Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis

Minimally invasive surgery as a treatment option for gastric cancer with liver metastasis: a comparison with open surgery

BACKGROUND

As minimally invasive techniques advances, minimally invasive surgery (MIS) has emerged as an alternative modality for advanced gastric cancer. In this study, we compared the short- and long-term surgical outcomes of MIS and conventional open surgery for gastric cancer liver metastasis (GCLM) in terms of safety, feasibility, and efficacy.

METHODS

This retrospective study used data from a prospective database at the Chinese People's Liberation Army General Hospital. From January 2006 to June 2016, 53 gastric cancer patients with synchronous liver metastasis accepted radical gastrectomy combined with either or both hepatectomy and radiofrequency ablation for liver metastases. The 53 patients enrolled in the study were divided into two groups: a conventional open surgery group (n = 42) and an MIS group (n = 11). Propensity score matching (PSM) analysis was performed to overcome possible bias.

RESULTS

With PSM performed at a 1:3 ratio, 11 patients who received MIS were compared with 33 open surgery cases. Mean operation time was significantly longer for the MIS group compared with the open surgery group (301 vs. 236 min, P = 0.032), while the open surgery group had a larger estimated blood loss than the MIS group (421 vs. 196 ml, P = 0.019). Time to first flatus and postoperative complications, including Clavien-Dindo classification, were similar in the two groups. However, patients undergoing MIS had a significantly shorter time to first sips of water (P = 0.020) and soft diet (P = 0.020) compared with open surgery counterparts. Long-term outcomes were comparable between groups (P = 0.090) after adjustment by PSM analysis.

CONCLUSIONS

MIS achieved superior short-term outcomes and comparable long-term outcomes compared with open surgery in GCLM patients. For experienced surgeons, both laparoscopic and robotic methods of MIS are reasonable approaches for the management of highly selected GCLM patients.

Operative and survival outcomes in a series of 100 consecutive cases of robot-assisted transhiatal esophagectomies

Robotic-assisted transhiatal esophagectomy (RATE) is a technically complex procedure with potential for improved postoperative outcomes. In this report, we describe our experience with RATE in a large case series. A retrospective review was conducted to collect clinical, outcomes, and survival data for 100 consecutive patients with esophageal cancer (n = 98) and benign (n = 2) conditions undergoing RATE between March 2007 and December 2014. Progression-free (PFS) and overall (OS) survival were estimated using the Kaplan-Meier curves with comparisons by log-rank tests. Median operative time and estimated blood loss were 264 minutes and 75 mL, respectively. Median intensive care unit stay was 1 day and median length of hospital stay was 8 days. Postoperative complications commonly observed were nonmalignant pleural effusion (38%) and recurrent laryngeal nerve injury (33%); 30 day mortality rate was 2%. Median number of lymph nodes removed during RATE was 17 and R0 resection was achieved in 97.8% patients. At the end of the median follow-up period of 27.7 months, median PFS was 41 months and median OS was 54 months. 1-year and 3-year PFS rates were 82% (95% CI, 75%-89%) and 53% (95% CI, 42%-62%), respectively, and OS rates were 95% (95% CI, 91%-99%) and 57% (95% CI, 46%-67%). In our experience, RATE is an effective and safe oncologic surgical procedure in a carefully selected group of patients with acceptable operative time, minimal blood loss, standard postoperative morbidity and adequate PFS and OS profiles.

Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer

BACKGROUND

Prostate cancer is commonly diagnosed in men worldwide. Surgery, in the form of radical prostatectomy, is one of the main forms of treatment for men with localised prostate cancer. Prostatectomy has traditionally been performed as open surgery, typically via a retropubic approach. The advent of laparoscopic approaches, including robotic-assisted, provides a minimally invasive alternative to open radical prostatectomy (ORP).

OBJECTIVES

To assess the effects of laparoscopic radical prostatectomy or robotic-assisted radical prostatectomy compared to open radical prostatectomy in men with localised prostate cancer.

SEARCH METHODS

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings with no restrictions on the language of publication or publication status, up until 9 June 2017. We also searched bibliographies of included studies and conference proceedings.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a direct comparison of laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RARP) to ORP, including pseudo-RCTs.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data. The primary outcomes were prostate cancer-specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence-free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to GRADE.

