Abstrakt Ostatní Leden 2012

General Robotic      (6)


Kuo, C. H., J. S. Dai, et al. (2012). “Kinematic design considerations for minimally invasive surgical robots: an overview.” Int J Med Robot.

BACKGROUND: Kinematic design is a predominant phase in the design of robotic manipulators for minimally invasive surgery (MIS). However, an extensive overview of the kinematic design issues for MIS robots is not yet available to both mechanisms and robotics communities. METHODS: Hundreds of archival reports and articles on robotic systems for MIS are reviewed and studied. In particular, the kinematic design considerations and mechanism development described in the literature for existing robots are focused on. RESULTS: The general kinematic design goals, design requirements, and design preferences for MIS robots are defined. An MIS-specialized mechanism, namely the remote center-of-motion (RCM) mechanism, is revisited and studied. Accordingly, based on the RCM mechanism types, a classification for MIS robots is provided. A comparison between eight different RCM types is given. Finally, several open challenges for the kinematic design of MIS robotic manipulators are discussed. CONCLUSIONS: This work provides a detailed survey of the kinematic design of MIS robots, addresses the research opportunity in MIS robots for kinematicians, and clarifies the kinematic point of view to MIS robots as a reference for the medical community. Copyright (c) 2012 John Wiley & Sons, Ltd.


Oouchida, K., S. Ieiri, et al. (2012). “[Robotic surgery for cancer treatment].” Gan To Kagaku Ryoho (Cancer and Chemotherapy) 39(1): 1-7.

Surgical operation is still one ofthe important options for treatment ofmany types ofcancer. In the present-day treatment ofcancer, patients’ quality of life is focused on and surgeons need to provide minimally invasive surgery without decreasing the curability ofdisease. Endoscopic surgery contributed to the prevalence ofminimally -invasive surgery. However it has also raised a problem regarding differences in surgical techniques among individual surgeons. Robot-assisted surgery provides some resolutions with 3D vision and increases the freedom of forceps manipulation. Furthermore, 3D visual magnification, scaling function, and the filtering function of surgical robots may make it possible for surgeons to perform microsurgery more delicate than open surgery. Here, we report the present status and the future of the representative surgical robot, and the da Vinci surgical system.


Rostenberg, B. and P. R. Barach (2011). “Design of cardiovascular operating rooms for tomorrow’s technology and clinical practice – Part one.” Progress in Pediatric Cardiology 32(2): 121-128.

Transformations in surgical models of care, including the advent of minimally invasive procedures, bio-robotics and imaging, have revolutionized the cardiovascular physical realm in terms of capability and procedure. An unacceptable number of avoidable patient safety incidents result from the widening disparity between surgical innovation and the environment in which it is applied. Design of cardiovascular operating rooms that aims to minimize the increasing problem of patient safety must consider the behavior of staff and patients as well as the complex interrelationships between culture, technology and achieving reliable, high quality cardiovascular outcomes. There is a need for better, evidence-based physical design guidelines for cardiovascular operating rooms. A better understanding of the relationship between the physical design and its impact on the flow, operations, and culture will positively impact on patient outcomes. © 2011 Elsevier Ireland Ltd.


Sanchez-Martin, F. M. and H. Villavicencio (2012). “Comments to the Article <<Robotic Surgery: History and Impact on Teaching>>.” Actas Urologicas Espanolas.


Schmitto, J. D., S. A. Mokashi, et al. (2011). “Past, present, and future of minimally invasive mitral valve surgery.” The Journal of heart valve disease 20(5): 493-498.

Minimally invasive mitral valve surgery (mini-MVS) has evolved into a safe and efficient surgical option for many patients. The overall complication rate is reduced, patient satisfaction increased, and hospital costs are lower with this approach, while providing safe and durable surgery. The repair/replacement of mitral valves via a minimally invasive technique represents a significant recent paradigm shift in cardiac surgery. The rapid development and refinement of minimally invasive valve surgery has enabled the repair of complex valves and, most importantly, has yielded similar results to those provided by standard surgical approaches.


Zietman, A. and G. Ibbott (2012). “A Clinical Approach to Technology Assessment: How Do We and How Should We Choose the Right Treatment?” Seminars in Radiation Oncology 22(1): 11-17.

