Abstrakt Ostatní Únor 2012

Carter, J., R. Penson, et al. (2012). “Contemporary quality of life issues affecting gynecologic cancer survivors.” Hematology/Oncology Clinics of North America 26(1): 169-194.

Regardless of cancer origin or age of onset, the disease and its treatment can produce short- and long-term sequelae (ie, sexual dysfunction, infertility, or lymphedema) that adversely affect quality of life (QOL). This article outlines the primary contemporary issues or concerns that may affect QOL and offers strategies to offset or mitigate QOL disruption. These contemporary issues are identified within the domains of sexual functioning, reproductive issues, lymphedema, and the contribution of health-related QOL in influential gynecologic cancer clinical trials. © 2012 Elsevier Inc.


Cavallo, F., A. Pietrabissa, et al. (2012). “Proficiency assessment of gesture analysis in laparoscopy by means of the surgeons musculo-skeleton model.” Annals of Surgery 255(2): 394-398.

Objective: This article presents the implementation of surgeons musculo-skeletal model for gesture analysis in laparoscopy, thereby providing a complete account of the objective metrics needed to evaluate surgical performance and to improve the design of new surgical instruments including robotic instrumentation for surgical procedures. Background: Previous published work has been based exclusively on the kinematics involved whereas, this study is focused on the dynamics and muscle contraction analysis to assess loads on bones and muscle fatigue during simulation of surgical interventions. Methods: Nine medical students and 2 fully trained surgeons participated in the experimental sessions using a virtual laparoscopic simulator. Movement was acquired by means of an Optical Localization System and processed by means of the biomechanical software platform ADAMS-LifeMOD. Results: The musculo-skeletal analysis allows calculation of how the muscles are used and their respective mean work during the exercises. Results, relative to biceps and trapezius for left and right arm, clearly demonstrate different proficiencies between surgeons and medical students and highlight differences in using different surgical instruments and assumption of different postures. Conclusions: The model provides data on the evaluation of biomechanical parameters of surgical gesture not only in kinematic terms but also includes analysis of the dynamics of muscle contraction analysis during surgical manipulations. © 2012 by Lippincott Williams & Wilkins.


Fiore, J. F., L. Browning, et al. (2012). “Hospital discharge criteria following colorectal surgery: A systematic review.” Colorectal Disease 14(3): 270-281.

Aim The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature. Methods A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study. Results The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined. Conclusion A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures. © 2010 The Authors. Colorectal Disease © 2010 The Association of Coloproctology of Great Britain and Ireland.


Shander, A. and M. Javidroozi (2012). “Strategies to reduce the use of blood products: A US perspective.” Current Opinion in Anaesthesiology 25(1): 50-58.

PURPOSE OF REVIEW: To describe the recent developments in the strategies to reduce allogeneic blood transfusions with emphasis on the impact on clinical outcomes. RECENT FINDINGS: Concerns over the safety, efficacy, and supply of allogeneic blood continue to necessitate its judicious use as the standard of care. Patient blood management is emerging as a multidisciplinary, multimodality strategy to address anemia and decrease bleeding with the goal of reduced transfusions and improved patient outcomes. Common risk factors for transfusion include anemia, blood loss, and inappropriate transfusion decisions. Several approaches are available to mitigate these. Recent data continue to support the effectiveness of various hematinics, hemostatic agents and devices, as well as intermittent discontinuation of anticoagulant therapy. Use of autotransfusion techniques, particularly cell salvage, is the other strategy with accumulating data supporting its safety and efficacy. Finally, implementation of evidence-based transfusion guidelines will help to target allogeneic blood to those patients who are likely to benefit from it and thus reduce or eliminate unnecessary exposure to blood. SUMMARY: Patient blood management is the timely use of safe and effective medical and surgical techniques designed to prevent anemia and decrease bleeding in an effort to improve patient outcome. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Van Den Berg, N. S., F. W. B. Van Leeuwen, et al. (2012). “Fluorescence guidance in urologic surgery.” Current Opinion in Urology 22(2): 109-120.

