Training current and future robotic surgeons simultaneously: initial experiences with safety and efficiency

Robotic surgery is experiencing a rapidly-increasing presence in the field of general surgery. The adoption of any new technology carries the challenge of training current and future surgeons in a safe and effective manner. We report our experience with the initiation of a robotic general surgery program at an academic institution while simultaneously incorporating surgical trainees. The initial procedure performed was robotic-assisted cholecystectomy (RAC). Concurrent with the introduction of a robotic general surgical program, our institution implemented a progressive surgical trainee curriculum for all active residents and fellows. Immediately after being credentialed to perform RAC, attending surgeons began incorporating surgical trainees into robotic procedures. We retrospectively reviewed our first 50 RACs and compared them with our previous 50 standard laparoscopic cholecystectomies (SLC) to determine the impact of rapid integration of surgical trainees on developing technologies. Despite new technology and novice surgeons, there was no difference in mean operative time between the SLC and RAC groups (75.3 vs. 84.1 min, p = 0.077). Two patients in the robotic-assisted group required intraoperative conversion. Hospital length of stay was similar between groups, with the majority of patients leaving the same day. There were no postoperative complications in either group. A robotic general surgery program can be initiated while concurrently instructing surgical trainees on robotic surgery in a safe and efficient manner. We report our initial experience with the adoption of this rapidly advancing technology and describe our training model.     

Robotic-assisted laparoscopic dissection of the infrarenal aorta and iliac artery: a technical description and early results

We report our initial experience with a novel robotic-assisted dissection of the infrarenal aorta and iliac arteries for the treatment of aortoiliac occlusive disease and abdominal aortoiliac aneurysm. Seven patients underwent the procedure using the da Vinci Surgical System. Transabdominal, retroperitonal dissection of the aorta and iliac arteries was completed using the robotic system; then, a mini-laparotomy and hand-sewn aorta-to-graft anastomosis were performed. There was no mortality in this series of patients. This novel technique may overcome the difficulty of aortic dissection in a purely laparoscopic aortic surgery and serves as a bridging step toward totally robotic-assisted aortic surgery.     

Robotic surgery for ureteropelvic junction obstruction

PURPOSE OF REVIEW: Robotic surgery for ureteropelvic junction obstruction is an evolving technique. We review the current literature related to this technique and discuss the current technique and outcomes of robotic pyeloplasty. RECENT FINDINGS: Recent advances in robotic-assisted surgery have allowed the successful completion of complex reconstructive procedures in the pediatric population, including the robotic-assisted laparoscopic pyeloplasty. Robotic-assisted laparoscopic pyeloplasty can be performed by either a transperitoneal or a retroperitoneal approach. Overall, the procedure is safe, efficacious, and may have particular benefits over open surgery. SUMMARY: The evolution of laparoscopic surgery in pediatric urology has been limited by the challenge of laparoscopic suturing. Robotic systems may offer the means to overcome this major impediment of laparoscopic surgery. The results of this review demonstrate that robotic-assisted laparoscopic pyeloplasty is safe, technically feasible, and efficacious in the pediatric population, and may be comparable to a contemporary series of open pyeloplasty. As the technology continues to evolve, the efficiency of the robotic system is likely to improve; however, the ultimate role of robotic-assisted or computer-assisted surgical systems remains unclear. To further determine the role of robotic systems in the management of ureteropelvic junction obstruction, rigorous prospective research is needed that combines surgical and technical outcomes with overall subjective or cosmetic outcome and economic analysis.     

Robotic kidney autotransplantation in a porcine model: a procedure-specific training platform for the simulation of robotic intracorporeal vascular anastomosis

