Abstrakt Ostatní Srpen 2011

“Microsurgery and Telemicrosurgery Training: A Comparative Study.”

Ramdhian, R. M., M. Bednar, et al. (2011).

Journal of Reconstructive Microsurgery.


Telemicrosurgery (TMS) is a new technique inspired by telesurgery and conventional microsurgery (CMS). One of the difficulties of CMS is learning to control physiological tremor. TMS eliminates the physiological tremor, thus theoretically simplifying microsurgical procedures, but no tactile feedback is provided while tying knots. The objective of this study was to assess if the learning curve for performing microsurgical anastomosis for TMS than with CMS was comparable. Thirty earthworms were anastomosed with 10/0 nylon sutures. In this study 15 anastomoses were performed under operating microscope and 15 under Da Vinci S ((R)) robot (Intuitive Surgical, Sunnyvale, CA). A single operator without experience in either technique performed all anastomoses. The evaluation consisted of measuring the time to perform each stitch, as well as to complete the anastomosis. The integrity of the anastomosis was tested by injection of saline solution into the earthworm to assess permeability and watertightness. The average time to complete a single suture was 296 seconds in the CMS group and 529 seconds in the TMS group. Permeability and watertightness of anastomosis was 86.66% in both groups. Learning was faster with CMS than with TMS. For untrained surgeon, the absence of tactile feedback is a limiting factor with TMS, however, the benefits of the TMS are: three-dimensional high definition vision, abolition of physiological tremor, motion scaling of gestures down to 5 times, use of three instruments at once, and extreme mobility.


“Are Pedicled Flaps Feasible in Robotic Surgery? Report of an Anatomical Study of the Kite Flap in Conventional Surgery Versus Robotic Surgery.”

Huart, A., S. Facca, et al. (2011).

Surgical Innovation.


Reconstruction of cutaneous defects of the hand has dramatically progressed. It should also benefit from the development of robot-assisted surgery. The aim of the present study was to consider the feasibility of a kite flap in robotic surgery. Two cadaver hands were used in this study, one for a conventional procedure, and one for a robotic surgical procedure using a da Vinci Si robot. The operative duration was measured, and all difficulties encountered during the procedures were reported. The total duration of the intervention was 19 minutes with the conventional procedure and 30 minutes with the robotic technique. Some difficulties were encountered, related both to lack of specific instrumentation and haptic feedback. Robotic surgery presents interesting advantages such as the suppression of physiological tremor, increased degrees of freedom, and enhanced precision and accuracy of hand maneuvers. In this study, it allowed the realization of a pedicled flap without any external help.


“A new dimension: robotic reconstruction in plastic surgery.”

Patel, N. P., J. Van Meeteren, et al. (2011).

 Journal of Robotic Surgery: 1-4.


Background: Robot-assisted surgery was first approved by the Federal Drug Administration in 1994. The robotic system has the advantages of three-dimensional visualization of the operating field, 7° range of motion, tremor elimination, 360°of freedom at 10-mm distance, and a comfortable, seated operating posture. The purpose of this paper is to present a new surgical tool, the robot, for use in reconstructive surgery. Methods: A case is presented in which the robotic system was used to elevate a pedicled, myocutaneous latissimus dorsi flap for shoulder reconstruction. Results: The robot was used successfully to harvest a pedicled latissimus dorsi flap. Since this case, we have used the robotic system to harvest one other pedicled latissimus flap for breast reconstruction as well as to perform the microvascular anastomoses in a radial forearm and rectus abdominus free flaps to the lower extremity. Conclusion: There is great potential for the use of robot as a surgical tool in the field of plastic surgery. The advantages are numerous, including superior visibility, greater range of motion as a more comfortable position for the operating surgeon. The limitations include the learning curve and the lack of biofeedback. © 2011 Springer-Verlag London Ltd.


“Author’s reply to the letter to the editor: “new technologies-based innovation changes surgical practice and research direction in solid cancers” (Reply to SEND-08-0644.R1).”

Choi, G. S. (2011).

Surgical Endoscopy 25(5): 1695-1696.

“When the decision is what to decide: using evidence inventory reports to focus health technology assessments.”

Mitchell, M. D., K. Williams, et al. (2011).

International Journal of Technology Assessment in Health Care 27(2): 127-132.


OBJECTIVES: Health systems frequently make decisions regarding acquisition and use of new technologies. It is desirable to base these decisions on clinical evidence, but often these technologies are used for multiple indications and evidence of effectiveness for one indication does not prove effectiveness for all. Here, we describe two examples of evidence inventory reports that were performed for the purposes of identifying how much and what type of published clinical evidence was available for a given technology, and the contexts in which those technologies were studied. METHODS: The evidence inventory reports included literature searches for systematic reviews and health technology assessment (HTA) reports, and systematic searches of the primary literature intended to count and categorize published clinical studies. The reports did not include analysis of the primary literature. RESULTS: The inventory reports were completed in 3 to 4 days each and were approximately ten pages in length, including references. Reports included tables listing the number of reported studies by specific indication for use, and whether or not there were randomized trials. Reports also summarized findings of existing systematic reviews and HTA reports, when available. Committees used the inventory reports to decide for which indications they wanted a full HTA report. CONCLUSIONS: Evidence inventory reports are a form of rapid HTA that can give decision makers a timely understanding of the available evidence upon which they can base a decision. They can help HTA providers focus subsequent reports on topics that will have the most influence on healthcare decision making.


“Treatment options for localized prostate cancer.”

