Variability of the temporal bone surface's topography: implications for otologic surgery

Otologic surgery is performed for a variety of reasons including treatment of recurrent ear infections, alleviation of dizziness, and restoration of hearing loss. A typical ear surgery consists of a tympanomastoidectomy in which both the middle ear is explored via a tympanic membrane flap and the bone behind the ear is removed via mastoidectomy to treat disease and/or provide additional access. The mastoid dissection is performed using a high-speed drill to excavate bone based on a pre-operative CT scan. Intraoperatively, the surface of the mastoid component of the temporal bone provides visual feedback allowing the surgeon to guide their dissection. Dissection begins in "safe areas" which, based on surface topography, are believed to be correlated with greatest distance from surface to vital anatomy thus decreasing the chance of injury to the brain, large blood vessels (e.g. the internal jugular vein and internal carotid artery), the inner ear, and the facial nerve. "Safe areas" have been identified based on surgical experience with no identifiable studies showing correlation of the surface with subsurface anatomy. The purpose of our study was to investigate whether such a correlation exists. Through a three-step registration process, we defined a correspondence between each of twenty five clinically-applicable temporal bone CT scans of patients and an atlas and explored displacement and angular differences of surface topography and depth of critical structures from the surface of the skull. The results of this study reflect current knowledge of osteogenesis and anatomy. Based on two features (distance and angular difference), two regions (suprahelical and posterior) of the temporal bone show the least variability between surface and subsurface anatomy.

Robotic-assisted total mesorectal excision with the aid of a single-port device

INTRODUCTION AND INDICATIONS: Robotic surgery has numerous advantages in rectal cancer surgery. Studies have reported the advantages associated with single-port approaches, such as eliminating the need for additional incisions, as well as the difficulties inherent in this technique. The authors present a hybrid technique that they performed using a robotic total mesorectal excision with the aid of a single port-device. Materials and methods. The authors performed the technique on 2 patients using a single-port device through an umbilical incision and 3 accessory ports for the robotic arms. There was no need to place ports for the assistant's equipment or for an assistant incision.

RESULTS AND COMPLICATIONS

The operation time was 177.5 minutes, and there were no intraoperative or postoperative complications. Both patients were discharged 7 days after the operation.

CONCLUSIONS

This technical variation is an additional step forward for oncological surgery with minimal damage to the abdominal wall.

Reverse-hybrid robotic mesorectal excision for rectal cancer

PURPOSE

The robotic system offers potential technical advantages over laparoscopy for total mesorectal excision with radical lymphadenectomy for rectal cancer. However, the requirement for fixed docking limits its utility when the working volume is large or patient repositioning is required. The purpose of this study was to evaluate short-term outcomes associated with a novel setup to perform total mesorectal excision and radical lymphadenectomy for rectal cancer by the use of a "reverse" hybrid robotic-laparoscopic approach.

METHODS

This is a prospective consecutive cohort observational study of patients who underwent robotic rectal cancer resection from January 2009 to March 2011. During the study period, a technique of reverse-hybrid robotic-laparoscopic rectal resection with radical lymphadenectomy was developed. This technique involves reversal of the operative sequence with lymphovascular and rectal dissection to precede proximal colonic mobilization. This technique evolved from a conventional-hybrid resection with laparoscopic vascular control, colonic mobilization, and robotic pelvic dissection. Perioperative and short-term oncologic outcomes were analyzed.

RESULTS

Thirty patients underwent reverse-hybrid resection. Median tumor location was 5 cm (interquartile range 3-9) from the anal verge. Median BMI was 27.6 (interquartile range 25.0-32.1 kg/m). Twenty (66.7%) received neoadjuvant chemoradiation. There were no conversions. Median blood loss was 100 mL (interquartile range 75-200). Total operation time was a median 369 (interquartile range 306-410) minutes. Median docking time was 6 (interquartile range 5-8) minutes, and console time was 98 (interquartile range 88-140) minutes. Resection was R0 in all patients; no patients had an incomplete mesorectal resection. Six patients (20%) underwent extended lymph node dissection or en bloc resection.

