Laparoscopic radical prostatectomy with a remote controlled robot

Robotic hypospadias surgery: a new evolution

The dictum that "there is nothing new in surgery not previously described," is quoted regularly and is particularly true of hypospadias. There is an ongoing search for solutions to many troublesome issues concerning surgical treatment of hypospadias, such as what age is the most appropriate to apply surgery, or in how many stages surgery should be performed. We present a case report of the first robotic hypospadias surgery to propose a departure from the standard practice, in the hope of expanding medical expertise and teaching globally. The use of a robot for reconstructive surgery is not novel; its use for extracorporeal surgery is, but we contend that there is no difference in the surgical steps to carry out a hypospadias repair. In addition, we envision that the benefits of applying robotic surgery for extracorporeal reconstructive procedures will greatly impact the current paradigm of surgery and surgical education. For those surgeons who already possess comfort with robotic skills, reconstructive procedures outside of a major cavity are feasible, and time will provide safety and efficacy data. Our hope is that others will join in the advancement of telesurgery and its applications and appreciate the potential expansion of surgical knowledge that will be afforded by this change in how we teach and operate.

A novel approach of robotic-assisted anterior resection with transanal or transvaginal retrieval of the specimen for colorectal cancer

BACKGROUND

The surgical robot (da Vinci S) is superior to conventional laparoscopy; it provides clearer, three-dimensional images and an extended range of motion for the instruments. We used this robot for laparoscopic surgery to perform a totally intracorporeal resection of the rectum and colorectal anastomosis, with transanal or transvaginal retrieval of specimens.

METHODS

We prospectively collected data on 13 patients who underwent robot-assisted rectal surgery by a single surgeon from January to March 2008. For low anterior resection (LAR), the splenic flexure was mobilized laparoscopically, followed by robotic rectal resection and anastomosis, and transanal removal of specimens in both male and female patients. We retrieved the specimen through the vagina in some female patients.

RESULTS

Eleven and two patients underwent LAR and anterior resection (AR), respectively. Mean operative time was 260.8 ± 62.9 (range 210-390) min with median robotic time of 118 ± 43.6 (range 122-186) min. There were three postoperative complications, in two patients. One patient had anastomotic bleeding and the other had anastomotic leakage following inferior mesenteric artery bleeding. The circumferential margins were clear. The tumor stage was I in four, II in two, and III in seven patients. In one patient, the distal resection margin was involved. The patients resumed an oral diet and were discharged on the third and seventh day after surgery.

CONCLUSION

Robotic-assisted laparoscopic methods were safe for AR in patients with colorectal cancer. This approach made it easier to perform a total mesorectal excision, anastomosis, and closure of the vaginal wall, and avoided the traditional abdominal incision.

Advances in robotic prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has emerged as an important treatment option for localized prostate cancer. As such, methods to improve instrumentation, technique, outcomes, and cost require continued investigation. For example, a recently introduced four-armed robotic system has limited the need for bedside assistants, while an enhanced understanding of pelvic anatomy as visualized robotically has led to valuable modifications in operative technique. Increased surgeon experience has decreased perioperative morbidity, and has resulted in short-term pathologic and functional outcomes that compare favorably with open radical prostatectomy. Meanwhile, quality-of-life studies using validated instruments are helping to define the time course of patient recovery. Nevertheless, costs associated with robotic surgery remain daunting. As the follow-up of patients treated with RALP matures, future studies, ideally with a prospective, randomized design, will be needed to establish the long-term oncologic efficacy of the procedure and to evaluate the overall advantages of RALP compared with open surgery.

Yonsei experience in robotic urologic surgery-application in various urological procedures

PURPOSE

The da Vinci robot system has been used to perform complex reconstructive procedures in a minimally invasive fashion. Robot-assisted laparoscopic radical prostatectomy has recently established as one of the standard cares. Based on experience with the robotic prostatectomy, its use is naturally expanding into other urologic surgeries. We examine our practical pattern and application of da Vinci robot system in urologic field.