The evidence required to support the use of new technology in medicine differs from that required for new drugs. On one extreme, very little may be required for small devices, but on the other strong evidence is required to support the use of truly novel, potentially dangerous, and high-cost machines. The randomized controlled trial is built into the evaluation of drugs and suits them well. It is not so well suited to the evaluation of major devices in which installation costs and return on investment are important. We discuss where the randomized controlled trial may still play a role and what alternatives may exist when this is not possible. We also discuss the role that independent bodies may have in determining whether or not a new device is not only safe but also adds to the medical landscape in a way that justifies its cost. © 2012 Elsevier Inc..

General Surgery      (12)


Beldi, G. (2012). “Technical feasibility of a robotic-assisted ventral hernia repair.” World Journal of Surgery 36(2): 453-454.


Boggi, U., S. Signori, et al. (2012). “Laparoscopic Robot-Assisted Pancreas Transplantation: First World Experience.” Transplantation 93(2): 201-206.

BACKGROUND.: Surgical complications are a major disincentive to pancreas transplantation, despite the undisputed benefits of restored insulin independence. The da Vinci surgical system, a computer-assisted electromechanical device, provides the unique opportunity to test whether laparoscopy can reduce the morbidity of pancreas transplantation. METHODS.: Pancreas transplantation was performed by robot-assisted laparoscopy in three patients. The first patient received a pancreas after kidney transplant, the second a simultaneous pancreas kidney transplantation, and the third a pancreas transplant alone. Operations were carried out through an 11-mm optic port, two 8-mm operative ports, and a 7-cm midline incision. The latter was used to introduce the grafts, enable vascular cross-clamping, and create exocrine drainage into the jejunum. RESULTS.: The two solitary pancreas transplants required an operating time of 3 and 5 hr, respectively; the simultaneous pancreas kidney transplantation took 8 hr. Mean warm ischemia time of the pancreas graft was 34 min. All pancreatic transplants functioned immediately, and all recipients became insulin independent. The kidney graft, revascularized after 35 min of warm ischemia, also functioned immediately. No patient had complications during or after surgery. At the longer follow-up of 10, 8, and 6 months, respectively, all recipients are alive with normal graft function. CONCLUSIONS.: We have shown the feasibility of laparoscopic robot-assisted solitary pancreas and simultaneous pancreas and kidney transplantation. If the safety and feasibility of this procedure can be confirmed by larger series, laparoscopic robot-assisted pancreas transplantation could become a new option for diabetic patients needing beta-cell replacement.


Choi, S. H., C. M. Kang, et al. (2012). “Robotic Anterior RAMPS in Well-Selected Left-Sided Pancreatic Cancer.” Journal of Gastrointestinal Surgery.


Choi, S. H., C. M. Kang, et al. (2011). “Robotic pylorus preserving pancreaticoduodenectomy with mini-laparotomy reconstruction in patient with ampullary adenoma.” Journal of the Korean Surgical Society 81(5): 355-359.

Robotic surgical system provides many unique advantages which might compensate the limitations of usual laparoscopic surgery. By using robotic surgical system, we performed robot-assisted laparoscopic pancreaticoduodenectomy (PD). A Sixty-two year old female patient with an ampullary mass underwent robot assisted PD due to imcomplete treatment of endoscopic ampullectomy. The removal of specimen and reconstruction were performed through small upper midline skin incision. Robot working time was about 8 hours, and blood loss was about 800 ml without blood transfusion. She returned to an oral diet on postoperative day 3. Grade B pancreatic leak was noted during the postoperative period, but was successfully managed by conservative management alone. We successfully performed da Vinci-assisted laparoscopic PD, and robot surgical system provided three-dimensional stable visualization and wrist-like motion of instrument facilitated complex operative procedures. More experiences are necessary to address real role of robot in far advanced laparoscopic pancreatic surgery. © 2011, the Korean Surgical Society.


Dunn, D. and N. Banerji (2011). “Incarcerated Hiatal Hernia After Robot-Assisted Esophagectomy: Transhiatal Versus Thoracoscopic Approach.” Surgical Endoscopy.


Gopinath, S. (2011). “Minimally invasive esophagectomy (MIE): Techniques and outcomes.” World Journal of Laparoscopic Surgery 4(1): 53-58.