CONCLUSIONS

Reverse-hybrid robotic surgery for rectal cancer maximizes the therapeutic applicability of the robotic and conventional laparoscopic techniques for optimized application in minimally invasive rectal surgery.

Robotic-assisted laparoscopic mesh sacrocolpopexy

The current 'gold standard' surgical repair for apical prolapse is the abdominal mesh sacrocolpopexy. Use of a robotic-assisted laparoscopic surgical approach has been demonstrated to be feasible as a minimally invasive approach and is gaining popularity amongst pelvic floor reconstructive surgeons. Although outcome data for robotic-assisted sacrocolpopexy (RASC) is only just emerging, several small series have demonstrated anatomic and functional outcomes, as well as complication rates, comparable to those reported for open surgery. The primary advantages thus far for RASC over open surgery include decreased blood loss and shorter hospital stay.

Advanced applications of robotics in digestive surgery

Laparoscopy is widely recognized as feasible and safe approach to many oncologic and benign digestive conditions and is associated with an improved early outcome. Robotic surgery promises to overcome intrinsic limitations of laparoscopic surgery by a three-dimensional view and wristed instruments widening indications for a minimally invasive approach. To date, the more interesting applications of robotic surgery are those operations restricted to one abdominal quadrant and requiring a fine dissection and digestive reconstruction. While robot-assisted rectal and gastric surgery are becoming well-accepted options among the surgical community, applications of robotics in hepato-biliary and pancreatic surgery are still debated.

Robotics for Pelvic Reconstruction

Robotic-assisted laparoscopy is increasingly used in female pelvic reconstructive surgery to combine the benefits of abdominally placed mesh for prolapse outcomes with the quicker recovery time associated with minimally invasive procedures. Level III data suggest that early outcomes of robotic sacrocolpopexy are similar to those of open sacrocolpopexy. A single randomized trial has provided level I evidence that robotic and laparoscopic approaches to sacrocolpopexy have similar short-term anatomic outcomes, although operating times, postoperative pain, and cost are increased with robotics. Patient satisfaction and long-term outcomes of both robotic and laparoscopic sacrocolpopexy are insufficiently studied despite their widespread use in the treatment of prolapse. Given the high reoperative rates for prolapse repairs, long-term follow-up is essential, and well-designed comparative effectiveness research is needed to evaluate pelvic floor surgery adequately.

Robotic-assisted bariatric surgery: a systematic review

BACKGROUND

Bariatric laparoscopic surgery has been shown to lead to sustainable weight-loss in obese individuals. Robotic-assisted laparoscopic surgery is proposed as the next major evolution in minimally invasive surgery. This study systematically reviews the literature regarding the feasibility and safety of robotic-assisted bariatric surgery in obese patients.

METHODS

A comprehensive search of electronic databases was completed for the period 2003 to 2010. Two independent reviewers assessed the studies for relevance, inclusion, and extracted data.

RESULTS

After an initial screen of 297 titles, 22 studies met the inclusion criteria. A total of 1253 patients with a mean preoperative body mass index of 46.6 kg/m(2) were obtained from 13 included studies. Major complications of malabsorptive procedures included eight anastomotic leaks (2.4%), bleeding (7/349 patients = 2%) and strictures/stenosis (13/430 patients = 3%). There were no reported deaths.

CONCLUSIONS

This systematic review demonstrates that robotic-assisted bariatric surgery is both a safe and feasible option for severely obese patients.

Surgical and pathological outcomes after right hemicolectomy: case-matched study comparing robotic and open surgery

OBJECTIVE

To compare the surgical and pathological outcomes of patients with right-sided colon cancers operated on by means of open and robotic surgery with extracorporeal anastomosis.

METHODS

Thirty-three consecutive patients who underwent robotic right hemicolectomy due to right-sided colon cancer were retrospectively well matched with 102 patients operated on by the open approach. Data were included in a prospectively maintained database.