Robotic-assisted kidney transplantation (RKT) with the Da Vinci (Intuitive, USA) platform has been recently developed to improve outcomes by decreasing surgical site complications and morbidity, especially in obese patients. This potential paradigm shift in the surgical technique of kidney transplantation is performed in only a few centers. For wider adoption of this high stake complex operation, we aimed to develop a procedure-specific simulation platform in a porcine model for the training of robotic intracorporeal vascular anastomosis and evaluating vascular anastomoses patency. This paper describes the requirements and steps developed for the above training purpose. Over a series of four animal ethics’ approved experiments, the technique of robotic-assisted laparoscopic autotransplantation of the kidney was developed in Amsterdam live pigs (60–70 kg). The surgery was based around the vascular anastomosis technique described by Menon et al. This non-survival porcine training model is targeted at transplant surgeons with robotic surgery experience. Under general anesthesia, each pig was placed in lateral decubitus position with the placement of one robotic camera port, two robotic 8 mm ports and one assistant port. Robotic docking over the pig posteriorly was performed. The training platform involved the following procedural steps. First, ipsilateral iliac vessel dissection was performed. Second, robotic-assisted laparoscopic donor nephrectomy was performed with in situ perfusion of the kidney with cold Hartmann’s solution prior to complete division of the hilar vessels, ureter and kidney mobilization. Thirdly, the kidney was either kept in situ for orthotopic autotransplantation or mobilized to the pelvis and orientated for the vascular anastomosis, which was performed end to end or end to side after vessel loop clamping of the iliac vessels, respectively, using 6/0 Gore-Tex sutures. Following autotransplantation and release of vessel loops, perfusion of the graft was assessed using intraoperative indocyanine green imaging and monitoring urine output after unclamping. This training platform demonstrates adequate face and content validity. With practice, arterial anastomotic time could be improved, showing its construct validity. This porcine training model can be useful in providing training for robotic intracorporeal vascular anastomosis and may facilitate confident translation into a transplant human recipient.     

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??Characteristics and strategies for pancreatic fistula after open??laparoscopic and robotic pancreaticoduodenectomy PENG Cheng-hong??SHI Yu-sheng. Department of General Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine??Shanghai 200025??China
Corresponding author??PENG Cheng-hong??E-mail??chhpeng@188.com
Abstract The development of minimally invasive surgery pointed out the new direction for the development of pancreatic surgery. But the postoperative complications??especially the occurrence of pancreatic fistula??PF?? is still threatening the postoperative recovery of patients. Laparoscopic and robotic-assisted surgeries provide a new researching field for reducing the incidence of PF. According the present experience??robotic-assisted pancreatic surgery can not reduce the incidence of postoperative PF significantly. But robotic-assisted surgery is more minimally invasive and exact than open and laparoscopic surgery.     

开放、腹腔镜及机器人辅助行胰十二指肠切除术后胰瘘特点及对策

微创手术的发展为胰腺外科手术指明了新的发展方向,然而其术后并发症尤其是胰瘘的发生仍严重影响病人的术后恢复。腹腔镜及机器人手术系统为减少胰十二指肠切除术术后胰瘘发生提供了新的研究领域。根据现有经验,机器人手术并不能明显降低术后胰瘘发生率,但在微创化和精确化方面明显优于开放和腹腔镜手术。     

The effect of obesity on laparoscopic and robotic-assisted colorectal surgery outcomes: an ACS-NSQIP database analysis

Advantages of robotic-assisted colorectal surgery have been reported, but the effect on outcomes between obese and non-obese patients undergoing laparoscopic and robotic-assisted colorectal surgery remains unclear. Patients who underwent elective laparoscopic and robotic colon or rectal resections between 2012 and 2014 were identified in the ACS-NSQIP database. Propensity score matching was performed to determine the effect of obesity on laparoscopic and robotic-assisted 30-day surgical outcomes. 29,172 patients met inclusion criteria; 27,693 (94.9%) underwent laparoscopic colorectal surgery while 1479 (5.1%) underwent robotic-assisted surgery. Mean BMI was 28.4 kg/m² and 35% of patients had a BMI ≥30 kg/m². A 10-to-1 propensity matching of laparoscopic to robotic approaches was performed, resulting in 14,770 (90.9%) laparoscopic patients and 1477 (9.1%) robotic-assisted patients available for analysis. Robotic-assisted surgery was associated with lower conversion to laparotomy (2.4 vs 3.4%; p = 0.04) and decreased length-of-stay (4.5±3.2 vs 5.1±4.5 days; p < 0.0001). After adjusting for BMI and surgical approach, obese patients undergoing robotic-assisted surgery had a reduced odds ratio for developing prolonged ileus (p = 0.03). Robotic-assisted colorectal surgery is associated with fewer conversions to laparotomy and shorter length-of-stays compared to laparoscopic surgery. Risk of prolonged ileus is significantly reduced in obese patients undergoing a robotic-assisted approach.     

