“Intraoperative augmented reality for laparoscopic colorectal surgery by intraoperative near-infrared fluorescence imaging and optical coherence tomography.”
Cahill, R. A. and N. J. Mortensen (2010).
Minerva Chirurgica 65(4): 451-461.
Advances in imaging quality and capability have been the major driver of the laparoscopic revolution that has dramatically impacted upon operative strategies and surgical patient care in recent years. Increasingly now the technological capacity is becoming available to supraselect or extend the useful clinical range of the electromagnetic spectrum beyond visible or white light This has markedly broadened the intraprocedural optical information available at intraluminal endoscopy and there is likely to be considerable similar benefit for laparoscopy. Rather than narrow band or ultraviolet imaging however, it is the near infrared (NIR) spectrum that seems of most potential to exploit during intra-abdominal endoscopy in particular as this energy range is capable of penetrating relatively deeply into tissues such as the mesentery and bowel wall without inducing thermal damage due to heat dissipation or indeed the intracellular effects associated with higher energy, shorter wavelength energies. By incorporating the NIR spectrum alongside more conventional laparoscopic imaging, a greater appreciation of tissue architecture, character and quality is possible in particular with respect to lymphatic and vascular channel anatomy and flow dynamics and also real-time optical histology (by NIR optical coherence tomography). Such a facility may significantly aid critical intraoperative decision making during colorectal operations by informing the surgeon regarding the most biologically relevant lymphatic basin and lymph nodes for any target area of interest (especially important if considering tailored operative extent for colorectal neoplasia), the sufficiency and quality of arterial supply (and hence inform re the perfusion of stapled intestinal ends prior to reanastomosis) and perhaps even in situ pathological assessment. This article provides a state of art overview of the fascinating potential of this emergent technological capability.
“Analgesic and antiemetic needs following minimally invasive vs open staging for endometrial cancer.” Fleming, N. D., L. J. Havrilesky, et al. (2011).
American Journal of Obstetrics and Gynecology 204(1).
OBJECTIVE: We sought to assess perioperative outcomes of minimally invasive vs open endometrial cancer staging procedures. STUDY DESIGN: A total of 181 consecutive patients underwent open or minimally invasive hysterectomy with or without lymphadenectomy. Perioperative outcomes, analgesic, and antiemetic use were compared. RESULTS: In all, 97 and 84 women underwent open and minimally invasive staging procedures, respectively. In the open staging group, median anesthesia time was shorter (197 vs 288 minutes; P < .0001), but recovery room stay (168 vs 140 minutes; P = .01) and hospital stay (4 vs 1 day; P < .0001) were longer. Median narcotic (13 vs 43 mg morphine equivalents; P < .0001) and antiemetic (43% vs 25%; P = .01) use were lower for minimally invasive surgery in the first 24 hours postoperatively. Median estimated blood loss was lower for minimally invasive procedures (100 vs 300 mL; P < .0001). CONCLUSION: Minimally invasive staging for endometrial cancer is associated with lower use of narcotics and antiemetics, and shorter hospital stay compared to open procedures. © 2011 Mosby, Inc.
“Measurement and Interpretation of Patient-Reported Outcomes in Surgery: An Opportunity for Improvement.”
Karanicolas, P. J., K. Bickenbach, et al. (2011).
Journal of Gastrointestinal Surgery: 1-8.