RESULTS

Mean operative time was longer in the robotic group (P < 0.001), 191.7 min (134-250) versus 136.2 (45-240) min in the open group. Estimated intraoperative blood loss was less in the robotic group, which presented a mean of 6.1 ml versus 94.8 ml in the open group (P < 0.001). Despite the similar length of the surgical specimen and number of lymph nodes retrieved between both groups, 15 or more lymph nodes were found in the specimen in 90 out of 102 patients (88.2%) operated on by the open technique versus 33 out of 33 patients (100%) who underwent robotic hemicolectomy (P = 0.038). The median length of postoperative hospital stay was shorter in the robotic group, 5 versus 8 days (P < 0.001). No other statistically significant difference was observed in terms of pathological and postoperative results.

CONCLUSIONS

Robotic right hemicolectomy is an oncologically safe and effective procedure. The number of lymph nodes retrieved in the robotic group compared with the open group of our series was more homogeneous, and none of the patients operated on with this technique had a suboptimal lymphadenectomy. Further clinical trials are needed to confirm current evidence and determine whether this can influence the prognosis.

Force feedback in a piezoelectric linear actuator for neurosurgery

BACKGROUND

Force feedback in robotic minimally invasive surgery allows the human operator to manipulate tissues as if his/her hands were in contact with the patient organs. A force sensor mounted on the probe raises problems with sterilization of the overall surgical tool. Also, the use of off-axis gauges introduces a moment that increases the friction force on the bearing, which can easily mask off the signal, given the small force to be measured.

METHODS

This work aims at designing and testing two methods for estimating the resistance to the advancement (force) experienced by a standard probe for brain biopsies within a brain-like material. The further goal is to provide a neurosurgeon using a master-slave tele-operated driver with direct feedback on the tissue mechanical characteristics. Two possible sensing methods, in-axis strain gauge force sensor and position-position error (control-based method), were implemented and tested, both aimed at device miniaturization. The analysis carried out was aimed at fulfilment of the psychophysics requirements for force detection and delay tolerance, also taking into account safety, which is directly related to the last two issues. Controller parameters definition is addressed and consideration is given to development of the device with integration of a haptic interface.

RESULTS

Results show better performance of the control-based method (RMSE < 0.1 N), which is also best for reliability, sterilizability, and material dimensions for the application addressed.

CONCLUSIONS

The control-based method developed for force estimation is compatible with the neurosurgical application and is also capable of measuring tissue resistance without any additional sensors. Force feedback in minimally invasive surgery allows the human operator to manipulate tissues as if his/her hands were in contact with the patient organs.

Robotic bladder diverticulectomy: technique and surgical outcomes

OBJECTIVES

Indications for surgical treatment of bladder diverticula include tumor, lower urinary tract symptoms refractory to medical treatment, renal dysfunction or recurrent urinary tract infections. We describe the technique and report the outcomes of robotic bladder diverticulectomy at our institution.

METHODS

A chart review of patients who underwent robotic bladder diverticulectomy at our institution from 2007 to 2010 was carried out. Indications for the procedure were: lower urinary tract symptoms (LUTS) not responding to medical treatment (2 patients), ureteral obstruction (1 patient), tumor arising in a diverticulum (2 patients) and diverticulum secondary to neurogenic bladder (1 patient). One patient also had renal dysfunction associated with ureteral insertion into the diverticulum and therefore underwent ipsilateral ureteroneocystostomy. Other additional procedures included transurethral resection of the prostate (1 patient) and bilateral pelvic lymph node dissection (1 patient). Perioperative and postoperative outcomes were analyzed.

RESULTS

Six patients (median age 61.5 years, range 19-75) underwent da Vinci diverticulectomy using a transperitoneal approach without the need for open conversion. Median operative time was 232 min (135-360 min.). Median estimated blood loss was 100 mL (50-150 mL). The Foley catheter was removed after a negative cystogram and median time to catheter removal was 7 days (7-12 days). Median hospital stay was 3 days (2-5 days). The only complication was a urinary tract infection managed with antibiotics.

CONCLUSIONS

Robotic surgery represents a reasonable minimally invasive treatment option for resection of bladder diverticula when indicated.