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.     

Robotic-assisted laparoscopic simple prostatectomy and bladder diverticulectomy with temporary clamping of internal iliac arteries

The minimally invasive approach for benign prostatic hyperplasia (BPH) is replacing open surgery. Laparoscopic and robotic techniques have benefits in treatment of BPH especially for large prostatic adenoma. We present a case of laparoscopic robotic-assisted simple prostatectomy with bilateral transient occlusion of internal iliac arteries. This could be an optional surgical technique when a significant blood loss is expected, for example in patients with an estimated volume of BPH larger than 100 ml or in patients who cannot suspend antiaggregant therapy. In this case we temporarily occluded the internal iliac arteries bilaterally with Bulldog clamps and the adenoma was enucleated according to Sotelo’s laparoscopic robotic-assisted technique. We had optimal results in terms of intraoperative and postoperative outcomes.     

Online Crowdsourcing to Explore Public Perceptions of Robotic-Assisted Orthopedic Surgery

BackgroundThe clinical benefits of robotic-assisted technology in total joint arthroplasty are unclear, but its use is increasing. This study employed online crowdsourcing to explore public perceptions and beliefs regarding robotic-assisted orthopedic surgery.MethodsA 30-question survey was completed by 588 members of the public using Amazon Mechanical Turk. Participants answered questions regarding robotic-assisted orthopedic surgery, sociodemographic factors, and validated assessments of health literacy and patient engagement. Multivariable logistic regression modeling was used to determine population characteristics associated with preference for robotic technology.ResultsMost respondents believe robotic-assisted surgery leads to better results (69%), fewer complications (69%), less pain (59%), and faster recovery (62%) than conventional manual methods. About half (49%) would prefer a low-volume surgeon using robotic technology to a high-volume surgeon using conventional manual methods. The 3 main concerns regarding robotic technology included lack of surgeon experience with robotic surgery, robot malfunction causing harm, and increased cost. Only half of respondents accurately understand the actual role of the robot in the operating room. Overall, 34% of participants have a clear preference for robotic-assisted surgery over a conventional manual approach. After multivariable regression analysis, Asian race, working in healthcare, early technology adoption, and prior knowledge of robotic surgery were independent predictors of preferring robotic-assisted surgery.ConclusionThe public’s unawareness of the dubious outcome superiority associated with robotic-assisted orthopedic surgery may contribute to misinformed decisions in some patients. Robotic-assisted technology appears to be a powerful marketing tool for surgeons and hospitals.     

Transition from open to robotic-assisted radical prostatectomy: 7 years experience at Hackensack University Medical Center

Background and objective Open radical prostatectomy (ORP) is the standard approach for the surgical management of localized prostate cancer. The steep learning curve for laparoscopic prostatectomy poses a challenge for surgeons with minimal laparoscopic experience. As robotic-assisted surgery becomes more prevalent in the urologic community, there appears to be an increasing interest in robotic-assisted radical prostatectomy (RARP) among urologists throughout the United States. We report on the impact of robotics on practice patterns in the treatment of localized prostate cancer at a single institution. Methods A retrospective review was conducted of radical prostatectomies performed between January 2000 and December 2006 at Hackensack University Medical Center (Hackensack, N.J.). Over this time period, our medical center acquired four da Vinci™ Surgical Systems. The trends for open and robotic-assisted prostatectomies were analyzed. Results Over a 7-year period (2000–2006), a total of 1252 radical prostatectomies were performed by 17 urologists: 469 (37%) ORPs and 783 (63%) RARPs. The total number of prostatectomies increased annually during this time period. The robotic-assisted procedure was predominantly performed by three (18%) urologists from 2001–2003, seven (41%) in 2004, nine (53%) in 2005, and 11 (65%) in 2006. As more urologists became trained in robotic-assisted surgery, the trend gradually shifted towards robotic-assisted prostatectomy. In 2001, only 9.6% of all radical prostatectomies at our institution were performed with robotic assistance; in 2006, this had risen to 92.8%. Conclusion The acquisition of the da Vinci™ Surgical System has allowed robotic-assisted surgery to be an available alternative to open surgery at a single institution. The implementation of robotic technology has led to the gradual adoption of robotic-assisted radical prostatectomy by many of the urologists that surgically treat prostate cancer. As a result, the percentage of open prostatectomies has steadily decreased over time, while trends in robotic-assisted prostatectomies have increased. The impact of robotics also appears to have had an influential effect on the total number of prostatectomies performed annually.     

