Robotic surgery: a current perspective

OBJECTIVE: To review the history, development, and current applications of robotics in surgery. BACKGROUND: Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving. METHODS: A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications. RESULTS: Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques. CONCLUSIONS: Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.     

单孔腹腔镜在子宫内膜异位症中的应用及研究进展

腹腔镜手术因其微创的优势,现已成为多种妇科良性、恶性疾病的主要手术方式,但是血管与内脏损伤、切口疝、感染、疼痛等问题在腹腔镜手术中依然存在,单孔腹腔镜通过减少穿刺通道的数量,可以在一定程度上减少这些并发症的发生,并具有更为明显的美容优势。目前单孔腹腔镜领域研究的前沿问题之一是其在子宫内膜异位症特别是卵巢子宫内膜异位囊肿中的应用。若干研究已经证实了单孔腹腔镜在子宫内膜异位症手术治疗中的安全性及可行性,但其是否会进一步损伤卵巢储备,目前仍存在争议。文献表明,在卵巢囊肿剔除术中尽量减少能量器械的使用或能在一定程度上保护卵巢储备。本文将对这些研究做一简单综述。     

Robotic surgery: vision into the future

The surgery robotics is in full expansion. The objective of all new sanitary new technology is to improve the results in the treatment of the different pathologies. We believe that our of future perspective both in the development of the current generation of surgical robots and in the improvements that could be incorporated to short and half term.     

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.     

Image-guided surgery in head and neck cancer: current practice and future directions of optical imaging

A key aspect for the postoperative prognosis of patients with head and neck cancer is complete tumor resection. In current practice, the intraoperative assessment of the tumor-free margin is dependent on visual appearance and palpation of the tumor. Optical imaging has the potential of traversing the gap between radiology and surgery by providing real-time visualization of the tumor, thereby allowing for image-guided surgery. The use of the near-infrared light spectrum offers 2 essential advantages: increased tissue penetration of light and an increased signal-to-background ratio of contrast agents. In this review, the current practice and limitations of image-guided surgery by optical imaging using intrinsic fluorescence or contrast agents are described. Furthermore, we provide an overview of the various molecular contrast agents targeting specific hallmarks of cancer that have been used in other fields of oncologic surgery, and we describe perspectives on its future use in head and neck cancer surgery.     

Nonheart-beating kidney donation: current practice and future developments

BACKGROUND: Nonheart-beating kidney donation (NHBD) is gaining acceptance as a method of donor pool expansion. However, a number of practitioners have concerns over rates of delayed graft function, acute rejection, and long-term graft survival. The ethical issues associated with NHBD are complex and may be a further disincentive. Tailored strategies for preservation, viability prediction, and immunosuppression for kidneys from this source have the potential to maximize the number of available organs. This review article presents the current practice of NHBD kidney transplantation, examines the results and draws comparisons with cadaveric kidneys, and explores some areas of potential development. METHODS: A review of the current literature on NHBD kidney donation was performed. RESULTS: The renewed interest in NHBD kidneys is driven by a continuing shortfall in available organs. Those centers involved in NHBD report an increase in kidney transplants of the order of 16% to 40% and there is no evidence that the financial costs are higher with NHBDs. The majority of experience comes from Maastricht category 2 NHBDs, where an estimation of warm time is possible. This is generally limited to 40 minutes. There are variations in the technique for kidney preservation prior to retrieval, but most centers use an aortic balloon catheter. Much work has looked at the ideal technique for kidney preservation prior to implantation. Evidence suggests that machine perfusion produces the best initial function rates, decreased use of adjuvant immunotherapy and fewer haemodialysis sessions than static cold storage. CONCLUSION: Despite being associated with poorer initial graft function, the long-term allograft survival of NHBD kidneys does not differ from the results of transplantation from cadaveric kidneys. Further, serum creatinine levels are generally equivalent. Constant reassessment of the ethical issues is required for donation to be increased while respecting public concerns. Use of viability assessment and tailoring of immune suppression for NHBD kidneys may allow a further increase in donation from this source.     

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.     

Cardiovascular magnetic resonance: current clinical practice and future potential

Cardiovascular magnetic resonance (CMR) is playing an increasing role in the noninvasive assessment of the cardiothoracic patient. It provides rapid, high-resolution anatomical coverage, and accurate functional cardiovascular assessment without the need for ionizing radiation. In this article, we discuss the fundamental principles of CMR and outline the established and newer indications for its use. Finally, the future potential for this technique in the cardiovascular arena is briefly outlined.     

Hip arthroscopy: evolution, current practice and future developments

Arthroscopic examination and treatment is an ever-increasing part of modern orthopaedic practice in this age of minimally invasive surgery. Arthroscopic procedures have been widespread in surgery of the knee and the shoulder for many years; however, the hip until relatively recently, has been largely neglected. Even now hip arthroscopy is not widely available; this may be due to the complexity of the procedure, the requirement of specialist equipment and a reportedly long learning curve. On the other hand, it has gone through a period of rapid growth over the last decade and is being performed in large numbers routinely in some centres around the world. Hip arthroscopy now provides excellent visualisation of not only the articular surfaces of the hip joint but also of the peritrochanteric or extra-articular space around the hip. Pathology of both the femoral head and the acetabulum along with the soft tissues of the hip, namely the ligamentum teres, the acetabular labrum, the synovial folds and synovium, is readily diagnosed. Modern techniques provide therapeutic options for a myriad of conditions and allow modulation of pathological processes early. Additionally hip arthroscopy is a relatively safe procedure with few complications and contraindications. However, the key to good outcomes is in the careful selection of patients and meticulous surgical technique. The aim of this review is to bring the reader up to date with an overview of the evolution of arthroscopy of the hip, review the current practice and explore possible future developments.     

Endoluminal and transluminal surgery: current status and future possibilities

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include “incisionless,” “endoluminal,” “transluminal,” and “natural orifice” transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.     

Blood conservation in surgery: current concepts and practice

Blood conservation is based on the principle of avoiding allogeneic blood transfusion with the aim of improving outcome and protecting patients' rights. Surgical patients receive a significant proportion of the allogeneic blood transfused in the hospital. Blood conservation in surgery greatly reduces overall allogeneic blood use, thereby reducing costs, hazards, and adverse outcomes. Blood conservation techniques aim to lower the "transfusion trigger," optimize the hematocrit, minimize blood loss, and optimize tissue oxygenation. Successful blood conservation involves a combination of techniques tailored to the individual patient. It requires planning and a multidisciplinary team approach but usually little technology. Bloodless medicine and surgery programs represent the gold standard in blood conservation. Blood conservation is evidence based, and it results in faster recovery, lower morbidity, lower mortality, shorter hospital stay, lower cost, and better patient (and physician) satisfaction while avoiding the hazards of allogeneic blood transfusion. Blood conservation is thus the current standard of care.