Morbid obesity with achalasia: a surgical challenge

Achalasia is a relatively rare medical condition that is classically not associated with obesity. The surgical treatment of a simultaneous occurrence of these two diseases requires careful consideration, and only a few reports can be found in the literature combining a Heller myotomy with gastric bypass, duodenal switch, or gastric banding. We report the case of a 69-year-old female patient with early achalasia and obesity who underwent simultaneous laparoscopic gastric sleeve resection and robotic Heller myotomy. No intra- or postoperative complications occurred. A follow-up at 6 weeks showed a significant weight loss and resolved symptoms of achalasia. The case illustrates that a simultaneous gastric sleeve resection and robotic Heller myotomy might be an option for the treatment of concurrent obesity and achalasia.

Robot-assisted surgery: applications in urology

The past decade has seen a dramatic shift in the surgical management of certain urologic conditions with the advent of a robotic surgical platform. In fact, the surgical management of prostate cancer has seen the most dramatic shift, with the majority of cases now being performed robotically. Technical refinements over the years have led to improved outcomes regarding oncologic and functional results. Recently, robotic surgery has also been utilized for the surgical management of bladder cancer, renal cancer, and other benign conditions. As further experience is gained and longer-term outcomes are realized, robotic surgery will likely play an increasing role in the surgical management of many urologic conditions.

Technical advances in robot-assisted laparoscopic radical prostatectomy

Since it was introduced in 1999, the da Vinci Surgical System has become an integral tool in urologic surgery, specifically in the management of localized prostate cancer. The original technique of robot-assisted laparoscopic prostatectomy (RALP) was developed and standardized in 2000 at the Institut Mutualiste Monsouris. Since that time, the technique of RALP has undergone various modifications. The driving force behind the evolution of the RALP technique in the past decade has been based on efforts to improve upon the three main objectives of surgery, namely the 'trifecta' of cancer cure and the preservation of potency and of urinary continence. In this review, we aim to provide an update on the midterm oncologic outcomes of RALP and focus specifically on two technical modifications that have been introduced in an effort to optimize the outcomes of potency and earlier return of urinary continence.

Telesurgery of Microscopic Micromanipulator System "NeuRobot" in Neurosurgery: Interhospital Preliminary Study

Object

Robotic surgery can be applied as a novel technology. Our master-slave microscopic-micromanipulator system (NeuRobot), which has a rigid endoscope and three robot-arms, has been developed to perform neurosurgical procedures, and employed successfully in some clinical cases. Although the master and slave parts of NeuRobot are directly connected by wire, it is possible to separate each part and to apply it to telesurgery with some modifications. To evaluate feasibility of NeuRobot in telesurgery, some basic experiments were performed.

Methods

The quality of telemedicine network system between Shinshu University and one of the affiliated hospitals, which was completely separated from other public network systems, was investigated. The communication delay was calculated from the transmitting and the receiving records in the computers set in each hospital. The relationship between the change in communication delay from the master part to the slave part of NeuRobot (0, 100, 300, 500 and 700 ms) respectively and feasibility of NeuRobot was investigated. The task performance time in each time changing group was compared. Feasibility of NeuRobot in telesurgical usage was evaluated. The master part and the slave part of NeuRobot placed in each hospital were connected through private network system. Interhospitally connected NeuRobot was compared with directly connected one in terms of task performance time.

Results

Less than 1 ms was required for corresponding the data in a steady transmitting state. Within 2 seconds after connection, relative time delay (maximum 40 ms) and packet loss were sometimes observed. The mean task performance time was significantly longer in over 500 ms delayed group compared with directly connected NeuRobot. There was no significant difference in the task performance time between directly connected NeuRobot and interhospitally connected NeuRobot.

Conclusion

Our results proved that telesurgical usage of NeuRobot was feasible. Telesurgical usage of telecontrolled manipulator system is recommended for application in a private network system in order to reduce technical and ethical problems. Some technical innovations will bring breakthrough to the telemedicine field.

Robotic-assisted total laparoscopic hysterectomy versus conventional total laparoscopic hysterectomy

OBJECTIVES

To compare patient characteristics, operative variables, and outcomes of 24 patients who underwent robotic-assisted total laparoscopic hysterectomy (TLH) with 44 patients who underwent conventional TLH. We retrospectively reviewed the charts of 44 patients with TLH and 24 patients with robotic TLH.