Background: Surgery may have a profound effect on patients’ health-related quality of life (QOL). To be optimally useful, trials that seek to guide clinical decision making should measure outcomes that are important to patients and report the results in a clinically meaningful way. We sought to explore how researchers currently measure and interpret QOL in surgical trials, using gastric cancer as a case study. Method: We performed a systematic review of randomized controlled trials (RCTs) of gastric cancer surgery published between 1966 and 2009 that included at least one patient-reported outcome (PRO). Investigators assessed trial eligibility and extracted data in duplicate using standardized forms, then resolved disagreements by consensus. Results: Our search identified 87 RCTs of gastric cancer surgery, of which 11 (13%) included at least one PRO. Ten RCTs measured one or more validated PROs, although six also included ad hoc measures. All manuscripts presented the results as raw scores and nine of the 11 trials identified a statistical difference between groups. All 11 manuscripts prominently reported the PRO results in the abstracts and conclusions, but only one discussed the clinical significance of the differences between groups. Conclusions: Most RCTs of gastric cancer surgery do not include measures of QOL and those that do suffer from important limitations. RCTs would be more useful to surgeons and patients if authors measured PROs and utilized existing approaches to present the results of PROs in ways that provide an intuitive sense of the magnitude of effects. © 2011 The Society for Surgery of the Alimentary Tract.
“Methodological issues in comparative effectiveness research: Clinical trials.”
Peduzzi, P., T. Kyriakides, et al. (2010).
American Journal of Medicine 123(12 SUPPL.).
The US Department of Veterans Affairs (VA) Cooperative Studies Program has been conducting comparative effectiveness clinical trials for nearly 4 decades in many disease areas, including cardiovascular disease/surgery, diabetes mellitus, mental health, neurologic disorders, cancer, infectious diseases, and rheumatoid arthritis. The features that have made this program advantageous for conducting comparative effectiveness clinical trials are described along with methodological considerations for future trials based on lessons learned from its experience conducting these types of studies. Some of the lessons learned involve managing risk factors, clinical equipoise, patient preferences, evolving technology, the use of usual care as a comparator and pharmaceutical issues related to study drug blinding. These issues are not unique to the VA but can play an important role in enabling valid comparisons between treatments that may have differences in delivery or mechanisms of action and could affect the execution and feasibility of conducting a clinical trial with a comparative effectiveness aim. We also outline some future directions for comparative effectiveness clinical trials. © 2010 Elsevier Inc. All rights reserved.
“Fertility-sparing surgery for young women with early-stage cervical cancer.”
Smith, J. R., S. Ghaem-Maghami, et al. (2011).
BJOG: An International Journal of Obstetrics and Gynaecology 118(3): 377-378.
“Differences in hand movements and task completion times between laparoscopic, robotically assisted, and open surgery: an in vitro study.”
Balasubramani, L., D. A. Milliken, et al. (2011).
Journal of Robotic Surgery: 1-4.
Surgical dexterity depends on economy and precision of movements, and this can be objectively measured using electromagnetic motion analysis. We have assessed the differences in hand movements and task completion times between open, laparoscopic and robotically assisted surgery during an exercise performed in vitro. A standard surgical exercise was performed using open, standard laparoscopic (SL) and robotically assisted laparoscopic (RAL) approaches. The total duration of the exercise was studied along with the number and duration of movements required to complete the exercise in each surgical modality. The time taken to complete the exercise was significantly longer in both the SL and RAL approaches when compared to the open route. However, it was found that RAL had significantly decreased number of movements (mean difference = 24 movements, P < 0.006) but a longer duration of each movement when compared to SL (mean difference = 0.13 s, P < 0.001). This study shows objectively that the exercise took longer to complete using the RAL approach than the standard open approach. However, RAL had more purposeful movements and required fewer movements to complete the exercise compared to SL. © 2011 Springer-Verlag London Ltd.
“Anaesthesia and robotic surgery: general principles.”
Francon, D. (2010).
Anesthésie et cœlioscopie robotisée: principes généraux: 1-5.
Robot-assisted laparoscopy has exponential growth. It imposes specific exaggerated postures for procedures of long duration. Clinical recommendations for this procedure are formulated. The influence of the combined effects of the Trendelenburg position and CO2 pneumoperitoneum must be known by the anaesthesia team and combined with anticipation and protocols in order to provide safe patient care during the preand postoperative period. Mean airway pressures, pulmonary compliance, intra-abdominal pressures and adequate muscle paralysis must be monitored frequently. Intraoperative considerations must be addressed by the anaesthesiologist and communicated to the surgeon for adaptation. The anaesthesiologist and the surgeon must work as a teamand make modifications as necessary in order tomake safer this innovative surgical practice. © 2010 Springer Verlag France.