Purpose of Review: Fluorescent tracers can provide anatomical and functional information without altering the visual surgical field. Despite the advances that are being made in tracer development, only a few fluorescent tracers are available for urological interventions. Recent Findings: Protoporphyrin IX, hypericin, fluorescein, and indocyanine green were shown to facilitate surgical resection in various ways. Hybrid imaging agents, combining radio and fluorescent labels, have shown improved integration between preoperative and intraoperative imaging. With the rise of surgical fluorescence guidance, various camera systems have been developed that are tailored for optimal detection of the fluorochromes of interest. Summary: In this review, the basics of fluorescence-guided surgery, including tracer and hardware requirements are discussed. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Guterman, J. (2012). “Generation robot.” Harvard Business Review 90(1-2): 150-151.


Sánchez-Martín, F. M. and H. Villavicencio (2012). “Comments to the Article «Robotic Surgery: History and Impact on Teaching».” Comentarios al artículo «Cirugía robótica: historia e impacto en la enseñanza».


Simorov, A., R. S. Otte, et al. (2012). “Review of surgical robotics user interface: what is the best way to control robotic surgery?” Surgical Endoscopy.

BACKGROUND: As surgical robots begin to occupy a larger place in operating rooms around the world, continued innovation is necessary to improve our outcomes. METHODS: A comprehensive review of current surgical robotic user interfaces was performed to describe the modern surgical platforms, identify the benefits, and address the issues of feedback and limitations of visualization. RESULTS: Most robots currently used in surgery employ a master/slave relationship, with the surgeon seated at a work-console, manipulating the master system and visualizing the operation on a video screen. Although enormous strides have been made to advance current technology to the point of clinical use, limitations still exist. A lack of haptic feedback to the surgeon and the inability of the surgeon to be stationed at the operating table are the most notable examples. The future of robotic surgery sees a marked increase in the visualization technologies used in the operating room, as well as in the robots’ abilities to convey haptic feedback to the surgeon. This will allow unparalleled sensation for the surgeon and almost eliminate inadvertent tissue contact and injury. CONCLUSIONS: A novel design for a user interface will allow the surgeon to have access to the patient bedside, remaining sterile throughout the procedure, employ a head-mounted three-dimensional visualization system, and allow the most intuitive master manipulation of the slave robot to date.


Sumi, Y., P. W. Dhumane, et al. (2012). “Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci ® Surgical System.” Journal of Robotic Surgery: 1-6.

We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon. © 2012 Springer-Verlag London Ltd.




Ahmed, I. (2011). “Moving paradigm towards scarless surgery (less is more).” Journal of the College of Physicians and Surgeons Pakistan 21(12): 721-722.


Bazzi, W., O. Raheem, et al. (2012). “Natural orifice transluminal endoscopic surgery in urology: Review of the world literature.” Urology Annals 4(1): 1-5.

Natural orifice transluminal endoscopic surgery (NOTES) has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES.


Bencsath, K. P., G. Falk, et al. (2012). “Single-Incision Laparoscopic Cholecystectomy: Do Patients Care?” Journal of Gastrointestinal Surgery 16(3): 535-539.