RESULTS

Robotic TLH was associated with a shorter hospital stay (1.0 vs 1.4 days, P=0.011) and a significant decrease in narcotic use (1.2 vs 5.0 units, P=0.002). EBL and droP in hemoglobin were not significantly different. The operative time was significantly longer in patients undergoing robotic TLH (142.2 vs 122.1 minutes, P=0.027). However, only need for laparoscopic morcellation, BMI, and uterine weight, not robotic use, were independently associated with increased operative times.

CONCLUSIONS

Robotic hysterectomy can be performed safely with comparable operative times to those of conventional laparoscopic hysterectomy. Postoperative measures were improved over measures for conventional laparoscopy.

Robotic surgery for cervical cancer

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being performed under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required.

CONCLUSION

Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.

Robotic colorectal surgery

Robotic colorectal surgery has gradually been performed more with the help of the technological advantages of the da Vinci system. Advanced technological advantages of the da Vinci system compared with standard laparoscopic colorectal surgery have been reported. These are a stable camera platform, three-dimensional imaging, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling, and instruments with multiple degrees of freedom. However, despite these technological advantages, most studies did not report the clinical advantages of robotic colorectal surgery compared to standard laparoscopic colorectal surgery. Only one study recently implies the real benefits of robotic rectal cancer surgery. The purpose of this review article is to outline the early concerns of robotic colorectal surgery using the da Vinci system, to present early clinical outcomes from the most current series, and to discuss not only the safety and the feasibility but also the real benefits of robotic colorectal surgery. Moreover, this article will comment on the possible future clinical advantages and limitations of the da Vinci system in robotic colorectal surgery.

Immediate impact of an intensive one-week laparoscopy training program on laparoscopic skills among postgraduate urologists

INTRODUCTION

Laparoscopic techniques are difficult to master, especially for surgeons who did not receive such training during residency. To help urologists master challenging laparoscopic skills, a unique 5-day mini-residency (M-R) program was established at the University of California, Irvine. The first 101 participants in this program were evaluated on their laparoscopic skills acquisition at the end of the 5-day experience.

METHODS

Two urologists are accepted per week into 1 of 4 training modules: (1) ureteroscopy/percutaneous renal access; (2) laparoscopic ablative renal surgery; (3) laparoscopic reconstructive renal surgery; and (4) robot-assisted prostatectomy. The program consists of didactic lectures, pelvic trainer and virtual reality simulator practice, animal and cadaver laboratory sessions, and observation or participation in human surgeries. Skills testing (ST) simulating open, laparoscopic, and robotic surgery is assessed in all of the M-R participants on training days 1 and 5. Tests include ring transfer, suture threading, cutting, and suturing. Performance is evaluated by an experienced observer using the Objective Structured Assessment of Technical Skill (OSATS) scoring system. Statistical methods used include the paired sample t test and analysis of variance at a confidence level of P<or=0.05.

RESULTS

Between July 2003 and June 2005, 101 urologists participated in the M-R program. The mean participant age was 47 years (range, 31 to 70). The open surgical format had the highest ST scores followed by the robotic and then the laparoscopic formats. The final ST scores were significantly higher than the initial ST scores (P<0.05) for the laparoscopic (58 vs. 52) and the robotic (114 vs. 95) formats. Open surgical ST scores did not change significantly during the training program (191 vs. 194) (P=0.17).

CONCLUSION

Laparoscopic and robotic ST scores, but not open ST scores, improved significantly during this intensive 5-day M-R program. The robotic ST scores demonstrated greater improvement than did the laparoscopic ST scores, suggesting that the transfer of laparoscopic skills may be improved using the robotic interface.