Mohan, R. and P. F. Schellhammer (2011).

 American Family Physician 84(4): 413-420.


In the United States, more than 90 percent of prostate cancers are detected by serum prostate-specific antigen testing. Most patients are found to have localized prostate cancer, and most of these patients undergo surgery or radiotherapy. However, many patients have low-risk cancer and can follow an active surveillance protocol instead of undergoing invasive treatments. Active surveillance is a new concept in which low-risk patients are closely followed and proceed to intervention only if their cancer progresses. Clinical guidelines can help in selecting between treatment or active surveillance based on the cancer’s stage and grade, the patient’s prostate-specific antigen level, and the comorbidity-adjusted life expectancy. Radical prostatectomy or external beam radiation therapy is recommended for higher-risk patients. These treatments are almost equivalent in effectiveness, but have different adverse effect profiles. Brachytherapy is an option for low- and moderate-risk patients. Evidence is insufficient to determine whether laparoscopic or robotic surgery or cryotherapy is superior to open radical prostatectomy.


“Survey on Surgical Instrument Handle Design: Ergonomics and Acceptance.”

Santos-Carreras, L., M. Hagen, et al. (2011).

Surgical Innovation.


Minimally invasive surgical approaches have revolutionized surgical care and considerably improved surgical outcomes. The instrumentation has changed significantly from open to laparoscopic and robotic surgery with various usability and ergonomics qualities.To establish guidelines for future designing of surgical instruments, this study assesses the effects of current surgical approaches and instruments on the surgeon. Furthermore, an analysis of surgeons’ preferences with respect to instrument handles was performed to identify the main acceptance criteria. In all, 49 surgeons (24 with robotic surgery experience, 25 without) completed the survey about physical discomfort and working conditions. The respondents evaluated comfort, intuitiveness, precision, and stability of 7 instrument handles. Robotic surgery procedures generally take a longer time than conventional procedures but result in less back, shoulder, and wrist pain; 28% of surgeons complained about finger and neck pain during robotic surgery. Three handles (conventional needle holder, da Vinci wrist, and joystick-like handle) received significantly higher scores for most of the proposed criteria.The handle preference is best explained by a regression model related only to comfort and precision (R (2) = 0.91) and is significantly affected by the surgeon’s background (P < .001). Although robotic surgery seems to alleviate physical discomfort during and after surgery, the results of this study show that there is room for improvement in the sitting posture and in the ergonomics of the handles. Comfort and precision have been found to be the most important aspects for the surgeon’s choice of an instrument handle. Furthermore, surgeons’ professional background should be considered when designing novel surgical instruments.


“The Surgical Procedure Assessment (SPA) score predicts intensive care unit length of stay after cardiac surgery.”

Wagener, G., M. Minhaz, et al. (2011).

Journal of Thoracic and Cardiovascular Surgery 142(2): 443-450.


Objective: The ability to predict intensive care unit length of stay greatly facilitates triage and resource allocation for postoperative cardiac surgical patients in the intensive care unit. We developed a simple, intuitive Surgical Procedure Assessment score that integrates surgical complexity (1, low; 2, intermediate; 3, high) with patient comorbidity (A, minimal; B, substantial). We hypothesized that the Surgical Procedure Assessment score would predict intensive care unit length of stay, discriminate preoperatively between fast-track and prolonged-stay patients, and compare favorably with more complex risk scores. Methods: After institutional review board approval, 1201 cardiac surgical patients were preoperatively assigned a Surgical Procedure Assessment score, as well as a Parsonnet, Tuman, Tu, and Cardiac Anesthesia Risk Evaluation score. We compared these scores with regard to prediction of intensive care unit length of stay, as well as their concordance in predicting intensive care unit length of stay of less than 48 hours (fast track) and more than 7 days (prolonged stay). Results: Intensive care unit length of stay increased significantly with increasing Surgical Procedure Assessment scores (P < .01, Cuzick’s test for trend). The lowest Surgical Procedure Assessment score (1A) predicted intensive care unit length of stay of less than 48 hours, and the higher Surgical Procedure Assessment scores (2B or 3) predicted intensive care unit length of stay of more than 7 days more accurately than the Parsonnet, Tuman, Tu and Cardiac Anesthesia Risk Evaluation scores. Conclusions: The Surgical Procedure Assessment score predicts intensive care unit length of stay better than other comparable scores. It is simple, intuitive, and easily understood by all caregivers and can preoperatively discriminate fast-track from prolonged-stay patients. It is a useful tool to facilitate intensive care unit triage. Copyright © 2011 by The American Association for Thoracic Surgery.


“Men’s perspectives on selecting their prostate cancer treatment.”

Xu, J., R. K. Dailey, et al. (2011).

Journal of the National Medical Association 103(6): 468-478.


OBJECTIVE: In the context of scientific uncertainty, treatment choices for localized prostate cancer vary, but reasons for this variation are unclear. We explored how black and white American men made their treatment decision. METHODS: Guided by conceptual model, we conducted semistructured interviews of 21 American (14 black and 7 white) men with recently diagnosed localized prostate cancer. RESULTS: Physician recommendation was very important in the treatment decision, but patient self-perception/values and attitudes/beliefs about prostate cancer were also influential. Patients who chose surgery believed it offered the best chance of cure and were more concerned that the cancer might spread if not surgically removed. Patients who chose radiation therapy believed it offered equal efficacy of cure but fewer side effects than surgery. Fear of future consequences was the most common reason to reject watchful waiting. Anecdotal experiences of family and friends were also important, especially in deciding “what not to do.” The new technology of robotic-assisted prostatectomy provided optimism for men who wanted surgery but feared morbidity associated with traditional open surgery. Few men seemed aware that treatment did not guarantee improved survival. CONCLUSION: Most men reported making “the best choice for me” by taking into account medical information and personal factors. Perceptions of treatment efficacy and side effects, which derived mainly from physicians’ descriptions and/or anecdotal experiences of family and friends, were the most influential factors in men’s treatment decision. By understanding factors that influence patients’ treatment decisions, clinicians may be more sensitive to individual patients’ preferences/concerns and provide more patient-centered care.


