Abstrakt Ostatní Duben 2012 | Česká společnost robotické chirurgie ČLS JEP

Collins, J., P. Dasgupta, et al. (2012). “Globalization of surgical expertise without losing the human touch: Utilising the network, old and new.” BJU International 109(8): 1129-1131.

Cronin, B., V. W. Sung, et al. (2012). “Vaginal cuff dehiscence: Risk factors and management.” American Journal of Obstetrics and Gynecology 206(4): 284-288.

Vaginal cuff dehiscence and evisceration are rare but serious complications of pelvic surgery, specifically hysterectomy. The data on risks of vaginal cuff dehiscence are variable, and there is no consensus on how to manage this complication. In our review, we present a summary of the risk factors, with symptoms, precipitating events, and treatment options for patients with vaginal cuff dehiscence after pelvic surgery. In addition, we provide a review of the current literature on this important surgical outcome and suggestions for future research on the incidence and prevention of vaginal cuff dehiscence. © 2012 Mosby, Inc.

Raschid Hoda, M. and P. Fornara (2012). “[Nephrectomy - pro laparoscopic.].” Urologe. Ausgabe A.

Laparoscopic radical nephrectomy (LRN) is considered as a standard of care for T2 renal masses and T1 tumors not treatable by nephron-sparing surgery. It can be performed transperitoneally, retroperitoneoscopic or hand-assisted. However, the morbidity after laparoscopic nephrectomy has been shown to be lower than the open procedure and patients seem to benefit from early mobilization, less pain medication, shorter hospital stays and an earlier return to normal daily activities. Furthermore, the extent of perioperative activation of the systemic stress response appears to be less during laparoscopic procedures. This has been shown to have evidently beneficial clinical impact on patient’s recovery; however, its importance for the oncologic prognosis is somewhat unclear. In addition, the progression-free and overall tumor-specific survival rates for laparoscopic nephrectomy are equivalent to those for open surgery. The experiences with robot-assistance for laparoscopic nephrectomy reported so far show no significant advantages over traditional laparoscopic nephrectomy. However, the problem of high costs of acquisition and operation of robots still remains unsolved. For the future, prospective studies are needed in order to compare the functional and oncological outcomes and cost-effectiveness of different methods of radical nephrectomy.

Wan, D. S. (2012). “New concepts in surgical treatment of rectal cancer.” Chinese Journal of Oncology 34(3): 161-164.

Wiggy, Z. (2012). “User Interfaces in the OR.” AORN Journal 95(4): 526-528.

Yoshida, M., K. Kubota, et al. (2012). “Indocyanine green injection for detecting sentinel nodes using color fluorescence camera in the laparoscopy-assisted gastrectomy.” Journal of Gastroenterology and Hepatology 27(SUPPL.3): 29-33.

Background and Aim: We seek for the accurate and simple method for detecting sentinel nodes of gastric cancer which can be popularized in community hospitals. The indocyanine green (ICG) fluorescence-guided method is reported to be sensitive. However, the ordinal fluorescence cameras have gray scale imaging and require a dark room. We have developed a new device, Hyper Eye Medical System (HEMS) which can simultaneously detect color and near-infrared rays and can be used under room light. This study was planned to examine whether submucosal injection of 0.5mL×4 of 50μg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery. Methods: The patients underwent gastrectomy for clinical T1a (mucosa)-T2 (muscularis propria) and clinical N0 were enrolled in the present study. As a preliminary trial, one case each of the ICG 25 and 100μg/mL, injected on the day before operation and intraoperative injection, was examined. Then, 10 cases injected 50μg/mL ICG on the day before operation were examined. Results: The ICG fluorescence of the patient injected 100μg/mL was too intense and that of the patient injected 25μg/mL was too faint. Sentinel lymph nodes were detected in all of 10 cases injected 50μg/mL, the day before operation and number of sentinel lymph nodes per patient was 3.6±2.1. Metastasis was observed in one case. All of ICG fluorescence-positive sentinel nodes were positive for the metastasis. In the patient who underwent intraoperative injection, sentinel lymphatic basins could be identified. Conclusion: The present study shows that HEMS-guided abdominal surgery is feasible under room light. Submucosal injection of 0.5mL×4 of 50μg/mL ICG on the day before operation is the adequate administration for detecting sentinel nodes using HEMS in the gastric cancer surgery. © 2012 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.

General Robotic (9)

Athanasiou, T., H. Ashrafian, et al. (2012). “The Tipping Point of Robotic Surgery In Healthcare: From Master-Slave to Flexible Access Bio-Inspired Platforms.” Surg Technol Int XXI: 28-34.

Surgical robots were introduced to overcome the technical issues of limited operative dexterity and inadequate visualization in complex body areas. Current surgical robotic systems are based on a master-slave relationship in which the master-surgeon provides operative guidance for the slave-robot to perform operative tasks. Robotic operations are most frequently applied in urology (primarily focusing on prostatectomy) and cardiac surgery. The evolution of surgical robotics has made significant strides in the past decade. There are, however, some limitatio0The future of robotic surgery promises several augmentations to provide improvements in surgical visualization, somatosensory perception, and enhanced robot-surgeon interactions. These can be achieved through advances in robotic research and academic healthcare leadership to develop the next generation of surgical robots such as the novel flexible access bio-inspired (FAB) platforms. The drive to move toward ever less-invasive and safer procedures while maintaining high-quality treatment outcomes has maintained the momentum of progress since the initial birth of minimally invasive surgery, so that robotic surgery can be increasingly applied in a wider range of healthcare settings.

Kenngott, H. G., I. Wegner, et al. (2012). “Magnetic tracking in the operation room using the da Vinci ® telemanipulator is feasible.” Journal of Robotic Surgery: 1-6.

