Abstrakt Ostatní Únor 2011

“Automation of a suturing device for minimally invasive surgery.”

Gopel, T., F. Hartl, et al. (2011).

Surgical Endoscopy.


BACKGROUND: In minimally invasive surgery, hand suturing is categorized as a challenge in technique as well as in its duration. This calls for an easily manageable tool, permitting an all-purpose, cost-efficient, and secure viscerosynthesis. Such a tool for this field already exists: the Autosuture EndoStitch((R)). In a series of studies the potential for the EndoStitch to accelerate suturing has been proven. However, its ergonomics still limits its applicability. The goal of this study was twofold: propose an optimized and partially automated EndoStitch and compare the conventional EndoStitch to the optimized and partially automated EndoStitch with respect to the speed and precision of suturing. METHODS: Based on the EndoStitch, a partially automated suturing tool has been developed. With the aid of a DC motor, triggered by a button, one can suture by one-fingered handling. Using the partially automated suturing manipulator, 20 surgeons with different levels of laparoscopic experience successfully completed a continuous suture with 10 stitches using the conventional and the partially automated suture manipulator. Before that, each participant was given 1 min of instruction and 1 min for training. Absolute suturing time and stitch accuracy were measured. The quality of the automated EndoStitch with respect to manipulation was tested with the aid of a standardized questionnaire. RESULTS: To compare the two instruments, t tests were used for suturing accuracy and time. Of the 20 surgeons with laparoscopic experience (fewer than 5 laparoscopic interventions, n = 9; fewer than 20 laparoscopic interventions, n = 7; more than 20 laparoscopic interventions, n = 4), there was no significant difference between the two tested systems with respect to stitching accuracy. However, the suturing time was significantly shorter with the Autostitch (P = 0.01). The difference in accuracy and speed was not statistically significant considering the laparoscopic experience of the surgeons. The weight and size of the Autostitch have been criticized as well as its cable. However, the comfortable handhold, automatic needle change, and ergonomic manipulation have been rated positive. CONCLUSION: Partially automated suturing in minimally invasive surgery offers advantages with respect to the speed of operation and ergonomics. Ongoing work in this field has to concentrate on minimization, implementation in robotic systems, and development of new operation methods (NOTES).




“Comparative-effectiveness research and good clinical practice for laparoscopic rectal surgery after neoadjuvant treatment.”

Hottenrott, C. (2011).

Surgical Endoscopy and Other Interventional Techniques 25(1): 328-330.




“Five year expanded prostate cancer index composite-based quality of life outcomes after prostatectomy for localized prostate cancer.”

Parker, W. R., R. Wang, et al. (2011).

BJU International 107(4): 585-590.


Study Type – Therapy (outcomes research) Level of Evidence 2c What’s known on the subject? and What does the study add? Previous studies typically assessed early outcomes (â 2 years) after prostatectomy often without individual pre-operative scores for comparison. Our study followed patients and provides long term results, five years post-operatively, and compared results to patients own baseline scores across all domains within EPIC. OBJECTIVE To document the Expanded Prostate cancer Index Composite (EPIC) results for men followed for 5 years after radical prostatectomy. PATIENTS AND METHODS EPIC and demographic information were prospectively obtained from 434 patients who received questionnaires preoperatively and 1, 4, 12, 24, 36, 48 and 60 months postoperatively. Paired t-tests compared scores at individual time points. Percentage return to baseline was calculated at all postoperative time points and multivariate analyses evaluated postoperative trends. RESULTS The mean age of patients was 63.4 years. Mean urinary function and incontinence worsen after prostatectomy, with recovery stable 12 months after surgery. Mean urinary bother returned to baseline by 4 months post-prostatectomy. Some 55.8% and 77.5% of patients return to their urinary function and bother baselines, respectively, 1 year after surgery. Mean sexual function and bother both declined after surgery, with new stable baselines achieved by 24 and 36 months post-prostatectomy, respectively. Of the patients, 24.2% returned to their sexual function baseline by 24 months. No postoperative improvement was noted in mean sexual bother until the 12 months post-prostatectomy. Of the patients, 36.8% returned to their sexual bother baseline by 36 months. Minimal change was noted in the bowel and hormonal domains. CONCLUSIONS Mean urinary function and incontinence did not recover to preoperative baseline after prostatectomy, although it did not add distress because mean urinary bother returned to pre-prostatectomy levels. Mean sexual function declined post-prostatectomy, with continued recovery up to 24 months. Sexual bother recovered later but, once it reached a new baseline, the distress does not lessen with time, probably indicating an inability to adjust to their functional loss. © 2010 THE AUTHORS. JOURNAL COMPILATION ;copy 2010 BJU INTERNATIONAL.