MAIN RESULTS

We included two unique studies with 446 randomised participants with clinically localised prostate cancer. The mean age, prostate volume, and prostate-specific antigen (PSA) of the participants were 61.3 years, 49.78 mL, and 7.09 ng/mL, respectively. Primary outcomes We found no study that addressed the outcome of prostate cancer-specific survival. Based on data from one trial, RARP likely results in little to no difference in urinary quality of life (MD -1.30, 95% CI -4.65 to 2.05) and sexual quality of life (MD 3.90, 95% CI -1.84 to 9.64). We rated the quality of evidence as moderate for both quality of life outcomes, downgrading for study limitations. Secondary outcomes We found no study that addressed the outcomes of biochemical recurrence-free survival or overall survival.Based on one trial, RARP may result in little to no difference in overall surgical complications (RR 0.41, 95% CI 0.16 to 1.04) or serious postoperative complications (RR 0.16, 95% CI 0.02 to 1.32). We rated the quality of evidence as low for both surgical complications, downgrading for study limitations and imprecision.Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at one day (MD -1.05, 95% CI -1.42 to -0.68 ) and up to one week (MD -0.78, 95% CI -1.40 to -0.17). We rated the quality of evidence for both time-points as low, downgrading for study limitations and imprecision. Based on one study, RARP likely results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI -0.32 to 0.34). We rated the quality of evidence as moderate, downgrading for study limitations.Based on one study, RARP likely reduces the length of hospital stay (MD -1.72, 95% CI -2.19 to -1.25). We rated the quality of evidence as moderate, downgrading for study limitations.Based on two study, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI 0.12 to 0.46). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1000 men (95% CI 78 fewer to 48 fewer). We rated the quality of evidence as low, downgrading for study limitations and indirectness.We were unable to perform any of the prespecified secondary analyses based on the available evidence. All available outcome data were short-term and we were unable to account for surgeon volume or experience.

AUTHORS' CONCLUSIONS

There is no high-quality evidence to inform the comparative effectiveness of LRP or RARP compared to ORP for oncological outcomes. Urinary and sexual quality of life-related outcomes appear similar.Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions. All available outcome data were short-term, and this study was unable to account for surgeon volume or experience.

Robot-assisted thyroidectomy using a gasless, transaxillary approach for the management of thyroid lesions: Indian experience

Aim:

Since last decades, more and more thyroidectomies have been performed by the minimally invasive method. Compared to conventional thyroidectomy, minimally invasive thyroidectomy has a superior cosmetic result. However, the outcome depends, in a large extent, on the skill of the operator and the learning curve is relatively long. Robotic thyroidectomy (RT) is a relatively new approach in treating thyroid lesions with improved ergonomics and surgical outcomes.

Purpose:

We performed a prospective study of robotic-assisted transaxillary approach for thyroidectomy in Indian patients to examine the feasibility of the procedure.

Materials and Methods:

A total of 35 patients underwent RT. Demographics, surgical indications, operative findings, postoperative functional outcome, local complications and pathological outcomes were recorded and analyzed.

Results:

The median age of the cohort was 28.6 years and 31 of the patients were women. The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). The median size of the largest nodule was 3.2 cm (range, 1.0–4.5 cm). Eighteen patients underwent less than total thyroidectomy and 17 patients underwent total thyroidectomy, with no conversion. The mean console time standard deviation was 115 min initially, and with experience, it reduced to 106 min for subsequent cases. The mean blood loss was 13 ml. Post-operative outcome was good with no serious complication noted in our series.

Conclusion:

Robotic-assisted thyroidectomy using a gasless transaxillary approach is a feasible, safe and noninferior surgical alternative for selected patients. We believe with time RT will be widened and it will be performed more often.

Advances in Laparoscopic Colorectal Surgery

Laparoscopic colorectal surgery has now become widely adopted for the treatment of colorectal neoplasia, with steady increases in utilization over the past 15 years. Common minimally invasive techniques include multiport laparoscopy, single-incision laparoscopy, and hand-assisted laparoscopy, with the choice of technique depending on several patient and surgeon factors. Laparoscopic colorectal surgery involves a robust learning curve, and fellowship training often lays the foundation for a high-volume laparoscopic practice. This article provides a summary of the various techniques for laparoscopic colorectal surgery, including operative steps, the approach to difficult patients, and the learning curve for proficiency.