In recent years, robotic assistance for surgical procedures has grown on a worldwide scale, particularly for use in more complex operations. Such operations usually require meticulous handling of tissue, involve a narrow working space and limit the surgeon’s sense of orientation in the human body. Improvement in both tissue handling and working within a narrow working space might be achieved through the use of robotic assistance. Soft tissue navigation might improve orientation by visualizing important target and risk structures intraoperatively, thereby possibly improving patient outcome. Prerequisites for navigation are its integration into the surgical workflow and accurate localization of both the instruments and patient. Magnetic tracking allows for good integration but is susceptible to distortion through metal or electro-magnetic interference, which may be caused by the operation table or a robotic system. We have investigated whether magnetic tracking can be used in combination with the da Vinci ® (DV) telemanipulator in terms of stability and precision. We used a common magnetic tracking system (Aurora ®, NDI Inc.) with the DV in a typical operation setup. Magnetic field distortion was evaluated using a measuring facility, with the following reference system: without any metal (R), operation table alone (T), DV in standby (D) and DV in motion (Dm). The maximum error of the entire tracking volume for R, T, D and Dm was 9.9, 32.8, 37.9 and 37.2 mm, respectively. Limiting the tracking volume to 190 mm (from cranial to caudal) resulted in a maximum error of 4.0, 8.3, 8.5 and 8.9 mm, respectively. When used in the operation room, magnetic tracking shows high errors, mainly due to the operation table. The target area should be limited to increase accuracy, which is possible for most surgical applications. The use of the da Vinci ® telemanipulator only slightly aggravates the distortion and can thus be used in combination with magnetic tracking systems. © 2012 Springer-Verlag London Ltd.

Leitao Jr, M. M. (2012). “Potential pitfalls of the rapid uptake of new technology in surgery: Can comparative effectiveness research help?” Journal of Clinical Oncology 30(8): 767-769.

Morel, P. (2012). “[Surgical robots: how far do we extend the limits of surgery?].” Robots chirurgicaux: jusqu’où va-t’on repousser les limites de la chirurgie? 8(325): 154-155.

Newton, R. C., D. P. Noonan, et al. (2012). “Robot-assisted transvaginal peritoneoscopy using confocal endomicroscopy: a feasibility study in a porcine model.” Surgical Endoscopy: 1-9.

Background: Optical biopsy methods such as probe-based confocal laser endomicroscopy (pCLE) provide useful intraoperative real-time information, especially during minimally invasive surgery with flexible endoscopic or robotic platforms. By translating the probe at constant pressure across the target tissue, undistorted “mosaics” can be produced. However, this poses ergonomic challenges with a conventional flexible endoscope. Methods: A 100 μm confocal depth pCLE probe was integrated into a previously described seven degrees-of-freedom articulated endoscopic robot. After estimating the average workspace created by a female pneumoperitoneum, the accessibility of the peritoneal cavity by the device for robot-assisted pCLE peritoneoscopy was calculated. To demonstrate its in vivo feasibility, the robot was inserted transvaginally in a pig, under laparoscopic vision. Optical biopsy was performed of several targets within the peritoneal cavity. Results: The workspace analysis calculated that 88 % of the surface of an estimated average female pneumoperitoneum could be contacted by the probe using the robot transvaginally. In vivo, the robot was manoeuvred to provide views of all abdominal and pelvic organs. At each target there was robotic acquisition of still pCLE images, and slowly translating images for the construction of increased field-of-view mosaics up to 2 mm in length. Optical biopsies took 1-2 min per target, and at 3.5 μm lateral resolution, the mosaic images showed characteristic features of anterior abdominal wall, liver, and spleen. Conclusion: In the porcine model, the robotically actuated method of performing peritoneoscopy and pCLE mosaicked optical biopsy is safe and provides a consistent means of acquiring near-histological grade images of submesothelial tissue. Clinical translation is likely to provide sufficient accessibility of the peritoneal cavity. © 2012 Springer Science+Business Media, LLC.

Shen, Z. J. and X. J. Wang (2012). “[Application of Da Vinci surgical system in surgery].” Zhonghua Yi Xue Za Zhi 92(8): 505-506.

Smith, A. L., E. M. Scott, et al. (2012). “Dual-console robotic surgery: a new teaching paradigm.” Journal of Robotic Surgery: 1-6.

Robotic surgery has emerged as an alternative option in minimally invasive gynecologic surgery. The development of the dual-console da Vinci Si Surgical System ® has enabled modification of the training atmosphere. We sought to investigate operative times and surgical outcomes while operating with the dual-console model in a training environment for our first fifty cases. We identified the first fifty patients who underwent robot-assisted total hysterectomy (TRH), with or without bilateral salpingo-oophorectomy (BSO), with or without pelvic and para-aortic lymph node dissection (PPALND), by use of the dual-console robotic system. Records were reviewed for patient demographics and surgical details. All surgery was conducted using the dual-console system and performed by staff physicians and fellows. Operative time was calculated from robotic docking until completion of the procedure. Cases were identified from November 2009 through July 2010. Mean age was 56.2 years (SD 13.35, 95 % CI 52.46-59.86). Mean BMI was 29.5 (SD 7.67, 95 % CI 27.35-31.61). Seventy-eight percent of these patients were considered overweight, including 12 defined as obese (BMI 30-34.9) and 10 patients classified as morbidly obese (BMI ≥ 35). Surgery completed included PPALND alone (n = 1); radical hysterectomy (n = 1); TRH only (n = 3); TRH/BSO (n = 25); and TRH/BSO/PPALND (n = 20). Mean total operating room time was 188.8 min (SD 55.31, 95 % CI 173.45-204.11). Mean total surgical time for all cases was 118.1 min (SD 44.28, 95 % CI 105.87-130.41). Two vascular injuries were encountered, with one requiring conversion to laparotomy. These results compare favorably with historically reported outcomes from single-console systems. Utilizing the dual-console enables use of an integrated teaching and supervising environment without compromising operative times or patient outcomes. © 2012 Springer-Verlag London Ltd.