“Robotic surgery: review of the latest advances, risks, and outcomes.”
Gastrich, M. D., J. Barone, et al. (2011).
Journal of Robotic Surgery: 1-19.
Using differing levels of evidence, we developed criteria to critically review 21 scientifically peer-reviewed articles on robot-assisted surgeries in various medical fields. The advantages and limitations of robotic systems are discussed and compared with traditional surgical methods. Since training in the use of robotic skills is essential, various training models are discussed to teach the complex skills necessary for robotic surgery. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. In addition, trials are needed to identify simulators for learners that can enhance the da Vinci performance in order to shorten the learning curve. © 2011 Springer-Verlag London Ltd.
“Robotic Surgical Training Program in Gynecology: How to Train Residents and Fellows.”
Geller, E. J., K. M. Schuler, et al. (2011).
Journal of Minimally Invasive Gynecology.
A protocol was established to standardize surgical training using the da Vinci Surgical System. Third- and fourth-year residents and first-year fellows in obstetrics and gynecology participated. The protocol includes online instruction and 2 hands-on modules: platform set-up and surgical skills. Platform set-up provides orientation to the console, visual platform, surgical cart (“robot”), camera set-up, port placement, and instrument insertion and removal. Surgical skills includes specific drills using rubber models that simulate human tissue: manipulation, dissection, and simple and advanced suturing. Performance times were recorded for each trainee, as well as previous robotic experience. Times were compared with goals established by Intuitive Surgical, Inc., to assess feasibility of this protocol and baseline robotic surgical aptitude. All trainees (n = 17) completed the training protocol. Performance times met goals for docking and dissection. These times also varied according to level of training. Performance times for manipulation and simple and advanced suturing were prolonged across all groups. Overall pass rates were 100% for docking, 90% for dissection, 11.8% for manipulation, and 0% for simple and advanced suturing. Dissection pass rates varied according to level of training. Performance times and pass rates were not improved with higher level of training or previous robotic experience. Resident and fellow instruction in new surgical technology is an important part of training in obstetrics and gynecology. Herein is reported a method to accomplish robotic training that standardizes instruction and assessment of skills. © 2011 AAGL.
“Ten years later, what is the role of robotic assistance in surgical oncology?”
Houvenaeghel, G. and E. Lambaudie (2010).
Dix ans après, quelle est la place de l’assistance robotisée en chirurgie oncologique ?: 1.
“Future and conclusions about robotic surgery – Indications, techniques, diffusion and ergonomics.”
Marchal, F., P. Rauch, et al. (2010).
Perspectives de la chirurgie robotique et conclusions – Indications, techniques, diffusion et ergonomie: 1-6.
Robotic surgery is a significant technological innovation of the last 10 years. Although the advantages of robotic surgery for surgeons are obvious, robotic surgery must also demonstrate benefits for patients. We present current and future indications in oncological surgery and technological advances in medicine. Technological improvements and low cost will make this technique popular. Learning time is also shorter than for standard laparoscopy. The most obvious benefit is for the surgeon, with better ergonomics and probably a decrease of musculoskeletal diseases secondary to standard laparoscopy. © 2010 Springer Verlag France.
“Differences in Grip Forces Among Various Robotic Instruments and da Vinci Surgical Platforms.”
Mucksavage, P., D. C. Kerbl, et al. (2011).
Journal of Endourology.
