is then resected and the defect is closed by suturing. Using this new system, we performed endorectal surgery on 10 patients with rectal tumors. Our series included four benign adenomas, two carcinomas in situ, two T2 cancers, and two carcinoid tumors. Results: The operation was performed successfully in all 10 cases. There were no significant operative complications and the postoperative course was excellent in all cases. Pathological analysis revealed that the surgical margins of all specimens were completely free from tumor. Conclusions: Our early clinical results suggest that the newly designed operating rectal tube with a side window simplifies the endorectal surgical procedure and facilitates the safe resection of rectal tumors < 40 mm in diameter.     

Pulmonary metastases from epithelial tumours: late results of surgical treatment.

OBJECTIVE: Development of distant metastases is one of the primary characteristics of malignant tumours. During the last decades, lung metastasectomy has been progressively accepted as a therapeutic option in oncology patients. The present paper aims to evaluate the long-term results and factors influencing prognosis in patients submitted to lung resection for metastases from extrapulmonary epithelial tumours. METHODS: We retrospectively analysed data of 202 patients undergoing 207 procedures of lung metastasectomy between January 1980 and December 2003. Factors that may influence long-term prognosis such as completeness of resection, histology of the tumour, disease-free interval, number of resected lesions, involvement of hilar or mediastinal lymph nodes, systemic treatments were investigated. RESULTS: Complete resection was carried out in 169 patients (83.7%). The more frequent lung resection was sublobar in 67.6% of cases, but rarely in selected patients bilobectomy or pneumonectomy has been carried out too. Perioperative morbidity and mortality were 7.7% and 0.9%. Mean disease-free interval was 49+/-48 months. Mean follow-up was 33+/-31 months, 5-year and 10-year survival rates for completely resected patients were 43% and 17%, respectively. By univariate and multivariate analyses, completeness of resection, disease-free interval of 36 months or more, and single resected metastasis were found to be significant prognostic factors. CONCLUSIONS: Resection of epithelial lung metastases allows an acceptable prognostic result in appropriately selected patients with very low perioperative morbidity and mortality. Factors such as high disease-free interval, single metastasis and completeness of resection are demonstrated and confirmed to be significantly associated with long-term survival.     

Application of a newly developed visual navigation system in humans. First results.

A visual navigation system (VN) was developed which uses intraoperatively stored endoscopic images together with their specific 3D-address. A special calibration enables one to recalculate the distortion of the endoscopic images. Several modules (e. g., landmark tracking, virtual back-movement) are offered to the neurosurgeon. The system was tested in 12 human subjects during neuroendoscopic interventions and worked without problems in nearly all cases. The possibilities of digital image navigation can be used especially for control of instrument movement in case of red-out situations or blurred vision. Many further developments of the VN system are possible in order to increase the safety of neuroendoscopic interventions.     

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...     

机器人手术系统在子宫移植中的应用进展

子宫移植是治疗绝对子宫因素不孕症的唯一治疗方法.血管解剖困难、手术时间长、术中损伤是限制子宫移植发展的主要问题.微创技术可以缩短手术时间,减少损伤,有助于复杂血管的解剖.有研究团队实现了机器人辅助下子宫移植,并且已经有后代成功分娩的报道.本文总结了已报道的机器人辅助下子宫移植手术,通过分析现有数据,讨论机器人手术系统在子宫移植中的应用及其影响.     

Preliminary report on postoperative results of newly designed stable total knee prosthesis

Summary A newly designed stable total knee prosthesis was made for the severely destructed knee. This prosthesis was named the Yoshino total knee prosthesis, and is a non-hinged type prosthesis consisting of a vitallium femoral component and a ultra-high molecular weight polyethylene tibial component. Clinical results of 127 Yoshino total knee arthroplasties showed the following characteristics: 1) good stability, and 2) good mobility. Stability was exceptionally good, and the results were the same as the hinged total knee prosthesis.

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Zusammenfassung Ein newer Typ der totalen Knieprothese wurde für den Ersatz des schwer beschädigten Knies hergestellt. Diese Prothese, zur Zeit Yoshino-Total-Knie-Prothese genannt, ist eine Art der achsellosen Prothesen mit dem Vitallium-Femoralkomponent und Polyethylen-Tibiakomponent von ultra-hohem Molekulargewicht. Unsere bisherige klinische Anwendung bei 127 Fällen zeigte folgende Resultate: 1) gute Stabilität und 2) gute Beweglichkeit des operierten Kniegelenks. Dabei muß betont werden, daß diese neuartige Knieprothese ganz stabil ist, wie die bisherigen Prothesen mit dem Achsel.