Robotic technological aids in esophageal surgery

Robotic technology is an emerging technology that has been developed in order to overcome some limitations of the standard laparoscopic approach, offering a stereoscopic three-dimensional visualization of the surgical field, increased maneuverability of the surgical tools with consequent increased movement accuracy and precision and improved ergonomics. It has been used for the surgical treatment of most benign esophageal disorders. More recently, it has been proposed also for patients with operable esophageal cancer. The current evidence shows that there are no real benefits of the robotic technology over conventional laparoscopy in patients undergoing a fundoplication for gastroesophageal reflux disease (GERD), hiatal closure for giant hiatal hernia, or Heller myotomy for achalasia. A few small studies suggest potential advantages in patients undergoing redo surgery for failed fundoplication or Heller myotomy, but large comparative studies are needed to better clarify the role of the robotic technology in these patients. Robot-assisted esophagectomy seems to be safe and effective in selected patients; however, there are no data showing superiority of this approach over both conventional laparoscopic and open surgery. The short-term and long-term oncologic results of ongoing randomized controlled trials (RCTs) are awaited to validate this approach for the treatment of esophageal cancer.

3D Vision Provides Shorter Operative Time and More Accurate Intraoperative Surgical Performance in Laparoscopic Hiatal Hernia Repair Compared With 2D Vision

Background. The aim of this study is to evaluate if 3-dimensional high-definition (3D) vision in laparoscopy can prompt advantages over conventional 2D high-definition vision in hiatal hernia (HH) repair. Study design. Between September 2012 and September 2015, we randomized 36 patients affected by symptomatic HH to undergo surgery; 17 patients underwent 2D laparoscopic HH repair, whereas 19 patients underwent the same operation in 3D vision. Results. No conversion to open surgery occurred. Overall operative time was significantly reduced in the 3D laparoscopic group compared with the 2D one (69.9 vs 90.1 minutes, P = .006). Operative time to perform laparoscopic crura closure did not differ significantly between the 2 groups. We observed a tendency to a faster crura closure in the 3D group in the subgroup of patients with mesh positioning (7.5 vs 8.9 minutes, P = .09). Nissen fundoplication was faster in the 3D group without mesh positioning ( P = .07). Conclusions. 3D vision in laparoscopic HH repair helps surgeon’s visualization and seems to lead to operative time reduction. Advantages can result from the enhanced spatial perception of narrow spaces. Less operative time and more accurate surgery translate to benefit for patients and cost savings, compensating the high costs of the 3D technology. However, more data from larger series are needed to firmly assess the advantages of 3D over 2D vision in laparoscopic HH repair.

Robotic gastrectomy versus open gastrectomy in the treatment of gastric cancer

BACKGROUND

Robotic gastrectomy (RG) has been developed to improve surgical quality and to overcome the limitations of conventional open gastrectomy (OG) for gastric cancer. The aim of this meta-analysis is to comprehensively compare the safety and efficacy between robotic surgery and open surgery for treating gastric cancer.

METHODS

Major databases were searched for retrospective case-matched studies comparing RG and OG for treating gastric cancer. A list of these studies, published in English from 1990 to 2016, was obtained independently by two reviewers from databases such as PubMed, MEDLINE, ScienceDirect, the China National Knowledge Infrastructure and Web of Science. Intraoperative data, oncological outcomes and postoperative complications were compared using Review Manager 5.3.

RESULTS

Seven studies involving 5970 patients with 606 cases of RG and 5364 cases of OG were included in this meta-analysis. Compared to OG, RG has a significantly longer operation time [weighted mean differences (WMD) = 63.72, 95 % confidence interval (CI) 33.83-93.61, P < 0.0001], lower blood loss (WMD: -129.74, 95 % CI -178.31 to -81.16, P < 0.00001) and shorter hospital stay (WMD = -2.39, 95 % CI -2.92 to -1.87; P < 0.00001). No statistical difference was noted based on the rate of overall postoperative complication, wound infection, bleeding, ileus and obstruction, abdominal collections and abscesses, and the rate of anastomotic leak in the RG versus OG. Postoperative oncological outcomes showed that there were also no statistical differences among the number of retrieved lymph nodes, proximal resection margin, distal resection margin except for tumor size (WMD = -1.60; 95 % CI -2.96 to -0.25; P = 0.02).

CONCLUSION

The results of this meta-analysis suggest that RG will be more accessible than conventional OG for gastric cancer. However, more prospective, well-designed, multicenter, randomized controlled trials are necessary to further evaluate the safety and efficacy as well as the long-term outcome of this technology.

Protocol for laparoscopic cholecystectomy: Is it rocket science?