Robotic-assisted laparoscopic colorectal surgery

Robotic assistance provides a number of potential benefits for laparoscopic surgery by addressing several inherent limitations. However, its utility in colorectal surgery has not been determined. This is a report of our initial experience with robot-assisted colon resections. We prospectively followed 10 patients who underwent robotic-assisted laparoscopic colorectal surgery using Zeus Microwrist System. Surgical outcomes were compared with those of 10 consecutive patients who underwent laparoscopic colorectal surgery in the same institution for similar indications prior to the start of robotic-assisted surgery. Six patients in each group had surgery for colorectal malignancy. All 10 robotic-assisted procedures were completed with no intraoperative complications, conversions, or mortality. The average blood loss was less than 150 mL in all cases. Morbidity and hospital stay were comparable to those for the patients undergoing standard laparoscopic procedures. Robotic surgery was associated with a significant increase in operative time of almost 1 hour. This time was reduced significantly after the first 4 cases. The value of robotic assistance in colorectal surgery needs to be further evaluated in a larger comparative study.     

达芬奇机器人胰腺癌根治术与技巧

近十年来,应用达芬奇机器人手术系统行胰腺癌根治性手术在国内外逐渐得到开展。尽管达芬奇机器人手术系统是传统腹腔镜技术的突破,但与传统腹腔镜胰腺手术相比,应用机器人行胰腺手术在trocar孔布局、切除程序、淋巴结清扫以及消化道重建等方面仍不尽相同。机器人胰十二指肠切除术复杂、高危、昂贵,每一例均需严格认真对待,每一个微小和不经意的错误都有可能造成患者巨大的精神、身体创伤。为提高手术的安全性和规范化,本文以胰十二指肠切除术为例,重点介绍了机器人胰腺癌根治术的经验与技巧,希望笔者的经验可以给予学习曲线内的同行提供临床借鉴和帮助。     

Robotic approaches to renal cancer

PURPOSE OF REVIEW: Robotic-assisted laparoscopic surgery has had considerable impact on the management of localized prostate cancer. The role of robot assistance in laparoscopic renal surgery is less well defined, however. RECENT FINDINGS: There have been few recently published papers regarding the robotic approach to management of renal cancer. SUMMARY: Few clear benefits have been demonstrated for robotic-assisted over the conventional laparoscopic approach for the management of renal cancer.     

Virtual reality-assisted robotic surgery simulation

For more than a decade, advancing computer technologies have allowed incorporation of virtual reality (VR) into surgical training. This has become especially important in training for laparoscopic procedures, which often are complex and leave little room for error. With the advent of robotic surgery and the development and prevalence of a commercial surgical system (da Vinci robot; Intuitive Surgical, Sunnyvale, CA), a valid VR-assisted robotic surgery simulator could minimize the steep learning curve associated with many of these complex procedures and thus enable better outcomes. To date, such simulation does not exist; however, several agencies and corporations are involved in making this dream a reality. We review the history and progress of VR simulation in surgical training, its promising applications in robotic-assisted surgery, and the remaining challenges to implementation.     

Robotic-Assisted Versus Laparoscopic Colectomy: Cost and Clinical Outcomes

Background and Objectives:

Laparoscopic colectomies, with and without robotic assistance, are performed to treat both benign and malignant colonic disease. This study compared clinical and economic outcomes for laparoscopic colectomy procedures with and without robotic assistance.

