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Cannata G, Leone N, Salzano A, Rebecchi F, Morino M. Training in the use of basic functions of the daVinci Xi ® robot: a comparative study of residents' skills. Updates Surg 2025:10.1007/s13304-025-02150-z. [PMID: 40088400 DOI: 10.1007/s13304-025-02150-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 02/26/2025] [Indexed: 03/17/2025]
Abstract
The rapid spread of the robotic surgical system has not been accompanied by an equally rapid creation of standardized training courses for the use of this technology.The purpose of our study was to evaluate skill acquisition in the handling and use of the daVinci Xi by comparing two groups of surgical residents. Surgical residents from the University of Turin were enrolled. The participants were divided into two groups: Group A: residents who had participated in at least 8 robotic surgical procedures, and Group B: residents who had never attended robotic surgery. All were administered two instructional videos on the patient cart and console exercises to be performed. Subsequently, the residents were tested and recorded to be evaluated by a senior surgeon experienced in robotic surgery, according to a previously assessed evaluation score. The time of the procedure was also recorded for each test. Patient cart exercises were completed by all participants. We found statistically significant differences between two groups for the first (p = 0.0000) and third (p = 0.0002) patient cart tests and for every test on the surgeon's console except the endoscope handling exercise. Group A scored higher on the patient cart exercises, and the difference reached statistical significance (p = 0.0001). The placement of a single hand-sewn knot on the silicone suture pad was the only exercise that was not fully completed by all participants and showed no statistical difference. The correlation analysis between surgical experience and final score was significant in Group A. The daVinci Xi robotic platform can be properly operated in its basic functions by young surgeons after a short training program even in the absence of previous exposure to robotic clinical procedure.
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Affiliation(s)
- Gaspare Cannata
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Nicola Leone
- Department of Surgical Sciences, University of Turin, Turin, Italy.
- Department of Surgical Sciences, University of Torino, C.So Dogliotti 14, 10126, Turin, Italy.
| | | | - Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, C.So Dogliotti 14, 10126, Turin, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, C.So Dogliotti 14, 10126, Turin, Italy
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Chahal B, Aydın A, Amin MSA, Ong K, Khan A, Khan MS, Ahmed K, Dasgupta P. Transfer of open and laparoscopic skills to robotic surgery: a systematic review. J Robot Surg 2023; 17:1207-1225. [PMID: 36418717 PMCID: PMC10374669 DOI: 10.1007/s11701-022-01492-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022]
Abstract
Due to its advantages over open surgery and conventional laparoscopy, uptake of robot-assisted surgery has rapidly increased. It is important to know whether the existing open or laparoscopic skills of robotic novices shorten the robotic surgery learning curve, potentially reducing the amount of training required. This systematic review aims to assess psychomotor skill transfer to the robot in clinical and simulated settings. PubMed, EMBASE, Cochrane Library and Scopus databases were systematically searched in accordance with PRISMA guidelines from inception to August 2021 alongside website searching and citation chaining. Article screening, data extraction and quality assessment were undertaken by two independent reviewers. Outcomes included simulator performance metrics or in the case of clinical studies, peri- and post-operative metrics. Twenty-nine studies met the eligibility criteria. All studies were judged to be at high or moderate overall risk of bias. Results were narratively synthesised due to heterogeneity in study designs and outcome measures. Two of the three studies assessing open surgical skill transfer found evidence of successful skill transfer while nine of twenty-seven studies evaluating laparoscopic skill transfer found no evidence. Skill transfer from both modalities is most apparent when advanced robotic tasks are performed in the initial phase of the learning curve but quality and methodological limitations of the existing literature prevent definitive conclusions. The impact of incorporating laparoscopic simulation into robotic training curricula and on the cost effectiveness of training should be investigated.
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Affiliation(s)
- Baldev Chahal
- MRC Centre for Transplantation, Guy's Hospital, King's College London, 5Th Floor Southwark Wing, London, SE1 9RT, UK
| | - Abdullatif Aydın
- MRC Centre for Transplantation, Guy's Hospital, King's College London, 5Th Floor Southwark Wing, London, SE1 9RT, UK.
- Department of Urology, King's College Hospital NHS Foundation Trust, London, UK.
| | | | - Kelly Ong
- Department of Urology, Princess Royal University Hospital, Orpington, UK
| | - Azhar Khan
- Department of Urology, King's College Hospital NHS Foundation Trust, London, UK
- Urology Centre, Guy's and St, Thomas' NHS Foundation Trust, London, UK
| | | | - Kamran Ahmed
- MRC Centre for Transplantation, Guy's Hospital, King's College London, 5Th Floor Southwark Wing, London, SE1 9RT, UK
- Department of Urology, King's College Hospital NHS Foundation Trust, London, UK
| | - Prokar Dasgupta
- MRC Centre for Transplantation, Guy's Hospital, King's College London, 5Th Floor Southwark Wing, London, SE1 9RT, UK
- Urology Centre, Guy's and St, Thomas' NHS Foundation Trust, London, UK
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Vyborniy MI, Kolygin AV, Petrov DI, Bolshakov GV. [Robotic sleeve gastrectomy: single-center experience]. Khirurgiia (Mosk) 2023:20-28. [PMID: 37916554 DOI: 10.17116/hirurgia202310120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice. MATERIAL AND METHODS We analyzed treatment outcomes in patients with morbid obesity who underwent robot-assisted sleeve gastrectomy between 2020 and 2023. The same team of surgeons performed all operations. Evolution of technique and preparation of the operating theatre were recorded. Demographic data of patients, surgery time (docking and total surgery time), simultaneity of intervention, intraoperative and postoperative complications, as well as weight loss after 6 months were retrospectively analyzed. RESULTS There were 15 robot-assisted sleeve gastrectomies between 2020 and 2023. Of these, 14 patients underwent surgery without complications. One patient was diagnosed with portal vein thrombosis that required anticoagulation. Median surgery time 194 [173.5; 241] min, period between incision and docking - 35 [30; 36] min. The length of hospital-stay was 3 days. The median weight loss after 6 months was 37.5% [29.5; 51.2]. CONCLUSION This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.
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Affiliation(s)
| | | | - D I Petrov
- Ilyinskaya Hospital, Krasnogorsk, Russia
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Ergun O, Gudeloglu A, Parekattil SJ. Robotic Surgery for Male Infertility and Chronic Scrotal Content Pain. J Endourol 2022; 36:S48-S60. [PMID: 36154453 DOI: 10.1089/end.2022.0259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Robot-assisted microsurgery is a trending approach for the treatment of male infertility and chronic scrotal pain. The advantages seem to include increased optical magnification, improved surgical efficiency, absent tremor, and similar outcomes with standard methods. This chapter covers robotic microsurgical application and techniques for: robot-assisted vasectomy reversal with vasovasostomy and vasoepididymostomy, varicocelectomy, microsurgical testicular sperm extraction, and targeted denervation of the spermatic cord.