“Laparoscopic cholecystectomy poses physical injury risk to surgeons: Analysis of hand technique and standing position.”

Youssef, Y., G. Lee, et al. (2011).

Surgical Endoscopy and Other Interventional Techniques 25(7): 2168-2174.


Background: This study compares surgical techniques and surgeon’s standing position during laparoscopic cholecystectomy (LC), investigating each with respect to surgeons’ learning, performance, and ergonomics. Little homogeneity exists in LC performance and training. Variations in standing position (side-standing technique vs. between-standing technique) and hand technique (one-handed vs. two-handed) exist. Methods: Thirty-two LC procedures performed on a virtual reality simulator were video-recorded and analyzed. Each subject performed four different procedures: one-handed/side-standing, one-handed/between-standing, two-handed/side-standing, and two-handed/between- standing. Physical ergonomics were evaluated using Rapid Upper Limb Assessment (RULA). Mental workload assessment was acquired with the National Aeronautics and Space Administration-Task Load Index (NASA-TLX). Virtual reality (VR) simulator-generated performance evaluation and a subjective survey were analyzed. Results: RULA scores were consistently lower (indicating better ergonomics) for the between-standing technique and higher (indicating worse ergonomics) for the side-standing technique, regardless of whether one- or two-handed. Anatomical scores overall showed side-standing to have a detrimental effect on the upper arms and trunk. The NASA-TLX showed significant association between the side-standing position and high physical demand, effort, and frustration (p < 0.05). The two-handed technique in the side-standing position required more effort than the one-handed (p < 0.05). No difference in operative time or complication rate was demonstrated among the four procedures. The two-handed/between-standing method was chosen as the best procedure to teach and standardize. Conclusions: Laparoscopic cholecystectomy poses a risk of physical injury to the surgeon. As LC is currently commonly performed in the United States, the left side-standing position may lead to increased physical demand and effort, resulting in ergonomically unsound conditions for the surgeon. Though further investigations should be conducted, adopting the between-standing position deserves serious consideration as it may be the best short-term ergonomic alternative. © 2011 Springer Science+Business Media, LLC.


“Just because you can doesn’t mean you should… because many of us really can’t!”

Cooper, M. (2011).

Archives of Surgery 146(7): 850.

“The devil is in the details.”

Eastham, J. A. and P. T. Scardino (2011).

European Urology 59(5): 708-709; discussion 710-701.

“Robot decisions: on the importance of virtuous judgment in clinical decision making.”

Gelhaus, P. (2011).

Journal of Evaluation in Clinical Practice.


Rationale, aims and objectives The aim of this article is to argue for the necessity of emotional professional virtues in the understanding of good clinical practice. This understanding is required for a proper balance of capacities in medical education and further education of physicians. For this reason an ideal physician, incarnating the required virtues, skills and knowledge is compared with a non-emotional robot that is bound to moral rules. This fictive confrontation is meant to clarify why certain demands on the personality of the physician are justified, in addition to a rule- and principle-based moral orientation and biomedical knowledge and skills. Methods Philosophical analysis of thought experiments inspired by science fiction literature by Isaac Asimov. Results Although prima facie a rule-oriented robot seems more reliable and trustworthy, the complexity of clinical judgment is not met by an encompassing and never contradictory set of rules from which one could logically derive decisions. There are different ways how the robot could still work, but at the cost of the predictability of its behaviour and its moral orientation. In comparison, a virtuous human doctor who is also bound to these rules, although less strictly, will more reliably keep at moral objectives, be understandable, be more flexible in case the rules come to their limits, and will be more predictable in these critical situations. Apart from these advantages of the virtuous human doctor referring to her own person, the most problematic deficit of the robot is its lacking deeper understanding of the inner mental events of patients which makes good contact, good communication and good influence impossible. Conclusion Although an infallibly rule-oriented robot seems more reliable at first view, in situations that require complex decisions like clinical practice the agency of a moral human person is more trustworthy. Furthermore, the understanding of the patient’s emotions must remain insufficient for a non-emotional, non-human being. Because these are crucial preconditions for good clinical practice, enough attention should be given to develop these virtues and emotional skills, in addition to the usual attention on knowledge, technical skills and the obedience to moral rules and principles.


“Surgery in space: the future of robotic telesurgery (Haidegger T, Szandor J, Benyo Z. Surg Endosc 2011; 25(3):681-690).”

Himpens, J. (2011).

Surgical Endoscopy.

“Navigating credentialing, privileging, and learning curves in robotics with an evidence and experienced-based approach.”

Lenihan, J. P., Jr. (2011).

Clinical Obstetrics and Gynecology 54(3): 382-390.


The rapid growth of robot-assisted surgery has created new challenges for hospitals to establish credentialing guidelines for new surgeons. Developing and maintaining these skills requires frequent practice. Borrowing from the aviation model that requires maintaining currency and demonstrating proficiency, robotic credentialing guidelines are being developed that will enable hospitals to insure patient safety and optimal outcomes. The utilization of computerized robotic simulators will, like flight simulators, also help surgeons to maintain and improve skills.