Background: Esophageal cancer is one of the major public health problems worldwide. Different methods of minimally invasive esophagectomy (MIE) have been described, and they represent a safe alternative for the surgical management of esophageal cancer in selected centres with high volume and expertise in them. The procedural goal is to decrease the high overall morbidity of a traditional open esophageal resection. Aims: This article reviews the most recent and largest series evaluation of MIE techniques. Methods: A literature search performed using search engines Google, HighWire press, SpringerLink, and Yahoo. Selected papers are screened for other related reports. Results: Though MIE requires greater expertise and a long learning curve, once technique has been mastered it greatly reduces the postoperative morbidity and mortality to a significant extent. There was not much difference in average operating time compared to open surgery but bleeding was less in MIE. Mean hospital stay was similar to open surgery. There was no significant difference in number and location of lymph nodes harvested. Conclusion: The current review shows that MIE with its decreased blood loss, minimal cardiopulmonary complications and decreased morbidity and oncological adequacy, represents a safe and effective alternative for the treatment of esophageal carcinoma. © Jaypee Brothers Medical Publishers (P) Ltd.


Katsuno, H., K. Maeda, et al. (2011). “[Robotic surgery for colon cancer].” Gan to kagaku ryoho. Cancer & chemotherapy 38(11): 1790-1792.

Krauss, A., T. Neumuth, et al. (2011). “Laparoscopic versus robot-assisted Nissen fundoplication in an infant pig model.” Pediatric Surgery International.

PURPOSE: Surgical robots are designed to facilitate dissection and suturing, although objective data on their superiority are lacking. This study compares conventional laparoscopic Nissen fundoplication (CLNF) to robot-assisted Nissen fundoplication (RANF) using computer-based workflow analysis in an infant pig model. METHODS: CLNF and RANF were performed in 12 pigs. Surgical workflow was segmented into phases. Time required to perform specific actions was compared by t test. The quality of knot-tying was evaluated by a skill scoring system. Cardia yield pressure (CYP) was determined to test the efficacy of the fundoplications, and the incidence of complications was compared. RESULTS: There was no difference in average times to complete the various phases, despite faster robotic knot-tying (p = 0.001). Suturing quality was superior in CLNF (p = 0.02). CYP increased similarly in both groups. Workflow-interrupting hemorrhage and pneumothorax occurred more frequently during CLNF (p = 0.040 and 0.044, respectively), while more sutures broke during RANF (p = 0.001). CONCLUSION: The robot provides no clear temporal advantage compared to conventional laparoscopy for fundoplication, although suturing was faster in RANF. Fewer complications were noted using the robot. RANF and CLNF were equally efficient anti-reflux procedures. For robotic surgery to manifest its full potential, more complex operations may have to be evaluated.


Lai, E. C. H., C. N. Tang, et al. “Robot-assisted laparoscopic hemi-hepatectomy: Technique and surgical outcomes.” International Journal of Surgery.

Background: Laparoscopic major hepatectomies remain a challenge for liver surgeons. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The use of robotic system in laparoscopic major hepatectomy was not known yet. Methods: Between December 2010 and July 2011, 6 right hemi-hepatectomies and 4 left hemi-hepatectomies were performed by robot-assisted laparoscopic approach. Prospectively collected data was analyzed retrospectively. Results: Overall mean duration of the operation was 347.4 ± 85.9 (SD) minutes. Mean duration of the operation for right hemi-hepatectomy was 364.8 ± 98.1 ml, while mean duration of the operation for left hemi-hepatectomy was 321.3 ± 67.8 ml. Overall mean operative blood loss was 407 ± 286.8 ml. Mean operative blood loss for right hemi-hepatectomy was 500 ± 303.3 ml, while mean operative blood loss for left hemi-hepatectomy was 156.9 ± 40.7 ml. No open conversion was needed. Three patients (30%) had postoperative complications. There was no mortality. Mean hospital stay was 6.7 ± 3.5 days. Conclusions: Our series indicate that in experienced hands, robot-assisted laparoscopic approach for hemi-hepatectomy is feasible and safe. As experience grows, this procedure will be more common. © 2011.


Lin, S., H. G. Jiang, et al. (2011). “Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer.” World Journal of Gastroenterology 17(47): 5214-5220.