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Affiliation(s)
| | | | - Sijo J Parekattil
- Avant Concierge Urology & University of Central Florida, Winter Garden, Florida, USA
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Hsia SK, Chuang YH, Chen CW. Auto-Tuned Motion Scaling in Teleoperation Based on Human Reaction Model Identification. IEEE Robot Autom Lett 2022. [DOI: 10.1109/lra.2021.3126342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kanitra JJ, Khogali-Jakary N, Gambhir SB, Davis AT, Hollis M, Moon C, Gupta R, Haan PS, Anderson C, Collier D, Henry D, Kavuturu S. Transference of skills in robotic vs. laparoscopic simulation: a randomized controlled trial. BMC Surg 2021; 21:379. [PMID: 34711220 PMCID: PMC8554974 DOI: 10.1186/s12893-021-01385-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 10/18/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Elucidating how robotic skills are best obtained will enable surgeons to best develop future robotic training programs. We perform a randomized controlled trial to assess the performance of robotic compared to laparoscopic surgery, transference of pre-existing skills between the two modalities, and to assess the learning curve between the two using novice medical students. METHODS Forty students were randomized into either Group A or B. Students practiced and were tested on a peg transfer task in either a laparoscopic simulator (LS) and robotic simulator (RS) in a pre-defined order. Performance, transference of skills and learning curve were assessed for each modality. Additionally, a fatigue questionnaire was issued. RESULTS There was no significant difference between overall laparoscopic scores (219 ± 19) and robotic scores (227 ± 23) (p = 0.065). Prior laparoscopic skills performed significantly better on robotic testing (236 ± 12) than without laparoscopic skills (216 ± 28) (p = 0.008). There was no significant difference in scores between students with prior robotic skills (223 ± 16) than without robotic skills (215 ± 22) (p = 0.162). Students reported no difference in fatigue between RS and LS. The learning curve plateaus at similar times between both modalities. CONCLUSION Novice medical students with laparoscopic skills performed better on a RS test than students without laparoscopic training, suggesting a transference of skills from laparoscopic to robotic surgery. These results suggest laparoscopic training may be sufficient in general surgery residencies as the skills transfer to robotic if used post-residency.
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Affiliation(s)
- John J Kanitra
- Department of Surgery, Ascension St. John Hospital, Detroit, MI, 48236, USA
| | - Nashwa Khogali-Jakary
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Sahil B Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA, 92868, USA
| | - Alan T Davis
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Michael Hollis
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Caroline Moon
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Rama Gupta
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Pamela S Haan
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Cheryl Anderson
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - Deborah Collier
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA
| | - David Henry
- Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Srinivas Kavuturu
- Department of Surgery, Michigan State University College of Human Medicine, 1200 E. Michigan Ave, Suite 655, Lansing, MI, 48912, USA.
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Ahmad SB, Rice M, Chang C, Zureikat AH, Zeh HJ, Hogg ME. dV-Trainer vs. da Vinci Simulator: Comparison of Virtual Reality Platforms for Robotic Surgery. J Surg Res 2021; 267:695-704. [PMID: 34348185 DOI: 10.1016/j.jss.2021.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND A virtual reality (VR) curriculum performed on the da Vinci Simulation System (DVSS) was previously shown to be effective in training fellows. The dV-Trainer is a separate platform with similar features to the da Vinci console, but its efficacy and utility versus the DVSS simulator are not well known. MATERIALS AND METHODS A mastery-based VR curriculum was completed by surgical fellows on the DVSS (2014-2016) and on the dV-Trainer (2016-2018) at a large academic center. Pre-test/post-test scores were used to evaluate performance between the two groups. Data was collected prospectively. RESULTS Forty-six fellows enrolled in the curriculum: surgical oncology (n=31), hepatobiliary (n=5), head/neck (n=4), endocrine (n=2), cardiothoracic (n=2), gynecology (n=1) and transplant surgery (n=1). Twenty-four used the DVSS and twenty-two used the dV-Trainer. Compared to the DVSS, the dV-Trainer was associated with lower scores on 2 of 3 VR modules in the pre-test (P=0.027, P<0.001, respectively) and post-test (P=0.021, P<0.001, respectively). Fellows in the dV-Trainer era scored lower on inanimate drills as well. Average VR curriculum score was lower on the dV-Trainer (71.3% vs 83.34%, P<0.001). dV-Trainer users spent more time completing the pre-test and post-test; however, overall simulator time to complete the curriculum was not significantly different (297 vs 231 minutes, P=0.142). Both groups showed improvement in scores after completion of the VR curriculum. CONCLUSIONS The dV-Trainer simulator allows for more usability outside the operating room to complete VR modules; however, the DVSS simulator group outperformed the dV-Trainer group on the post-test.
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Affiliation(s)
- Sarwat B Ahmad
- University of Pittsburgh Medical Center, , Pittsburgh, PA,.
| | - MaryJoe Rice
- University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Herbert J Zeh
- University of Texas Southwestern Medical Center, Dallas, TX
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Lee E, Lee K, Kang SH, Lee S, Won Y, Park YS, Ahn SH, Suh YS, Kim HH. Usefulness of articulating laparoscopic instruments during laparoscopic gastrectomy for gastric adenocarcinoma. JOURNAL OF MINIMALLY INVASIVE SURGERY 2021; 24:35-42. [PMID: 35601278 PMCID: PMC8966001 DOI: 10.7602/jmis.2021.24.1.35] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 04/30/2023]
Abstract
Purpose Conventional straight-shaped laparoscopic surgical instruments have limitations that, unlike robotic surgery, the wrist joint cannot be used. This study aimed to analyze the short-term safety and feasibility of ArtiSential (Livsmed), a new articulating laparoscopic instrument, which obviates the limitations of conventional laparoscopic surgery and allows the wrist joint to be used freely over 360° as in robotic surgery. Methods The study included patients who underwent conventional laparoscopy or laparoscopy with the ArtiSential instrument. Patients who underwent laparoscopic gastrectomy for primary gastric adenocarcinoma in our institution were retrospectively reviewed. The groups were propensity score matched in a 11 ratio. Primary endpoint was incidence of early postoperative complication (postoperative 30-day morbidity and mortality) and secondary endpoints were operative outcomes. Results A total of 327 patients (147 of the conventional group and 180 of the ArtiSential group) were propensity score matched. After propensity score matching was performed, each group comprised of 122 patients. Both groups were comparable with regard to operation time, estimated blood loss, number of retrieved lymph nodes, and length of hospital stay. The ArtiSential group had a faster time to a fluid diet (2.6 ± 1.3 days vs. 2.3 ± 0.6 days, p = 0.015). There was no statistically significant difference in early postoperative complications between the two groups (the conventional group, 23.0%; the ArtiSential group, 26.2%; p = 0.656). Conclusion The current study showed that the use of ArtiSential is a safe and feasible option without increasing operation time, length of hospital stay, and intraoperative bleeding.