Introduction: Single-incision approaches to laparoscopic cholecystectomy typically involve increasing the size of the umbilical incision and eliminating three smaller incisions, but it is not intuitive that patients would view this as a benefit. We hypothesize that when patient satisfaction with standard laparoscopic cholecystectomy is assessed, most dissatisfaction will be linked to the umbilical incision and, given the option, patients would actually wish to eliminate this incision. Methods: Two hundred eighty-one female patients aged 18 to 40 years who underwent laparoscopic cholecystectomy over a 2-year period were identified, and data were collected on 125 patients. Results: Fewer than half of patients correctly remembered the number of incisions they had, with 57 patients (45. 6%) recalling fewer incisions than were present. Of 58 patients reporting one site to be more painful, 38 (65. 5%) cited the umbilical site as the most painful. Eighty-one patients (68. 6%) would have preferred to eliminate an incision, with 51 of these (63. 0%) choosing to eliminate the umbilical incision. Conclusion: As single-incision cholecystectomy enlarges what is already a painful and undesirable incision, and since patients often do not recall the smaller incisions, we should ask ourselves whether surgeons and industry care more about this technique than do the patients to whom we offer it. © 2011 The Society for Surgery of the Alimentary Tract.


Fareed, K., O. M. Zaytoun, et al. (2012). “Robotic single port suprapubic transvesical enucleation of the prostate (R-STEP): initial experience.” BJU International.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Single port transvesical enucleation of the prostate (STEP) performed through a solitary suprapubic incision using a single access port inserted directly into the bladder has been demonstrated to be technically feasible but still challenging.3. Despite being feasible and providing adequate relief of bladder outlet obstruction, robotic STEP carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. OBJECTIVE: * To report our initial experience with a novel robot assisted single port procedure for the management of benign prostatic hyperplasia (BPH). METHODS: * Between March 2009 and July 2010, nine patients with symptomatic BPH were scheduled for robotic single port suprapubic transvesical enucleation of the prostate (R-STEP). * Prior to intervention, all were submitted to preoperative transrectal ultrasound of the prostate and uroflowmetry. * The surgical procedure included an initial transurethral incision of the prostatic apex. With the patient in the supine position, an approximate 3 cm lower midline incision was made. A cystotomy was created and a GelPort(R) laparoscopic system positioned in the bladder. The da Vinci S robotic operating system was docked through the GelPort(R) platform and enucleation was performed. * Perioperative outcomes and short-term postoperative functional outcomes were assessed. Intra-operative and postoperative complications, graded according to the Dindo-Clavien system, were recorded. RESULTS: * One patient was excluded from the analysis as the procedure was aborted and converted to open simple prostatectomy. * Median operative time was 3.9 h. Median visual analogue pain scale on discharge was 2. Estimated blood loss was 425 mL. Two patients required intra-operative blood transfusion. * Postoperatively, two patients developed clot retention and required evacuation and fulguration (grade IIIb), one of them had a deep vein thrombosis (grade II) and a urinary tract infection (grade II). One patient was admitted to the intensive care unit after a myocardial infarction (grade IVa). All patients were discharged after a median of 4.5 days. * There was almost three and four times postoperative improvement in both median maximum flow (Qmax) and average flow (Qave) rates, respectively. CONCLUSION: * The first series of R-STEP is reported herein. Despite being feasible and providing adequate relief of bladder outlet obstruction, the procedure carries a high risk of complications. Further evolution of the technique is likely to be strictly dependent on the development of instrumentation. Thus, its role in the surgical armamentarium of BPH remains to be determined.


Gaujoux, S., L. Maggiori, et al. (2012). “Safety, Feasibility, and Short-Term Outcomes of Single Port Access Colorectal Surgery: A Single Institutional Case-Matched Study.” Journal of Gastrointestinal Surgery 16(3): 629-634.

Background: Feasibility of single port access (SPA) colorectal surgery has been established for various procedures from ileocecal resection to proctectomy. Nevertheless, its benefits compared to conventional laparoscopy still need to be assess. The aim of this study was to compare SPA to conventional colorectal laparoscopic surgery in a single institutional case-matched study. Methods: From July 2009 to July 2010, 25 SPA colorectal resections were matched on main predictive risk factors of postoperative complications, in a one to two fashion, with patient having the same procedure for the same indication by conventional laparoscopy. Results: Patient characteristics were comparable between both groups. SPA was successfully performed in 24 of 25 patients, with a need to conversion to standard laparoscopy in one case (4%). SPA was associated with a significantly shorter median operative time (130 vs 180 min, p = 0. 04) and hospital stay (6 vs 7 days, p = 0. 005). Postoperative morbidity rates were similar between the two groups (4% vs 16%, p = 0. 25). Conclusion: SPA colorectal resection can be safely performed in selected patients with results comparable to those observed after conventional laparoscopic surgery. However, larger studies including randomized controlled trail are needed to demonstrate possible benefits of SPA colorectal resection over conventional colorectal laparoscopic surgery. © 2011 The Society for Surgery of the Alimentary Tract.