Wilhelm, D., M. Kranzfelder, et al. (2012). “Computer aided interventions in oncology – Are they really worth it?” Telematisch unterstützte Interventionen in der Onkologie – Was bringen sie?: 1-6.

Nowadays, computer aided interventions are increasingly applied in different fields of oncology. Beside intraoperative navigation systems, mainly used for liver and brain surgery, robotic assisted interventions represent another key aspect. Moreover, also in percutaneous and transluminal therapeutic interventions, telematic support is strongly recommended and helpful. In this article we aimed to give an overview on the different fields of computer aided interventions in oncology, while it is also intended to balance out its effective value in tumor therapy. © 2012 Springer-Verlag.

Yates, D. R., C. Vaessen, et al. (2012). “History of robotic surgery in surgery: A progressive evolution towards a surgical revolution.” Histoire de la robotique en chirurgie : Une évolution progressive vers une révolution chirurgicale 41(4): 427-433.

Single Port_DaVinci (5)

Cestari, A., N. M. Buffi, et al. (2012). “Feasibility and Preliminary Clinical Outcomes of Robotic Laparoendoscopic Single-Site (R-LESS) Pyeloplasty Using a New Single-Port Platform.” European Urology.

This study tested the technical feasibility and short-term perioperative outcomes of the novel da Vinci Single-Site Instrumentation platform for the treatment of upper ureteropelvic junction obstruction (UPJO) in a selected group of patients. Nine patients underwent robotic laparoendoscopic single-site (R-LESS) pyeloplasty using a new single-site platform for UPJO at our department of urology. All the procedures were completed without the need for traditional robotic surgery or laparoscopic/open conversion, although in one patient with congenital hepatomegaly it was necessary to use an auxiliary 3-mm trocar to retract the liver properly and expose the surgical field. Mean operative time was 166min, and no intraoperative complications were recorded. The indwelling catheter was removed on postoperative day 2 in five patients and on postoperative day 3 in four patients. Patients were discharged the day after drain removal. One patient experienced transient hyperpyrexia, treated with antibiotics. No other complications were observed. All patients had the DJ stent removed 4 wk after surgery, following a negative urine culture and abdominal ultrasound evaluation. The five patients who reached a 3-mo follow-up had a clinical resolution of preoperative symptoms and hydronephrosis at the abdominal ultrasound. The same results were maintained in the two patients with 6-mo follow-up evaluations. In selected patients, R-LESS pyeloplasty using the new single-port platform appears to be a technically feasible and reproducible surgical procedure for the minimally invasive treatment of UPJO. Prolonged follow-up and larger series are required to confirm its potential role as a valid alternative to standard robotic pyeloplasty.

Konstantinidis, K. M., P. Hirides, et al. (2012). “Cholecystectomy using a novel Single-Site ® robotic platform: early experience from 45 consecutive cases.” Surgical Endoscopy: 1-8.

Background: The aim of this work was to study the feasibility, safety, and efficacy of single-incision robotic cholecystectomy using a novel platform from Intuitive Surgical. Methods: All operations were performed by the same surgeon. Parameters assessed included patient history, indication for surgery, operation time, complication rate, conversion rate, robot-related issues, length of hospital stay, postoperative pain, and time to return to work. All patients were followed for a 2-month period postoperatively. Results: Forty-five patients (22 women, 23 men) underwent single-incision robotic cholecystectomy from March 1 to July 15, 2011. There were no conversions to either conventional laparoscopy or laparotomy, although in three cases a second trocar was used. There were no major complications apart from a single case of postoperative hemorrhage. Average patient age was 47 ± 12 years (range = 27-80 years) and average BMI was 30 kg/m 2 (mean = 28.8 ± 4 kg/m 2, range = 18.4-46.7 kg/m 2). The primary indication for surgery was gallstones. The mean operation time (skin-to-skin) was 84.5 ± 25.5 min (range = 51-175 min), docking time was 5.8 ± 1.5 min (range = 4-11 min), and console time (net surgical time) was 43 ± 21.9 min (range = 21-121 min). Intraoperative blood loss was negligible. There were no collisions between the robotic arms and no other robot-related problems. Average postoperative length of stay was less than 24 h. The mean Visual Analog Pain Scale Score 6 h after the operation was 2.2 ± 1.51 (range = 0-6) and patients returned to normal activities in 4.48 ± 2.3 days (range = 1-9 days). Conclusions: Single-Site ® is a new platform offering a potentially more stable and reliable environment to perform single-port cholecystectomy. Both simple and complicated cholecystectomies can be performed with safety. The technique is possible in patients with a high BMI. The induction of pneumoperitoneum using the new port and the docking process require additional training. © 2012 Springer Science+Business Media, LLC.

Pietrabissa, A., F. Sbrana, et al. (2012). “Overcoming the Challenges of Single-Incision Cholecystectomy With Robotic Single-Site Technology.” Archives of Surgery.