PATIENTS AND METHODS

Robotic urologic surgery has been performed during a period from July 2005 to August 2008 in a total of 708 cases. Surgery was performed by 7 operators. In our series, radical prostatectomy was performed in 623 cases, partial nephrectomy in 43 cases, radical cystectomy in 11 cases, nephroureterectomy in 18 cases and other surgeries in 15 cases.

RESULTS

In the first year, robotic urologic surgery was performed in 43 cases. However, in the second year, it was performed in 164 cases, and it was performed in 407 cases in the third year. In the first year, only prostatectomy was performed. In the second year, partial nephrectomy (2 cases), nephroureterectomy (3 cases) and cystectomy (1 case) were performed. In the third year, other urologic surgeries than prostatectomy were performed in 64 cases. The first robotic surgery was performed with long operative time. For instance, the operative time of prostatectomy, partial nephrectomy, cystectomy and nephroureterectomy was 418, 222, 340 and 320 minutes, respectively. Overall, the mean operative time of prostatectomy, partial nephrectomy, cystectomy and nephrourectectomy was 179, 173, 309, and 206 minutes, respectively.

CONCLUSION

Based on our experience at a single-institution, robot system can be used both safely and efficiently in many areas of urologic surgeries including prostatectomy. Once this system is familiar to surgeons, it will be used in a wide range of urologic surgery.

Randomized comparison of extraperitoneal and transperitoneal access for robot-assisted radical prostatectomy

PURPOSE

Although extraperitoneal robot-assisted radical prostatectomy (RARP) is gaining popularity, the majority of these procedures are performed transperitoneally. The purpose of this study was to compare the transperitoneal and extraperitoneal approaches for RARP.

PATIENTS AND METHODS

We randomized 62 consecutive patients undergoing RARP into two equal groups according to the route of access. The groups were evaluated for age, body mass index (BMI), preoperative serum prostate specific antigen (PSA) concentration, total operating time, estimated blood loss, specimen weight, pathologic Gleason score and stage, intraoperative and postoperative complications, and surgical-margin status.

RESULTS

No significant differences were noted the extraperitoneal and transperitoneal groups with respect total operative time (181 v 191 minutes), blood loss (199 v 163 mL), pathologic Gleason score (6.6 v 6.7), specimen weight (53 v 48 g), or positive-margin status (0 v 1 patient). There were no significant differences in age (56 v 59 years) or PSA (7.8 v 6.1 ng/dL). However, the BMI was significantly higher in the extraperitoneal group (29.8 v 26.5 kg/m(2); P < 0.01). The only complication in the study was a urine leak, which occurred in the transperitoneal group and was managed conservatively.

CONCLUSIONS

There were no significant differences in operative parameters in the two groups. Choice of access should be based on patient characteristics as well as surgeon preference. Patients who have had abdominal operations are best suited for the extraperitoneal route. Surgeons should be familiar with both approaches in order to provide patients with the best care.

Da Vinci prostatectomy: athermal nerve sparing and effect of the technique on erectile recovery and negative margins

As da Vinci prostatectomy (dVP) grows in use, urologists continue to work to achieve improved sexual function while maintaining oncologic outcomes. This author set out to evaluate the impact of three different nerve-sparing techniques on not only 12-month and early erectile functional recovery but on negative margin rates as well. The author completed 400 dVP procedures, 300 of which were nerve-sparing. Series 1 utilized selective bipolar cautery for nerve sparing, series 2 used an athermal "clip and peel" posterior dissection technique, and series 3 used an athermal combined anterior and posterior dissection technique with clips and sharp dissection alone. Operative times, blood loss, and margin rates were recorded for all cases, and erectile function was measured by means of pre- and post-operative Sexual Health Inventory for Men (SHIM) score. For series 1, 2, and 3, the average total operative time was 111, 83, and 75 min, average console time was 78, 53, and 58 min, average blood loss was 125, 137, and 150 ml, respectively. Erections capable of intercourse at 3 months were seen in 14% of patients in series 1, 24% of the men in series 2, and 71% of the men in series 3. Negative margin rates were 78% for series 1, 76% for series 2, and 83% for series 3. Recovery of erectile function in the author's dVP series favors an athermal technique. Short-term data on the combined anterior/posterior approach, including the preservation of the lateral prostatic fascia in the nerve sparing, was the superior of the two athermal techniques evaluated. In addition, this combined anterior and posterior method of nerve sparing using sharp dissection and clips also resulted in the lowest positive margin rates in the author's series.