AIM: To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer. METHODS: A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model. RESULTS: Eight studies matched the selection criteria and reported on 661 subjects, of whom 268 underwent RS and 393 underwent LS for rectal cancer. Compared the perioperative outcomes of RS with LS, reports of RS indicated favorable outcomes considering conversion (WMD: 0.25; 95% CI: 0.11-0.58; P = 0.001). Meanwhile, operative time (WMD: 27.92, 95% CI: -13.43 to 69.27; P = 0.19); blood loss (WMD: -32.35, 95% CI: -86.19 to 21.50; P = 0.24); days to passing flatus (WMD: -0.18, 95% CI: -0.96 to 0.60; P = 0.65); length of stay (WMD: -0.04; 95% CI: -2.28 to 2.20; P = 0.97); complications (WMD: 1.05; 95% CI: 0.71-1.55; P = 0.82) and pathological details, including lymph nodes harvested (WMD: 0.41, 95% CI: -0.67 to 1.50; P = 0.46), distal resection margin (WMD: -0.35, 95% CI: -1.27 to 0.58; P = 0.46), and positive circumferential resection margin (WMD: 0.54, 95% CI: 0.12-2.39; P = 0.42) were similar between RS and LS. CONCLUSION: RS for rectal cancer is superior to LS in terms of conversion. RS may be an alternative treatment for rectal cancer. Further studies are required. © 2011 Baishideng.


Park, I. J., Y. N. You, et al. (2012). “Reverse-hybrid robotic mesorectal excision for rectal cancer.” Diseases of the Colon and Rectum 55(2): 228-233.

PURPOSE: : The robotic system offers potential technical advantages over laparoscopy for total mesorectal excision with radical lymphadenectomy for rectal cancer. However, the requirement for fixed docking limits its utility when the working volume is large or patient repositioning is required. The purpose of this study was to evaluate short-term outcomes associated with a novel setup to perform total mesorectal excision and radical lymphadenectomy for rectal cancer by the use of a “reverse” hybrid robotic-laparoscopic approach. METHODS: : This is a prospective consecutive cohort observational study of patients who underwent robotic rectal cancer resection from January 2009 to March 2011. During the study period, a technique of reverse-hybrid robotic-laparoscopic rectal resection with radical lymphadenectomy was developed. This technique involves reversal of the operative sequence with lymphovascular and rectal dissection to precede proximal colonic mobilization. This technique evolved from a conventional-hybrid resection with laparoscopic vascular control, colonic mobilization, and robotic pelvic dissection. Perioperative and short-term oncologic outcomes were analyzed. RESULTS: : Thirty patients underwent reverse-hybrid resection. Median tumor location was 5 cm (interquartile range 3-9) from the anal verge. Median BMI was 27.6 (interquartile range 25.0-32.1 kg/m). Twenty (66.7%) received neoadjuvant chemoradiation. There were no conversions. Median blood loss was 100 mL (interquartile range 75-200). Total operation time was a median 369 (interquartile range 306-410) minutes. Median docking time was 6 (interquartile range 5-8) minutes, and console time was 98 (interquartile range 88-140) minutes. Resection was R0 in all patients; no patients had an incomplete mesorectal resection. Six patients (20%) underwent extended lymph node dissection or en bloc resection. CONCLUSIONS: : Reverse-hybrid robotic surgery for rectal cancer maximizes the therapeutic applicability of the robotic and conventional laparoscopic techniques for optimized application in minimally invasive rectal surgery.


Schneider, C. M., P. D. Peng, et al. “Robot-assisted laparoscopic ultrasonography for hepatic surgery.” Surgery.