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Affiliation(s)
- Eunju Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kanghaeng Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - So Hyun Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sangjun Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yongjoon Won
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yun-Suhk Suh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Willuth E, Hardon SF, Lang F, Haney CM, Felinska EA, Kowalewski KF, Müller-Stich BP, Horeman T, Nickel F. Robotic-assisted cholecystectomy is superior to laparoscopic cholecystectomy in the initial training for surgical novices in an ex vivo porcine model: a randomized crossover study. Surg Endosc 2021; 36:1064-1079. [PMID: 33638104 PMCID: PMC8758618 DOI: 10.1007/s00464-021-08373-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/09/2021] [Indexed: 12/11/2022]
Abstract
Background Robotic-assisted surgery (RAS) potentially reduces workload and shortens the surgical learning curve compared to conventional laparoscopy (CL). The present study aimed to compare robotic-assisted cholecystectomy (RAC) to laparoscopic cholecystectomy (LC) in the initial learning phase for novices. Methods In a randomized crossover study, medical students (n = 40) in their clinical years performed both LC and RAC on a cadaveric porcine model. After standardized instructions and basic skill training, group 1 started with RAC and then performed LC, while group 2 started with LC and then performed RAC. The primary endpoint was surgical performance measured with Objective Structured Assessment of Technical Skills (OSATS) score, secondary endpoints included operating time, complications (liver damage, gallbladder perforations, vessel damage), force applied to tissue, and subjective workload assessment. Results Surgical performance was better for RAC than for LC for total OSATS (RAC = 77.4 ± 7.9 vs. LC = 73.8 ± 9.4; p = 0.025, global OSATS (RAC = 27.2 ± 1.0 vs. LC = 26.5 ± 1.6; p = 0.012, and task specific OSATS score (RAC = 50.5 ± 7.5 vs. LC = 47.1 ± 8.5; p = 0.037). There were less complications with RAC than with LC (10 (25.6%) vs. 26 (65.0%), p = 0.006) but no difference in operating times (RAC = 77.0 ± 15.3 vs. LC = 75.5 ± 15.3 min; p = 0.517). Force applied to tissue was similar. Students found RAC less physical demanding and less frustrating than LC. Conclusions Novices performed their first cholecystectomies with better performance and less complications with RAS than with CL, while operating time showed no differences. Students perceived less subjective workload for RAS than for CL. Unlike our expectations, the lack of haptic feedback on the robotic system did not lead to higher force application during RAC than LC and did not increase tissue damage. These results show potential advantages for RAS over CL for surgical novices while performing their first RAC and LC using an ex vivo cadaveric porcine model. Registration number researchregistry6029 Graphic abstract ![]()
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Affiliation(s)
- E Willuth
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - S F Hardon
- Department of Surgery, Amsterdam UMC-VU University Medical Center, Amsterdam, The Netherlands
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - F Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - C M Haney
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - E A Felinska
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - K F Kowalewski
- Department of Urology and Urological Surgery, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T Horeman
- Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - F Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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Ngu JCY, Tsang CBS, Koh DCS. The da Vinci Xi: a review of its capabilities, versatility, and potential role in robotic colorectal surgery. ROBOTIC SURGERY (AUCKLAND) 2017; 4:77-85. [PMID: 30697566 PMCID: PMC6193435 DOI: 10.2147/rsrr.s119317] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Xi is the latest da Vinci surgical system approved for use in colorectal surgery. With its novel overhead architecture, slimmer boom-mounted arms, extended instrument reach, guided targeting, and integrated auxiliary technology, the Xi manages to address several limitations of earlier models. The versatility of this new system allows it to be implemented in a wide range of colorectal procedures - from complex multiquadrant colectomies to challenging mesorectal dissections in the pelvis. While commonly criticized for its cost and prolonged operative time, robotic colorectal surgery holds the potential for enhanced ergonomics, superior precision, and a reduction in the learning curve involved in training an expert surgeon. This review appraises the existing literature on robotic colorectal surgery while elaborating how the improved capabilities of the Xi serve to usher in a new era of minimally invasive colorectal surgery.
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Affiliation(s)
| | - Charles Bih-Shiou Tsang
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore
- Colorectal Clinic Associates, Mount Elizabeth Novena Specialist Center, Singapore
| | - Dean Chi-Siong Koh
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore
- Colorectal Clinic Associates, Mount Elizabeth Novena Specialist Center, Singapore
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Status and Prospects of Robotic Gastrectomy for Gastric Cancer: Our Experience and a Review of the Literature. Gastroenterol Res Pract 2017. [PMID: 28626474 PMCID: PMC5463113 DOI: 10.1155/2017/7197652] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Since the first report of robotic gastrectomy, experienced laparoscopic surgeons have used surgical robots to treat gastric cancer and resolve problems associated with laparoscopic gastrectomy. However, compared with laparoscopic gastrectomy, the superiority of robotic procedures has not been clearly proven. There are several advantages to using robotic surgery for gastric cancer, such as reduced estimated blood loss during the operation, a shorter learning curve, and a larger number of examined lymph nodes than conventional laparoscopic gastrectomy. The increased operation time observed with a robotic system is decreasing because surgeons have accumulated experience using this procedure. While there is limited evidence, long-term oncologic outcomes appear to be similar between robotic and laparoscopic gastrectomy. Robotic procedures have a significantly greater financial cost than laparoscopic gastrectomy, which is a major drawback. Recent clinical studies tried to demonstrate that the benefits of robotic surgery outweighed the cost, but the overall results were disappointing. Ongoing studies are investigating the benefits of robotic gastrectomy in more complicated and challenging cases. Well-designed randomized control trials with large sample sizes are needed to investigate the benefits of robotic gastrectomy compared with laparoscopic surgery.
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Arevalo G, Harris K, Sadiq A, Calin ML, Nasri B, Singh K. Repair of Morgagni Hernia in Adults with Primary Closure and Mesh Placement: First Robotic Experience. J Laparoendosc Adv Surg Tech A 2016; 27:529-532. [PMID: 27500540 DOI: 10.1089/lap.2016.0360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Morgagni hernia (MH) is an uncommon type of diaphragmatic hernia, especially in adults. Laparoscopic or thorascopic approaches have been described in adults. There are few reported cases using the Da Vinci robot in children and no previously described cases in adults. We report our early experience and technique using the robotic approach for MH repair in adults and its potential advantages. METHOD Robotic repair of MH was performed in 3 female patients. Four trocars were used to gain access to the abdomen. The hernia contents were reduced, the sac excised, and the defect closed primarily. A 4 × 6 inch bioabsorbable coating mesh was used in 2 patients and a biologic mesh in 1 for reinforcement. RESULTS Robotic repair of MH was technically successful in all 3 patients. The average operative time was 199.3 minutes, and difficult hernia exposure in one case caused prolonged surgical time. There were no intraoperative complications. Additional interventions, including a repair of a transverse colon serosal tear during the reduction of hernia contents, occurred in 1 patient. Two of the 3 female patients were discharged on postoperative day 1, whereas the other patient was discharged on postoperative day 3. There were no postoperative complications. CONCLUSION Robotic MH repair is an alternative minimally invasive approach for adults that allows for precise sac excision and primary tension-free repair with mesh reinforcement.
