Abstrakt Technologie Listopad 2009

“Early experience with single incision transumbilical laparoscopic adjustable gastric banding using the SILS PortTM.”

Saber, A. A. and T. H. El-Ghazaly (2009).

International Journal of Surgery 7(5): 456-459.


Background: The rapid progression of single-incision laparoscopic surgery (SILS) into the realm of advanced surgical procedures has been fueled in recent years by the development of flexible instrumentation necessary to restore triangulation lost in the divergent nature of this approach, and multichannel ports that addressed the challenges regarding the limited range of movement of trocars in close proximity. We herein are reporting our early experience using the SILS PortTM to perform single incision transumbilical laparoscopic gastric banding in five of our patients. Methods: Five carefully selected female patients (body mass indices between 35 and 45 kg/m2 with peripheral obesity) underwent laparoscopic gastric banding using this single incision transumbilical technique. The same surgeon performed all surgical interventions. For all five patients, the same perioperative protocol and operative techniques were implemented. Results: A total of five single incision transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 111 min. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months. Conclusion: Single incision transumbilical laparoscopic adjustable gastric banding using SILS PortTM is a safe and feasible evolving approach. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome. © 2009 Surgical Associates Ltd.




“Early experience with single-access transumbilical adjustable laparoscopic gastric banding.”

Saber, A. A. and T. H. El-Ghazaly (2009).

Obesity Surgery 19(10): 1442-1446.


Background: Laparoscopic adjustable gastric banding is the most common bariatric procedure performed worldwide; since FDA approval was granted for it in June 2001, the procedure has been steadily gaining popularity in the USA. We herein report our early experience with single-access transumbilical laparoscopic gastric banding. This approach to the procedure is performed mainly through a single incision in the umbilicus. This single incision is also utilized for the implantation of the port for subsequent band adjustments. Methods: Eight patients were carefully selected (body mass indices between 35 and 45 kg/m2 with peripheral obesity), and each underwent laparoscopic gastric banding using this single-incision transumbilical technique. The same surgeon performed all surgical interventions. For each of the eight patients, the same perioperative protocol and operative techniques were implemented. Results: Seven out of eight attempted single-access transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 105 min. One out of the eight patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 2.6 months. Conclusion: Single-access transumbilical laparoscopic adjustable gastric banding is a safe and feasible evolving approach in a selected group of patients. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome. © 2009 Springer Science + Business Media, LLC.




“Perioperative Outcomes in Patients Undergoing Conventional Laparoscopic Versus Laparoendoscopic Single-site Pyeloplasty.”

Tracy, C. R., J. D. Raman, et al. (2009).

Urology 74(5): 1029-1034.


Objectives: To compare the outcomes of laparoendoscopic single-site (LESS) surgery with conventional laparoscopic pyeloplasty (CLP) before LESS can be widely accepted. LESS surgery is a novel technique for performing laparoscopic pyeloplasty through a single incision. Methods: Fourteen patients undergoing less pyeloplasty were matched 2:1 with regard to age and side of surgery to a previous cohort of 28 patients who underwent CLP. All patients underwent surgery for symptomatic ureteropelvic junction obstruction and/or delayed urinary excretion based on functional imaging. Intracorporeal suturing was aided through a 5-mm instrument placed in the eventual drain site. Results: No difference was observed between the LESS and CLP cohorts in regard to preoperative characteristics. Postoperatively, no difference was noted between LESS and CLP cases in regard to length of stay (77 vs 74 hours; P = .69), morphine equivalents required (34 vs 38; P = .93), minor postoperative complications (14.3% vs 14.3%; P = 1.0), or major postoperative complications (21.4% vs 10%; P = .18). Median operative times (207 vs 237.5 minutes; P <.001) and median estimated blood loss (30 vs 72.5 mL; P = .002) were lower in patients undergoing LESS. Detailed follow-up imaging revealed a success rate of 96% for CLP at 14.6 months (86% follow-up) and 100% for LESS at 6.8 months (71% follow-up). Conclusions: Although LESS pyeloplasty is feasible, all measured perioperative outcomes are similar to CLP. Further studies are needed to better define the appropriate role of LESS surgery in urology. © 2009 Elsevier Inc. All rights reserved.