OBJECTIVE: To analyze the preliminary experience with the new da Vinci single-site technology for cholecystectomy. HYPOTHESIS: Single-incision laparoscopic cholecystectomy is technically challenging and a related learning curve clearly exists. A novel approved robotic single-port platform has recently been introduced. This technology may help overcome some of the limitations of manual single-incision surgery relating to triangulation of instruments, ergonomics, and surgical exposure. DESIGN: A prospective longitudinal observational study was conducted on 100 consecutive da Vinci single-site cholecystectomies. SETTING: Five Italian centers of robotic general surgery. MAIN OUTCOME MEASURES: Primary end points were feasibility without conversion and the absence of major complications. Operative times were analyzed to define the learning curve using a mixed regression model. A questionnaire collected the opinions of the surgeons involved in using the new technique. RESULTS: Two patients underwent conversion. No major intraoperative complications occurred, but there were 12 minor incidents (7 ruptures of the gallbladder and 5 cases of minor bleeding from the gallbladder bed). Mean (SD) total operative time was 71 (19) minutes, with a mean (SD) console time of 32 (13) minutes. No significant reduction in the operative times was observed with the increasing of each surgeon’s experience. The technique was judged more complex than standard 4-port laparoscopy but easier than single-incision laparoscopy. CONCLUSIONS: Da Vinci single-site cholecystectomy is an easy and safe procedure for expert robotic surgeons. It allows the quick overcoming of the learning curve typical of single-incision laparoscopic surgery and may potentially increase the safety of this approach.

Richstone, L. (2012). “Editorial Comment on END-2011-0573-TE.R1.” Journal of Endourology.

Editorial comment on Robotic-Assisted Laparoendoscopic Single-Site Pyeloplasty: Technique Using the da Vinci Si Robotic Platform.

White, M. A., R. Autorino, et al. (2012). “Robotic laparoendoscopic single-site surgery:The way forward.” Archivos Espanoles de Urologia 65(3): 357-365.

OBJECTIVES: LaparoEndoscopic Single-Site (LESS) surgery presents many technical and ergonomic obstacles. The solution to these current limitations may lie within emerging technologies, primarily the daVinci robotic platform. The purpose of this review was to examine the available literature as it pertains to robotic laparoendoscopic single-site surgery (R-LESS) and detail our experience with this approach at our institution. METHODS: An electronic literature search was conducted using the Medline database to identify all publications relating to R-LESS and/Mor robotic single port surgery in urology. Additionally, a retrospective review of our single center experience was completed. RESULTS: Fifteen original articles and two abstracts were identified in the literature and included dry lab investigation, animal experiments, single case reports, cumulative series, and two retrospective comparative analyses. Most detailed technique, perioperative outcomes, and associated procedural nuances. CONCLUSIONS: R-LESS urologic surgery is feasible and can be performed using several approaches. R-LESS reduces difficulties encountered with conventional LESS urologic surgery. An ideal robotic system is needed and would be task specific, deployable through a single incision, possess articulating instruments, and have reduced external housings.

Single Port_Lap (15)

Autorino, R., J. H. Kaouk, et al. (2012). “Urological Laparoendoscopic Single Site Surgery: Multi-Institutional Analysis of Risk Factors for Conversion and Postoperative Complications.” Journal of Urology.

Purpose: We analyzed the incidence of and risk factors for complications and conversions in a large contemporary series of patients treated with urological laparoendoscopic single site surgery. Materials and Methods: The study cohort consisted of consecutive patients treated with laparoendoscopic single site surgery between August 2007 and December 2010 at a total of 21 institutions. A logistic regression model was used to analyze the risks of conversion, and of any grade and only high grade postoperative complications. Results: Included in analysis were 1,163 cases. Intraoperatively complications occurred in 3.3% of cases. The overall conversion rate was 19.6% with 14.6%, 4% and 1.1% of procedures converted to reduced port laparoscopy, conventional laparoscopic/robotic surgery and open surgery, respectively. On multivariable analysis the factors significantly associated with the risk of conversion were oncological surgical indication (p = 0.02), pelvic surgery (p <0.001), robotic approach (p <0.001), high difficulty score (p = 0.004), extended operative time (p = 0.03) and an intraoperative complication (p = 0.001). A total of 120 postoperative complications occurred in 109 patients (9.4%) with major complications in only 2.4% of the entire cohort. Reconstructive procedure (p = 0.03), high difficulty score (p = 0.002) and extended operative time (p = 0.02) predicted high grade complications. Conclusions: Urological laparoendoscopic single site surgery can be done with a low complication rate, resembling that in laparoscopic series. The conversion rate suggests that early adopters of the technique have adhered to the principles of careful patient selection and safety. Besides facilitating future comparisons across institutions, this analysis can be useful to counsel patients on the current risks of urological laparoendoscopic single site surgery. © 2012 American Urological Association Education and Research, Inc.

Ceppa, E. P., C. W. Park, et al. (2012). “Single-incision laparoscopic right colectomy: An efficient technique.” Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 22(2): 88-94.

PURPOSE: Laparoscopic right colectomy has an established patient benefit. We sought to demonstrate that a single-incision approach to laparoscopic right colectomy is safe, reproducible, and efficient. METHODS: Photographs were acquired from cases to depict a step-by-step approach. We collected operative, pathologic, and postoperative outcomes from 8 patients who underwent a single-incision laparoscopic right colectomy. RESULTS: There were no intraoperative complications nor deaths and 3 complications postoperatively. The average return of bowel function and length of stay was 3 and 5 days, respectively. Pathologic assessment revealed negative margins and an average of 17 lymph nodes harvested from the specimens. CONCLUSIONS: Single-incision laparoscopic right colectomy is an evolving technique and likely to supplant conventional laparoscopic colectomy because of its equivalent and reproducible outcomes and the ease of the procedure. We depict our preferred method and review the current literature of single-incision right colectomy. © 2012 Lippincott Williams & Wilkins, Inc.

Cho, Y. J., M. L. Kim, et al. (2012). “Laparoendoscopic single-site surgery (LESS) versus conventional laparoscopic surgery for adnexal preservation: A randomized controlled study.” Int J Womens Health 4(1): 85-91.