“Peak and end effects in patients daily recall of pain and fatigue: A within-subjects analysis.”

Schneider, S., A. A. Stone, et al. (2011).

Journal of Pain 12(2): 228-235.


Clinical research often relies on retrospective recall of symptom levels, but the information contained in these ratings is not well understood. The “peak-and-end rule” suggests that the most intense (peak) and final (end) moments of an experience disproportionately influence retrospective judgments, which may bias self-reports of somatic symptoms. This study examined the extent to which peak and end symptom levels systematically affect patients day-to-day recall of pain and fatigue. Rheumatology patients (N = 97) completed 5 to 6 momentary ratings of pain and fatigue per day as well as a daily recall rating of these symptoms for 28 consecutive days. For pain, peak and end momentary ratings predicted daily recall of average pain beyond the actual average of momentary ratings. This effect was small, yet was confirmed in both between-person and within-person (repeated measures) analyses. For fatigue, neither peak nor end momentary symptoms significantly contributed to daily recall. Of note, the evidence for peak- and end-effects in recall of pain and fatigue varied significantly between individual patients. These findings suggest that peak- and end-effects create a small bias in recall reports of pain, but not fatigue. However, there are considerable individual differences in susceptibility to peak and end heuristics. Perspective: The peak-end cognitive heuristic could bias end-of-day recall of pain and fatigue. An effect was shown for pain, but not for fatigue. The effects were small and were unlikely to substantially bias end-of-day assessments. Individuals were shown to differ in the degree that the heuristic was associated with recall. © 2011 by the American Pain Society.




“Robotic surgery: The present or the future?”

Giné, L. (2010).

Cirugía robótica: ¿Presente o futuro? 11(4): 169-170.




“How Do We Improve Techniques in Robotic Surgery?”

Guru, K. and M. Menon (2011).

Journal of Urology.




“Future and conclusions about robotic surgery : Indications, techniques, diffusion and ergonomics.”

Marchal, F., P. Rauch, et al. (2011).

Perspectives de la chirurgie robotique et conclusions : Indications, techniques, diffusion et ergonomie 13(1): 51-56.


Robotic surgery is a significant technological innovation of the last 10 years. Although the advantages of robotic surgery for surgeons are obvious, robotic surgery must also demonstrate benefits for patients. We present current and future indications in oncological surgery and technological advances in medicine. Technological improvements and low cost will make this technique popular. Learning time is also shorter than for standard laparoscopy. The most obvious benefit is for the surgeon, with better ergonomics and probably a decrease of musculoskeletal diseases secondary to standard laparoscopy. © 2010 Springer Verlag France.




“Wrestling over robotic surgery.”

Nelson, B. (2011).

Cancer Cytopathol 119(1): 2.




“Setting up robotic surgery in gynaecology: the experience of the Strasbourg teaching hospital.”

Sananès, N., O. Garbin, et al. (2011).

Journal of Robotic Surgery: 1-4.


