“Anaesthesia and minimally invasive surgery.”
Doyle, P. W. and M. Hendricks (2009).
Anaesthesia and Intensive Care Medicine 10(7): 328-331.
As with so many different forms of anaesthesia, anaesthesia for minimally invasive surgery is dependent on the type of surgery being performed and the impact of the surgical procedure itself on the human body. With an increase in the number of surgical specialties embracing laparoscopic procedures, anaesthetists must consider the risks and benefits to the patient. On the whole, laparoscopic procedures are well tolerated. The advantages of laparoscopic surgery compared with open procedures are associated with reduced morbidity and mortality. The reductions in acute pain and postoperative respiratory tract infections and ileus allow earlier mobilization and lead to earlier discharge. Laparoscopy also improves the cosmetic appearance. It improves the view of the operative field and enables alternative anatomical views to be seen. Anaesthesia per se is fairly standard in minimally invasive surgery, but it is the comprehension of the effects of the position of the patient and that of the pneumoperitoneum that can make the difference between a successful or less elegant outcome. Â© 2009 Elsevier Ltd. All rights reserved.
“Diffusion theory and knowledge dissemination, utilization, and integration in public health.”
Green, L. W., J. M. Ottoson, et al. (2009).
Annual Review of Public Health 30: 151-174.
Legislators and their scientific beneficiaries express growing concerns that the fruits of their investment in health research are not reaching the public, policy makers, and practitioners with evidence-based practices. Practitioners and the public lament the lack of relevance and fit of evidence that reaches them and barriers to their implementation of it. Much has been written about this gap in medicine, much less in public health. We review the concepts that have guided or misguided public health in their attempts to bridge science and practice through dissemination and implementation. Beginning with diffusion theory, which inspired much of public health’s work on dissemination, we compare diffusion, dissemination, and implementation with related notions that have served other fields in bridging science and practice. Finally, we suggest ways to blend diffusion with other theory and evidence in guiding a more decentralized approach to dissemination and implementation in public health, including changes in the ways we produce the science itself. Copyright Â© 2009 by Annual Reviews. All rights reserved.
“Does robotic assistance improve efficiency in performing complex minimally invasive surgical procedures?”
Jayaraman, S., D. Quan, et al. (2009).
Surgical Endoscopy: 1-5.
Objective: We used a model of biliary-enteric anastomosis to test whether da Vinci robotics improves performance on a complex minimally invasive surgical (MIS) procedure. Methods: An ex vivo model for choledochojejunostomy was created using porcine livers with extrahepatic bile ducts and contiguous intestines. MIS choledochojejunostomies were performed in two arms: group 1 (laparoscopic, nÂ =Â 30) and group 2 (da Vinci assisted, nÂ =Â 30). Procedures were performed by three surgeons with graduated MIS expertise: surgeon A (MISÂ +Â robotics), surgeon B (experienced MIS), and surgeon C (basic MIS). Each surgeon performed ten procedures per group. The primary objective was time to complete anastomoses using each method. Secondary objectives included anastomosis quality, impact of experience on performance, and learning curve. Results: da Vinci led to faster anastomoses than laparoscopy (28.0 vs. 35.9Â min, pÂ =Â 0.002). Surgeon A’s mean operative times were equivalent with both techniques (24.5 vs. 22.3Â min). Surgeons B and C experienced faster operative times with robotics over laparoscopy alone (39.4 vs. 28.6Â min, pÂ =Â 0.01; and 43.8 vs. 33.0Â min, pÂ =Â 0.008, respectively). Surgeon A did not demonstrate a learning curve with either laparoscopy (22.4 vs. 22.4Â min, pÂ =Â not significant, NS) or robotics (24.7 vs. 19.8Â min, pÂ =Â NS). Surgeon B demonstrated nonsignificant improvement with laparoscopy (46.6 vs. 39.5Â min, pÂ =Â NS). With robotic assistance, a learning curve was demonstrated (36.8 vs. 24.7Â min, pÂ =Â 0.02). Surgeon C demonstrated a learning curve with laparoscopy (58.3 vs. 33.2Â min, pÂ =Â 0.004), but no improvement was noted with robot assistance (32.2 vs. 34.7Â min, pÂ =Â NS). Conclusions: da Vinci improves time to completion and quality of choledochojejunostomy over laparoscopy in an ex vivo bench model. This advantage is more pronounced in the hands of surgeons with less MIS experience. Conversely, robotics may allow less experienced surgeons to perform more complex operations without first developing advanced laparoscopic skills; however, there may be benefit to first obtaining fundamental skills. Â© 2009 Springer Science+Business Media, LLC.
“Robotic and laparoscopic surgery: Cost and training.”
Patel, H. R. H., A. Linares, et al.
Robotic prostatectomy training as part of mainstream surgical training will be difficult. The primary problems revolve around the inconsistencies of standard sugery. Many surgeons are still in the learning curve, as is the understanding of the true capabilities of the robot. The important elements of robotic surgery actually enhance basic laparoscopic techniques. The prostate has been shown to be an organ where this new technology has a niche. As we move toward cross specialty use the robot although extremely expensive, may be the best way to train the laparoscopic surgeon of the future. Â© 2009 Elsevier Ltd. All rights reserved.