Laparoscopic cholecystectomy (LC) does not require advanced techniques, and its performance has therefore rapidly spread worldwide. However, the rate of biliary injuries has not decreased. The concept of the critical view of safety (CVS) was first documented two decades ago. Unexpected injuries are principally due to misidentification of human factors. The surgeon's assumption is a major cause of misidentification, and a high level of experience alone is not sufficient for successful LC. We herein describe tips and pitfalls of LC in detail and discuss various technical considerations. Finally, based on a review of important papers and our own experience, we summarize the following mandatory protocol for safe LC: (1) consideration that a high level of experience alone is not enough; (2) recognition of the plateau involving the common hepatic duct and hepatic hilum; (3) blunt dissection until CVS exposure; (4) Calot's triangle clearance in the overhead view; (5) Calot's triangle clearance in the view from underneath; (6) dissection of the posterior right side of Calot's triangle; (7) removal of the gallbladder body; and (8) positive CVS exposure. We believe that adherence to this protocol will ensure successful and beneficial LC worldwide, even in patients with inflammatory changes and rare anatomies.

Using Contact Forces and Robot Arm Accelerations to Automatically Rate Surgeon Skill at Peg Transfer

OBJECTIVE

Most trainees begin learning robotic minimally invasive surgery by performing inanimate practice tasks with clinical robots such as the Intuitive Surgical da Vinci. Expert surgeons are commonly asked to evaluate these performances using standardized five-point rating scales, but doing such ratings is time consuming, tedious, and somewhat subjective. This paper presents an automatic skill evaluation system that analyzes only the contact force with the task materials, the broad-bandwidth accelerations of the robotic instruments and camera, and the task completion time.

METHODS

We recruited N = 38 participants of varying skill in robotic surgery to perform three trials of peg transfer with a da Vinci Standard robot instrumented with our Smart Task Board. After calibration, three individuals rated these trials on five domains of the Global Evaluative Assessment of Robotic Skill (GEARS) structured assessment tool, providing ground-truth labels for regression and classification machine learning algorithms that predict GEARS scores based on the recorded force, acceleration, and time signals.

RESULTS

Both machine learning approaches produced scores on the reserved testing sets that were in good to excellent agreement with the human raters, even when the force information was not considered. Furthermore, regression predicted GEARS scores more accurately and efficiently than classification.

CONCLUSION

A surgeon's skill at robotic peg transfer can be reliably rated via regression using features gathered from force, acceleration, and time sensors external to the robot.

SIGNIFICANCE

We expect improved trainee learning as a result of providing these automatic skill ratings during inanimate task practice on a surgical robot.

Risk factors for postoperative complications in robotic general surgery

The feasibility and safety of robotically assisted procedures in general surgery have been reported from various groups worldwide. Because postoperative complications may lead to longer hospital stays and higher costs overall, analysis of risk factors for postoperative surgical complications in this subset of patients is clinically relevant. The goal of this study was to identify risk factors for postoperative morbidity after robotic surgical procedures in general surgery. We performed an observational monocentric retrospective study. All consecutive robotic surgical procedures from November 2001 to December 2013 were included. One thousand consecutive general surgery patients met the inclusion criteria. The mean overall postoperative morbidity and major postoperative morbidity (Clavien >III) rates were 20.4 and 6 %, respectively. This included a conversion rate of 4.4 %, reoperation rate of 4.5 %, and mortality rate of 0.2 %. Multivariate analysis showed that ASA score >3 [OR 1.7; 95 % CI (1.2-2.4)], hematocrit value <38 [OR 1.6; 95 % CI (1.1-2.2)], previous abdominal surgery [OR 1.5; 95 % CI (1-2)], advanced dissection [OR 5.8; 95 % CI (3.1-10.6)], and multiquadrant surgery [OR 2.5; 95 % CI (1.7-3.8)] remained independent risk factors for overall postoperative morbidity. It also showed that advanced dissection [OR 4.4; 95 % CI (1.9-9.6)] and multiquadrant surgery [OR 4.4; 95 % CI (2.3-8.5)] remained independent risk factors for major postoperative morbidity (Clavien >III). This study identifies independent risk factors for postoperative overall and major morbidity in robotic general surgery. Because these factors independently impacted postoperative complications, we believe they could be taken into account in future studies comparing conventional versus robot-assisted laparoscopic procedures in general surgery.

Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial

AIM

The purpose of this prospective randomized study was to compare robot-assisted and laparoscopic ventral rectopexy procedures for posterior compartment procidentia in terms of restoration of the anatomy using magnetic resonance (MR) defaecography.