Introduction: This study describes and evaluates a novel, robot-assisted laparoscopic ultrasonographic device for hepatic surgery. Laparoscopic liver surgery is being performed with increasing frequency. One major drawback of this approach is the limited capability of intraoperative ultrasonography (IOUS) using standard laparoscopic devices. Robotic surgery systems offer the opportunity to develop new tools to improve techniques in minimally invasive surgery. This study evaluates a new integrated ultrasonography (US) device with the da Vinci Surgical System for laparoscopic visualization, comparing it with conventional handheld laparoscopic IOUS for performing key tasks in hepatic surgery. Methods: A prototype laparoscopic IOUS instrument was developed for the da Vinci Surgical System and compared with a conventional laparoscopic US device in simulation tasks: (1) In vivo porcine hepatic visualization and probe manipulation, (2) lesion detection accuracy, and (3) biopsy precision. Usability was queried by poststudy questionnaire. Results: The robotic US proved better than conventional laparoscopic US in liver surface exploration (85% success vs 73%; P = .030) and tool manipulation (79% vs 57%; P = .028), whereas no difference was detected in lesion identification (63 vs 58; P = .41) and needle biopsy tasks (57 vs 48; P = .11). Subjects found the robotic US to facilitate better probe positioning (80%), decrease fatigue (90%), and be more useful overall (90%) on the post-task questionnaire. Conclusion: We found this robot-assisted IOUS system to be practical and useful in the performance of important tasks required for hepatic surgery, outperforming free-hand laparoscopic IOUS for certain tasks, and was more subjectively usable to the surgeon. Systems such as this may expand the use of robotic surgery for complex operative procedures requiring IOUS. © 2011 Mosby, Inc. All rights reserved.


Single Port       (7)

 Gunderson, C. C., J. Knight, et al. (2012). “The risk of umbilical hernia and other complications with laparoendoscopic single-site surgery.” Journal of Minimally Invasive Gynecology 19(1): 40-45.

Study Objective: To estimate the risk of umbilical hernia and other latent complications in women who underwent laparoendoscopic single-site surgery (LESS) for a gynecologic indication. Design: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting: Four tertiary care academic medical centers. Patients: Women undergoing LESS for a benign or malignant gynecologic indication from 2009 to 2011. Interventions: A total of 211 women underwent LESS via a single 1.5- to 2.0-cm umbilical incision. All surgeries were performed by advanced gynecologic laparoscopists. Incisions were repaired with a running, delayed absorbable suture. Subject demographics and clinical variables were collected and surgical outcomes analyzed. Measurements and Main Results: Median age and body mass index were 45 years and 30 kg/m2, respectively. Approximately half of study subjects underwent a hysterectomy with or without salpingo-oophorectomy, and 15% had a diagnosis of cancer. Overall, 0.9% of women were diagnosed with a preoperative umbilical hernia, and 2.4% of women experienced a major perioperative complication. After a median postoperative follow-up time of 16 months, 2.4% had development of an umbilical hernia. However, 4/5 of these women had significant risk factors for fascial weakening independent of LESS, including requirement for a second abdominal surgery in 1 subject and a cancer diagnosis with postoperative chemotherapy administration in 2 subjects. When these subjects deemed “high risk” for incisional disruption were excluded from the analysis, the umbilical hernia rate was 0.5% (1/207). On univariable analysis, obesity was the only factor associated with complications (p = .04). Conclusion: When performed by advanced laparoscopic surgeons, laparoendoscopic single-site gynecologic surgery is associated with a low risk of major adverse events. Additionally, the overall umbilical hernia rate was 2.4% and was lower (0.5%) in subjects without significant comorbidities. © 2012 AAGL.


Karimyan, V., F. Orihuela-Espina, et al. (2011). “Spatial awareness in Natural Orifice Transluminal Endoscopic Surgery (NOTES) navigation.” International Journal of Surgery.