Methods:

Patients aged ≥18 years having primary inpatient laparoscopic colectomy procedures (cecectomy, right hemicolectomy, left hemicolectomy, and sigmoidectomy) identified by International Classification of Diseases, Ninth Edition procedure codes performed between 2009 and the second quarter of 2011 from the Premier Hospital Database were studied. Patients were matched to a control cohort using propensity scores for disease, comorbidities, and hospital characteristics and were matched 1:1 for specific colectomy procedure. The outcomes of interest were hospital cost of laparoscopic robotic-assisted colectomy compared with traditional laparoscopic colectomy, surgery time, adverse events, and length of stay.

Results:

Of 25 758 laparoscopic colectomies identified, 98% were performed without robotic assistance and 2% were performed with robotic assistance. After matching, 1066 patients remained, 533 in each group. Lengths of stay were not significantly different between the matched cohorts, nor were rates of major, minor, and/or surgical complications. Inpatient procedures with robotic assistance were significantly more costly than those without robotic assistance ($17 445 vs $15 448, P = .001). Operative times were significantly longer for robotic-assisted procedures (4.37 hours vs 3.34 hours, P < .001).

Conclusion:

Segmental colectomies can be performed safely by either laparoscopic or robotic-assisted methods. Increased per-case hospital costs for robotic-assisted procedures and prolonged operative times suggest that further investigation is warranted when considering robotic technology for routine laparoscopic colectomies.     

Robotic-assisted laparoscopic cholecystectomy

We report a case of laparoscopic cholecystectomy that was performed using a robotic surgical system. A 70-year-old woman underwent laparoscopic robotic cholecystectomy ZEUS, the robotic system used in our study, has three interactive robotic arms fixed to the side of the operating table. The arms are controlled by the surgeon, who sits at a remote computer console. The surgeon's movements can be scaled down, and tremor is filtered out. The robotic-assisted laparoscopic cholecystectomy was completed in 42 min. The time to set up the robot was 22 mins. All of the surgically reproducible robotic maneuvers were performed without any particular difficulty. The robotic movements were stable, accurate, and reliable, as well as easy to control with precision. Our preliminary experience indicates that robotic laparoscopic cholecystectomy is safe and can be as fast as conventional laparoscopic cholecystectomy. However, further clinical applications of robotic surgery are needed to confirm this observation.     

Laparoscopic aortic surgery: recent development in instrumentation

Beside conventional and endovascular techniques, laparoscopic surgery is becoming a third way to treat patients presenting with aortoiliac occlusive or aneurysmal diseases. Several different laparoscopic techniques have been described, but most authors are stressing on the need for development of a specific laparoscopic aortic instrumentation, in order to decrease the operative and clamping times and to reduce the learning curve. This article is presenting an overview of what is already available, as laparoscopic aortic clamps or laparoscopic intestinal retractor, and what is still experimental, like laparoscopic aortic staplers, anastomotic devices or robotic surgical systems. This important technologic challenge should lead to two major orientations: development of qualitative in vitro and in vivo experiments to test these new products and training courses to teach the manipulation of it. Minimally aggressive techniques are well adapted to a western population, which becomes older, and has access to constantly improving medical care; however, only a specific and ergonomic instrumentation will allow these new techniques to be widely embraced by the vascular surgical community.     

Laparoscopic Aortic Surgery: Recent Development in Instrumentation

Beside conventional and endovascular techniques, laparoscopic surgery is becoming a third way to treat patients presenting with aortoiliac occlusive or aneurysmal diseases. Several different laparoscopic techniques have been described, but most authors are stressing on the need for development of a specific laparoscopic aortic instrumentation, in order to decrease the operative and clamping times and to reduce the learning curve. This article is presenting an overview of what is already available, as laparoscopic aortic clamps or laparoscopic intestinal retractor, and what is still experimental, like laparoscopic aortic staplers, anastomotic devices or robotic surgical systems. This important technologic challenge should lead to two major orientations: development of qualitative in vitro and in vivo experiments to test these new products and training courses to teach the manipulation of it. Minimally aggressive techniques are well adapted to a western population, which becomes older, and has access to constantly improving medical care; however, only a specific and ergonomic instrumentation will allow these new techniques to be widely embraced by the vascular surgical community.