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Affiliation(s)
- Gabriel Arevalo
- 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana
| | - Kathryn Harris
- 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana
| | - Aziz Sadiq
- 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana
| | - Marius L Calin
- 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana
| | - Baongoc Nasri
- 2 Department of Surgery, Bronx-Lebanon Hospital , New York, New York
| | - Kirpal Singh
- 1 Department of General Surgery, Saint Vincent Hospital Indianapolis , Indianapolis, Indiana
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13
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Sánchez R, Rodríguez O, Rosciano J, Vegas L, Bond V, Rojas A, Sanchez-Ismayel A. Robotic surgery training: construct validity of Global Evaluative Assessment of Robotic Skills (GEARS). J Robot Surg 2016; 10:227-31. [PMID: 27039189 DOI: 10.1007/s11701-016-0572-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/06/2016] [Indexed: 12/14/2022]
Abstract
The objective of this study is to determine the ability of the GEARS scale (Global Evaluative Assessment of Robotic Skills) to differentiate individuals with different levels of experience in robotic surgery, as a fundamental validation. This is a cross-sectional study that included three groups of individuals with different levels of experience in robotic surgery (expert, intermediate, novice) their performance were assessed by GEARS applied by two reviewers. The difference between groups was determined by Mann-Whitney test and the consistency between the reviewers was studied by Kendall W coefficient. The agreement between the reviewers of the scale GEARS was 0.96. The score was 29.8 ± 0.4 to experts, 24 ± 2.8 to intermediates and 16 ± 3 to novices, with a statistically significant difference between all of them (p < 0.05). All parameters from the scale allow discriminating between different levels of experience, with exception of the depth perception item. We conclude that the scale GEARS was able to differentiate between individuals with different levels of experience in robotic surgery and, therefore, is a validated and useful tool to evaluate surgeons in training.
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Affiliation(s)
- Renata Sánchez
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela.,Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela
| | - Omaira Rodríguez
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela. .,Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela.
| | - José Rosciano
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela
| | - Liumariel Vegas
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela
| | - Verónica Bond
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela
| | - Aram Rojas
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela
| | - Alexis Sanchez-Ismayel
- Robotic Surgery Program. University Hospital of Caracas, Medicine Faculty, Central University of Venezuela, Caracas, Venezuela.,Robotic and Minimally Invasive Surgery (UNIC), Caracas, Venezuela
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14
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Abstract
BACKGROUND Laparoscopic and robotic surgeries have become popular, and this popularity is increasing. However, the environment in which such surgeries are performed is rarely discussed. Similar to arthrosurgery performed in water, artificial ascites could be a new environment for laparoscopic surgery. This study was performed to determine whether robotic surgery is applicable to complicated suturing underwater. MATERIAL AND METHODS A da Vinci Surgical System S was used. A weighted fabric sheet was placed at the bottom of a tank. Identical sets were made for each environment: One tank was dry, and the other was filled with water. The suturing task involved placement of a running silk suture around the perimeter of a small circle. The task was performed eight times in each environment. The task time and integrity score were determined. The integrity score was calculated by evaluating accuracy, tightness, thread damage, and uniformity; each factor was evaluated using a five-point scale. RESULTS Although statistically significant differences were not shown in either task time or integrity score between the underwater and air environments, robotic suturing underwater is not inferior to performance in air. CONCLUSIONS The feasibility of robotic suturing underwater was confirmed under the herein-described experimental conditions.
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Affiliation(s)
- Masahiko Kawaguchi
- a Department of General and Cardiothoracic Surgery , Kanazawa University , Ishikawa , Japan
| | - Masanari Shimada
- a Department of General and Cardiothoracic Surgery , Kanazawa University , Ishikawa , Japan
| | - Norihiko Ishikawa
- a Department of General and Cardiothoracic Surgery , Kanazawa University , Ishikawa , Japan
| | - Go Watanabe
- a Department of General and Cardiothoracic Surgery , Kanazawa University , Ishikawa , Japan
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15
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Ali S, Taylor BM, Schlachta CM. Evaluation of pilot experience with robotic-assisted proctectomy and coloanal anastomosis for rectal cancer. Can J Surg 2015; 58:188-92. [PMID: 26011851 DOI: 10.1503/cjs.013814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Robotic-assisted proctectomy with coloanal anastomosis (RPCA) is an innovative technique of pelvic dissection for low rectal cancer. Our objective was to evaluate our pilot experience with this procedure compared with open proctectomy with coloanal anastomosis (OPCA). METHODS We performed a retrospective 5-year review of all consecutive cases of RPCA and OPCA performed at our institute. We focused on tumour characteristics, quality of surgery, analgesic requirements, average length of hospital stay (LOS), complications and long-term outcomes. RESULTS Three patients underwent RPCA and 25 had OPCA. The average duration of surgery was similar (288 min for RPCA v. 285 min for OPCA). Four patients in the OPCA group had positive or very close margins, and 2 had a mesorectal defect less than 5 mm. The average LOS was 6.66 and 9.29 days in the RPCA and OPCA groups, respectively, and the average duration of epidural or patient-controlled anesthesia was 2.67 and 5.16 days, respectively. We did not perform a statistical comparison because of the discordant size and sex distribution between the groups. There were no perioperative complications in the RPCA group, and all patients had negative margins and adequate lymph node retrievals with no long-term complications or recurrence recorded so far. CONCLUSION Our very early experience with RPCA is quite encouraging, suggesting that it is a safe alternative to OPCA with a similar duration and the added benefits of a minimally invasive procedure, including decreased LOS and reduced postoperative analgesic requirements.
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Affiliation(s)
- Syed Ali
- The Canadian Surgical Technologies and Advanced Robotics, London Health Sciences Centre, and the Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | - Brian M Taylor
- The Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario
| | - Christopher M Schlachta
- The Canadian Surgical Technologies and Advanced Robotics, London Health Sciences Centre, and the Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario
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16
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Son T, Hyung WJ. Robotic gastrectomy for gastric cancer. J Surg Oncol 2015; 112:271-8. [PMID: 26031408 DOI: 10.1002/jso.23926] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 04/08/2015] [Indexed: 12/18/2022]
Abstract
Robotic surgery for gastric cancer overcomes technical difficulties with laparoscopic gastrectomy. Its benefits include reduced intraoperative bleeding and shorter hospital stays; it is also easier to learn. Because accuracy increases during lymphadenectomy, a larger number of lymph nodes is likely to be retrieved using robotic gastrectomy. Higher costs and longer operation times have hindered the widespread adaptation and use of robotic surgery. In this review, we summarize the current status and issues regarding robotic gastrectomy.