Robotic-assisted laparoscopic radical prostatectomy: The Ohio State University technique

Robotic radical prostatectomy is a new innovation in the surgical treatment of prostate cancer. The technique is continuously evolving. In this article we demonstrate The Ohio State University technique for robotic radical prostatectomy. Robotic radical prostatectomy is performed using the da Vinci surgical system. The video demonstrates each step of the surgical procedure. Preliminary results with robotic prostatectomy demonstrate the benefits of minimally invasive surgery while also showing encouraging short-term outcomes in terms of continence, potency and cancer control. Robotic radical prostatectomy is an evolving technique that provides a minimally invasive alternative for the treatment of prostate cancer. Our experience with the procedure now stands at over 1,300 cases.

Historia de la robótica: de Arquitas de Tarento al Robot da Vinci. (Parte II)

Robotic surgery is a reality. In order to to understand how new robots work is interesting to know the history of ancient (see part i) and modern robotics. The desire to design automatic machines imitating humans continued for more than 4000 years. Archytas of Tarentum (at around 400 a.C.), Heron of Alexandria, Hsieh-Fec, Al-Jazari, Bacon, Turriano, Leonardo da Vinci, Vaucanson o von Kempelen were robot inventors. At 1942 Asimov published the three robotics laws. Mechanics, electronics and informatics advances at XXth century developed robots to be able to do very complex self governing works. At 1985 the robot PUMA 560 was employed to introduce a needle inside the brain. Later on, they were designed surgical robots like World First, Robodoc, Gaspar o Acrobot, Zeus, AESOP, Probot o PAKI-RCP. At 2000 the FDA approved the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA), a very sophisticated robot to assist surgeons. Currently urological procedures like prostatectomy, cystectomy and nephrectomy are performed with the da Vinci, so urology has become a very suitable speciality to robotic surgery.

[Da Vinci advanced robotic laparoscopic surgery: origin and current clinical application in urology, and comparison with open and laparoscopic surgery]

Over the last decade, open surgery, which is able to perform large extirpations and repairs of fragile tissues, is gradually being substituted with laparoscopic surgery due to the high benefits the latter entails for the patients, an also due to the learning difficulties for surgeons who must make up for such deficiencies applying higher efforts and a larger amount of stress. Robotic surgery stands in for the limitations of conventional laparoscopic surgery by means of performing more ergonomic and more accurate surgeries, particularly in the case of the most complex and difficult to access operations, such as radical prostatectomy. This review will perform a reminder of the history and clinical applications of new advanced and robotic technologies, and also a comparison with open surgery and conventional laparoscopy.

Robot-assisted versus pure laparoscopic radical prostatectomy

The aim of this study is to report the relative advantages and disadvantages of the radical prostatectomy with a laparoscopic (LRP) and a robotic (RALP) approach. A medline search was performed. Published data regarding perioperative parameters, complications, oncological results, functional results were analyzed. Shorter learning curves have been reported with the RALP. Intra-operative and post-operative outcomes appear to be comparable between the two approaches. The average time for LRP is 234 min (151-453) versus 182 min (141-250) for RALP. Estimated blood loss for the LRP averages 482 ml (185-850) versus 234 ml (75-500) for the RALP. Complication rates in single institution studies are similar. Long-term outcomes data on PSA progression is not yet available for LRP or RALP due to their relatively short existence. RALP appears to offer a significant benefit to the laparoscopically naïve surgeon with respect to learning curve when compared to LRP. This, however, comes at an increased cost. Intra-operative and post-operative outcomes appear to be similar. Longer follow-up data is necessary to compare oncological and functional outcomes.

Comparison of two-dimensional and three-dimensional suturing: is there a difference in a robotic surgery setting?

BACKGROUND AND PURPOSE

Robotic surgery allows three-dimensional (3D) viewing of tissues. We compared two-dimensional (2D) and 3D suturing drills using the daVinci surgical system to determine if the latter is advantageous.