Teleoperated surgical robots could provide a genuine breakthrough in laparoscopy and it is for this reason that the development of robot-assisted laparoscopy is one of the priorities of the Strasbourg University Hospitals’ strategic plan. The hospitals purchased a da Vinci S® robot in June 2006 and Strasbourg has, in IRCAD, one of the few robotic surgery training centres in the world. Our experience has, however, revealed the difficulties involved in setting up robotic surgery, the first of which are organizational issues. This prospective work was carried out between December 2007 and September 2008, primarily to examine the possibility of setting up robotic surgery on a regular basis for gynaecological surgical procedures at the Strasbourg University Hospitals. We maintained a “logbook” in which we prospectively noted all the resources implemented in setting up the robotic surgery service. The project was divided into two phases: the preparatory phase up until the first hysterectomy and then the second phase with the organization of subsequent hysterectomies. The first surgical procedure took 5 months to organize, and followed 25 interviews, 10 meetings, 53 telephone conversations and 48 e-mails with a total of 40 correspondents. The project was presented to seven separate groups, including the hospital medical commission, the gynaecology unit committee and the surgical staff. Fifteen members of the medical and paramedical team attended a two-day training course. Preparing the gynaecology department for robotic surgery required freeing up 8.5 days of “physician time” and 12.5 days of “nurse time”. In the following five months, we performed five hysterectomies. Preparation for each procedure involved on average 5 interviews, 19 telephone conversations and 11 e-mails. The biggest obstacle was obtaining an operating slot, as on average it required 18 days, four telephone calls and four e-mails to be assigned a slot in the operating theatre schedule, which is prepared on average 28 days in advance. It is extremely important for organising robotic surgery and assembling the surgical teams to have a series of operating slots allocated a sufficiently long time in advance. Considerable benefits would be had by setting up a team of anaesthetists and especially perioperative nurses dedicated to robotic surgery. © 2011 Springer-Verlag London Ltd.



“The learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease.”

Novotn, T., M. Dvork, et al. (2011).

Journal of Vascular Surgery 53(2): 414-420.


Background Since the end of the 20th century, robot-assisted surgery has been finding its role among other minimally invasive methods. Vascular surgery seems to be another specialty in which the benefits of this technology can be expected. Our objective was to assess the learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease in a group of 40 patients. Methods Between May 2006 and January 2010, 40 patients (32 men, 8 women), who were a median age of 58 years (range, 48-75 years), underwent 40 robot-assisted laparoscopic aortofemoral reconstructions. Learning curve estimations were used for anastomosis, clamping, and operative time assessment. For conversion rate evaluation, the cumulative summation (CUSUM) technique was used. Statistical analysis comparing the first and second half of our group, and unilateral-to-bilateral reconstructions were performed. Results We created 21 aortofemoral and 19 aortobifemoral bypasses. The median proximal anastomosis time was 23 minutes (range, 18-50 minutes), median clamping time was 60 minutes (range, 40-95 minutes), and median operative time was 295 minutes (range, 180-475 minutes). The 30-day mortality rate was 0%, and no graft or wound infection or cardiopulmonary or hepatorenal complications were observed. During the median 18-month follow-up (range, 2-48 months), three early graft occlusions occurred (7%). After reoperations, the secondary patency of reconstructions was 100%. Data showed a typical short learning curve for robotic proximal anastomosis creation with anastomosis and clamping time reduction. The operative time learning curve was flat, confirming the procedure’s complexity. There were two conversions to open surgery. CUSUM analysis confirmed that an acceptable conversion rate set at 5% was achieved. Comparing the first and second half of our group, all recorded times showed statistically significant improvements. Differences between unilateral and bilateral reconstructions were not statistically significant. Conclusions Our results show that the success rate of robot-assisted laparoscopic aortofemoral bypass grafting is high and the complication rate is low. Anastomosis creation, one of the main difficulties of laparoscopic bypass grafting, has been overcome using the robotic operating system and its learning curve is short. However, the endoscopic dissection of the aortoiliac segment remains the most difficult part of the operation and should be addressed in further development of the method to reduce the operative times. Long-term results and potential benefits of this minimally invasive method have to be verified by randomized controlled clinical trials. © 2011 Society for Vascular Surgery.




“Robotic microsurgery 2011: male infertility, chronic testicular pain, postvasectomy pain, sports hernia pain and phantom pain.”

Parekattil, S. J. and M. S. Cohen (2011).

Current Opinion in Urology 21(2): 121-126.