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Affiliation(s)
- Taeil Son
- Department of Surgery, Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.,Gastric Cancer Center, Yonsei Cancer Hospital, Yonsei University Health System, Seoul, South Korea.,Robot and MIS Center, Severance Hospital, Yonsei University Health System, Seoul, South Korea
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17
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Lee JS, Hong TH. In vivo porcine training model for laparoscopic Roux-en-Y choledochojejunostomy. Ann Surg Treat Res 2015; 88:306-10. [PMID: 26029675 PMCID: PMC4443261 DOI: 10.4174/astr.2015.88.6.306] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 11/30/2014] [Accepted: 12/15/2014] [Indexed: 12/12/2022] Open
Abstract
Purpose The purpose of this study was to develop a porcine training model for laparoscopic choledochojejunostomy (CJ) that can act as a bridge between simulation models and actual surgery for novice surgeons. The feasibility of this model was evaluated. Methods Laparoscopic CJ using intracorporeal sutures was performed on ten animals by a surgical fellow with no experience in human laparoscopic CJ. A single layer of running sutures was placed in the posterior and anterior layers. Jejunojejunostomy was performed using a linear stapler, and the jejunal opening was closed using absorbable unidirectional sutures (V-Loc 180). Results The average operation time was 131.3 ± 36.4 minutes, and the CJ time was 57.5 ± 18.4 minutes. Both the operation time and CJ time showed a steady decrease with an increasing number of cases. The average diameter of the CBD was 6.4 ± 0.8 mm. Of a total of ten animals, eight were sacrificed after the procedure. In two animals, a survival model was evaluated. Both pigs recovered completely and survived for two weeks, after which both animals were sacrificed. None of the animals exhibited any signs of bile leakage or anastomosis site stricture. Conclusion The porcine training model introduced in this paper is an adequate model for practicing laparoscopic CJ. Human tissue simulation is excellent.
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Affiliation(s)
- Jun Suh Lee
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Tae Ho Hong
- Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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18
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Coratti A, Annecchiarico M, Di Marino M, Gentile E, Coratti F, Giulianotti PC. Robot-assisted gastrectomy for gastric cancer: current status and technical considerations. World J Surg 2015; 37:2771-81. [PMID: 23674257 DOI: 10.1007/s00268-013-2100-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Robot-assisted gastrectomy has been reported as a safe alternative to the conventional laparoscopy or open approach for treating early gastric carcinoma. To date, however, there are a limited number of published reports available in the literature. METHODS We assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations. RESULTS In gastric surgery, the biggest advantage of robotic surgery is the ease and reproducibility of D2-lymphadenectomy. Reports show that even the intracorporeal digestive restoration is facilitated by use of the robotic approach, particularly following total gastrectomy. Additionally, the accuracy of robotic dissection is confirmed by decreased blood loss, as reported in series comparing robot-assisted with laparoscopic gastrectomy. The learning curve and technical reproducibility also appear to be shorter with robotic surgery and, consequently, robotics can help to standardize and diffuse minimally invasive surgery in the treatment of gastric cancer, even in the later stages. This is important because the application of minimally invasive surgery is limited by the complexity of performing a D2-lymphadenectomy. The potential to reproduce D2-lymphadenectomy, enlarged resections, and complex reconstructions provides robotic surgery with an important role in the therapeutic strategy of advanced gastric cancer. CONCLUSIONS While published reports have shown no significant differences in surgical morbidity, mortality, or oncological adequacy between robot-assisted and conventional laparoscopic gastrectomy, more studies are needed to assess the indications and oncological effectiveness of robotic use in the treatment of gastric carcinoma. Herein, the authors assess the current status of robotic surgery in the treatment of gastric cancer, focusing on the technical details and oncological considerations.
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Affiliation(s)
- Andrea Coratti
- Department of General Surgery, Misericordia Hospital, Grosseto, Italy,
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19
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Agresta F, Campanile FC, Vettoretto N, Silecchia G, Bergamini C, Maida P, Lombari P, Narilli P, Marchi D, Carrara A, Esposito MG, Fiume S, Miranda G, Barlera S, Davoli M. Laparoscopic cholecystectomy: consensus conference-based guidelines. Langenbecks Arch Surg 2015; 400:429-53. [PMID: 25850631 DOI: 10.1007/s00423-015-1300-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/24/2015] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery. METHODS In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.
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Affiliation(s)
- Ferdinando Agresta
- Department of Surgery, Presidio Ospedaliero di Adria (RO), Adria, RO, Italy,
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20
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Current status of minimally invasive surgery for gastric cancer: A literature review to highlight studies limits. Int J Surg 2015; 17:34-40. [PMID: 25758348 DOI: 10.1016/j.ijsu.2015.02.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/05/2015] [Accepted: 02/26/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastric cancer represents a great challenge for health care providers and requires a multidisciplinary approach in which surgery plays the main role. Minimally invasive surgery has been progressively developed, first with the advent of laparoscopy and more recently with the spread of robotic surgery, but a number of issues are currently being investigate, including the limitations in performing effective extended lymph node dissections and, in this context, the real advantages of using robotic systems, the possible role for advanced Gastric Cancer, the reproducibility of completely intracorporeal techniques and the oncological results achievable during follow-up. METHOD Searches of MEDLINE, Embase and Cochrane Central Register of Controlled Trials were performed to identify articles published until April 2014 which reported outcomes of surgical treatment for gastric cancer and that used minimally invasive surgical technology. Articles that deal with endoscopic technology were excluded. RESULTS A total of 362 articles were evaluated. After the review process, data in 115 articles were analyzed. CONCLUSION A multicenter study with a large number of patients is now needed to further investigate the safety and efficacy as well as long-term outcomes of robotic surgery, traditional laparoscopy and the open approach.
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21
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Costi R, Gnocchi A, Di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20:13382-13401. [PMID: 25309071 PMCID: PMC4188892 DOI: 10.3748/wjg.v20.i37.13382] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/23/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.
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22
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Liu XX, Jiang ZW, Chen P, Zhao Y, Pan HF, Li JS. Full robot-assisted gastrectomy with intracorporeal robot-sewn anastomosis produces satisfying outcomes. World J Gastroenterol 2013; 19:6427-6437. [PMID: 24151361 PMCID: PMC3801313 DOI: 10.3748/wjg.v19.i38.6427] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 08/07/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility and safety of full robot-assisted gastrectomy with intracorporeal robot hand-sewn anastomosis in the treatment of gastric cancer.
METHODS: From September 2011 to March 2013, 110 consecutive patients with gastric cancer at the authors’ institution were enrolled for robotic gastrectomies. According to tumor location, total gastrectomy, distal or proximal subtotal gastrectomy with D2 lymphadenectomy was fully performed by the da Vinci Robotic Surgical System. All construction, including Roux-en-Y jejunal limb, esophagojejunal, gastroduodenal and gastrojejunal anastomoses were fully carried out by the intracorporeal robot-sewn method. At the end of surgery, the specimen was removed through a 3-4 cm incision at the umbilicus trocar point. The details of the surgical technique are well illustrated. The benefits in terms of surgical and oncologic outcomes are well documented, as well as the failure rate and postoperative complications.