“Robotic single-site surgery.”

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

Curr Opin Urol.


PURPOSE OF REVIEW: Minimally invasive urology is rapidly advancing, and single-site laparoscopic surgery is being explored clinically. Such laparoscopic procedures are technically challenging and require an experienced laparoscopic surgeon due to the lack of port placement triangulation and instrument clashing. RECENT FINDINGS: The da Vinci surgical system, with its Endowrist technology, three-dimensional visualization, and motion scaling, has recently been used during single-site surgery, with the aim of reducing technical challenges posed by single-site surgery. To date, we have completed a total of 13 robotic single-site surgeries utilizing the da Vinci system. A total of seven kidney procedures and six pelvic procedures were completed. Total operative time of 195 and 258 min, estimated blood loss of 184 and 175 ml, and hospital stay of 2.3 and 2.8 days were observed for the kidney and pelvic single-site robotic surgery, respectively. SUMMARY: Robotic single-site surgery is feasible and effective using current robotic system, however, with considerable limitations. Robotic systems designed specifically for single-site approach have the potential of alleviating several of the limitations, which exist with traditional laparoendoscopic single-site surgery.




“Surgical performance in a virtual environment.”

Choi, M. Y. and G. R. Sutherland (2009).

On the Horizon 17(4): 345-355.


Purpose – The purpose of this paper is to determine the effect of video game and surgical experience on the ability to adapt to and use the neuroArm virtual reality (VR) simulator. Design/methodology/approach – A total of 48 participants, comprising video gamers, medical students, surgical residents, and qualified surgeons, were recruited. Subjects played three video games and completed a questionnaire. Three pre-determined tasks simulating surgical procedures were performed using the simulator. Performance was measured by time for task completion, number of errors, and quality of outcome. Findings – Gamers outperformed other groups on all measures of performance at almost every task on the VR simulator. All groups showed interval improvement in performance. As age of participants increased, irrespective of their sex and group, their quality of performance decreased and time to complete tasks increased. Initially, the men outperformed the women at every task, however, the difference decreased with repetition. Research limitations/implications – More participants are needed to increase statistical significance of the results, in particular female participants. Practical implications – This study showed that gamers adapted rapidly to the neuroArmtrainer, which could be attributed to enhanced visual attention and spatial distribution skills from video game play. Therefore, visuospatial skills may become strong elements in the selection criterion for future generations of surgical trainees. Originality/value – This study evaluated performance on the neuroArm trainer for the first time. The results provide insight into the design of a training program that helps select and prepare future surgeons for robotic surgery. © Emerald Group Publishing Limited.




“Intraoperative monitoring of laparoscopic skill development based on quantitative measures.”

Cristancho, S. M., A. J. Hodgson, et al. (2009).

Surgical Endoscopy and Other Interventional Techniques 23(10): 2181-2190.


Background: Methods for evaluating standard skills in the operating room typically are based on direct observation and checklists, but such evaluations are time consuming and can be subject to bias. It often is possible to acquire more objective measurements using surgical simulators. However, motor performance in simulators can differ significantly from that in the operating room. Intraoperative assessment is particularly challenging because of the significant variability between procedures related to differences in the patients, the surgical setup, and the team. This study aimed to evaluate the feasibility of using a new framework for interpreting quantitative measures acquired in the operating room to distinguish between levels of laparoscopic skill development. Methods: Two levels of surgical skill development were observed, namely, those of three fourth-year residents and three attending surgeons performing three laparoscopic cholecystectomies each. Electromagnetic position sensors were attached by the surgeons to a 5-mm curved dissector and a 5-mm atraumatic grasper. From the tools’ position histories and video recordings, time, kinematics, and movement transition measures were extracted. Various measures such as the Kolmogorov-Smirnov statistic and the Jensen-Shanon Divergence were used to provide intuitive dimensionless difference measures ranging from 0 to 1. These scores were used to compare residents and expert surgeons executing two surgical tasks: exposure of Calot’s triangle and dissection of the cystic duct and artery. Results: The two groups could be clearly differentiated in both tasks during monitoring for the dominant hand (analysis of variance [ANOVA] and Mann-Whitney; p < 0.05) but not for the nondominant hand. Conclusions: It is practical to acquire time, kinematic, and movement transition measures intraoperatively using video and electromagnetic position-sensing technologies. Principal component analysis proved to be a useful technique for presenting differences between skill levels based on those measures. The authors conclude that objective assessment of intraoperative surgical motor behavior is feasible and likely practical. © 2008 Springer Science+Business Media, LLC.