PURPOSE OF REVIEW: The use of robotic assistance during microsurgical procedures has evolved from its early beginnings in the early 2000s. Currently, its use is expanding in the treatment of male infertility and patients with chronic testicular or groin pain. The addition of this technology may allow an improvement in outcomes as when the operating microscope was introduced in microsurgery. However, this is yet to be proven. RECENT FINDINGS: This review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, microsurgical denervation of the spermatic cord for chronic testicular or groin pain, post-vasectomy pain, sports hernia pain, postnephrectomy, donor nephrectomy and phantom groin pain. Preliminary animal studies show an advantage in terms of improved operative efficiency and improved surgical outcomes. Preliminary human clinical studies appear to support these findings. The use of robotic assistance during robotic microsurgical vasovasostomy appears to decrease operative duration and improve early postoperative sperm counts compared to the pure microsurgical technique. SUMMARY: Long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising and evidence is mounting, but further evaluation is warranted.




“Robot-assisted anterior lumbar interbody fusion in a swine model in vivo test of the da vinci surgical-assisted spinal surgery system.”

Yang, M. S., D. H. Yoon, et al. (2011).

Spine 36(2): E139-E143.


Study Design.: The use of the da Vinci Surgical System to perform an anterior lumbar interbody fusion in a swine model to identify the technical properties, processes, merits, demerits, and limitations of a video-assisted robotic surgical system. Objective.: This study was designed to demonstrate the feasibility of using a robotic surgical system to perform spinal surgery. Summary of Background Data.: Video-assisted laparoscopic anterior fusion was first reported in 1995 and afterward was spotlighted for several years. However, this technique has not become popular because of technical difficulties and complications associated with video-assisted procedures on the spine. As such, there is a demand for investigations to improve this technology. The da Vinci Surgical System provides 3-dimensional visualization as well as uniquely dexterous instruments that are remarkably similar to human hands. Video-assisted surgery with the da Vinci Surgical System robot has already provided great value to the fields of urology, cardiology, gynecology, and general surgery over the last decade. Preclinical studies for application of this system in spinal surgery have recently been conducted. Methods.: A pig underwent anterior lumbar interbody fusion using da Vinci Surgical System assistance, with Tyche expandable cages used for preparation of endplates and cage placement. The setup time, operation time, amount of bleeding, and the number of complications associated with robotic manipulation were recorded. Before euthanasia, the animal underwent radiologic examination to confirm proper placement of cages. Results.: The total duration of the procedure took 6 hours, with some complications related to frozen armsand robotic arm collision. Even so, there was neither any significant nerve or vessel injury nor peritoneal organ damage. Furthermore, radiologic assessment confirmed proper position of the cage in the center of the disc space. Conclusion.: Use of the da Vinci Surgical System to perform an anterior spinal procedure was shown to be safe and effective in a swine animal model. The utilization of this advanced technology shows promise to reduce the incidence of complications compared with other approaches. It requires further testing in animal models and cadavers, along with serial comparisons to current procedures. Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


“Innovation in surgical education – A driver for change.”

Aggarwal, R. and A. Darzi (2010).



The delivery of healthcare is undergoing a major transition period across the globe. Drivers for change range from the introduction of new technologies such as primary angioplasty and robotic surgery, to restriction in work hours of trainee doctors. © 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland.




“Review of available methods of simulation training to facilitate surgical education.”

Bashankaev, B., S. Baido, et al. (2011).

Surgical Endoscopy and Other Interventional Techniques 25(1): 28-35.


The old paradigm of “see one, do one, teach one” has now changed to “see several, learn the skills and simulation, do one, teach one.” Modern medicine over the past 30 years has undergone significant revolutions from earlier models made possible by significant technological advances. Scientific and technological progress has made these advances possible not only by increasing the complexity of procedures, but also by increasing the ability to have complex methods of training to perform these sophisticated procedures. Simulators in training labs have been much more embraced outside the operating room, with advanced cardiac life support using hands-on models (CPR “dummy”) as well as a fusion with computer-based testing for examinations ranging from the United States medical licensure exam to the examinations administered by the American Board of Surgery and the American Board of Colon and Rectal Surgery. Thus, the development of training methods that test both technical skills and clinical acumen may be essential to help achieve both safety and financial goals. © 2010 Springer Science+Business Media, LLC.




“Background-incorporated volumetric model for patient-specific surgical simulation: A segmentation-free, modeling-free framework.”