     

Laparoscopic aortic surgery in a swine model using a newly designed intestine retraction system

BACKGROUND: Recently, the feasibility of laparoscopic surgery for aortic occlusive and aneurysmal disease has been demonstrated in clinical studies. However, aortic access is compromised by poor exposure of the operative field from uncontrolled bowel. Currently available retractors are inadequate. The development of new retracting instruments therefore may facilitate laparoscopic aortic surgery. METHODS: Two paddles inserted in a polyester bilayer (mobile device, group A) or a mesh net fixed to the abdominal wall (fixed device, group B) were used to retain the bowel. Six female piglets (28-30 kg) in each group underwent laparoscopic aortic surgery. RESULTS: Mean time to deploy the device was 22 +/- 12 min in group A and 36 +/- 34 min in group B (n.s.). Vascular surgery time averaged 60 +/- 24 min in group A and 68 +/- 16 min in group B (n.s.), the time to withdraw the nets was respectively 3.6 +/- 1.2 min and 13.5 +/- 8.2 min (p < 0.05). Total surgery time was 155 +/- 41 min vs. 174 +/- 49 min (n.s.). Two retraction failures have been registered (1 in group A and 1 in group B). No major complications were documented. CONCLUSIONS: Both nets provided adequate exposure of the infrarenal aorta. Vascular surgery time and blood loss were similar in both groups. Nevertheless, the handling of the mobile device (group A) seemed to be more comfortable in direct comparison. The newly developed retraction devices might facilitate the performance of laparoscopic aortic surgery.     

Metachronous renal tumours after surgical management of oncocytoma

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Oncocytoma is a benign renal tumour that cannot be differentiated from renal cell carcinoma radiographically. Follow‐up after surgery for oncocytoma is highly variable and the natural history of surgically treated renal oncocytoma is poorly defined. We sought to assess the risk of metachronous renal tumours in a cohort of patients treated surgically for renal oncocytoma. We report a large cohort of oncocytoma patients following surgical management. This study defines the risk of metachronous renal tumours after surgical treatment of renal oncocytoma. Our findings suggest that patients with metachronous renal tumours after treatment of renal oncocytoma may have a smaller risk of renal cell carcinoma compared with patients presenting with a primary renal mass. Our findings did not support concern for increased risk of renal cell carcinoma following surgical treatment of primary renal oncocytoma.

OBJECTIVE

? To assess the risk of metachronous renal cell carcinoma (RCC) and benign renal tumours after surgical treatment of primary renal oncocytoma.

PATIENTS AND METHODS

? Patients treated for primary renal oncocytoma between 1970 and 2007 were identified. Tumours were reviewed by a urological pathologist and patients were followed for subsequent renal tumours.

RESULTS

? Of 424 patients with a median follow up of 7.1 year, 17 (4.0%) patients were diagnosed with a metachronous renal tumour at a median of 3.0 years (range 0.3–16 years). Of the 17 metachronous tumours, eight were oncocytoma, four were RCC and five were not resected or biopsied. ? Eleven metachronous tumours occurred after solitary unilateral oncocytoma, five occurred after multifocal unilateral oncocytoma, and one occurred after multifocal bilateral oncocytoma. ? Estimated 10‐year tumour‐free and RCC tumour‐free survival was 94.8% and 98.7%, respectively. Patients with primary multifocal oncocytoma were at higher risk of metachronous tumour (hazard ratio 4.0; P = 0.007). Initial oncocytoma size (hazard ratio 1.1; P = 0.11) was not highly associated with risk of tumour recurrence.

CONCLUSIONS

? To our knowledge, we report the largest cohort of oncocytoma after surgical management. Metachronous renal neoplasm in a patient with previous oncocytoma is more likely to be benign compared with patients who present with a renal tumour for the first time. Multifocal primary oncocytoma is associated with metachronous renal tumours. ? Overall, the risk of metachronous RCC in a patient with an oncocytoma is similar to that of the general population, which does not support the use of routine cross‐sectioning imaging surveillance.