MATERIALS AND METHODS

Twenty-eight anastomotic drills were completed by seven surgeons using the daVinci robot. Three surgeons had considerable (>6 months) robotic experience, and four had none. Drills were performed randomly in both dimensional modes in a blinded fashion. Drill 1 was an interrupted four stitch and drill 2 a running closure. All tasks were kept uniform. We recorded time to completion, difficulty, and accuracy. The drills were evaluated by two independent reviewers for accuracy and major errors (i.e., broken suture, torn graft).

RESULTS

The average operative time per drill in two dimensions was 13.1 minutes (range 6.9-21.9 minutes) and in three dimensions was 8.5 minutes (range 4.7-12.8 minutes) (P<0.001). Drill 1 was 6.1 minutes faster in three dimensions (mean 9.2 minutes; P<0.01), and drill 2 was 2.9 minutes faster (mean 7.8 minutes; P=0.03). Both advanced and novice groups were faster in 3D (P<0.01). There were two major errors in the 3D performances and 5 in the 2D exercises (P<0.05). The participants correctly identified the dimensional mode 92.9% of the time (P<0.01).

CONCLUSION

The anastomosis was completed 65% faster using 3D with equal, if not greater, accuracy. Drill 1 was improved to a greater degree than drill 2, suggesting most benefit of 3D views during knot tying. Use of three dimensions outperformed two dimensions in both groups. Surgeons can immediately benefit from 3D viewing during robotic surgery.

[Mechatronic in functional endoscopic sinus surgery. First experiences with the daVinci Telemanipulatory System]

BACKGROUND

This study examines the advantages and disadvantages of a commercial telemanipulator system (daVinci, Intuitive Surgical, USA) with computer-guided instruments in functional endoscopic sinus surgery (FESS).

METHODS

We performed five different surgical FESS steps on 14 anatomical preparation and compared them with conventional FESS. A total of 140 procedures were examined taking into account the following parameters: degrees of freedom (DOF), duration , learning curve, force feedback, human-machine-interface.

RESULTS

Telemanipulatory instruments have more DOF available then conventional instrumentation in FESS. The average time consumed by configuration of the telemanipulator is around 9+/-2 min. Missing force feedback is evaluated mainly as a disadvantage of the telemanipulator. Scaling was evaluated as helpful. The ergonomic concept seems to be better than the conventional solution.

DISCUSSION

Computer guided instruments showed better results for the available DOF of the instruments. The human-machine-interface is more adaptable and variable then in conventional instrumentation. Motion scaling and indexing are characteristics of the telemanipulator concept which are helpful for FESS in our study.

Robot-assisted laparoscopic partial nephrectomy: the NYU technique

The introduction of the daVinci surgical system has changed the way both surgeon and patient view radical prostatectomy. We hypothesized that the same theoretical and tangible benefits may be realized when employing the system for partial nephrectomy. This paper reviews our technique of robot-assisted laparoscopic partial nephrectomy (RALPN) utilizing the daVinci surgical system. Intraoperative hilar clamping is utilized in all cases. With the daVinci system, the tumor is excised with cold scissors, biopsies are taken from the base for frozen-section study, sutures are placed at the base, Gelfoam/fibrin glue is activated in the defect, a Surgicel bolster is laid in the defect, and mattress sutures are placed prior to releasing the clamp. After performing 12 RALPNs, it appears this technique is safe, feasible, and reproducible both for small exophytic masses and for deeper lesions involving the collecting system. A RALPN requires two surgeons, both well versed in laparoscopic and robotic techniques.

Recent trends in surgical treatment of localized prostate cancer

Prostate cancer and its various forms of treatment remain a source of significant controversy and morbidity despite recent advances. In response, there is an increasing trend toward the development of treatments aimed at cancer prevention and at maximizing the preservation of function without sacrificing cancer control. This article reviews the current prostate cancer literature and reports on improvements in existing surgical treatments and developing technologies aimed toward achieving these goals. Specific therapies addressed include improvements in surgical techniques, laparoscopy, robotics, cryosurgical and thermal ablation, and high-intensity focused ultrasound.

