Abstrakt Technologie Květen 2009

“Flexible Robotics.”

Aron, M. and M. M. Desai (2009).

Urologic Clinics of North America 36(2): 157-162.

Robotic technology is being increasingly used for a variety of surgical procedures. This article describes some novel flexible robotic platforms that may enhance the capabilities of flexible endoscopy and provides a rationale for robotic technology’s further development and future use. It also reviews some recent experimental and clinical usages of flexible robotic technology to perform ureterorenoscopy and to provide treatment of stones. © 2009 Elsevier Inc. All rights reserved.




“An integrated pneumatic tactile feedback actuator array for robotic surgery.”

Franco, M. L., C. H. King, et al. (2009).

The international journal of medical robotics + computer assisted surgery : MRCAS 5(1): 13-19.

BACKGROUND: A pneumatically controlled balloon actuator array has been developed to provide tactile feedback to the fingers during robotic surgery. METHODS: The actuator and pneumatics were integrated onto a robotic surgical system. Potential interference of the inactive system was evaluated using a timed robotic peg transfer task. System performance was evaluated by measuring human perception of the thumb and index finger. RESULTS: No significant difference was found between performance with and without the inactive mounted actuator blocks. Subjects were able to determine inflation location with > 95% accuracy and five discrete inflation levels with both the index finger and thumb with accuracies of 94% and 92%. Temporal tests revealed that an 80 ms temporal separation was sufficient to detect balloon stimuli with high accuracy. CONCLUSIONS: The mounted balloon actuators successfully transmitted tactile information to the index finger and thumb, while not hindering performance of robotic surgical movements.




“The EndoAssist robotic camera holder as an aid to the introduction of laparoscopic colorectal surgery.”

Gilbert, J. (2009).

Annals of the Royal College of Surgeons of England.

INTRODUCTION Introducing laparoscopic colorectal surgery is a challenge to the whole surgical team. It is usual for an assistant to hold the laparoscope and be responsible for the surgeon’s view of the operative field and a lack of expertise in the assistant can add significant difficulties. The EndoAssist is a robotic device that replaces the human assistant and ensures steady visualisation of the operative field and a view which can be controlled by the surgeon. This study describes its use in the introduction of laparoscopic colorectal surgery to a unit.PATIENTS AND METHODS The EndoAssist was employed for the introduction of laparoscopic colorectal surgery in a unit with previous experience of this device for laparoscopic cholecystectomy. It was used in a consecutive series of 77 laparoscopic colectomy operations.RESULTS The robotic device proved successful in the whole range of colorectal operations and a reliable assistant. No problems specific to the device were encountered.CONCLUSIONS The EndoAssist robot is a useful laparoscopic assistant and aided in the introduction of laparoscopic colorectal surgery.




“Natural orifice cholecystectomy using a miniature robot.”

Lehman, A. C., J. Dumpert, et al. (2009).

Surgical Endoscopy 23(2): 260-266.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) is surgically challenging. Current endoscopic tools provide an insufficient platform for visualization and manipulation of the surgical target. This study demonstrates the feasibility of using a miniature in vivo robot to enhance visualization and provide off-axis dexterous manipulation capabilities for NOTES. METHODS: The authors developed a dexterous, miniature robot with six degrees of freedom capable of applying significant force throughout its workspace. The robot, introduced through the esophagus, completely enters the peritoneal cavity through a transgastric insertion. The robot design consists of a central “body” and two “arms” fitted respectively with cautery and forceps end-effectors. The arms of the robot unfold, allowing the robot to flex freely for entry through the esophagus. Once in the peritoneal cavity, the arms refold, and the robot is attached to the abdominal wall using the interaction of magnets housed in the robot body with magnets in an external magnetic handle. Video feedback from the on-board cameras is provided to the surgeon throughout a procedure. RESULTS: The efficacy of this robot was demonstrated in three nonsurvivable procedures in a porcine model, namely, abdominal exploration, bowel manipulation, and cholecystectomy. After insertion, the robot was attached to the interior abdominal wall. The robot was repositioned throughout the procedure to provide optimal orientations for visualization and tissue manipulation. The surgeon remotely controlled the actuation of the robot using an external console to assist in the procedures. CONCLUSION: This study has shown that a dexterous miniature in vivo robot can apply significant forces in arbitrary directions and improve visualization to overcome many of the limitations of current endoscopic tools for performing NOTES procedures.




“Minimal contamination of the human peritoneum after transvesical incision.”

McGee, S. M., J. C. Routh, et al. (2009).

Journal of Endourology 23(4): 659-663.