Objective: To compare the operative outcomes, postoperative pain, and subsequent convalescence after laparoendoscopic single-site surgery (LESS) or conventional laparoscopic surgery for adnexal preservation. Study design: From December 2009 to September 2010, 63 patients underwent LESS (n = 33) or a conventional laparoscopic surgery (n = 30) for cyst enucleation. The overall operative outcomes including postoperative pain measurement using the visual analog scale (VAS) were evaluated (time points 6, 24, and 24 hours). The convalescence data included data obtained from questionnaires on the need for analgesics and on patient-reported time to recovery end points. Results: The preoperative characteristics did not significantly differ between the two groups. The postoperative hemoglobin drop was higher in the LESS group than in the conventional laparoscopic surgery group (P = 0.048). Postoperative pain at each VAS time point, oral analgesic requirement, intramuscular analgesic requirement, and the number of days until return to work were similar in both groups. Conclusion: In adnexa-preserving surgery performed in reproductive-age women, the operative outcomes, including satisfaction of the patients and convalescence after surgery, are comparable for LESS and conventional laparoscopy. LESS may be a feasible and a promising alternative method for scarless abdominal surgery in the treatment of young women with adnexal cysts. © 2012 Cho et al, publisher and licensee Dove Medical Press Ltd.

Clark, C. E., L. Liasis, et al. (2012). “The evidence for single-incision laparoscopic colectomy: is it time to adopt?” Minerva Chirurgica 67(2): 111-126.

Laparoscopic colorectal surgery has advantages over open surgery including shorter postoperative length of hospital stay, early return of bowel function, decreased complications and reduced postoperative pain. Innovative minimally invasive surgery techniques such as single-incision laparoscopic surgery (SIL) have emerged to further enhance outcomes of conventional laparoscopy. This technique uses a single small incision for access of all instruments and specimen extraction. This concept has been proposed to improve cosmesis and enhance recovery. Technological advances have been introduced to overcome the challenges of co-axial instrument movement and collision that is inherent to SIL surgery. The application of SIL techniques to colorectal surgery is in its infancy, but gaining significant momentum. Early case reports and series have shown feasibility and safety. Emerging comparative studies of SIL colectomy to standard laparoscopic techniques are providing evidence of equivalency with potential benefit in outcomes such as reduced early postoperative pain and shortened length of hospital stay. The application of the SIL platform to robotics and transanal surgery demonstrates the broadening scope of this innovative field. However, we must be cognizant of the impact on surgeon training and resident education. In this review we present the current evidence supporting the application of SIL to colorectal surgery.

De Sio, M., C. Quattrone, et al. (2012). “Patient selection for less urological surgery.” Archivos Espanoles de Urologia 65(3): 280-284.

Laparoendoscopic single-site surgery (LESS) should theoretically improve perioperative results and cosmesis minimizing skin incision. LESS surgery is technically demanding and the result of any procedure depends on the surgeon skill and experience, on the condition to be treated and finally on careful patient selection. As cosmesis is the main advantage over standard laparoscopy, LESS is particularly indicated in young patients with low BMI. While at the beginning LESS surgery was limited to demolitive procedures, increasing experience lead to widen indications to reconstructive and more challenging conditions. New technologies and robotics may increase LESS indications in the next future.

Fagotti, A., D. M. Boruta Ii, et al. (2012). “First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: A multicentric retrospective study.” American Journal of Obstetrics and Gynecology 206(4): 353.e351-353.e356.

OBJECTIVE: We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer. STUDY DESIGN: This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011. RESULTS: All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control. CONCLUSION: LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer. © 2012 Mosby, Inc.

Hillyer, S. and J. Kaouk (2012). “Laparoendoscopic single site pelvic surgery: is there any room?” Archivos Espanoles de Urologia 65(3): 342-347.

OBJECTIVES: Our purpose was to summarize the current status of Laparo-endocopic single site surgery (LESS) in the pelvis. METHODS: A comprehensive literature search was conducted in May 2011 using the medline database to identify publications relating to LESS surgery in the pelvis. RESULTS: LESS can be safely performed in the pelvis with comparable outcomes to standard minimally invasive approaches. Small series have demonstrated good outcomes in the hands of experienced surgeons in a number of urological settings in the pelvis. Challenges in LESS surgery are continual being overcome by advancing technologies such as with the robotic platform;however, significant improvements are necessary to reduce the difficulty with LESS surgery and dispersion amongst urological surgeons. CONCLUSION: LESS pelvic procedures are evolving. Wide ranges of procedures have been described using LESS approach, however, in small series and short follow-up. Further examination of LESS pelvic approach with well-designed studies will be crucial to determine the future role of such an approach.

Hyun Han, D., M. Shi Lim, et al. (2012). “Laparoendoscopic single site adrenal surgery.” Archivos Espanoles de Urologia 65(3): 336-341.

Laparoscopic adrenal surgery is a standard procedure for the management of benign adrenal pathology and small malignant tumors. There has been an increasing interest over the last few years in the use of laparoendoscopic single-site surgery (LESS). From recent literatures, LESS adrenalectomy was demonstrated that this technique was safe and feasible despite the relatively difficult anatomical location of the adrenal gland. We reviewed the surgical techniques and outcomes of LESS adrenalectomy including robot-assisted approach and gave an overview of the current role of LESS in adrenalectomy.

Lee, J. Y., D. H. Kang, et al. (2012). “Laparoendoscopic single-site surgery for benign urologic disease with a homemade single port device: Design and tips for beginners.” Korean Journal of Urology 53(3): 165-170.