Hung, K. W. C., M. Nakao, et al. (2011).

International Journal of Computer Assisted Radiology and Surgery 6(1): 35-45.


Purpose: Patient-specific surgical simulation imposes both practical and technical challenges. We propose a segmentation-free, modeling-free framework that creates medical volumetric models for intuitive volume deformation and manipulation in patient-specific surgical simulation. Methods: The proposed framework creates a volumetric model based upon a new form of mesh structure, a Volume Proxy Mesh (VPM). The model can be generated in two phases: the vertex placement phase and mesh improvement phase. Vertices of a VPM are assigned to an initial location by curvature-based vertex placement method, and followed by mesh improvement performed by Particle Swarm Optimization (PSO). Results: The framework is applied to several kidney CT volume data. Using the framework, the resulting models are closely tailored to the detailed features of the datasets. Moreover, the resulting VPM meshes can support broader spectrum deformation between the manipulated organ and its surrounding tissues. Progress in the mesh quality of the final mesh also shows that PSO is feasible for mesh improvement. Conclusion: The framework was applied to several kidney CT volume datasets. Using the framework, the resulting models are closely tailored to the detailed features of the datasets. Moreover, the resulting VPM meshes can support broader spectrum deformation between the manipulated organ and its surrounding tissues. Evaluation of final mesh quality shows that PSO is feasible for mesh improvement. © 2010 CARS.




“Best Practices for Robotic Surgery Training and Credentialing.”

Lee, J. Y., P. Mucksavage, et al. (2011).

Journal of Urology.


PURPOSE: With the rapid and widespread adoption of robotics in surgery, the minimally invasive surgical landscape has changed markedly within the last half decade. This change has had a significant impact on patients, surgeons and surgical trainees. This is no more apparent than in the field of urology. As with the advent of any new surgical technology, it is imperative that we develop comprehensive and responsible training and credentialing initiatives to ensure surgical outcomes and patient safety are not compromised during the learning process. MATERIALS AND METHODS: A literature search was conducted on surgical training curricula as well as robotic surgery training and credentialing to provide best practice recommendations for the development of a robotic surgery training curriculum and credentialing process. RESULTS: For trainees to attain the requisite knowledge and skills to provide safe and effective patient care, surgical training in robotics should involve a structured, competency based curriculum that allows the trainee to progress in a graduated fashion. This structured curriculum should involve preclinical and clinical components to facilitate the proper adoption and application of this new technology. Robotic surgery credentialing should involve an expert determined, standardized educational process, including a minimum criterion of proficiency. CONCLUSIONS: Rather than being based on a set number of completed cases, robotic surgery credentialing should involve the demonstration of proficiency and safety in executing basic robotic skills and procedural tasks. In addition, the accreditation process should be iterative to ensure accountability to the patient.




“Implementation of simulation in surgical practice: Minimally invasive surgery has taken the lead: The Dutch experience.”

Schreuder, H. W. R., G. Oei, et al. (2011).

Medical Teacher 33(2): 105-115.


Minimal invasive techniques are rapidly becoming standard surgical techniques for many surgical procedures. To develop the skills necessary to apply these techniques, box trainers and/or inanimate models may be used, but these trainers lack the possibility of inherent objective classification of results. In the past decade, virtual reality (VR) trainers were introduced for training minimal invasive techniques. Minimally invasive surgery (MIS) is, by nature, very suitable for this type of training. The specific psychomotor skills and eye-hand coordination needed for MIS can be mastered largely using VR simulation techniques. It is also possible to transfer skills learned on a simulator to real operations, resulting in error reduction and shortening of procedural operating time. The authors aim to enlighten the process of gaining acceptance in the Netherlands for novel training techniques. The Dutch Societies of Surgery, Obstetrics and Gynecology, and Urology each developed individual training curricula for MIS using simulation techniques, to be implemented in daily practice. The ultimate goal is to improve patient safety. The authors outline the opinions of actors involved, such as different simulators, surgical trainees, surgeons, surgical societies, hospital boards, government, and the public. The actual implementation of nationwide training curricula for MIS is, however, a challenging step. © 2011 Informa UK Ltd All rights reserved.