“New developments in computer-assisted surgery (CAS): From intraoperative imaging to ultrasound-based navigation.”

Federspil, P. A. (2009).

Neue Entwicklungen in der computerassistierten Chirurgie: Von der intraoperativen Bildgebung bis zur ultraschallbasierten Navigation 57(10): 983-989.


Ever faster processor capacity is having an impact on computer-assisted or computer-aided surgery (CAS). The fusion of different imaging modalities enables functional data such as PET-CT, for example, to be available in image-guided surgery. Referencing of image data is the key to precise navigation. Intraoperative data acquisition is a new approach to improving accuracy. Thus, intraoperative CT conducted under navigational support enables automatic referencing of up-to-date image data. Alternatively, intraoperative magnetic resonance imaging or intraoperative sonography can be performed. Ultrasound systems have already been successfully integrated in existing navigational systems to compensate for intraoperative tissue shifting. Ultrasound systems may play a role in the future as a single modality in image-guided surgery in soft tissue of the neck and skull bone. © Springer Medizin Verlag 2009.




“Uncertainty inclusion in budgeting technology adoption at a hospital level: Evidence from a multiple case study.”

Lettieri, E. (2009).

Health Policy 93(2-3): 128-136.


Objectives: The shortage of resources for healthcare has risen the quest for more rational models and practices for technology selection at a hospital level. Uncertainty is a critical issue. This paper aims to shed first light on this issue through an investigation on the content and the process of budgeting technology adoption with respect to uncertainty. Methods: An exploratory multi-case study was carried out to gain a better understanding of the current practice of technology assessment at a hospital level. Five Italian hospitals were selected. Key informants from the budget committees have been interviewed with a structured questionnaire based on the results of an electronic literature search. Results: Five domains of uncertainty have been identified. They have been deployed in a list of 15 relevant issues that should be reviewed during the budget process. The hospitals in the sample cope with these issues in a peculiar manner. Organisational uncertainty is broadly overcome. Reporting about technology performance after the adoption is missing. Conclusion: Policy makers should facilitate hospitals: (a) to develop a multi-disciplinary and evidence based practice for technology selection, (b) to assess and manage uncertainty, and (c) to build a reporting system regarding technology performance in order to build fair practices for technology selection and support continuous learning. © 2009 Elsevier Ireland Ltd. All rights reserved.




“Robotic surgical education: A collaborative approach to training postgraduate urologists and endourology fellows.”

Mirheydar, H., M. Jones, et al. (2009).

Journal of the Society of Laparoendoscopic Surgeons 13(3): 287-292.


Objective: Currently, robotic training for inexperienced practicing surgeons is primarily done vis-à-vis industry and/or society-sponsored day or weekend courses, with limited proctorship opportunities. The objective of this study was to assess the impact of an extended-proctorship program at up to 32 months of follow-up. Methods: An extended-proctorship program for roboticassisted laparoscopic radical prostatectomy was established at our institution. The curriculum consisted of 3 phases: (1) completing an Intuitive Surgical 2-day robotic training course with company representatives; (2) serving as assistant to a trained proctor on 5 to 6 cases; and (3 performing proctored cases up to 1 year until confidence was achieved. Participants were surveyed and asked to evaluate on a 5-point Likert scale their operative experience in robotics and satisfaction regarding their training Results: Nine of 9 participants are currently performing robotic-assisted laparoscopic radical prostatectomy (RALP independently. Graduates of our program have performed 477 RALP cases. The mean number of cases performed within phase 3 was 20.1 (range, 5 to 40) prior to independent practice. The program received a rating of 4.2/5 for effectiveness in teaching robotic surgery skills. Conclusion: Our robotic program, with extended proctoring has led to an outstanding take-rate for disseminating robotic skills in a metropolitan community. © 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by the Society of Laparoendoscopic Surgeons, Inc.