Abstract Introduction: The da Vinci((R)) surgical platform is becoming increasingly available and utilized. Due to the lack of haptic feedback, visual cues are necessary to estimate grip forces and tissue tensions during surgery. We directly measured the grip forces of robotic EndoWrist((R)) instruments using the three available da Vinci robotic surgical platforms. Methods: Robotic instruments were tested in the da Vinci S, Si, and Standard systems. A load cell was placed in a housing unit that allowed for measurement of the grip forces applied by the tip of each robotic instrument. Each instrument was tested six times, and all data were analyzed using Student’s t-tests or analysis of variance when appropriate. Results: Slight differences in grip force were seen when the instrument was tested through 2 degrees of freedom at the tip (p = 0.02, analysis of variance) and when comparing a new instrument to an older instrument (p = 0.001 at the neutral position). There was no statistical difference in grip force between the left and right robotic arms. There was a broad range of grip forces between the various robotic instruments. The lowest grip force was registered in the double fenestrated grasper (2.26 +/- 0.15 N), whereas the highest was seen in the Hem-o-lok((R)) clip applier (39.92 +/- 0.89 N). In comparison to the S and Si, the Standard platform appeared to have significantly higher grip forces. Conclusion: Different grip forces were observed among the various robotic instruments commonly used during urologic surgery and between the Standard and the S and Si platforms.
“Robots and service innovation in health care.”
Oborn, E., M. Barrett, et al. (2011).
Journal of Health Services Research and Policy 16(1): 46-50.
Robots have long captured our imagination and are being used increasingly in health care. In this paper we summarize, organize and criticize the health care robotics literature and highlight how the social and technical elements of robots iteratively influence and redefine each other. We suggest the need for increased emphasis on sociological dimensions of using robots, recognizing how social and work relations are restructured during changes in practice. Further, we propose the usefulness of a ‘service logic’ in providing insight as to how robots can influence health care innovation. © The Royal Society of Medicine Press Ltd. 2011.
“Robotics in urological surgery: Review of current status and maneuverability, and comparison of robot-assisted and traditional laparoscopy.”
Singh, I. (2011).
Computer Aided Surgery 16(1): 38-45.
To assess the current state of robot-assisted urological surgery, the literature concerning surgical robotic systems, surgical telemanipulators and laparoscopic systems was reviewed. Aspects of these systems pertaining to maneuverability were evaluated, with a view to quantifying their stability and locomotive properties and thereby determining their suitability for use in assisted laparoscopic procedures, particularly robot-assisted laparoscopic urological surgery. The degree of maneuverability and versatility of a robotic system determine its utility in the operating room, and the newer-generation surgical robotic systems have been found to possess a higher degree of maneuverability than older class 1 and class 2 systems. It is now clearly established that robots have an important place in the urologist’s armamentarium for minimally invasive surgery; however, the long-term outcomes of several urological procedures (other than robot-assisted radical prostatectomy) performed with the da Vinci surgical robotic system have yet to be evaluated. © 2011 Informa UK Ltd. All rights reserved.
“Robot-assisted resection of paraspinal schwannoma.”
Yang, M. S., K. N. Kim, et al. (2011).
Journal of Korean Medical Science 26(1): 150-153.
Resection of retroperitoneal tumors is usually perfomed using the anterior retroperitoneal approach. Our report presents an innovative method utilizing a robotic surgical system. A 50-yr-old male patient visited our hospital due to a known paravertebral mass. Magnetic resonance imaging showed a well-encapsulated mass slightly abutting the abdominal aorta and left psoas muscle at the L4-L5 level. The tumor seemed to be originated from the prevertebral sympathetic plexus or lumbosacral trunk and contained traversing vessels around the tumor capsule. A full-time robotic transperitoneal tumor resection was performed. Three trocars were used for the robotic camera and working arms. The da Vinci Surgical System® provided delicate dissection in the small space and the tumor was completely removed without damage to the surrounding organs and great vessels. This case demonstrates the feasibility of robotic resection in retroperitoneal space. Robotic surgery offered less invasiveness in contrast to conventional open surgery. © 2011 The Korean Academy of Medical Sciences.
“Robot-assisted anterior lumbar interbody fusion in a Swine model in vivo test of the da vinci surgical-assisted spinal surgery system.”
Yang, M. S., H. Yoon do, et al. (2011).