Purpose: A single surgeon skilled in conventional laparoscopic surgery used laparoendoscopic single-site surgery (LESS) to treat benign urological diseases. This study reports our surgical results and introduces a simple technique with tips based on our experience. Materials and Methods: LESS surgery was performed on 116 patients by use of a homemade single-port device composed of an Alexis wound retractor and a powder-free surgical glove. Cases were 44 varicocelectomies (including 8 bilateral cases), 38 renal cyst marsupializations (including 3 bilateral cases), 26 ureterolithotomies (with 1 concomitant ureterolithotomy and contralateral renal cyst marsupialization), 4 prostatic enucleations, and 4 bladder rupture repairs. The mean patient age was 44.43±16.46 years (range, 11 to 76 years), and the male-to-female ratio was 87:29. Results: In one ureterolithotomy case, LESS was converted to conventional laparoscopic surgery. The mean operative time was 87.03±45.03 minutes, the estimated blood loss was 61.90 ml (range, 0 to 2,000 ml), and the mean hospital stay was 3.03±2.12 days. Two patients underwent single-port transvesical enucleation of the prostate (STEP) requiring patient-controlled anesthesia. No patients developed major complications, and all patients were satisfied, with 75.86% expressing a high degree of satisfaction. Conclusions: We report successful treatment outcomes for LESS in 116 cases of benign urological disease. Our findings suggest that LESS can replace conventional laparoscopy. © The Korean Urological Association, 2012.

Lewandowski, P. M., S. Leslie, et al. (2012). “Laparo-endoscopic single-site donor nephrectomy: techniques and outcomes.” Archivos Espanoles de Urologia 65(3): 318-328.

OBJECTIVES: Living donor nephrectomy is a unique surgical procedure in urological practice and must optimize the trifecta of: patient safety, minimal morbidity and successful graft function. The laparoscopic technique has become the gold standard over the last decade for harvesting the kidney from a living donor. Laparo-endoscopic single-site (LESS) surgery is an attempt to further enhance cosmetic benefits and reduce the morbidity for potential kidney donors. We have summarized and reviewed the literature of LESS-DN and described the techniques and outcomes. METHODS: Using the National Library of Medicine database, the English language literature was reviewed from 2006 to 2011. Keyword searches included LESS, Donor, Nephrectomy, Living, Single-site, e-NOTES, Mini-invasive, Laparoscopic, Single-port. Within the bibliography of selected references, additional sources were retrieved. RESULTS: After Gill’s description of the first four patients to undergo LESS-DN, we found five series published describing the surgical techniques of LESS-DN as well as the outcomes. We have outlined in detail the various techniques of the trans-umbilical LESS-DN and compared the outcomes with conventional LDN. We also briefly discuss new innovative techniques of LESS-DN. CONCLUSIONS: LESS-DN is a safe albeit technically challenging alternative to LDN. LESS-DN appears to have comparable results to LDN in terms of graft function, patient morbidity, and cosmesis. Further long term results and the development in parallel with other LESS procedures is required before LESS-DN is to be considered a standard of care.

Ma, L. L., H. Bi, et al. (2012). “Laparoendoscopic single-site radical cystectomy and urinary diversion: Initial experience in China using a homemade single-port device.” Journal of Endourology 26(4): 355-359.

Purpose: We report our initial experience with the first series of laparoendoscopic single-site (LESS) radical cystectomy and urinary diversion performed by a single surgeon using a homemade single-port device at a single institution in China. Patients and Methods: Between December 2010 and February 2011, we performed five LESS radical cystectomis using a homemade single-port device composed of an inverted cone device of polycarbonate and a powder-free surgical glove. The port was placed into a 5-cm periumbilical incision. The conventional laparoscope and laparoscopic instruments were inserted through the single-port. No additional ports were needed for radical cystoprostatectomy and bilateral standard pelvic lymphadenectomy. Cutaneous ureterostomy and ileal conduit urinary diversion were used for our patients, respectively. Perioperatively, oncologic data and complications were collected and analyzed. Results: All the procedures were completed successfully. The mean extirpative operative time was 208.2 (168-280) minutes, estimated blood loss was 270 (100-500) mL, bowel recovering time was 9.75 (6-12) days, and postoperative hospital stay was 19.5 (14-28) days. One patient needed a transfusion of 400 mL of red blood cells. The pathologic evaluation revealed negative margins and negative lymph node involvement. After the operations, one patient had a bowel obstruction, while another patient died from cardiac disease. Mean follow-up time was 143 (110-173) days. Conclusions: In our experience, LESS radical cystectomy is clinically feasible and safe for selected patients, but requires a learning curve. Our homemade single-port device is a cost-effective and convenient device. Although the initial outcomes have been promising, the long-term oncologic evaluation of these patients awaits. © Copyright 2012, Mary Ann Liebert, Inc.

Olweny, E. O., S. L. Best, et al. (2012). “New technology and applied research: what the future holds for less and notes.” Archivos Espanoles de Urologia 65(3): 434-443.

Rapid technological developments in the 1970′s contributed to the emergence of operative laparoscopy as a revolution in surgery. In recent years, there has been a surge of interest in laparoendoscopic single-site (LESS) and natural orifice translumenal endoscopic surgery (NOTES), novel techniques that have the potential to further minimize the invasiveness and morbidity of surgery. Innovations in instrument design and in novel surgical platforms including robotic technology have rapidly been developed in an effort to enhance the future clinical applicability of these techniques. In this chapter, we review the current status and future directions of LESS and NOTES technology, focusing on the current research in the field.

Stewart, D. B. and E. Messaris (2012). “Outcomes for Consecutive Patients Undergoing Single-Site Laparoscopic Colorectal Surgery.” Journal of Gastrointestinal Surgery 16(5): 849-856.