RESULTS: From a total of 110 enrolled patients, radical gastrectomy could not be performed in 2 patients due to late stage disease; 1 patient was converted to laparotomy because of uncontrollable hemorrhage, and 1 obese patient was converted due to difficult exposure; 2 patients underwent extra-corporeal anastomosis by minilaparotomy to ensure adequate tumor margin. Robot-sewn anastomoses were successfully performed for 12 proximal, 38 distal and 54 total gastrectomies. The average surgical time was 272.52 ± 53.91 min and the average amount of bleeding was 80.78 ± 32.37 mL. The average number of harvested lymph nodes was 23.1 ± 5.3. All specimens showed adequate surgical margin. With regard to tumor staging, 26, 32 and 46 patients were staged as I, II and III, respectively. The average hospitalization time after surgery was 6.2 d. One patient experienced a duodenal stump anastomotic leak, which was mild and treated conservatively. One patient was readmitted for intra-abdominal infection and was treated conservatively. Jejunal afferent loop obstruction occurred in 1 patient, who underwent re-operation and recovered quickly.
CONCLUSION: This technique is feasible and can produce satisfying postoperative outcomes. It is also convenience and reliable for anastomoses in gastrectomy. Full robotic hand-sewn anastomosis may be a minimally invasive technique for gastrectomy surgery.
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23
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An analysis of the impact of previous laparoscopic hysterectomy experience on the learning curve for robotic hysterectomy. J Robot Surg 2013; 7:295-9. [PMID: 27000926 DOI: 10.1007/s11701-012-0388-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/21/2012] [Indexed: 10/27/2022]
Abstract
To analyze and compare the safety and perioperative outcomes of newly trained robotic surgeons with previous laparoscopic hysterectomy experience (TLH Exp) and those without previous laparoscopic hysterectomy experience (Non-TLH Exp). The purpose is to determine the effect of previous advanced laparoscopic skills on the performance in robotic assisted laparoscopic surgery. We will also compare the perioperative outcomes between the total laparoscopic hysterectomies (TLH), and robotic assisted laparoscopic hysterectomies (RALH) of a single experienced (TLH Exp) robotic surgeon. The purpose is to determine benefits and/or risks, if any, of one approach over the other in the hands of an experienced laparoscopic surgeon. Prospective data were collected on the first consecutive series of RALH performed by (TLH Exp) and (Non-TLH Exp) surgeons, with perioperative outcomes and morbidity being evaluated. In addition, retrsopective data were collected on a consecutive series of patients in a TLH group and compared with the outcomes in the robotic group for benign hysterectomies by the same surgeon. The parameters that were analyzed for associations with these two groups were estimated blood loss (EBL), Hb drop, length of hospital stay (LOS), procedure time, pain medication use, and complications. The (TLH Exp) group had 64 patients, and the (Non-TLH Exp) group had 72 patients. When comparing patients in the (TLH Exp) group with patients in (Non-TLH Exp) group, the mean age was 44 and 45 (P = 0.8), mean BMI was 27.7 and 29.5 kg/m(2) (P = 0.2), mean procedure time was 121 and 174 min (P < 0.05), mean console time was 70 and 119 min (P < 0.05), mean EBL was 64 and 84 ml (P = 0.3), with a Hb drop 1.7 and 1.33 (P = 0.2), uterine weight was 192 and 205 gms (P = 0.7), and length of stay was 1.07 and 1.33 days (P = 0.2), respectively. The (TLH Exp) surgeons had a lower OR, procedure and console time, but a higher hemoglobin drop, with no difference in EBL. There were no operative deaths, or conversions in either group. Morbidity occurred in two patients (3 %) in each group, with no statistically significant difference between the groups. In the (TLH Exp) group it included a blood transfusion and a readmission for a postoperative ileus. In the (Non-TLH Exp), the complications included a blood transfusion and a return to the OR for a vaginal cuff dehiscence. When comparing a single (TLH Exp) surgeon's own TLH versus RALH, there were 64 RALH and 49 TLH cases. There was a statistically significant difference in the mean procedure time 121.1 versus 88.8 min (P < 0.05), mean Hb drop 1.7 versus 2.3 (P < 0.05), and mean EBL 64.2 versus 158 ml (P < 0.05), respectively. The RALH group had a longer procedure time, but lower Hb drop, and less estimated blood loss. There were no operative deaths, or conversions in either group. Morbidity occurred in 2 patients in the robotic group, and included one blood transfusion, and one postoperative ileus. There were no complications noted in the laparoscopic hysterectomy group. Previous advanced laparoscopic skills appear to only significantly impact the length of the procedure, but not other variables. Robotic surgery may level the playing field between the basic and advanced laparoscopic surgeon for robotic assisted laparoscopic hysterectomy. In comparing the outcomes of RALH versus TLH by a single surgeon, the robotic assistance appeared to lengthen the procedure time, but reduce the amount of blood loss. Robotic surgery may offer a benefit of reduced blood loss at the expense of longer operating time. Similar studies including different surgeons are needed to validate these points, and thereby determine the risk-benefit balance between the two approaches for benign simple hysterectomies.
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24
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Boggi U, Signori S, De Lio N, Perrone VG, Vistoli F, Belluomini M, Cappelli C, Amorese G, Mosca F. Feasibility of robotic pancreaticoduodenectomy. Br J Surg 2013; 100:917-25. [PMID: 23640668 DOI: 10.1002/bjs.9135] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy is feasible, but requires adaptations to established surgical techniques. The improved dexterity offered by robotic assistance provides the opportunity to see whether laparoscopic pancreaticoduodenectomy can be performed safely when faithfully reproducing the open operation. METHODS Patients were selected for robotic pancreaticoduodenectomy when generally suitable for laparoscopy. Obese patients were excluded, and those with pancreatic cancer were highly selected. A prospectively designed database was used for data collection and analysis. RESULTS Of 238 patients undergoing pancreaticoduodenectomy, 34 (14·3 per cent) were operated on robotically. No procedure was converted to conventional laparoscopy or open surgery, despite three patients requiring segmental resection of the superior mesenteric/portal vein and reconstruction. The mean duration of operation was 597 (range 420-960) min. The mean number of lymph nodes retrieved and analysed from patients with neoplasia was 32 (range 15-76). Four patients required blood transfusions and five developed postoperative complications exceeding Clavien-Dindo grade II. There were four grade B pancreatic fistulas. One patient died on postoperative day 40. Excess mean operative cost compared with open resection was €6193. CONCLUSION Selected patients can safely undergo robotic pancreaticoduodenectomy. The main downsides are high costs and prolonged operating times compared with open resection.
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Affiliation(s)
- U Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy.