Spine (Phila Pa 1976) 36(2): E139-143.
STUDY DESIGN: the use of the da Vinci Surgical System to perform an anterior lumbar interbody fusion in a swine model to identify the technical properties, processes, merits, demerits, and limitations of a video-assisted robotic surgical system. OBJECTIVE: this study was designed to demonstrate the feasibility of using a robotic surgical system to perform spinal surgery. SUMMARY OF BACKGROUND DATA: video-assisted laparoscopic anterior fusion was first reported in 1995 and afterward was spotlighted for several years. However, this technique has not become popular because of technical difficulties and complications associated with video-assisted procedures on the spine. As such, there is a demand for investigations to improve this technology. The da Vinci Surgical System provides 3-dimensional visualization as well as uniquely dexterous instruments that are remarkably similar to human hands. Video-assisted surgery with the da Vinci Surgical System robot has already provided great value to the fields of urology, cardiology, gynecology, and general surgery over the last decade. Preclinical studies for application of this system in spinal surgery have recently been conducted. METHODS: a pig underwent anterior lumbar interbody fusion using da Vinci Surgical System assistance, with Tyche expandable cages used for preparation of endplates and cage placement. The setup time, operation time, amount of bleeding, and the number of complications associated with robotic manipulation were recorded. Before euthanasia, the animal underwent radiologic examination to confirm proper placement of cages. RESULTS: the total duration of the procedure took 6 hours, with some complications related to frozen armsand robotic arm collision. Even so, there was neither any significant nerve or vessel injury nor peritoneal organ damage. Furthermore, radiologic assessment confirmed proper position of the cage in the center of the disc space. CONCLUSION: use of the da Vinci Surgical System to perform an anterior spinal procedure was shown to be safe and effective in a swine animal model. The utilization of this advanced technology shows promise to reduce the incidence of complications compared with other approaches. It requires further testing in animal models and cadavers, along with serial comparisons to current procedures.
“Interest of robot-assisted laparoscopy in the resident surgical training: major advantage or modern gadget?”
Coulomb, M. A., N. E. Menager, et al. (2010).
Place de la coelioscopie robot-assistée dans la formation de l’interne en chirurgie: atout majeur ou gadget moderne ?: 1-2.
The place and the potential value of robot-assisted laparoscopy in the training of residents in surgery have not yet been evaluated. The aim here is to highlight the role of residents, and the profit they may realize by participating in robot-assisted laparoscopy. We use our six months’ experience at the Prof. Houvenaeghel surgical department of gynaecologic oncology in Paoli-Calmettes Institute, Marseille. © 2010 Springer Verlag France.
“Toward effective pediatric minimally invasive surgical simulation.”
Hamilton, J. M., K. Kahol, et al. (2011).
Journal of Pediatric Surgery 46(1): 138-144.
Background/Purpose: Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons. Methods: We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency. Results: For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups. Conclusion: Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool. © 2011 Elsevier Inc. All rights reserved.
“Surgical Simulation in Pediatric Urologic Education.”
Lendvay, T. S. (2011).
Current Urology Reports: 1-7.
The drive to achieve improved patient outcomes and patient safety has led to innovation in surgical education. The century-old teaching paradigms of “see one, do one, teach one” and training by opportunity are inappropriate in a surgical world of rapidly introduced advanced technologies. The need for improved surgical education methods is no more critical than in pediatric surgery, where the complexity of patient diseases and the physical size of the patients tend to challenge the limitations of existing surgical technology and skill. Surgical simulation offers extraordinary opportunities to teach multiple clinical scenarios in a safe, nonhuman patient environment where performance feedback is immediate and objective. Although minimally invasive surgical techniques (laparoscopic and robotic) are ideally suited for computer-assisted or virtual reality training, medical decision-making simulation for minimally invasive surgery and open surgery is in its infancy and, arguably, the most important aspect of effective surgical practice. © 2011 Springer Science+Business Media, LLC.