Background and Purpose: The recent literature has questioned the infectious risk of natural orifice translumenal endoscopic surgery (NOTES). The need for a clean portal of entry may be important to minimize peritoneal contamination after NOTES. Our study examines the resultant microbial contamination of the human peritoneum after transvesical incision and exposure of the abdomen to bladder contents during robot-assisted laparoscopic prostatectomy (RALP) to better understand the potential for infection in transvesical NOTES. Patients and Methods: Sixty consecutive men undergoing RALP for clinically localized prostate adenocarcinoma from January to May 2008 were prospectively studied as part of a database approved by an Institutional Review Board. The patient’s preoperative urine microscopy values, complete blood cell count, and prostate-specific antigen (PSA) levels were recorded, along with the total length of time the cystotomy was open to the peritoneum. Intraoperative samplings of peritoneal fluid were collected before and after transvesical incision and sent for anaerobic, aerobic and fungal cultures. Results: Patients undergoing RALP had peritoneal exposure after transvesical incision for an average of 118 minutes. Five of 60 (8.3%) patients had evidence of novel aerobic bacterial contamination of the peritoneum after RALP. No patient had a positive anaerobic culture or fungal culture from the peritoneum. Preoperative serum leukocyte and PSA levels were elevated in patients with peritoneal contamination P<0.05). Remaining clinicopathologic features, total operative time, or open cystotomy time did not predict peritoneal contamination. Conclusion: Prolonged peritoneal exposure to bladder contents demonstrates minimal contamination of the abdominal cavity and is without postoperative infectious significance. This study may overestimate bacterial contamination via the bladder during RALP, because the specific bacteria seen may have originated from the seminal or prostatic fluid during prostatectomy. Transvesical incision would effectively be a clean portal of entry for NOTES with its low rate of peritoneal contamination. Copyright 2009, Mary Ann Liebert, Inc.




“An evaluation of knot integrity when tied robotically and conventionally.”

Muffly, T., T. C. McCormick, et al. (2009).

American Journal of Obstetrics and Gynecology 200(5).

Objective: The purpose of this study was to evaluate the knot integrity of 3 commonly used sutures in sacrocolpopexy that were tied conventionally (by hand) and robotically. Study Design: Knots were tied with polyglactin 910, polypropylene, and polyester, with 5-6 knots tied, depending on the suture used. We compared the knots that were subjected to tensile force until the suture broke or untied. Results: The mean force that was required for the suture to untie was 47.7 ± 18.8 (SD) Newtons and was seen only among the robotically tied polyglactin 910 knots. Robotically tied polyglactin 910 knots were significantly weaker than all other robotic and conventional knots that were tested (P < .05). The tying modality and material interaction was significant (P < .001), which suggests that the effect of suture material varied, depending on the tying modality. Conclusion: Knot failure rates for conventional or robotically tied suture varied based on the suture material that was used. © 2009 Mosby, Inc. All rights reserved.




“Single Port Access (SPAâ„¢) cholecystectomy: A completely transumbilical approach.”

Podolsky, E. R., S. J. Rottman, et al. (2009).

Journal of Laparoendoscopic and Advanced Surgical Techniques 19(2): 219-222.

We have seen substantial changes in minimally invasive surgery since its development in the early 1900s. Over the past 10 years, the addition of natural orifice transluminal endoscopic surgery and robotics has turned our attention to improved cosmesis and advancements in instrumentation. We have developed a new technique – single port access (SPA) surgery – and have applied it to the cholecystectomy. In this paper, we present and review the application of this access technique to the first 5 consecutive patients that underwent an SPA cholecystectomy. All 5 patients were female, with an average age of 45 years and an average weight of 172 pounds. Indications included biliary dyskinesia and symptomatic cholelithiasis. Average operative time was 121 minutes in these initial 5 cases. All but 1 patient was discharged in 24 hours. At 6 months, no umbilical hernias were observed. This new technique allows for a complete cholecystectomy to be performed entirely through the umbilicus without the need for additional retraction sites or transabdominal sutures. This procedure utilizes the same basic technique of the laparoscopic cholecystectomy already employed by general surgeons. Therefore, the SPA cholecystectomy can be readily learned and performed by many surgeons without the need for expensive or experimental equipment. Using a single portal of entry to the abdominal cavity, the umbilicus, cosmesis, and scar reduction is achieved. © 2009 Mary Ann Liebert, Inc.




“Looking ahead in long-term care: the next 50 years.”

Robinson, K. M. and S. C. Reinhard (2009).

Nurs Clin North Am 44(2): 253-62.