“International survey study of attitudes towards robotic surgery.”

Markar, S. R., I. Kolic, et al. (2011).

Journal of Robotic Surgery: 1-5.


The field of robotic surgery is rapidly advancing both in terms of the surgical procedures performed and the potential applications of this technology. This survey study attempts to evaluate the opinions of the public regarding a number of issues in robotic surgery. A web-based survey study was constructed using the web-based software “Kwiksurveys”. This survey was then advertised and distributed over the Internet to gain responders from a wide range of socio-economic groups and in a number of countries. Responses were collected over a six-month period. One-hundred and fifty-five participants took part in this survey study. The mean age of participants was 35.5 ± 3.4 years. The majority of participants (52%) were either comfortable or totally comfortable with the current version of robotic surgery during which a surgeon in the same room controls instruments inside the patient. Sixty-eight percent of responders reported they would be very uncomfortable with the idea of not seeing the operating surgeon in person before or after surgery. Forty-five percent of participants reported they would consider the idea of an internal robot operating internally with little or no external scarring. This survey study has demonstrated that currently the public seem to be comfortable with the current version of robotic surgery, with the operating surgeon in the same room as the patient. The results of this survey study show that even with technical advances in robotic surgery, patients will still want to have contact with their operating surgeon. © 2011 Springer-Verlag London Ltd.


“Stray Electrical Currents in Laparoscopic Instruments Used in da Vinci((R)) Robot-Assisted Surgery: An In Vitro Study.”

Mendez-Probst, C. E., G. Vilos, et al. (2011).

Journal of Endourology.


Abstract Background and Purpose: The da Vinci((R)) surgical system requires the use of electrosurgical instruments. The re-use of such instruments creates the potential for stray electrical currents from capacitive coupling and/or insulation failure. We used objective measures to report the prevalence and magnitude of such stray currents. Materials and Methods: Thirty-seven robotic instruments were tested using an electrosurgical unit (ESU) at pure coagulation and cut waveforms at four different settings. Conductive gel-coated instruments were tested at 40W, 80W, and maximum ESU output (coagulation 120W, cut 300W). The magnitude of stray currents was measured by an electrosurgical analyzer. Results: At coagulation waveform in open air, 86% of instruments leaked a mean of 0.4W. In the presence of gel-coated instruments, stray currents were detected in all instruments with means (and standard deviation) of 3.4W (+/-2), 4.1W (+/-2.3), and 4.1W (+/-2.3) at 40W, 80W, and 120W, respectively. At cut waveform in open air, none of the instruments leaked current, while gel-coated instruments leaked a mean of 2.2W (+/-1.3), 2.2W (+/-1.9) and 3.2W (+/-1.9) at 40W, 80W, and 300W, respectively. Conclusions: All tested instruments in our study demonstrated energy leakage. Stray currents were higher during coagulation (high voltage) waveforms, and the magnitude was not always proportionate to the ESU settings. Stray currents have the potential to cause electrical burns. We support the programmed end of life of da Vinci instruments on the basis of safety. Consideration should be given to alternate energy sources or the adoption of active electrode monitoring technology to all monopolar instruments.


“[Computer-assisted surgery].”

Micali, S. (2011).

La Chirurgia Computer Assistita (Computer Assisted Surgery – CAS). 78(1): 52-59.


The broad range of Computer Assisted Surgery (CAS) represents the integration of computer technology in surgical procedures for presurgical planning, guiding or manipulation. Surgical robots and surgical endoscopic navigation are the most challenging applications to urology. A surgical robot is defined as a computer-controlled manipulator with artificial sensing which can be programmed to move, and position tools to carry out surgical tasks. In urology, robots have been tested in two areas: endourology and laparoscopy. Surgical navigation allows the surgeon to process data from pre- and intraoperative sources, aiming at purification and presentation of the most relevant information. Image-guided systems (IGS), augmented reality (AR) and navigation in endoscopic soft tissue surgery represent the three main topics of surgical urological navigation. IGS involve matching the coordinates from medical imaging (preoperative registration) with coordinates from the patient in the operating room (registration and updating images). IGS have become the standard of care in providing navigational assistance during neurosurgery, offering subsurface and functional information to the surgeon.


“The da vinci((R)) surgical system overcomes innate hand dominance.”

Mucksavage, P., D. C. Kerbl, et al. (2011).

Journal of Endourology 25(8): 1385-1388.


Abstract Background and Purpose: The robotic surgical platform has allowed for improved ergonomics, tremor filtration, and more precise surgical movements during minimally invasive surgery. We examined the impact of the da Vinci((R)) Surgical System on the lateralization of manual dexterity, or handedness, innate to most surgeons. Methods: Manual dexterity assessments were conducted among 19 robotic novices using two different skills tests: The Purdue Pegboard Test and a needle targeting test. After an initial robotic basic skills training seminar, subjects underwent testing using both open and robotic approaches. Test performance using both approaches was then compared among all subjects. Results: The majority of subjects (84%) were right handed, and all subjects described their dominant hand as significantly or moderately more dexterous than their nondominant hand. The participants had significant differences between the dominant and nondominant hand in open skills tasks using the Purdue Pegboard test (15.4 vs 14.6 pegs, P=0.023) and needle targeting test (4.5 vs 3.7 targets, P=0.015). When the same tasks were performed using the robot, the differences in handedness were no longer observed (P=0.203, P=0.764). Conclusion: The da Vinci robot is capable of eliminating innate dexterity or handedness among novice surgical trainees. This provides evidence of another beneficial aspect of robot-assisted surgery over traditional laparoscopic surgery and may facilitate operative performance of complex tasks.