Robotic-assisted anatomic radical prostatectomy: technical difficulties due to a large median lobe

The case of a robot-assisted laparoscopic radical prostatectomy in a patient with a 143-gram prostate with a large median lobe is reported. The aim of the study was to delineate the difficulties and concern when confronted with such a situation. The technical difficulties, possible preventive methods, correction and management are discussed briefly with the hope of aiding urologists when performing radical prostatectomy in patients with large median lobe prostates.

Robotic radical prostatectomy: a minimally invasive therapy for prostate cancer

The robotic radical prostatectomy technique involves the use of the da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) assistance with three-dimensional stereoscopic visualization and ergonomic multijointed instruments. This article presents our results after treating 750 patients with robot-assisted radical prostatectomy at the Vattikuti Institute of Urology.

Vattikuti Institute Prostatectomy: A Technique of Robotic Radical Prostatectomy: Experience in More than 1000 Cases

The Vattikuti Institute prostatectomy (VIP), a robotic radical prostatectomy approach, was conceived, designed, and refined with the goal of finding the most surgeon-friendly technique while minimizing patient morbidity and continuing to follow the standards of open radical prostatectomy. In this approach, the entire procedure is performed extraperitoneally after the ports have been placed transperitoneally and the bladder is dissected off the anterior abdominal wall. The evolution of the VIP is an amalgam of knowledge gained from the different procedures and recreated mixing in the technical nuances of robotic assistance. The procedure has been modified further from what we began with to obtain better outcomes. In our experience, robotic assistance, with its virtues of wristed movements, three-dimensional magnified vision, and filtered movements, allowed us to adjudicate a better operation with good oncologic and functional outcomes. It is also associated with decreased morbidity and earlier convalescence with excellent cosmesis. It is an ideal choice of the treatment at our center for localized cancer of prostate. Herein, the technique is described, detailing the different steps.

Anatomic Guide for Port Placement for DaVinci Robotic Radical Prostatectomy

BACKGROUND AND PURPOSE

At present, robotic arm port placement for daVinci trade mark robot-assisted laparoscopic radical prostatectomy is based on the umbilicus. However, the robotic arm has a maximum manufactured required working distance of 25 cm. Accordingly, normal variability of patient height, weight, and umbilical location can leave the working arms too short to reach the membranous urethra. We present data to support port placement using the pubis, rather than the umbilicus, as the landmark.

MATERIALS AND METHODS

If we assume the 25-cm working distance of the robot arm (Z) equals the hypotenuse of a triangle and the Y axis is the sum of the distance from the membranous urethra to the skin (Y1) plus the displacement of the skin secondary to CO(2) insufflation (Y2), then the horizontal distance X is from the robot port site to the pubis. To ascertain Y1, we randomly selected the CT scans of 25 men and measured the depth from the skin over the pubis to the membranous urethra. To determine Y2, we measured the change in height from the table of the port site after CO(2) insufflation in 11 robotic laparoscopic prostatectomies.

RESULTS

The average distance of Y1 was 11 cm; Y2 was 6 cm. Using the formula (Z(2) - (Y1 + Y2)(2))(1/2), the maximum distance X from the port site to the pubis, for an average man, should not exceed 18 cm.

CONCLUSION

The optimal landmark for calculating the placement of ports for the daVinci robotic arm placement should be the pubis and not the umbilicus. Tall men (>72 inches) are at risk for exceeding functional robot arm length, and in these men, port sites should not be more than 18 cm from the pubis.

Surgical Robotics and Laparoscopic Training Drills

PURPOSE

We investigated the impact of robotics on surgical skills by comparing traditional laparoscopy with the da Vinci Surgical System in the performance of various laparoscopic training drills.

SUBJECTS AND METHODS

Twenty-one surgeons performed eight timed drills of increasing difficulty with a laparoscopic trainer and the da Vinci Surgical System (Intuitive Surgical Sunnyvale, CA). The mean time to drill completion, drill time variance, and statistical analysis were performed. Surgeons were also questioned about their perception of the robotic technology following completion of the drill series.

RESULTS

The mean time required to complete the first drill was 69 seconds with laparoscopy and 57 seconds with the robotic system. The mean times for drill two were 67 seconds with laparoscopy and 44 seconds with robotics; for drill three, the times were 88 seconds for laparoscopy and 61 seconds for robotics, and for drill four, 186 seconds with laparoscopy and 71 seconds with robotics. Only the first drill failed to show a statistically significant difference between the laparoscopic and robotic groups.