“Establishing a training program for residents in robotic surgery.”

Moles, J. J., P. E. Connelly, et al. (2009).

Laryngoscope 119(10): 1927-1931.


Objectives/Hypothesis: To develop a program for teaching robotic skills to residents. To assess the development of proficiency in basic robotic surgical skills in a resident cohort. Study Design: Prospective educational project using a commercially available surgical robot. Residents use a surgical robot to complete a designated set of tasks intended to simulate surgical maneuvers. Performance is analyzed for errors and total time of procedure. Methods: Otolaryngology residents are introduced to robotic surgery with a tutorial on the usage of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA). Participants perform defined exercises accomplishing the following tasks: circular pin transfer, simultaneous bimanual carrying, precision bead drop, needle passing, and suture tying. Performance of these tasks can be quantitatively assessed. Results: An educational program for teaching residents basic robotic skills can easily be introduced into a residency program. Resident progress in acquiring robotic surgical skills can be measured. The analysis of variance for composite score revealed statistically significant effects for task (F4,24 = 8.11, P <.01) and trial (F2,12, = 5.71, P < .01). Conclusions: Robotic surgery will likely become an integral part of otolaryngologic surgical practice. Training programs in robotic surgery need to be formally established in residency programs. We present a preliminary program for introducing robotic surgical skills in residency training. © 2009 The American Laryngological, Rhinological and Otological Society, Inc.




“Robotic surgery in male infertility and chronic orchialgia.”

Parekattil, S. J. and M. S. Cohen (2009).

Curr Opin Urol.


PURPOSE OF REVIEW: The use of robotic assistance during microsurgical procedures is currently being explored in the treatment of male infertility and patients with chronic testicular pain. Whether the addition of this technology would allow a corresponding improvement in outcomes as when the operating microscope was introduced in microsurgery is yet to be seen. RECENT FINDINGS: The present review covers new robotic microsurgical tools and applications of the robotic platform in microsurgical procedures such as vasectomy reversal, varicocelectomy, denervation of the spermatic cord for chronic testicular pain and microsurgical vascular anastomosis. Preliminary animal studies appear to 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 significantly improve early postoperative sperm counts compared with the pure microsurgical technique. SUMMARY: As with any new technology, long-term prospective controlled trials are necessary to assess the true cost-benefit ratio for robotic assisted microsurgery. The preliminary findings are promising, but further evaluation is warranted.




“The impact of environmental noise on robot-assisted laparoscopic surgical performance.”

Siu, K. C., I. H. Suh, et al. (2009).



Background: An operating room is a noisy environment. How noise affects performance during robotic surgery remains unknown. We investigated whether noise during training with the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) would affect the performance of simple operative tasks by the surgeon. Methods: Twelve medical students performed 3 inanimate operative tasks (bimanual carrying, suture tying, and mesh alignment) on the da Vinci Surgical System with or without the presence of noise. Prerecorded noise from an actual operating room was used. The kinematics of the robotic surgical instrument tips and the muscle activation patterns of the subjects were evaluated. Results: We found noise effects for all 3 tasks with increases in the time to task completion (23%) (P = .046), the total distance traveled (8%) (P = .011) of the surgical instrument tips, and the muscle activation volume (87%) (P = .015) with the presence of noise. We confirmed that the mesh alignment task was the most difficult task with the greatest time to task completion and the greatest muscle activation volume, whereas the suture tying task and the bimanual carrying could be considered the intermediate and the least difficult task, respectively. The noise effects were significantly greater while performing more difficult tasks. Conclusion: Our findings demonstrated that noise degraded robotic surgical performance; however, the impact of noise on robotic surgery will depend on the level of difficulty of the task. Subsequent research is required to identify how different types of noise, such as random or rhythmic sounds, affect the performance of operative tasks using robots such as the da Vinci. © 2009 Mosby, Inc. All rights reserved.