OBJECTIVE: To characterise navigational patterns in the abdominal cavity associated with different spatial awareness status of the operator during navigation of Natural Orifice Transluminal Endoscopic Surgery (NOTES). It is hypothesised that poor spatial awareness will manifest as erratic navigational patterns and poor performance. SUBJECTS AND METHODS: Ten endoscopic novices navigated a defined course in a NOTES phantom (NOSsE) simulating the path of peritoneoscopic examination. Subjects performed the task three times without and once with an additional laparoscopic camera. Electromagnetic tracking was used to trace the tip of the endoscope during the navigation. Metrics of performance included the number of correctly visualised course targets, between targets localisation time and path length, and total completion time. Spatial awareness was explored by means of topological modelling of the navigation trace. Spatial navigation maps were generated from the tip trace footprint, differentiated using the Earth Movers Distance (EMD) and captured in a two dimensional chart where proximity in the projected space reflects similarity of navigation behaviour. Groups were identified displaying idiosyncratic target to target transitions in endoscopic navigation behaviour. RESULTS: No significant differences were found between four sessions in terms of the path length. Time was statistically improved when using supplemental visualisation (p<0.05). Four awareness groups were identified based on the subjects exhibited navigation footprint over the frontal plane, namely: (1) consistent navigation and performance; (2) inconsistent navigation and performance; (3) improvements in navigation and performance despite undifferentiated behavioural signatures; and (4) inconsistent navigation with improvements in performance. CONCLUSIONS: Tracking the tip of the endoscope permits reconstruction of the navigation path during extraluminal navigation. The spatial location of the tip of the endoscope during navigation was used to unveil the operator’s spatial awareness. Navigation routes in this study have been projected onto a 2D scene, related to performance and classified according to exhibited spatial awareness. Our assessment of this relationship suggests that poor spatial awareness is accompanied by erratic manoeuvres, often leading to poor performances, and vice versa. Tracking the location of the tip of the endoscope is an important issue in NOTES, and similarly understanding the spatial awareness of the operator is crucial in terms of the safety in NOTES. This work may have significant implications for training and assessment of new NOTES or minimally invasive surgeons. It may also lead to the new designs of endoscopes for NOTES.


Kihara, K. (2012). “Application of gasless laparoendoscopic single port surgery, GasLESS, to partial nephrectomy for renal cell carcinoma: GasLESS-clampless partial nephrectomy as a multiply satisfactory method.” International Journal of Urology 19(1): 3-4.

Landry, C. S., D. S. Kwon, et al. (2011). “Operative technique for single incision robot-assisted transaxillary thyroid surgery.” World Journal of Endocrine Surgery 3(2): 83-88.

During the past five years, transaxillary approaches to thyroid surgery have been introduced into surgical literature. These techniques were initially performed using traditional endoscopy, and most recently with a surgical robot. This manuscript describes our approach to robot- assisted transaxillary surgery (RATS) for thyroidectomy using a single axillary incision. Because of the steep learning curve, this procedure is best implemented with a team approach. The ideal team consists of a console surgeon who operates the robot, a bedside surgeon who assists with retraction and troubleshoots robotic arm collisions and a circulating assistant who helps optimize the efficiency of the operation. © Jaypee Brothers Medical Publishers (P) Ltd.


Miernik, A., M. Schoenthaler, et al. (2012). “Pre-bent instruments used in single-port laparoscopic surgery versus conventional laparoscopic surgery: comparative study of performance in a dry lab.” Surgical Endoscopy.

BACKGROUND: Different types of single-incision laparoscopic surgery (SILS) have become increasingly popular. Although SILS is technically even more challenging than conventional laparoscopy, published data of first clinical series seem to demonstrate the feasibility of these approaches. Various attempts have been made to overcome restrictions due to loss of triangulation in SILS by specially designed SILS-specific instruments. This study involving novices in a dry lab compared task performances between conventional laparoscopic surgery (CLS) and single-port laparoscopic surgery (SPLS) using newly designed pre-bent instruments. METHODS: In this study, 90 medical students without previous experience in laparoscopic techniques were randomly assigned to undergo one of three procedures: CLS, SPLS using two pre-bent instruments (SPLS-pp), or SPLS using one pre-bent and one straight laparoscopic instrument (SPLS-ps). In the dry lab, the participants performed four typical laparoscopic tasks of increasing difficulty. Evaluation included performance times or number of completed tasks within a given time frame. All performances were videotaped and evaluated for unsuccessful attempts and unwanted interactions of instruments. Using subjective questionnaires, the participants rated difficulties with two-dimensional vision and coordination of instruments. RESULTS: Task performances were significantly better in the CLS group than in either SPLS group. The SPLS-ps group showed a tendency toward better performances than the SPLS-pp group, but the difference was not significant. Video sequences and participants` questionnaires showed instrument interaction as the major problem in the single-incision surgery groups. CONCLUSIONS: Although SILS is feasible, as shown in clinical series published by laparoscopically experienced experts, SILS techniques are demanding due to restrictions that come with the loss of triangulation. These can be compensated only partially by currently available SILS-designed instruments. The future of SILS depends on further improvements in the available equipment or the development of new approaches such as needlescopically assisted or robotically assisted procedures.