“[Quality control in the implementation of new surgical procedures : Da Vinci robot-assisted systems.].”

Niegisch, G., R. Rabenalt, et al. (2011).

Urologe. Ausgabe A.


Robot assistance in the surgical treatment of urological malignancies is gaining increasing importance. As is the case in already established surgical procedures, the quality of robot-assisted surgery needs to be controlled and evaluated by appropriate measures. Baseline-parameters of treated patients should be documented precisely. General and operation type-specific parameters should be evaluated in short- as well as in mid-term follow-up. Appropriate and validated instruments should be used. Only by using these measures will it be possible to compare robot-assisted procedures of different institutions and historical data of conventional surgery with regard to oncological and functional efficacy.


“Clinical outcomes with robotic surgery.”

Ponnusamy, K., C. Mohr, et al. (2011).

Current Problems in Surgery 48(9): 577-656.


“In Brief.”

Ponnusamy, K., C. Mohr, et al. (2011).

Current Problems in Surgery 48(9): 570-575.


“Microsurgery and Telemicrosurgery Training: A Comparative Study.”

Ramdhian, R. M., M. Bednar, et al. (2011).

Journal of Reconstructive Microsurgery.


Telemicrosurgery (TMS) is a new technique inspired by telesurgery and conventional microsurgery (CMS). One of the difficulties of CMS is learning to control physiological tremor. TMS eliminates the physiological tremor, thus theoretically simplifying microsurgical procedures, but no tactile feedback is provided while tying knots. The objective of this study was to assess if the learning curve for performing microsurgical anastomosis for TMS than with CMS was comparable. Thirty earthworms were anastomosed with 10/0 nylon sutures. In this study 15 anastomoses were performed under operating microscope and 15 under Da Vinci S ((R)) robot (Intuitive Surgical, Sunnyvale, CA). A single operator without experience in either technique performed all anastomoses. The evaluation consisted of measuring the time to perform each stitch, as well as to complete the anastomosis. The integrity of the anastomosis was tested by injection of saline solution into the earthworm to assess permeability and watertightness. The average time to complete a single suture was 296 seconds in the CMS group and 529 seconds in the TMS group. Permeability and watertightness of anastomosis was 86.66% in both groups. Learning was faster with CMS than with TMS. For untrained surgeon, the absence of tactile feedback is a limiting factor with TMS, however, the benefits of the TMS are: three-dimensional high definition vision, abolition of physiological tremor, motion scaling of gestures down to 5 times, use of three instruments at once, and extreme mobility.



“Urologic Laparoendoscopic Single-Site Surgery (LESS): current status.”

Autorino, R. and F. J. Kim (2011).

Urologia 78(1): 32-41.


The evolution of minimally invasive surgery led to the development of laparo-endoscopic single-site surgery (LESS). The feasibility of almost all types of urologic procedures has been shown. Comparative series between conventional laparoscopy and LESS for different kidney procedures suggest a non-inferiority of LESS over standard laparoscopy but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instruments clashing, lacks of true triangulation, in-line vision are the main concerns of LESS surgery. LESS pre-bent and articulating instruments have been designed but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Da Vinci® assisted LESS procedures have been performed. The available robotic platform remains bulky, but innovative instruments and platforms may facilitate the future unrestricted development of LESS. A steep learning curve limits the application of LESS procedures to well trained and experienced surgeons. Nevertheless, the adoption of LESS principles and the clinical experience with LESS techniques have significantly grown in the past few years worldwide. Improvements in the instruments and platforms will expand the application of LESS surgery, allowing us to better assess its advantages and disadvantages compared to other minimally invasive procedures.


“Robotic-assisted laparoendoscopic single-site surgery (R-LESS) in urology: An evidence-based analysis.”

Barret, E., R. Sanchez-Salas, et al. (2011).

Minerva Urologica e Nefrologica 63(2): 115-122.


The objective of this manuscript is to provide an evidence-based analysis of the current status and future perspectives of robotic laparoendoscopic single-site surgery (R-LESS). A PubMed search has been performed for all relevant urological literature regarding natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). All clinical and investigative reports for robotic LESS and NOTES procedures in the urological literature have been considered. A significant number of clinical urological procedures have been successfully completed utilizing R-LESS procedures. The available experience is limited to referral centers, where the case volume is sufficient to help overcome the challenges and learning curve of LESS surgery. The robotic interface remains the best fit for LESS procedures but its mode of use continues to evolve in attempts to improve surgical technique. We stand today at the dawn of R-LESS surgery, but this approach may well become the standard of care in the near future. Further technological development is needed to allow widespread adoption of the technique.


“Laparoendoscopic single-site and transvaginal nephrectomy.”

Candace, F. G. and M. T. Gettman (2011).

Minerva Urologica e Nefrologica 63(2): 169-174.