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25
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Marano A, Hyung WJ. Robotic gastrectomy: the current state of the art. J Gastric Cancer 2012; 12:63-72. [PMID: 22792518 PMCID: PMC3392326 DOI: 10.5230/jgc.2012.12.2.63] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 06/12/2012] [Indexed: 01/02/2023] Open
Abstract
Since the first laparoscopic gastrectomy for cancer was reported in 1994, minimally invasive surgery is enjoying its wide acceptance. Numerous procedures of this approach have developed, and many patients have benefited from its effectiveness, which has been recently demonstrated for early gastric cancer. However, since laparoscopic surgery is not exempt from some limitations, the robotic surgery system was introduced as a solution by the late 1990's. Many experienced surgeons have embraced this new emerging method that provides undoubted technical and minimally invasive advantages. To date, several studies have concentrated to this new system, and have compared it with open and laparoscopic approach. Most of them have reported satisfactory results concerning the post-operative short-term outcomes, but almost all believe that the role of robotic gastrectomy is still out of focus, especially because long-term outcomes that can prove robotic oncologic equivalency are lacking, and operative costs and time are higher in comparison to the open and laparoscopic ones. This article is a review about the current status of robotic surgery for the treatment of gastric cancer, especially, focusing on the technical aspects, comparisons to other approaches and future prospects.
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Affiliation(s)
- Alessandra Marano
- Division of Surgical Oncology, Department of Surgery, San Giovanni Battista Hospital, University of Turin, Turin, Italy
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26
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Yoon HM, Kim YW, Lee JH, Ryu KW, Eom BW, Park JY, Choi IJ, Kim CG, Lee JY, Cho SJ, Rho JY. Robot-assisted total gastrectomy is comparable with laparoscopically assisted total gastrectomy for early gastric cancer. Surg Endosc 2011; 26:1377-81. [PMID: 22083338 DOI: 10.1007/s00464-011-2043-0] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 10/20/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopically assisted total gastrectomy (LATG) is technically difficult. Robot surgery has theoretical advantages such as increased degrees of freedom of instruments and a three-dimensional view. The current study aimed to determine whether a robot-assisted total gastrectomy (RATG) has a real benefit over LATG in terms of surgical and oncologic outcomes. METHODS A single-center case-control study was conducted. The study included 36 patients who underwent RATG and 65 patients who underwent LATG at the National Cancer Center in Korea between February 2009 and May 2011. No patients were excluded from the analysis within the study period. Clinicopathologic data, operative data, postoperative morbidity, and pathologic data were analyzed by Student's t-tests and Chi-square tests, as indicated. RESULTS The mean age of the patients was 53.9 ± 11.7 years in the RATG group and 56.9 ± 12.3 years in the LATG group (P = 0.236). The mean BMI was 23.2 ± 2.5 kg/m(2) in the RATG group and 23.6 ± 3.4 kg/m(2) in the LATG group (P = 0.494). The mean postoperative hospital stay was 8.8 ± 3.3 days in the RATG group and 10.3 ± 10.8 days in the LATG group (P = 0.416). The mean operative time was 305.8 ± 115.8 min in the RATG group and 210.2 ± 57.7 min in the LATG group (P < 0.001). The mean number of dissected lymph nodes was 42.8 ± 12.7 in the RATG group and 39.4 ± 13.4 in the LATG group (P = 0.209). Postoperative complications were experienced by 6 patients (16.7%) in the RATG group and 10 patients (15.4%) in the LATG group (P = 0.866). CONCLUSION Despite early experiences, RATG was shown to be comparable with LATG in terms of surgical and oncologic outcomes. However, no apparent benefit is associated with RATG to date.
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Affiliation(s)
- Hong Man Yoon
- Gastric Cancer Branch, Research Institute and Hospital, National Cancer Center, 323 Ilsanro, Ilsandong-gu, Goyang-si, 411-769, Gyeonggi-do, Korea
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27
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Nguyen Y, Miroir M, Kazmitcheff G, Ferrary E, Sterkers O, Grayeli AB. From Conception to Application of a Tele-Operated Assistance Robot for Middle Ear Surgery. Surg Innov 2011; 19:241-51. [DOI: 10.1177/1553350611426012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The authors’ goal was to design and evaluate a robot dedicated to middle ear surgery. Specifications for dimensions, forces, and kinematics were collected, based on the otosclerosis procedure. The robot structure has a compact geometry with 3 linear and 3 rotatory motors. It is remotely piloted via a robot–surgeon interface under operative microscope. Ability to reach anatomical targets, to perform stapedectomy, and to place prosthesis in a model of stapedotomy was evaluated by 6 surgeons. Multiple anatomical targets in the middle ear could be successfully reached without damaging surrounding structures. The robot could be used under operative microscope with minimal visual field impairment or jointly with a 4-mm endoscope through the external auditory canal to perform stapedectomy in temporal bone specimens. Prosthesis could be inserted in the stapedotomy model. The assistance robot is the first prototype with 6 degrees of freedom, a kinematic structure, and dimensions optimized for tele-operated middle ear surgery.
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Affiliation(s)
| | | | | | - Evelyne Ferrary
- Paris Diderot University, Paris, France
- AP-HP, Hôpital Beaujon, Clichy, France
| | - Olivier Sterkers
- Paris Diderot University, Paris, France
- AP-HP, Hôpital Beaujon, Clichy, France
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Woo Y, Hyung WJ, Pak KH, Obama K, Noh SH. Successful cholecystectomy during robotic gastrectomy. MINIM INVASIV THER 2011; 21:276-81. [PMID: 22049943 DOI: 10.3109/13645706.2011.628996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgeons have successfully combined various laparoscopic procedures with increasing technical ease. However, few reports exist regarding the feasibility of combined robotic operations. We present our institution's successful concomitant robotic surgery for early gastric cancer and coexisting gallbladder disease. MATERIAL AND METHODS From our prospectively collected database, seven patients who received robotic cholecystectomies during their robotic gastric cancer operations were retrospectively compared to 247 patients who underwent robotic gastrectomies alone. Preoperative patient characteristics, operative factors, postoperative length of stay, and complications were evaluated. RESULTS The preoperative patient characteristics and operative factors did not differ between the two groups. All robotic cholecystectomies were performed with the same ports and instruments used during robotic gastrectomies without open conversion, robot redocking or patient repositioning. Mean time to perform robotic cholecystectomies was 15.1 + 3.2 minutes. The combined group had no mortality, one wound infection, and one intraabdominal fluid collection at the gastric resection bed, which were comparable to the gastrectomy alone group. The mean postoperative length of hospital stay was unaltered by the addition of the cholecystectomy. CONCLUSIONS Robotic cholecystectomies can safely and efficiently be combined with robotic gastric cancer surgery, yielding several benefits. Improving robotic technology and experience may allow surgeons to efficiently combine more complicated procedures.