Paek, J., S. W. Kim, et al. (2011). “Learning curve and surgical outcome for single-port access total laparoscopic hysterectomy in 100 consecutive cases.” Gynecologic and Obstetric Investigation 72(4): 227-233.

Aims: To define the learning curve for single-port access (SPA) total laparoscopic hysterectomy (TLH) and evaluate the surgical outcomes. Methods: Patient demographics and segmental operating times of all 100 patients who underwent SPA-TLH by a single surgeon were analyzed. Patients were arranged in order based on surgery date. Results: 100 patients underwent SPA-TLH. There was no conversion to conventional laparoscopy or laparotomy. The median time until the removal of a specimen (T R) was 45 min and the median time for closure of the vaginal cuff (T C) was 18 min. The median total operating time from skin opening to closure (T O) was 80 min. T R, T C, and T O decreased significantly over the study period. The T C decreased significantly from the first 20 cases to the next 20 (p = 0.028) and the T O from the second 20 cases to the next 20 (p = 0.029). Conclusions: Proficiency for SPA-TLH was achieved after 40 cases. Operating time and postoperative hemoglobin drop decreased with experience, without increasing complication. © 2011 S. Karger AG, Basel.


Seideman, C. A., Y. K. Tan, et al. (2012). “Robotic-assisted laparoendoscopic single-site pyeloplasty: technique using the da Vinci(R) Si robotic platform.” Journal of Endourology.

Conventional laparoscopic dismembered pyeloplasty (LP) is an established alternative to open pyeloplasty given equivalent intermediate-term outcomes and decreased morbidity. Laparoendoscopic single-site (LESS) pyeloplasty has the potential to further decrease the morbidity of LP, while yielding superior cosmesis. It is however technically very challenging even with the use of an accessory port, largely due to the difficulty of intracorporeal suturing through a single umbilical incision. Application of the da Vinci robotic surgical platform to LESS pyeloplasty (R-LESS) has the potential to overcome these limitations. We herein describe our technique for R-LESS pyeloplasty using the da Vinci(R) Si robot. We have found that use of the robotic system in conjunction with certain technique modifications helps to reduce the technical difficulty of LESS pyeloplasty and to shorten the physical learning curve associated with the procedure.

Training  (5)

 Ehdaie, B., C. Tracy, et al. (2011). “Evaluation of laparoscopic curricula in American urology residency training.” Journal of Endourology 25(11): 1805-1810.

Purpose: The goal of this study is to evaluate the role of laparoscopic curricula and simulation technology in urology residency training from the perspectives of residents over a 2-year period. Materials and Methods: An anonymous survey was given to urology residents attending the American Urological Association Basic Sciences Course in 2008 and 2009. We evaluated laparoscopic simulator use within a curriculum and use of simulators outside of a curriculum. Face and content validity of simulators were analyzed on a 5-point Likert scale questionnaire. Responses were compared using the unpaired Student t test and chi-square with P<0.05 considered significant. Results: There were 114 surveys (81.4% response rate) and 76 surveys (43% response rate) evaluated from 2008 and 2009, respectively. Access to a surgical simulator increased from 74.6% to 78%. The percentage of programs with a laparoscopic curriculum expanded from 16.9% to 44%. In 2009, simulators were used more frequently by residents in programs with curricula compared with residents without curricula (P=0.03). In 2008, 48% of residents and in 2009 72% of residents reported using simulators as “never” or “once or twice a year.” Of residents, 93% stated that urology programs should use laparoscopic curricula and 82% think simulators should be involved in the curricula. One third of residents agreed that simulators are helpful for skill acquisition, and 80% described their current laparoscopic curriculum as inadequate. Conclusions: The number of urology programs that have invested in simulators continues to expand. Despite access to laparoscopic simulators, residents rarely use them. Residents in programs with laparoscopic curricula report using surgical simulators more often than residents without curricula. Laparoscopic curricula are important, and the incorporation of simulators enhances surgical education. © 2011, Mary Ann Liebert, Inc.


Lallas, C. D., Davis, et al. (2012). “Robotic Surgery Training with Commercially Available Simulation Systems in 2011: A Current Review and Practice Pattern Survey from the Society of Urologic Robotic Surgeons.” Journal of Endourology.