Significant energy has been applied to development of minimally-invasive techniques in surgery to decrease morbidity, improve cosmesis, and hasten postoperative convalescence without compromising surgical outcomes. The evolution of laparoscopy has revolutionized simple, radical and donor nephrectomy in appropriately selected patients, exchanging large flank and abdominal incisions for small “keyhole” incisions. Surgeons continue to pursue innovative approaches to minimize the morbidity of procedures. Natural orifice translumenal endoscopic surgery (NOTES) eliminates entirely the need for abdominal incisions, while laparoendoscopic singlesite (LESS) surgery permits placement of multiple instruments through a single incision. Together, they represent two novel approaches developed within the last decade that have been successfully applied to nephrectomy in both the laboratory and clinical settings. Here, the transvaginal and LESS approaches to nephrectomy are reviewed.


“Robotic single-site surgery: from research to clinical practice?”

Escobar, P. F. (2011).

Journal of Gynecologic Oncology 22(2): 65-66.


“Single-port laparoscopic total proctocolectomy with ileal pouch-anal anastomosis: Initial operative experience.”

Geisler, D. P., H. T. Kirat, et al. (2011).

Surgical Endoscopy and Other Interventional Techniques 25(7): 2175-2178.


Background: Single-port laparoscopic surgery (SPLS) has been used in urologic, gynecologic, general, and colorectal surgery. We herein report our experience with the use of SPLS for total proctocolectomy with ileal pouch-anal anastomosis (RP/IPAA). Methods: All patients who underwent a RP/IPAA using SPLS between June and September 2009 were identified from a prospectively maintained laparoscopic database. All procedures were performed with the use of a 5-mm Olympus EndoEye™ and traditional laparoscopic instruments via a SILS™ port placed at the planned ileostomy site. Results: There were five patients (3 male) included in the study. Median age was 43 years (range = 13-47 years). Median body mass index was 20.66 kg/m2 (range = 14.63-25.97 kg/m2). Diagnoses included ulcerative colitis (n = 4) and familial adenomatous polyposis (n = 1). Median ASA score was 2 (range = 1-3). Median operative time was 153 min (range = 132-278 min). Median estimated blood loss was 100 ml (range = 50-200 ml). There were no conversions to either a conventional laparoscopic or an open procedure. Median time to return of bowel function was 2 days. Median length of stay was 4 days (range = 3-6 days). Postoperative complications included two patients with partial small-bowel obstructions. Both resolved with conservative management. All patients had their ileostomies closed. Conclusion: RP/IPAA using SPLS is a safe technique. Additional studies are needed to compare SPLS to conventional laparoscopy and open surgery with respect to operative times, convalescence, and outcomes. © 2010 Springer Science+Business Media, LLC.


“Minimum incision endoscopic radical prostatectomy: Clinical and oncological outcomes at a single institute.”

Koie, T., H. Yamamoto, et al. (2011).

European Journal of Surgical Oncology.


Aims: The objective of this study was to investigate the clinical and oncological outcomes of prostatectomy patients undergoing minimum incision endoscopic radical prostatectomy (MIE-RP). Methods: Between September 2005 and May 2010, 541 patients underwent MIE-RP with bilateral lymphadenectomy for clinically localized prostate cancer at Hirosaki University Hospital. The present retrospective study enrolled 375 patients who had not received neoadjuvant or adjuvant therapy. MIE-RP was performed through a 6-cm suprapubic midline incision. A 30° laparoscope was conveniently positioned on the head side of the patient for precise observation and monitoring. Results: The median operating time was 119 min, and the estimated blood loss was 900 ml. The most frequent perioperative complication was leakage from the vesicourethral anastomosis (6.7%), and rectal injury occurred in 1.0%. Overall, 31.2% of the patients had a positive surgical margin, including 11.1% with pT2, 52.9% with pT3 and 100% with pT4 diseases. The post-operative median follow-up period was 40.5 months (range, 2-56.5 months). The 5-year PSA-free survival rate was 71.6%. In multivariate analysis, high-risk patients (according to the D’Amico risk criteria), pathological T stage and positive surgical margins were identified as independent predictors of PSA-free survival. The limitations of this study included a retrospective study, relatively short follow-up period and single-institution nature of the study. Conclusions: MIE-RP is a safe and minimally invasive procedure that may represent a reliable alternative to laparoscopic and robotic-assisted RP. © 2011 Elsevier Ltd. All rights reserved.





“Robotic single-port transumbilical total hysterectomy: a pilot study.”

Nam, E. J., S. W. Kim, et al. (2011).

Journal of Gynecologic Oncology 22(2): 120-126.


OBJECTIVE: To evaluate the feasibility of robotic single-port transumbilical total hysterectomy using a home-made surgical glove port system. METHODS: We retrospectively reviewed the medical records of patients who underwent robotic single-port transumbilical total hysterectomy between January 2010 and July 2010. All surgical procedures were performed through a single 3-4-cm umbilical incision, with a multi-channel system consisting of a wound retractor, a surgical glove, and two 10/12-mm and two 8 mm trocars. RESULTS: Seven patients were treated with robotic single-port transumbilical total hysterectomy. Procedures included total hysterectomy due to benign gynecological disease (n=5), extra-fascial hysterectomy due to carcinoma in situ of the cervix (n=1), and radical hysterectomy due to cervical cancer IB1 (n=1). The median total operative time was 109 minutes (range, 105 to 311 minutes), the median blood loss was 100 mL (range, 10 to 750 mL), and the median weight of the resected uteri was 200 g (range, 40 to 310 g). One benign case was converted to 3-port robotic surgery due to severe pelvic adhesions, and no post-operative complications occurred. CONCLUSION: Robotic single-port transumbilical total hysterectomy is technically feasible in selected patients with gynecological disease. Robotics may enhance surgical skills during single-port transumbilical hysterectomy, especially in patients with gynecologic cancers.