“Laparascopic surgery and robotic-guided surgery.”
Shemer, J. (2009).
Surgical procedures are constantly developing in intricacy due to both technological innovation and professional medical competency. Over the past decades new trends reveal interest in minimally invasive procedures, a decline in invasive techniques and developments in imaging technology and telemedicine. Since 1985, laparoscopic surgery has facilitated new horizons in a wide range of clinical fields: gynecology, urology, chest and abdominal surgery, orthopedics, cardiology and more. Recently, robotic surgery has emerged, using these techniques and improving outcomes through better imaging and treatment, decreasing the side effects of the classic operation. These sophisticated instruments are technical tools in the hands of the skilled professional and deserve the attention of the medical community and decision-makers. Preliminary understanding of the adoption and implementation of new medical technologies may improve the rate of their utilization enabling appropriate preparedness within the health system.
“Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload.”
Stefanidis, D., F. Wang, et al. (2009).
Surgical Endoscopy: 1-6.
Background: Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room. Methods: Medical students (nÂ =Â 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastro-gastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da VinciÂ®) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects’ self-reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; pÂ <Â 0.05 was considered significant. Results: Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595Â Â±Â 22Â s versus 459Â Â±Â 137Â s, respectively; pÂ <Â 0.001), achieve higher overall scores (0Â Â±Â 1 versus 95Â Â±Â 128, respectively; pÂ <Â 0.001), and commit fewer errors per knot (1.15Â Â±Â 1.35 versus 0.05Â Â±Â 0.26, respectively; pÂ <Â 0.001). Subjects’ overall score did not improve between the first and third attempt for laparoscopic suturing (0Â Â±Â 0 versus 0Â Â±Â 0; pÂ =Â NS) but improved significantly for robotic suturing (49Â Â±Â 100 versus 141Â Â±Â 152; pÂ <Â 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99Â Â±Â 15 versus 57Â Â±Â 23; pÂ <Â 0.001). Conclusions: Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed. Â© 2009 Springer Science+Business Media, LLC.
“Robot-Assisted Vitreoretinal Surgery. Development of a Prototype and Feasibility Studies in an Animal Model.”
Ueta, T., Y. Yamaguchi, et al.
Purpose: To develop a prototype robotic system designed to assist vitreoretinal surgery and to evaluate its accuracy and maneuverability. Design: Experimental study. Participants: This study used harvested porcine eyes. Methods: After development of a prototype robotic system, pointing accuracy tests of the system were performed on graph paper and in harvested porcine eyes. The average maximal deviation from the aiming point to the actual position of the tip of the instrument was compared between manually conducted procedures and those conducted with robotic assistance. The feasibility of creating posterior vitreous detachment (PVD), retinal vessel sheathotomy (RVS), and retinal vessel microcannulation also were evaluated in porcine eye models, and the success rates of 4 consecutive attempts for each kind of procedure were evaluated. Main Outcome Measures: The average maximum deviation in pointing accuracy tests both on graph paper and in animal eye models was a main outcome measure. The success rate of making PVD, RVS, and retinal vessel microcannulation was the other primary outcome measure. Results: The pointing accuracy was superior with robotic assistance both on graph paper (327.0 Î¼m vs. 32.3 Î¼m) and in animal eye models (140.8 Î¼m vs. 33.5 Î¼m). Creating PVD, RVS, and retinal vessel microcannulation was feasible in 4 of 4 attempts, 4 of 4 attempts, and 2 of 4 attempts, respectively. The 2 failures in microcannulation were considered to be the result of difficulty in visual differentiation between the retinal vessel and retina in harvested porcine eyes. Conclusions: Improved accuracy and desirable feasibility of a prototype robotic system to assist vitreoretinal surgery were shown in this study. Research for wider implementation of robot-assisted surgery should be continued; there are some hurdles to overcome. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Â© 2009 American Academy of Ophthalmology.
“Understanding statistical analysis in the surgical literature: Some key concepts.”
Young, J. (2009).
ANZ Journal of Surgery 79(5): 398-403.
Understanding the fundamentals of statistical analysis allows surgeons to evaluate the logic and validity of statistical methods presented in published papers in order to make a judgement about the quality of the reported findings. This paper presents an overview of some basic concepts, with an emphasis on principles rather than on mathematical detail, which relate to selecting the correct statistical test and interpreting the results of statistical analysis. The most important factor in determining the appropriate significance test is the type of outcome data that have been collected. A significance test is used to calculate a probability (P) value, which is a measure of the strength of the effect seen in the study, but additional useful information is obtained from confidence intervals that indicate not only the size and direction of the effect but also the precision of the study. Judgements about the clinical importance of a result should be based on the size of the effect seen rather than the P value, as the latter is strongly influenced by the size of the study. Â© 2009 Royal Australasian College of Surgeons.