Background: Single-site laparoscopy (SSL) represents an innovation whose wider adoption may be limited by technical challenges and a current dearth of outcomes data. Methods: A retrospective review of prospectively collected data was performed on all consecutive laparoscopic colorectal resections, including elective and emergent surgeries. Patient demographics and operative details were collected, and outcomes were analyzed for 30 days following surgery. Results: Forty-one single-site laparoscopic procedures were performed, with 12 (29%) being nonelective. Surgeries included seven right colectomies, eight sigmoidectomies, four ileocolectomies, five total colectomies, two low anterior resections, and two abdominoperineal resections. The most frequent indication for surgery was inflammatory bowel disease (31.7%), followed by cancer (24.4%) and diverticular disease (24.4%). Thirty-seven percent of the patients had undergone previous abdominal surgery, with 64% of these having undergone previous laparotomy. One (2.5%) patient required conversion to multiple trocar laparoscopy, and five (12%) required conversion to laparotomy. Mean length of hospital stay was 4.2 days for SSL without a conversion. There was one anastomotic leak, no postoperative bleeding, no surgical site infections, and no deaths. The readmission rate was 14%. Conclusions: SSL is safe when applied to unselected patients undergoing colorectal surgery, including those patients who have undergone a previous laparotomy. © 2011 The Society for Surgery of the Alimentary Tract.

Turini, G., A. Moglia, et al. (2012). “Patient-specific surgical simulator for the pre-operative planning of single-incision laparoscopic surgery with bimanual robots.” Computer Aided Surgery 17(3): 103-112.

Introduction: The trend of surgical robotics is to follow the evolution of laparoscopy, which is now moving towards single-incision laparoscopic surgery. The main drawback of this approach is the limited maneuverability of the surgical tools. Promising solutions to improve the surgeon’s dexterity are based on bimanual robots. However, since both robot arms are completely inserted into the patient’s body, issues related to possible unwanted collisions with structures adjacent to the target organ may arise. Materials and Methods: This paper presents a simulator based on patient-specific data for the positioning and workspace evaluation of bimanual surgical robots in the pre-operative planning of single-incision laparoscopic surgery. Results: The simulator, designed for the pre-operative planning of robotic laparoscopic interventions, was tested by five expert surgeons who evaluated its main functionalities and provided an overall rating for the system. Discussion: The proposed system demonstrated good performance and usability, and was designed to integrate both present and future bimanual surgical robots. © 2012 Informa UK Ltd.

Wolthuis, A. M., F. Penninckx, et al. (2012). “Outcomes for case-matched single-port colectomy are comparable with conventional laparoscopic colectomy.” Colorectal Disease 14(5): 634-641.

Aim With the introduction of single-port surgery, expected advantages are improved cosmesis, decrease of pain and shorter length of stay. The aim of this study was to compare early outcomes of single-port colectomy with those of conventional laparoscopic colectomy. Method All consecutive patients undergoing single-port colectomy between January and June 2010 were identified from a prospective database. They were matched for age, sex, body mass index, American Society of Anesthesiology score and type of resection with patients who had conventional laparoscopic colectomy. All perioperative data, analgesic requirement, pain scores and inflammatory response were compared using the Wilcoxon signed-rank and McNemar tests. Results Fourteen patients [five men, nine women; median age (interquartile range) 56 (30-73) years, body mass index (interquartile range) 22 (20-24) kg/m 2] underwent single-port colectomy and were matched with patients who had conventional laparoscopic colectomy. Median operating times, estimated blood loss, pain scores, analgesic requirement, inflammatory response and length of hospital stay were similar. Median increase in incision length was significantly higher in the single-port group (P=0.004), but maximal incision length for specimen extraction was comparable. There were no anastomotic leaks, wound infections or 30-day readmissions. Conclusion In a case-matched setting with a small sample size, single-port laparoscopic colectomy has comparable outcomes to conventional laparoscopic colectomy. © 2011 The Association of Coloproctology of Great Britain and Ireland.

Training (7)

Arain, N. A., G. Dulan, et al. (2012). “Comprehensive proficiency-based inanimate training for robotic surgery: reliability, feasibility, and educational benefit.” Surgical Endoscopy.

BACKGROUND: We previously developed a comprehensive proficiency-based robotic training curriculum demonstrating construct, content, and face validity. This study aimed to assess reliability, feasibility, and educational benefit associated with curricular implementation. METHODS: Over an 11-month period, 55 residents, fellows, and faculty (robotic novices) from general surgery, urology, and gynecology were enrolled in a 2-month curriculum: online didactics, half-day hands-on tutorial, and self-practice using nine inanimate exercises. Each trainee completed a questionnaire and performed a single proctored repetition of each task before (pretest) and after (post-test) training. Tasks were scored for time and errors using modified FLS metrics. For inter-rater reliability (IRR), three trainees were scored by two raters and analyzed using intraclass correlation coefficients (ICC). Data from eight experts were analyzed using ICC and Cronbach’s alpha to determine test-retest reliability and internal consistency, respectively. Educational benefit was assessed by comparing baseline (pretest) and final (post-test) trainee performance; comparisons used Wilcoxon signed-rank test. RESULTS: Of the 55 trainees that pretested, 53 (96 %) completed all curricular components in 9-17 h and reached proficiency after completing an average of 72 +/- 28 repetitions over 5 +/- 1 h. Trainees indicated minimal prior robotic experience and “poor comfort” with robotic skills at baseline (1.8 +/- 0.9) compared to final testing (3.1 +/- 0.8, p < 0.001). IRR data for the composite score revealed an ICC of 0.96 (p < 0.001). Test-retest reliability was 0.91 (p < 0.001) and internal consistency was 0.81. Performance improved significantly after training for all nine tasks and according to composite scores (548 +/- 176 vs. 914 +/- 81, p < 0.001), demonstrating educational benefit. CONCLUSION: This curriculum is associated with high reliability measures, demonstrated feasibility for a large cohort of trainees, and yielded significant educational benefit. Further studies and adoption of this curriculum are encouraged.