“Miniature in vivo cameras for use in singleincision robotic surgery.”

Otten, N. D., S. M. Farritor, et al. (2011).

Biomedical Sciences Instrumentation 47: 165-170.


Single-incision surgery provides numerous benefits over traditional open and laparoscopic surgery techniques including reduced pain, shortened recovery times, and minimal tissue scarring. The use of miniature in vivo robots inserted through a single incision offers additional advantages over conventional laparoscopy in improved maneuverability and dexterity. One consequence of performing surgical procedures through a small single incision is the loss of direct visualization through a large open incision or visualization via laparoscopic cameras inserted through additional ports. For this reason, a miniature in vivo actuated camera was designed to pass through a single incision and attach to a miniature in vivo robot, providing live video feedback at the control of the surgeon. The device was tested in a lab setting and porcine model surgery and demonstrated successful movement, control, and high-quality visualization, indicating the device’s functionality and feasibility for use in single-incision robotic surgery.


“Laparoendoscopic single site (LESS) radical prostatectomy: A review of the initial experience.”

Silberstein, J. L., N. E. Power, et al. (2011).

Minerva Urologica e Nefrologica 63(2): 123-129.


Surgical treatment for prostate cancer has changed dramatically in recent years due to the incorporation of minimally invasive techniques in the surgical armamentarium. Open surgical approaches to the prostate have largely given way to laparoscopic and robotic techniques. In order to further reduce incisional morbidity and improve cosmesis, there has been a recent interest in laparoendoscopic single site (LESS) approaches to the prostate. Despite a rising interest, there is little available data on these procedures. We performed a systematic review of the literature using MEDLINE, OVID, and Web of Science to identify all publications including LESS radical prostatectomy to date. Manual bibliographic review of cross-referenced items was also performed. We attempt to identify and summarize existing data on these procedures both with and without robotic assistance. Additionally, we review the emerging devices, instruments, cameras, and ports that have made these procedures possible. Next, we offer insight into how this rapidly moving field may transition in the future. Finally, we provide our commentary on this surgical approach, its impact on urology, and how it may help us evolve in the future.


“Isobaric laparoendoscopic single-site surgery with wound retractor for adnexal tumors: A single center experience with the initial 100 cases.”

Takeda, A., S. Imoto, et al. (2011).

European Journal of Obstetrics Gynecology and Reproductive Biology 157(2): 190-196.


Objective: To report our experience with isobaric (gasless) transumbilical laparoendoscopic single-site (LESS) surgery in 100 patients with adnexal tumors at a single center. Study design: In each case, a wound retractor was used as a working port through a 2.5-cm vertical umbilical incision. The surgical view was secured with the subcutaneous abdominal wall-lift method. Surgical procedures were performed using conventional laparoscopic instruments under vision with a rigid 30°, 5-mm EndoEYE laparoscope. Clinical data regarding patient demographics and surgical outcomes were retrospectively analyzed. Results: Between August 2009 and July 2010, one hundred and seventeen tumors from 100 cases were treated with isobaric LESS surgery (unilateral salpingo-oophorectomy, 46; unilateral cystectomy, 33; bilateral cystectomy, 8; bilateral salpingo-oophorectomy, 6; unilateral cystectomy and contralateral cyst wall ablation, 4; unilateral cystectomy and contralateral salpingo-oophorectomy, 2; and unilateral salpingectomy, 1). Three normal adnexa were prophylactically resected at the same time as contralateral salpingo-oophorectomy of a diseased ovary. Previous abdominal surgery was noted in 20 cases. Emergency surgery was performed in 7 cases. Six pregnant women were treated in the late first trimester. Median tumor diameter was 6.9 cm. Median surgical duration was 55 min and median blood loss was 10 mL. Conversion to conventional laparoscopic surgery was noted in one case of recurrent endometriotic cyst with severe adhesion. Laparotomic conversion was not experienced. Prolonged administration of antibiotics with extended hospitalization was required in 7 cases due to elevated inflammatory parameters. There were no major surgical complications in this series. The technique yielded excellent cosmetic results with minimum postoperative scar concealed within the umbilicus. With exclusion of 4 endometriotic cysts treated with cyst wall ablation, pathological diagnosis was obtained for 113 tumors (dermoid cyst, 54; endometriotic cyst, 21; serous cystadenoma, 19; mucinous cystadenoma, 9; paraovarian cyst, 8; serous borderline tumor, 1; and paraovarian serous papillary borderline tumor, 1). Conclusions: With efficient wound retraction to create a wide and flexible orifice during instrumentation, the transumbilical wound retraction system combined with the subcutaneous abdominal wall-lift method contributes favorably to LESS surgery as a safe, feasible and reproducible alternative for a variety of ablative and reconstructive applications in the management of adnexal tumors. © 2011 Elsevier Ireland Ltd.


“Development of a teaching tool for women with a gynecologic malignancy undergoing minimally invasive robotic-assisted surgery.”

Castiglia, L. L., N. Drummond, et al. (2011).

Clinical Journal of Oncology Nursing 15(4): 404-410.


Women undergoing minimally invasive robotic-assisted surgery for a gynecologic malignancy have many questions and concerns related to the cancer diagnosis and surgery. The provision of information enhances coping with such illness-related challenges. A lack of print materials for these patients prompted the creation of a written teaching tool to improve informational support. A booklet was developed using guidelines for the design of effective patient education materials, including an iterative process of collaboration with healthcare providers and women who had undergone robotic-assisted surgery, as well as attention to readability. The 52-page booklet covers the trajectory of the woman’s experience and includes the physical, psychosocial, and sexual aspects of recovery.