Karimyan, V., F. Orihuela-Espina, et al. (2012). “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. © 2011 Surgical Associates Ltd.


Park, J. H., M. K. Walz, et al. (2011). “Robot-assisted posterior retroperitoneoscopic adrenalectomy: single port access.” J Korean Surg Soc 81 Suppl 1: S21-24.

Laparoscopic adrenalectomy has become a gold standard in adrenal gland surgery. More recently, some minimally invasive trials have been conducted on single access surgery on the adrenal gland. In this study, we introduce our first experiences of robot-assisted posterior retroperitoneoscopic adrenalectomy using single-port access and the da Vinci system.




Ahmed, K., T. Amer, et al. (2011). “How to develop a simulation programme in urology.” BJU International 108(11): 1698-1702.

            What’s known on the subject? and What does the study add? Inanimate trainers and simulators have been shown to facilitate the skill acquisition of urologists. However, there are significant challenges to integrating standalone simulation programmes into mainstream urology curricula. This study provides a framework to overcome these challenges and discusses the advantages of centralised urology simulation centres and their potential to serve as key adjuncts in the certification and validation process of urologists. Fixed performance-based outcomes of inanimate trainers and simulators have been praised as useful adjuncts in urology for reducing the learning curve associated with the acquisition of new technical and non-technical skills without compromising patient safety. Simulators are becoming an integral part of the urology training curriculum and their effectiveness is totally dependent on the structure of the programme implemented. The present paper discusses the fundamental concepts of centralized urology centres and their potential to serve as key adjuncts in the certification and validation process of urologists. In summary, proficiency-based curricula with well structured endpoints and objective tools for validating proficiency are critical in developing a simulation programme in urology. We concludes that more educational research into the outcomes of integrated urology curricula followed by trainee/trainer opinion surveys will help address some of these criteria. © 2011 BJU INTERNATIONAL.


Dulan, G., R. V. Rege, et al. (2012). “Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology.” American Journal of Surgery.

BACKGROUND: The authors previously developed a comprehensive, proficiency-based robotic training curriculum that aimed to address 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to determine the content and face validity of this curriculum. METHODS: Expert robotic surgeons (n = 12) rated each deconstructed skill regarding relevance to robotic operations, were oriented to the curricular components, performed 3 to 5 repetitions on the 9 exercises, and rated each exercise. RESULTS: In terms of content validity, experts rated all 23 deconstructed skills as highly relevant (4.5 on a 5-point scale). Ratings for the 9 inanimate exercises indicated moderate to thorough measurement of designated skills. For face validity, experts indicated that each exercise effectively measured relevant skills (100% agreement) and was highly effective for training and assessment (4.5 on a 5-point scale). CONCLUSIONS: These data indicate that the 23 deconstructed skills accurately represent the appropriate content for robotic skills training and strongly support content and face validity for this curriculum.


Dulan, G., R. V. Rege, et al. (2012). “Proficiency-based training for robotic surgery: construct validity, workload, and expert levels for nine inanimate exercises.” Surgical Endoscopy.