Hashimoto, D. A., E. D. Gomez, et al. (2012). “Intraoperative Resident Education for Robotic Laparoscopic Gastric Banding Surgery: A Pilot Study on the Safety of Stepwise Education.” Journal of the American College of Surgeons.

Background: Incorporation of robotic surgery into resident education poses questions regarding intraoperative teaching and patient care. This study aimed to evaluate the impact of gradually increasing resident console responsibility on resident competency and patient safety, in the presence of a proctor and bedside surgeon, for robotic laparoscopic-assisted gastric banding (R-LAGB) compared with the classical training model (CTM) of residents as first assistant. Study Design: Eight clinical year 4 (CY4) residents completed 60 R-LAGB using a one-to-one proctored training model (PTM). R-LAGB was distilled into 7 key steps: gastroesophageal-junction dissection, gastrohepatic ligament dissection, retrogastric space creation, band placement, band closure, gastrogastric suturing, and port placement. Residents performed more complex steps after each case to gain competency in all aspects of the operation. Patient demographics, comorbidities, operative complications, operating times, and clinical outcomes were compared with a control group of 287 R-LAGB cases completed using the CTM (n = 15 CY4 residents). Results: All residents using the PTM were able to successfully complete an R-LAGB as primary surgeon after a median of 8 operations (range 5 to 11); no residents in the CTM completed an R-LAGB as primary surgeon. Mean operative time was statistically greater in the PTM group (99.3 ± 22.1 minutes) vs CTM (91.5 ± 21.1 minutes) (p = 0.001). There were no intraoperative complications in either group; incidence of postoperative complications was similar between groups. Conclusions: All residents in the proctored setting claimed competence and have persistent console experience without significantly increasing procedure complications. PTM, otherwise known as stepwise education, is a safe, standardized method to train surgical residents in R-LAGB.

Patel, H. R. H. and B. P. Patel (2012). “Virtual reality surgical simulation in training.” Expert Review of Anticancer Therapy 12(4): 417-420.

Perrenot, C., M. Perez, et al. (2012). “The virtual reality simulator dV-Trainer((R)) is a valid assessment tool for robotic surgical skills.” Surgical Endoscopy.

BACKGROUND: Exponential development of minimally invasive techniques, such as robotic-assisted devices, raises the question of how to assess robotic surgery skills. Early development of virtual simulators has provided efficient tools for laparoscopic skills certification based on objective scoring, high availability, and lower cost. However, similar evaluation is lacking for robotic training. The purpose of this study was to assess several criteria, such as reliability, face, content, construct, and concurrent validity of a new virtual robotic surgery simulator. METHODS: This prospective study was conducted from December 2009 to April 2010 using three simulators dV-Trainers((R)) (MIMIC Technologies((R))) and one Da Vinci S((R)) (Intuitive Surgical((R))). Seventy-five subjects, divided into five groups according to their initial surgical training, were evaluated based on five representative exercises of robotic specific skills: 3D perception, clutching, visual force feedback, EndoWrist((R)) manipulation, and camera control. Analysis was extracted from (1) questionnaires (realism and interest), (2) automatically generated data from simulators, and (3) subjective scoring by two experts of depersonalized videos of similar exercises with robot. RESULTS: Face and content validity were generally considered high (77 %). Five levels of ability were clearly identified by the simulator (ANOVA; p = 0.0024). There was a strong correlation between automatic data from dV-Trainer and subjective evaluation with robot (r = 0.822). Reliability of scoring was high (r = 0.851). The most relevant criteria were time and economy of motion. The most relevant exercises were Pick and Place and Ring and Rail. CONCLUSIONS: The dV-Trainer((R)) simulator proves to be a valid tool to assess basic skills of robotic surgery.

Smith, A. L., E. M. Scott, et al. (2012). “Dual-console robotic surgery: a new teaching paradigm.” Journal of Robotic Surgery: 1-6.

Wang, M. H., B. Chen, et al. (2012). “Pediatric urology fellowship training: Are we teaching what they need to learn?” Journal of Pediatric Urology.

Objective: Pediatric urology training has traditionally been based on an apprenticeship model. As part of our curriculum re-development, we surveyed recent graduates (2007-2009) regarding the teaching of clinical/surgical skills and medical knowledge during their training. Methods: 44 pediatric urologists who completed 2 years of ACGME (Accreditation Council for Graduate Medical Education)-accredited programs and had been practicing for at least 18 months were anonymously surveyed. An IRB-approved survey was developed by a team of educators at the Johns Hopkins School of Medicine and Bloomberg School of Public Health. Results: 31 of 44 responded to 100% of the questions; 90% of the respondents felt their fellowship successfully prepared them for discussing surgical options and performing the procedures that they are now doing; 74% felt well trained to manage perioperative complications and 65% felt well trained to manage non-surgical problems. Faculty feedback/supervision, independent reading, and conferences were rated as a very effective method of teaching (87%). Top three procedures they wished they had learned: laparoscopic/robotic surgery, hypospadias repair, and augmentation/Mitrofanoff. Top three non-surgical topics: urinary tract infection, voiding dysfunction, and billing/coding. Conclusion: It is reassuring that ACGME fellowship-trained pediatric urologists feel prepared in commonly performed procedures and perioperative care. Faculty supervision/feedback is highly valued. © 2012 Journal of Pediatric Urology Company.

Perrenot, C., M. Perez, et al. (2012). “The virtual reality simulator dV-Trainer((R)) is a valid assessment tool for robotic surgical skills.” Surgical Endoscopy.