CONCLUSIONS

The robotic system allowed surgeons to complete drills faster than traditional laparoscopy. Novice laparoscopic surgeons performed three of the four drills faster robotically than did expert laparoscopic surgeons. These findings may indicate that the attributes of the robotic system level the playing field between surgeons of different skill levels. The next generation of surgeons must focus on this evolving technology and its application in the operating room of the future.

Robotic surgery: a current perspective

OBJECTIVE

To review the history, development, and current applications of robotics in surgery.

BACKGROUND

Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving.

METHODS

A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications.

RESULTS

Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques.

CONCLUSIONS

Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.

Robotic Surgery: Urologic Implications

Current medical robots have nothing in common with the anthropomorphic robots in science fiction classics. They are in fact, manipulators, working on a master-slave principle. Robots can be defined as "automatically controlled multitask manipulators, which are freely programmable in three or more spaces." The success of robots in surgery is based on their precision, lack of fatigue, and speed of action. This review describes the theory, advantages, disadvantages, and clinical utilization of mechanical and robotic arm systems to replace the second assistant and provide camera direction and stability during laparoscopic surgery. The Robotrac system (Aesculap, Burlingame, CA), the First Assistant (Leonard Medical Inc, Huntingdon Valley, PA), AESOP (Computer Motion, Goleta, CA), ZEUS (Computer Motion), and the da Vinci (Intuitive Surgical, Mountain View, CA) system are reviewed, as are simple mechanical-assist systems such as Omnitract (Minnesota Scientific, St. Paul, MN), Iron Intern (Automated Medical Products Corp., New York, NY), the Bookwalter retraction system (Codman , Somerville, NJ), the Surgassistant trade mark (Solos Endoscopy, Irvine, CA), the Trocar Sleeve Stabilizer (Richard Wolf Medical Instruments Corp., Rosemont, IL), and the Endoholder (Codman, Somerville, NJ).

Laparoscopic and robotic surgical training in urology

The most important change in urology during the past decade was the development of minimally invasive surgery, particularly laparoscopy. However, the main drawback of laparoscopy is a steep learning curve, which results from the significant changes in the surgical environment. Although laparoscopy can provide important advantages for the patient, including decreased length of hospitalization, decreased analgesic requirement, and a shortened postoperative convalescence, one concern has been whether laparoscopic techniques should be learned solely in the operating room. For example, sports, music, and aviation are practiced before an actual performance is ever undertaken. In this review, the advantages and limitations of all available training modalities in minimally invasive surgery are described. Testing basic laparoscopic skills on inanimate models, becoming familiar with the principles of dissection and hemostasis on living animals, and studying surgical anatomy on cadavers should be considered as indispensable and complementary elements for laparoscopic training in the future. In addition, telementoring with the help of modern image processing and virtual reality eventually may become the basis of tomorrow's surgical instruction.

Transcontinental robot-assisted remote telesurgery: feasibility and potential applications

OBJECTIVE

To show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology.

SUMMARY BACKGROUND DATA

Technical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances.

METHODS

To verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service).

RESULTS

The operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery.

CONCLUSIONS

Remote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide.

Computer-assisted robotic heller myotomy: initial case report

PURPOSE

Our objective was to determine the efficacy of computer-assisted robotic laparoscopic Heller myotomy.

METHODS

A 76-year-old woman with a significant history of achalasia was evaluated for laparoscopic Heller myotomy. The daVinci surgical system was used throughout the procedure.

RESULTS

Computer assistance allowed scaling of hand motions from a range of 2:1 to 5:1. Successful dissection of the esophageal musculature was accomplished, and a Toupet-type fundoplication was performed. The patient was discharged from the hospital the day after surgery with five port incisions, each <1 cm.

CONCLUSIONS

Telemanipulator computer-assisted surgical devices may have applications in procedures that require advanced and finely tuned motions, such as Heller myotomy. The benefits of extra magnification and three-dimensional imaging can help prevent esophageal perforation and identify residual circular muscle fibers.