Abstract Objectives: Virtual reality (VR) simulation has the potential to standardize surgical training for robotic surgery. We sought to evaluate all commercially available VR robotic simulators. Materials and Methods: A MEDLINE((R)) literature search was performed of all applicable keywords. Available VR simulators were evaluated with regard to face, content, and construct validation. Additionally, a survey was e-mailed to all members of the Endourological Society, querying the pervasiveness of VR simulators in robotic surgical training. Finally, each company was e-mailed to ask for a price quote for their respective system. Results: There are four VR robotic surgical simulators currently available: RoSS, dV-Trainer, SEP Robot, and da Vinci((R)) Skills Simulator. Each system is represented in the literature and all possess varying degrees of face, content, and construct validity. Although all systems have basic skill sets with performance analysis and metrics software, most do not contain procedural components. When evaluating the results of our survey, most respondents did not possess a VR simulator although almost all believed there to be great potential for these devices in robotic surgical training. With the exception of the SEP Robot, all VR simulators are similar in price. Conclusions: VR simulators have a definite role in the future of robotic surgical training. Although the simulators target technical components of training, their largest impact will be appreciated when incorporated into a comprehensive educational curriculum.


Lee, J. Y., P. Mucksavage, et al. (2012). “Validation Study of a Virtual Reality Robotic Simulator-Role as an Assessment Tool?” Journal of Urology.

PURPOSE: Virtual reality simulators are often used for surgical skill training since they facilitate deliberate practice in a controlled, low stakes environment. However, to be considered for assessment purposes rigorous construct and criterion validity must be demonstrated. We performed face, content, construct and concurrent validity testing of the dV-Trainer robotic surgical simulator. MATERIALS AND METHODS: Urology residents, fellows and attending surgeons were enrolled in this institutional review board approved study. After a brief introduction to the dV-Trainer each subject completed 3 repetitions each of 4 virtual reality tasks on it, including pegboard ring transfer, matchboard object transfer, needle threading of rings, and the ring and rail task. One week later subjects completed 4 similar tasks using the da Vinci(R) robot. Subjects were assessed on total task time and total errors using the built-in scoring algorithm and manual scoring for the dV-Trainer and the da Vinci robot, respectively. RESULTS: Seven experienced and 13 novice robotic surgeons were included in the study. Experienced surgeons were defined by greater than 50 hours of clinical robotic console time. Of novice robotic surgeons 77% ranked the dV-Trainer as a realistic training platform and 71% of experienced robotic surgeons ranked it as useful for resident training. Experienced robotic surgeons outperformed novices in many dV-Trainer and da Vinci robot exercises, particularly in the number of errors. On pooled data analysis dV-Trainer total task time and total errors correlated with da Vinci robot total task time and total errors (p = 0.026 and 0.011, respectively). CONCLUSIONS: This study confirms the face, content, construct and concurrent validity of the dV-Trainer, which may have a potential role as an assessment tool.


Nixon, I. J., F. L. Palmer, et al. (2012). “An integrated simulator for endolaryngeal surgery.” Laryngoscope 122(1): 140-143.

The acquisition and maintenance of skills in transoral microlaryngeal surgery requires extended practice. Effective mentoring of such single-operator procedures is not possible, making it important for trainee surgeons to acquire basic skills outside of the operating room before participating in procedures on patients. Currently available training simulators use either synthetic materials or human tissue, both of which have limitations. We have designed a hybrid simulator that incorporates a porcine larynx in to an airway training manikin, providing both accurate airway anatomy and natural tissue handling characteristics. This model allows training in the skills required for suspension laryngoscopy and the resection of laryngeal lesions. Further applications could include development of surgical techniques and instruments, and use in accreditation of training and revalidation of trained surgeons. © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.


Schreuder, H. W. R., R. Wolswijk, et al. (2012). “Training and learning robotic surgery, time for a more structured approach: A systematic review.” BJOG: An International Journal of Obstetrics and Gynaecology 119(2): 137-149.

Background Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons. Objectives To review the literature on training and learning strategies for robotic assisted laparoscopic surgery. Search strategy A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed. Selection criteria We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism. Data collection and analysis Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation. Main results We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme. Authors’ conclusions Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes. © 2011 RCOG.