During the next 50 years, demographic aging-including graying of the baby boomers, increased longevity, and lower fertility rates-will change the needs for long-term care in the United States. These trends will have a great impact on the federal budget related to spending for Social Security, Medicare, and Medicaid. Future years will see a more diverse population with increased aggressive treatment of chronic illness. Consumers of health care and their family caregivers will take more active steps to manage and coordinate their own care. Housing trends that produce more senior-friendly communities will encourage independent living rather than seniors’ having to move into institutions; increased incentives for use of home- and community community-based care will allow people to stay longer in their own homes in the community. Technological advances, such as the use of robots who serve as companions and assistants around the house, will also decrease the need for institutional living.




“Miniature In Vivo Robotics and Novel Robotic Surgical Platforms.”

Shah, B. C., S. L. Buettner, et al. (2009).

Urologic Clinics of North America 36(2): 251-263.

Robotic surgical systems, such as the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California), have revolutionized laparoscopic surgery but are limited by large size, increased costs, and limitations in imaging. Miniature in vivo robots are being developed that are inserted entirely into the peritoneal cavity for laparoscopic and natural orifice transluminal endoscopic surgical (NOTES) procedures. In the future, miniature camera robots and microrobots should be able to provide a mobile viewing platform. This article discusses the current state of miniature robotics and novel robotic surgical platforms and the development of future robotic technology for general surgery and urology. © 2009 Elsevier Inc. All rights reserved.




“Technological Advances in Robotic-Assisted Laparoscopic Surgery.”

Tan, G. Y., R. K. Goel, et al. (2009).

Urologic Clinics of North America 36(2): 237-249.

In this article, the authors describe the evolution of urologic robotic systems and the current state-of-the-art features and existing limitations of the da Vinci S HD System (Intuitive Surgical, Inc.). They then review promising innovations in scaling down the footprint of robotic platforms, the early experience with mobile miniaturized in vivo robots, advances in endoscopic navigation systems using augmented reality technologies and tracking devices, the emergence of technologies for robotic natural orifice transluminal endoscopic surgery and single-port surgery, advances in flexible robotics and haptics, the development of new virtual reality simulator training platforms compatible with the existing da Vinci system, and recent experiences with remote robotic surgery and telestration. © 2009 Elsevier Inc. All rights reserved.




“The current status of robotic pelvic surgery: results of a multinational interdisciplinary consensus conference.”

Wexner, S. D., R. Bergamaschi, et al. (2009).

Surgical Endoscopy 23(2): 438-443.

BACKGROUND: Despite the significant benefits of laparoscopic surgery, limitations still exist. One of these limitations is the loss of several degrees of freedom. Robotic surgery has allowed surgeons to regain the two lost degrees of freedom by introducing wristed laparoscopic instruments. METHODS: At the first Pelvic Surgery Meeting held in Brescia in June 2007, the participants focused on the role of robotic surgery in pelvic operations surgery for malignancy including prostate, rectal, uterine, and cervical carcinoma. All members of the interdisciplinary panel were asked to define the role of robotic surgery in prostate, rectal, and uterine carcinoma. All key statements were reformulated until a consensus within the group was achieved (Murphy et al., Health Technol Assess 2(i-v):1-88, 1998). For the systematic review, a comprehensive literature search was performed in Medline and the Cochrane Library from January 1997 to June 2007. The keywords used were Da Vinci, telemonitoring, laparoscopy, neoplasms for urology, colorectal, gynecology, visceral surgery, and minimally invasive surgery. The pelvic surgery meeting was supported by Olympus Medical Systems Europa. RESULTS: As of December 31, 2007, there were 795 unit shipments worldwide of the Da Vinci((R)): 595 in North America, 136 in Europe, and 64 in the rest of the world (http://investor.intuitivesurgical.com/phoenix.zhtml?c=122359&p=irol-faq#22324 ). It was estimated that, during 2007, approximately 50,000 radical prostatectomies were performed with the Da Vinci robot system in the USA, reflecting market penetration of 60% of radical prostatectomies in the USA. This utilization represents 50% growth as in 2006 only 42% of all radical prostatectomies performed in the USA employed robotics. CONCLUSION: While robotic prostatectomy has become the most widely accepted method of prostatectomy, robotic hysterectomy and proctectomy remain far less widely accepted. The theoretical benefits of the increased degrees of freedom and three-dimensional visualization may be outweighed in these areas by the loss of haptic feedback, increased operative times, and increased cost.




“Natural Orifice Translumenal Endoscopic Surgery.”

White, W. M., G. P. Haber, et al. (2009).

Urologic Clinics of North America 36(2): 147-155.

This article presents a fair and balanced review of natural orifice translumenal endoscopic surgery. The article chronicles the history and technical aspects of natural orifice translumenal endoscopic surgery with particular emphasis on its application in urology. It is hoped that this article serves as a straightforward and pragmatic reference for practicing and academic urologists. © 2009 Elsevier Inc. All rights reserved.