BACKGROUND: We previously developed nine inanimate training exercises as part of a comprehensive, proficiency-based robotic training curriculum that addressed 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to evaluate construct validity, workload, and expert levels for the nine exercises. METHODS: Expert robotic surgeons (n = 8, fellows and faculty) and novice trainees (n = 4, medical students) each performed three to five consecutive repetitions of nine previously reported exercises (five FLS models with or without modifications and four custom-made models). Each task was scored for time and accuracy using modified FLS metrics; task scores were normalized to a previously established (preliminary) proficiency level and a composite score equaled the sum of the nine normalized task scores. Questionnaires were administered regarding prior experience. After each exercise, participants completed a validated NASA-TLX Workload Scale to rate the mental, physical, temporal, performance, effort, and frustration levels of each task. RESULTS: Experts had performed 119 (range = 15-600) robotic operations; novices had observed </=1 robotic operation. For all nine tasks and the composite score, experts achieved significantly better performance than novices (932 +/- 67 vs. 618 +/- 111, respectively; P < 0.001). No significant differences in workload between experts and novices were detected (32.9 +/- 3.5 vs. 32.0 +/- 9.1, respectively; n.s.). Importantly, frustration ratings were relatively low for both groups (4.0 +/- 0.7 vs. 3.8 +/- 1.6, n.s.). The mean performance of the eight experts was deemed suitable as a revised proficiency level for each task. CONCLUSION: Using objective performance metrics, all nine exercises demonstrated construct validity. Workload was similar between experts and novices and frustration was low for both groups. These data suggest that the nine structured exercises are suitable for proficiency-based robotic training.


Hattori, A., N. Suzuki, et al. (2012). “Training System for NOTES and SPS Surgery Robot That Enables Spatiotemporal Retrospective Analysis of the Training Process.” Studies in Health Technology and Informatics 173: 166-170.

Within the digestive organ surgery robot R&amp;D project, our research team aims to develop a surgical robot training device with an interface identical to that of the actual device. The training device uses an organ model that changes shape in real time to train operators to grab, cut open, and cut off soft tissues and close wounds using the actual device. To increase the effectiveness of the training device, we added functions to save the movements of the robot in training and changes in the operation field. By recreating the situation during training, we were able to analyze in four dimensions (4D) various changes in the operation field that the operator cannot see during training. This new function not only enabled us to analyze the contents of the training in detail, but also to report any problems in development and design of the actual device.


Hung, A. J., C. K. Ng, et al. (2012). “Validation of a novel robotic-assisted partial nephrectomy surgical training model.” BJU International.

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? One area of particular growth for robotic surgery has been partial nephrectomy. Despite a perceived notion that robotic-assisted partial nephrectomy is more easily adaptable compared to laparoscopic partial nephrectomy, there is nonetheless an associated learning curve. Validated training models with a corresponding assessment method for robotic-assisted partial nephrectomy were previously unavailable. We have designed and validated a RAPN surgical model appropriate for resident and fellow training. OBJECTIVE: * To evaluate the face, content and construct validities of a novel ex vivo surgical training model for robotic-assisted partial nephrectomy (RAPN). METHODS: * We prospectively identified participants as novice (not completed any robotic console cases), intermediate (at least one robotic console case but <100 cases), and expert (>/=100 robotic console cases). Each participant performed a partial nephrectomy using the da Vinci Si Surgical System on an ex vivo porcine kidney with an embedded Styrofoam ball that mimics a renal tumour. Subjects completed a post-study questionnaire assessing training model realism and utility. Participants were anonymously judged by three expert reviewers using a validated laparoscopic assessment tool. Performance between groups was compared using the tukey-kramer test. RESULTS: * The 46 participants recruited for this study included 24 novices, nine intermediates, and 13 experts. Overall, expert surgeons rated the training model as ‘very realistic’ (median visual analogue score 7/10) (face validity). Experts also rated the model as an ‘extremely useful’ training tool for residents (median 9/10) and fellows (9/10) (content validity), although less so for experienced robotic surgeons (5/10). Experts outscored novices on overall performance (P= 0.0002) as well as individual metrics, including ‘depth perception,”bimanual dexterity,”efficiency,”tissue handling,”autonomy,”precision,’ and ‘instrument and camera awareness’ (P < 0.05) (construct validity). Experts similarly outperformed intermediates in most metrics (P < 0.05). CONCLUSION: * Our novel ex vivo RAPN surgical model has demonstrated face, content and construct validity. Future development of this model should include simulation of haemostasis management and renal reconstruction.