“Comparison of robotic-assisted laparoscopy versus conventional laparoscopy on skill acquisition and performance.”

Kho, R. M. (2011).

Clinical Obstetrics and Gynecology 54(3): 376-381.


With an increasing adoption of robotics in gynecologic surgery, training and acquisition of robotic skills become pertinent. The learning curve for the acquisition of robotic skills has been studied using different assessment measurements in both the laboratory and surgical setting. In the laboratory setting, task acquisition and performance is superior with the robotic platform compared with conventional laparoscopy. The 3-dimensional viewing condition provides a perceptive advantage. Learning curve for robotics in the clinical setting is indirectly assessed. Conclusive statements regarding the learning curve comparing robotics with conventional laparoscopy in the surgical setting are difficult to make. To date, clinical studies are limited by lack of standard definitions and objective assessment measurements.


“Robotics Training Program: Evaluation of the Satisfaction and the Factors That Influence Success of Skills Training in a Resident Robotics Curriculum.”

Lucas, S. M., D. A. Gilley, et al. (2011).

Journal of Endourology.


Abstract Purpose: We present our experience of training residents in a weekend robotic training program to assess its effectiveness and perceived usefulness. Methods: Bimonthly training sessions were arranged such that residents could sign up for hour-long, weekend training sessions. They are required to complete four training sessions. Five tasks were scored for time and accuracy: Peg-Board, checkerboard, string running, pattern cutting, and suturing. Participants completed surveys (5-point Likert scale) regarding program utility, ease of attendance, and interest in future weekend training sessions. Results: Mean number of trials completed by 19 residents was >4, and 16 completed the trials within an average of 13.7+/-8.1 mos. Significant improvements (P<0.05) were seen in final trials for Peg-Board accuracy (95.8% vs 79.0%), checkerboard deviation (4.8% vs 18.2%), and time (293 s vs 404 s), pattern-cutting time (257 s vs 399 s), and suture time (203 s vs 305 s). Time to previous session correlated with relative improvement in Peg-Board and pattern-cutting time (r=0.300 and 0.277, P=0.021 and 0.041), but no specific training interval was predictive of improvement. Residents found the course easy to attend (3.6), noted skills improvement (4.1), and found it useful (4.0). Conclusion: Training in the weekend sessions improved performance of basic tasks on the robot. Training interval had a modest effect on some exercises and may be more important for difficult tasks. This training program is a useful supplement to resident training and would be easy to implement in most programs.


“Surgical model-view-controller simulation software framework for local and collaborative applications.”

MacIel, A., G. Sankaranarayanan, et al. (2011).

International Journal of Computer Assisted Radiology and Surgery 6(4): 457-471.


Purpose: Surgical simulations require haptic interactions and collaboration in a shared virtual environment. A software framework for decoupled surgical simulation based on a multi-controller and multi-viewer model-view-controller (MVC) pattern was developed and tested. Methods: A software framework for multimodal virtual environments was designed, supporting both visual interactions and haptic feedback while providing developers with an integration tool for heterogeneous architectures maintaining high performance, simplicity of implementation, and straightforward extension. The framework uses decoupled simulation with updates of over 1,000 Hz for haptics and accommodates networked simulation with delays of over 1,000 ms without performance penalty. Results: The simulation software framework was implemented and was used to support the design of virtual reality-based surgery simulation systems. The framework supports the high level of complexity of such applications and the fast response required for interaction with haptics. The efficacy of the framework was tested by implementation of a minimally invasive surgery simulator. Conclusion: A decoupled simulation approach can be implemented as a framework to handle simultaneous processes of the system at the various frame rates each process requires. The framework was successfully used to develop collaborative virtual environments (VEs) involving geographically distributed users connected through a network, with the results comparable to VEs for local users. © 2010 CARS.


“[Interest of robot-assisted laparoscopy in the initial surgical training: Resident survey.].”

Menager, N. E., M. A. Coulomb, et al. (2011).

Gynecologie, Obstetrique et Fertilite.


OBJECTIVE: This survey evaluated if residents felt a benefit to their participation in robot-assisted procedures and highlights the interest of robot in the initial surgical training. PATIENTS AND METHODS: A questionnaire was submitted to 33 residents participating as assistants in robot-assisted surgical procedures in our department and to seven residents of the Chapel Hill hospital, North Carolina, USA. Items rated their experience with the robot, their feeling during the surgical procedures and whether they thought they improved their technical skills. RESULTS: The majority of French residents felt passive during the procedures (97%) or bored (75%); most of them found an immediate interest to learn anatomy (72.7%) and surgical procedures (66.7%). Then, a minority of them reported an improvement of their knowledge in anatomy (39.4%), in surgical procedures (24.2%), and conventional laparoscopy (9.1%). Most of French residents are not willing to repeat the experience as an assistant (81.8%), whereas they showed great interest in practicing robot-assisted surgery later. The oldest residents benefited more than younger in learning anatomy and surgical procedures. US resident’ ratings concerning the contribution of the robot in their training were generally more positive. They were all convinced they made progress in anatomy, as in surgical techniques and they all wanted to repeat such procedures. DISCUSSION AND CONCLUSION: This work demonstrates the pedagogical value of using the robot for teaching surgical procedures and anatomy. It also suggests the establishment of training programs dedicated to the learning of robot-assisted surgery in gynaecology, in parallel with training in conventional laparoscopy.