Robotic-assisted laparoscopic cystoprostatectomy for prostatic carcinosarcoma

Carcinosarcoma of the prostate is a rare neoplasm with malignant epithelial and mesenchymal components. Herein, we report the case of a patient who underwent multiple transurethral resections of the prostate showing adenocarcinoma initially then carcinosarcoma. He underwent a robotic-assisted laparoscopic cystoprostatectomy, bilateral pelvic lymph node dissection, and ileal conduit urinary diversion and was discharged on postoperative day 7. Carcinosarcoma is discussed as an extremely rare malignancy of the prostate, with less than 50 cases reported in the literature. Robotic-assisted radical cystoprostatectomy is also discussed as a new procedure in minimally invasive surgery and as the first reported use for prostatic carcinosarcoma.

Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report

BACKGROUND AND OBJECTIVES

Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure.

METHODS

A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours.

RESULTS

At 3 months after surgery, the patient had no recurrent symptoms.

CONCLUSIONS

The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.

Robot-assisted laparoscopic partial nephrectomy

The indications for nephron-sparing surgery and for minimally invasive surgery are continually expanding. Nephron-sparing surgery, also known as partial nephrectomy, presents a challenge to the minimally invasive surgeon. Herein, we describe our technique of robot-assisted laparoscopic partial nephrectomy. This approach may have potential advantages of including easier excision and suturing. Moderate training is required.

A review of surgical techniques for radical prostatectomy

Since the early 20th century, radical prostatectomy has been used in the treatment of prostate cancer. However, before the widespread acceptance of prostate-specific antigen screening, the majority of cancers were clinically advanced and not amenable to cure, so relatively few men were candidates for this procedure. Modern advances have contributed dramatically to the reduction of complications and morbidity associated with radical prostatectomy. As a result, the procedure has become the most common treatment selected by men with localized prostate cancer. This article reviews several issues regarding radical prostatectomy, including surgical techniques, cancer control, intraoperative localization of the cavernous nerves, patient selection, and laparoscopic versus robotic approaches.

Minimally Invasive Therapy for Prostate Cancer: Use of Nomograms to Counsel Patients about the Choice and Probable Outcome of Therapy

Despite dramatic and recently accelerated advances in the reduction of morbidity linked to radical prostatectomies, significant short- and long-term morbidity is still associated with this surgical procedure. Currently both surgical and nonsurgical minimally invasive options are available for men with clinically localized prostate cancer, including laparoscopic and robotic radical prostatectomy, brachytherapy, and cryosurgical ablation of the prostate, with others, such as high intensity focused ultrasound, under investigation. In continued efforts to improve patient outcomes and to tailor treatment options to individual patient circumstances, nomograms have been developed and are increasingly being used by physicians and patients, alike, to guide therapeutic choices at each stage of disease. This tool predicts the possibility of successful treatment for the patient based on factors such as prostate-specific antigen levels, clinical stage of disease, and biopsy results. The current and future development, design, availability, and use of nomograms is described along with the historic and newer minimally invasive treatment options for prostate cancer.

Telerobotic laparoscopic repair of incisional ventral hernias using intraperitoneal prosthetic mesh

Laparoscopic ventral hernia repair shortens the length of hospital stay and achieves low rates of hernia recurrence. The inherent difficulties of performing advanced laparoscopy operations, however, have limited the adoption of this technique by many surgeons. We hypothesized that the virtual operative field and hand-like instruments of a telerobotic surgical system could overcome these limitations. We present herein the first 2 reported cases of telerobotic laparoscopic ventral hernia repair with mesh. The operations were accomplished with the da Vinci telerobotic surgical system. The hernia defects were repaired with dual-sided, expanded polytetrafluoroethylene (ePTFE) mesh. The mesh was secured in place with 8 sutures that were passed through the abdominal wall, and 5-mm surgical tacks were placed around the circumference of the mesh. The 2 operations were accomplished with total operative times of 120 and 135 minutes and total operating room times of 166 and 180 minutes, respectively. The patients were discharged home on postoperative days 1 and 4. The surgeon sat in an ergonomically comfortable position at a computer console that was remote from the patient. Immersion of the surgeon within the 3-dimensional virtual operative field expedited each stage of these procedures. The articulation of the wristed telerobotic instruments greatly facilitated reaching the anterior abdominal cavity near the abdominal wall. This report indicates that telerobotic laparoscopic ventral hernia repair is feasible and suggests that telepresence technology facilitates this procedure.