Jansen, F. W. and E. Hiemstra (2012). “Laparoscopic skills training using inexpensive box trainers: Which exercises to choose when constructing a validated training course.” BJOG: An International Journal of Obstetrics and Gynaecology 119(3): 263-265.

Kumar, R., A. Jog, et al. (2012). “Objective measures for longitudinal assessment of robotic surgery training.” Journal of Thoracic and Cardiovascular Surgery.

Objectives: Current robotic training approaches lack the criteria for automatically assessing and tracking (over time) technical skills separately from clinical proficiency. We describe the development and validation of a novel automated and objective framework for the assessment of training. Methods: We are able to record all system variables (stereo instrument video, hand and instrument motion, buttons and pedal events) from the da Vinci surgical systems using a portable archival system integrated with the robotic surgical system. Data can be collected unsupervised, and the archival system does not change system operations in any way. Our open-ended multicenter protocol is collecting surgical skill benchmarking data from 24 trainees to surgical proficiency, subject only to their continued availability. Two independent experts performed structured (objective structured assessment of technical skills) assessments on longitudinal data from 8 novice and 4 expert surgeons to generate baseline data for training and to validate our computerized statistical analysis methods in identifying the ranges of operational and clinical skill measures. Results: Objective differences in operational and technical skill between known experts and other subjects were quantified. The longitudinal learning curves and statistical analysis for trainee performance measures are reported. Graphic representations of the skills developed for feedback to the trainees are also included. Conclusions: We describe an open-ended longitudinal study and automated motion recognition system capable of objectively differentiating between clinical and technical operational skills in robotic surgery. Our results have demonstrated a convergence of trainee skill parameters toward those derived from expert robotic surgeons during the course of our training protocol. © 2011 The American Association for Thoracic Surgery.


Louie-Johnsun, M., R. Ouyang, et al. (2012). “Laparoscopic radical prostatectomy: Introduction of training during our first 50 cases.” ANZ Journal of Surgery.

Background: The study aims to assess the initial experience of laparoscopic radical prostatectomy (LRP) in a regional centre in Australia which includes Fellowship training during our first 50 cases. Methods: Data were collected prospectively from our first 50 consecutive patients who underwent LRP for localized prostate cancer between September 2009 and October 2010. All cases were performed or supervised by the primary surgeon. Patient details, operative details, complications, early oncological and functional outcomes were analysed. Results: The median age was 65 (45-76) years and median preoperative prostate-specific antigen was 7.5 (2.5-23) ng/mL, with palpable disease present in 48%. Using D’Amico’s risk stratification, 14%, 74% and 12% were in low, intermediate and high-risk categories, respectively. Forty percent of cases were training cases with a median of 5 (2-8) of 10 operative steps performed by the Fellow. There was one open conversion and no rectal injuries. Mean operative time was 288 (175-440)min and with blood transfusion rate of 6%. Mean length of stay was 2.5 (1-6)days. Positive surgical margin rates for pT2 and pT3 disease were 14% and 52%, respectively, although for the last 25 cases they were 7% and 30%, respectively. Continence rate was 86% at 6months, and 45% and 33% of preoperatively potent patients were potent after bilateral and unilateral nerve preservation at 6months. Conclusion: LRP has been safely introduced in a regional centre with establishment of a Fellowship training programme, with early results comparable with other open, laparoscopic and robotic series. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.


Nakamura, L. Y., G. L. Martin, et al. (2012). “Comparing the portable laparoscopic trainer with a standardized trainer in surgically naïve subjects.” Journal of Endourology 26(1): 67-72.