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Affiliation(s)
- Yanghee Woo
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Lee HH, Hur H, Jung H, Jeon HM, Park CH, Song KY. Robot-assisted distal gastrectomy for gastric cancer: initial experience. Am J Surg 2011; 201:841-845. [PMID: 21741513 DOI: 10.1016/j.amjsurg.2010.05.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 04/30/2010] [Accepted: 05/04/2010] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study evaluated the feasibility and safety of robotic surgery in gastrectomy for gastric cancer. METHODS Between April and October 2009, 12 patients who were diagnosed with stage I gastric cancer underwent robot-assisted distal gastrectomy (RADG) using the da Vinci System (Intuitive Surgical, Sunnyvale, CA). The clinical and pathological characteristics of the patients and surgical outcome were analyzed. RESULTS All procedures were completed successfully, with no laparoscopic or open conversion. The mean operating time was 253 minutes (range 170-365), and the mean blood loss was 135 mL (range 30-500). The resection margin was negative in all specimens, and a mean of 46 (range 21-115) lymph nodes was retrieved. The mean time to resume a soft diet and hospital stay was 4.6 and 6.6 days, respectively. Acute pancreatitis occurred in 1 patient and resolved with conservative management. CONCLUSIONS In our initial experience, RADG was feasible, enabling a fast patient recovery and good operative outcome.
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Affiliation(s)
- Han Hong Lee
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Ban Po-Dong, Seocho-Gu 137-701, Seoul, Korea
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Ng JSY, Fong YF, Tong PSY, Yong EL, Low JJH. Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery (GRACES) in a Tertiary Referral Centre. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2011. [DOI: 10.47102/annals-acadmedsg.v40n5p208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Robotic-assisted gynaecologic surgery is gaining popularity and it offers the advantages of laparoscopic surgery whilst overcoming the limitations of operative dexterity. We describe our experience with the first 40 cases operated under the GRACES (Gynaecologic Robot-Assisted Cancer and Endoscopic Surgery) programme at the Department of Obstetrics & Gynecology, National University Hospital, Singapore. Materials and Methods: A review was performed for the first 40 women who had undergone robotic surgery, analysing patient characteristics, surgical timings and surgery-related complications. All cases were performed utilising the da Vinci® surgical system (Intuitive Surgical, Sunnyvale, CA) with 3 arms and 4 ports. Standardised instrumentation and similar cuff closure techniques were used. Results: Seventeen (56%) were for endometrial cancer and the rest, for benign gynaecological disease. The mean age of the patients was 52.3 years. The average docking time was 11 minutes (SD 0.08). The docking and operative times were analysed in tertiles. Data for patients with endometrial cancer and benign cases were analysed separately. There were 3 cases of complications- cuff dehiscence, bleeding from vaginal cuff and tumour recurrence at vaginal vault. Conclusion: Our caseload has enabled us to replicate the learning curve reported by other centres. We advocate the use of a standard instrument set for the first 20 cases. We propose the following sequence for successful introduction of robot-assisted gynaecologic surgery – basic systems training, followed shortly with a clinical case, and progressive development of clinical competence through a proctoring programme.
Key words: Clinical outcomes, Cost effectiveness, Gynaecology, Learning curve, Robotics
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Affiliation(s)
- Joseph SY Ng
- National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yoke Fai Fong
- National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Pearl SY Tong
- National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Eu Leong Yong
- National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jeffrey JH Low
- National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up. J Robot Surg 2011; 5:175-80. [PMID: 27637704 DOI: 10.1007/s11701-011-0244-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 01/03/2011] [Indexed: 10/18/2022]
Abstract
We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months' follow-up. Median follow-up was 62 months (range 36-84) and mean age was 67 (43-83) years. Mean operating time was 3.1 (2.15-5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3-4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years' follow-up.
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Marchal F, Rauch P, Verhaeghe JL, Guillemin F. Perspectives de la chirurgie robotique et conclusions. ONCOLOGIE 2011. [DOI: 10.1007/s10269-010-1980-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Robotic duodenojejunostomy for superior mesenteric artery syndrome in a teenager. J Robot Surg 2010; 4:265-9. [PMID: 27627956 DOI: 10.1007/s11701-010-0215-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Accepted: 08/31/2010] [Indexed: 10/19/2022]
Abstract
Superior mesenteric artery syndrome (SMAS) involves vascular compression of the third part of the duodenum, eventually leading to gastrointestinal obstruction. Duodenojejunostomy is indicated after failure of conservative management and in chronic cases. We report a case of a cachetic 16-year-old girl with dyskeratosis congenita who suffered from SMA syndrome for 18 months. Upper endoscopy and preoperative imaging (upper GI series and abdominal CT scan) confirmed the diagnosis. A da Vinci-assisted duodenojejunostomy was performed after obtaining informed consent from the patient and her parents. Intraoperatively, a dilated duodenum to the level of D3 was noted. A side-to-side two-layer handsewn anatomosis was performed. The patient was discharged home on postoperative day #3. She gained 1.4 kg within 1 month. Twenty-one months later, she remains asymptomatic with a total weight gain of 3.2 kg. To our knowledge, this is the first reported case of a robot-assisted duodenojejunostomy for SMAS.
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Differences in postoperative outcomes, function, and cosmesis: open versus robotic thyroidectomy. Surg Endosc 2010; 24:3186-94. [DOI: 10.1007/s00464-010-1113-z] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 05/01/2010] [Indexed: 01/19/2023]
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Pigazzi A, Luca F, Patriti A, Valvo M, Ceccarelli G, Casciola L, Biffi R, Garcia-Aguilar J, Baek JH. Multicentric study on robotic tumor-specific mesorectal excision for the treatment of rectal cancer. Ann Surg Oncol 2010; 17:1614-20. [PMID: 20087780 DOI: 10.1245/s10434-010-0909-3] [Citation(s) in RCA: 211] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recently, traditional laparoscopic anterior resection has been used for rectal cancer, offering good functional results compared with open resection and resulting in better early postoperative outcomes. Few studies investigating the role of robot-assisted tumor-specific rectal surgery (RTSRS) have been carried out to show its feasibility. The aim of the study was to verify on a multicentric basis the perioperative and oncologic outcome of RTSRS. METHODS One hundred forty-three consecutive patients undergoing RTSR in three centers were reviewed. Pathologic data, and postoperative and oncologic outcome measures were prospectively collected and analyzed by an independent researcher. RESULTS A total of 112 restorative surgeries and 31 abdominoperineal resections were carried out. Conversion rate was 4.9%, mean blood loss was 283 ml, and mean operative time was 297 min. The number of harvested nodes (14.1 +/- 6.5) and margin status compared favorably with those of open series (mean distal margin 2.9 +/- 1.8 cm; negative radial margin in 142 cases). The 3-year overall survival rate was 97%, and no isolated local recurrences were found at mean follow-up of 17.4 months. CONCLUSION RTSRS is a safe and feasible procedure that may facilitate mesorectal excision. Randomized clinical trials and longer follow-up are needed to evaluate a possible influence of RTSRS on patient survival.
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Affiliation(s)
- Alessio Pigazzi
- Division of General and Oncologic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
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