Purpose: To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in subjects who have had no previous laparoscopic experience. Materials and Methods: Twenty-nine medical students were given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group subjects were advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared. Results: Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. The facility group did objectively better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 vs 2.4 point average increase, P=0.03). Conclusions: Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is comparable to the standard trainer for improvement of basic laparoscopic skills. © 2012, Mary Ann Liebert, Inc.


Punak, S. and S. Kurenov (2012). “A simple master-slave control mapping setup to learn robot-assisted surgery manipulation.” Studies in Health Technology and Informatics 173: 356-358.

A simple, but yet effective application for learning and testing instrument manipulation of available (and future) master-slave control robot-assisted surgical systems has been created. As an example, the paper describes a simple mapping of da Vinci surgical system master-slave control with two haptic devices acts as the master control.


Sankaranarayanan, G., V. S. Arikatla, et al. (2012). “A simulation framework for tool tissue interactions in robotic surgery.” Studies in Health Technology and Informatics 173: 440-444.

Robotic surgery is preferred over other traditional methods due to reduced complications and improved ergonomics for the operating surgeon. They are also a perfect platform for telesurgery. Automated surgery in which the robot is allowed to do various surgical tasks with minimal intervention is getting wider attention recently. In this paper, we introduce a simulation framework that can realistically simulate tool tissue interactions in robotic surgery, which can be used to design and test various control methodologies for automated surgical tasks. We present preliminary results from simulating a simple model of a surgical robot interacting with a volumetric model while performing a grasping and hold task.


Schreuder, H. W., R. Wolswijk, et al. (2012). “Training and learning robotic surgery, time for a more structured approach: a systematic review.” BJOG 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.


Sumi, Y., P. W. Dhumane, et al. (2012). “Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci ® Surgical System.” Journal of Robotic Surgery: 1-6.

We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon. © 2012 Springer-Verlag London Ltd.


Sweet, R. M., R. Beach, et al. (2012). “Introduction and validation of the american urological association basic laparoscopic urologic surgery skills curriculum.” Journal of Endourology 26(2): 190-196.

Background and Purpose: The Fundamentals of Laparoscopic Surgery (FLS ™) skills curriculum has validity evidence supporting use for assessing laparoscopic skills for general surgeons. As charged by the American Urological Association (AUA) Laparoscopy, Robotic, and New Surgical Technology Committee, we sought to develop and validate a urology-specific FLS, referred to as the Basic Laparoscopic Urologic Surgery (BLUS) skills curriculum. The psychomotor component consists of three existing FLS tasks and one new clip-applying task. Materials and Methods: An animate renal artery model was designed for a clip-applying skills task. We assessed the acceptability and construct validity of using BLUS for basic laparoscopic skills assessment for urologists. A cohort of practicing urologists, fellows, residents, and medical students completed the tasks at the AUA Annual Meetings in 2010 and 2011. Results: All exercises were acceptable and demonstrated excellent face and content validity (&gt;4.5/5 on a five-point Likert scale). Practicing clinical urologists (N=81) outperformed residents and medical students (N=35) in time to completion of circle cut (P&lt;0.01) and in keeping scissor tips toward the center of the circle (P&lt;0.01). Practicing urologists who reported &gt;3 laparoscopic procedures per week were faster at the peg-transfer exercise (P&lt;0.05) and the cutting exercise (P&lt;0.01) than those reporting one to two procedures. More errors were committed for clip-applying among practicing urologists who perform one to two laparoscopic procedures (1.24) vs. those who perform &gt;3 procedures (0.57) per week (P&lt;0.01). Conclusions: All exercises including the novel clip-applying model demonstrated good acceptability and evidence of construct validity (face, content, concurrent and convergent validity) for assessment of basic laparoscopic skill for urologic surgeons. © Copyright 2012, Mary Ann Liebert, Inc. 2012.