METHOD

Sixteen female patients (four with total prolapse, twelve with intussusception) underwent robot-assisted ventral mesh rectopexy (RVMR) and 14 female patients (two with prolapse, twelve with intussusception) laparoscopic ventral mesh rectopexy (LVMR). Primary outcome measures were perioperative parameters, complications and restoration of anatomy as assessed by MR defaecography, which was performed preoperatively and 3 months after surgery.

RESULTS

Patient demographics, operation length, operating theatre times and length of in-hospital stay were similar between the groups. The anatomical defects of rectal prolapse, intussusception and rectocele and enterocele were similarly corrected after rectopexy in either technique as confirmed with dynamic MR defaecography. A slight residual intussusception was observed in three patients with primary total prolapse (two RVMR vs one LVMR) and in one patient with primary intussusception (RVMR) (P = 0.60). Rectocele was reduced from a mean of 33.0 ± 14.9 mm to 5.5 ± 8.4 mm after RVMR (P < 0.001) and from 24.7 ± 17.5 mm to 7.2 ± 3.2 mm after LVMR (P < 0.001) (RVMR vs LVMR, P = 0.10).

CONCLUSION

Robot-assisted laparoscopic ventral rectopexy can be performed safely and within the same operative time as conventional laparoscopy. Minimally invasive ventral rectopexy allows good anatomical correction as assessed by MR defaecography, with no differences between the techniques.

Efficacy of the Da Vinci surgical system in colorectal surgery comparing with traditional laparoscopic surgery or open surgery

In order to compare the curative effect of the Da Vinci surgical system (DVSS) with laparoscopic surgery (LS) or open surgery for colorectal resection, literature search was conducted in PubMed, Excerpt Medica Database (Embase), and Cochrane library up to January 15, 2016. Odds ratio (OR) and weighted mean difference with their corresponding 95% confidence intervals were used as effect size for evaluation of different outcomes. In total, 10 studies consisting of 2767 patients were included for the meta-analysis. As a result, there were no significant differences between DVSS and LS/open surgery in the long-term oncologic outcomes ( p > 0.05). However, DVSS achieved a significantly lower length of hospital stay and estimated blood loss (EBL), but a longer operation time. Moreover, DVSS showed a significantly reduced conversion to open surgery than LS (OR = 0.19, 95% confidence interval: 0.08–0.48). Subgroup analysis indicated that DVSS had different results in rectal adenocarcinoma and colon cancer subgroups on outcomes of conversion to open surgery and operation time. DVSS is superior to LS/open surgery in length of hospital stay and EBL, but needs longer operation time. Long-term outcomes of DVSS are comparable with the other approaches. From long-term perspective, DVSS has an equivalent effect to the other two techniques.

Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery

INTRO

Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.

METHODS

Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.

RESULTS

Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).

CONCLUSION

These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.

First 101 Robotic General Surgery Cases in a Community Hospital

BACKGROUND AND OBJECTIVES

The general surgeon's robotic learning curve may improve if the experience is classified into categories based on the complexity of the procedures in a small community hospital. The intraoperative time should decrease and the incidence of complications should be comparable to conventional laparoscopy. The learning curve of a single robotic general surgeon in a small community hospital using the da Vinci S platform was analyzed.

METHODS

Measured parameters were operative time, console time, conversion rates, complications, surgical site infections (SSIs), surgical site occurrences (SSOs), length of stay, and patient demographics.

RESULTS

Between March 2014 and August 2015, 101 robotic general surgery cases were performed by a single surgeon in a 266-bed community hospital, including laparoscopic cholecystectomies, inguinal hernia repairs; ventral, incisional, and umbilical hernia repairs; and colorectal, foregut, bariatric, and miscellaneous procedures. Ninety-nine of the cases were completed robotically. Seven patients were readmitted within 30 days. There were 8 complications (7.92%). There were no mortalities and all complications were resolved with good outcomes. The mean operative time was 233.0 minutes. The mean console operative time was 117.6 minutes.

CONCLUSION

A robotic general surgery program can be safely implemented in a small community hospital with extensive training of the surgical team through basic robotic skills courses as well as supplemental educational experiences. Although the use of the robotic platform in general surgery could be limited to complex procedures such as foregut and colorectal surgery, it can also be safely used in a large variety of operations with results similar to those of conventional laparoscopy.

Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: the current evidence

The aim of this meta-analysis was to comprehensively compare the safety and efficacy of robotic-assisted rectal cancer surgery (RRCS) and open rectal cancer surgery (ORCS). Electronic database (PubMed, EMBASE, Web of Knowledge, and the Cochrane Library) searches were conducted for all relevant studies that compared the short-term and long-term outcomes between RRCS and ORCS. Odds ratios (ORs), mean differences, and hazard ratios were calculated. Seven studies involving 1074 patients with rectal cancer were identified for this meta-analysis. Compared with ORCS, RRCS is associated with a lower estimated blood loss (mean difference [MD]: −139.98, 95% confidence interval [CI]: −159.11 to −120.86; P < 0.00001), shorter hospital stay length (MD: −2.10, 95% CI: −3.47 to −0.73; P = 0.003), lower intraoperative transfusion requirements (OR: 0.52, 95% CI: 0.28 to 0.99, P = 0.05), shorter time to flatus passage (MD: −0.97, 95% CI = −1.06 to −0.88, P < 0.00001), and shorter time to resume a normal diet (MD: −1.71.95% CI = −3.31 to −0.12, P = 0.04). There were no significant differences in surgery-related complications, oncologic clearance, disease-free survival, and overall survival between the two groups. However, RRCS was associated with a longer operative time. RRCS is safe and effective.

Minimally invasive surgery of rectal cancer: current evidence and options

Minimally invasive surgery (MIS) of colorectal cancer has become more popular in the past two decades. Laparoscopic colectomy has been accepted as an alternative standard approach in colon cancer, with comparable oncologic outcomes and several better short-term outcomes compared to open surgery. Unlike the treatment for colon cancer, however, the minimally invasive approach in rectal cancer has not been established. In this article, we summarize the current status of MIS for rectal cancer and explore the various technical options.

Robotic vs. Laparoscopic Roux-En-Y Gastric Bypass: a Systematic Review and Meta-Analysis

We aim to summarize the available literature on patients treated with robotic RYGB and compare the clinical outcomes of patients treated with robotic RYGB with those treated with the standard laparoscopic RYGB. A systematic literature search of PubMed and Scopus databases was conducted in accordance with the PRISMA guidelines. Fourteen comparative and 11 non-comparative studies were included in this study, reporting data on 5145 patients. This study points to comparable clinical outcomes between robotic and laparoscopic RYGB. Robotic-assisted RYGB was associated with significantly less frequent anastomotic stricture events, reoperations, and a decreased length of hospital stay compared with the standard laparoscopic procedures; however, these findings should be interpreted with caution given the low number and poor quality of the studies currently available in the literature.

Underwater robotic suturing

BACKGROUND

Laparoscopic and robotic surgeries have become popular, and this popularity is increasing. However, the environment in which such surgeries are performed is rarely discussed. Similar to arthrosurgery performed in water, artificial ascites could be a new environment for laparoscopic surgery. This study was performed to determine whether robotic surgery is applicable to complicated suturing underwater.

MATERIAL AND METHODS

A da Vinci Surgical System S was used. A weighted fabric sheet was placed at the bottom of a tank. Identical sets were made for each environment: One tank was dry, and the other was filled with water. The suturing task involved placement of a running silk suture around the perimeter of a small circle. The task was performed eight times in each environment. The task time and integrity score were determined. The integrity score was calculated by evaluating accuracy, tightness, thread damage, and uniformity; each factor was evaluated using a five-point scale.

RESULTS

Although statistically significant differences were not shown in either task time or integrity score between the underwater and air environments, robotic suturing underwater is not inferior to performance in air.

CONCLUSIONS

The feasibility of robotic suturing underwater was confirmed under the herein-described experimental conditions.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Laparoscopic colorectal surgery: Current status and implementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studies and meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients’ characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intra-corporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Assessing the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer: A randomized clinical trial

BACKGROUND

Robotic gastrectomy is increasingly used in gastric cancer patients. This study assessed the safety and efficacy of full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer.

METHODS

Three hundred and eleven patients were randomized into an open gastrectomy group or a robotic gastrectomy group, and digestive restorations were performed under direct vision and with intracorporeal robot-sewn anastomosis, respectively. Length of postoperative hospital stay, number of lymph node dissections, surgical duration, blood loss, and complication rate after surgery were recorded.

RESULTS

There were no significant differences in the number of lymph node dissections (30.9 ± 10.4 vs. 29.3 ± 9.7 days, P = 0.281) or complication rates (10.3 vs. 9.3%, P = 0.756) between the two groups. Surgical duration was significantly longer in the robotic gastrectomy group than in the open gastrectomy group (242.7 ± 43.8 vs. 192.4 ± 31.5 min, P = 0.002), whereas blood loss was less (94.2 ± 51.5 vs. 152.8 ± 76.9 ml, P < 0.001), length of postoperative hospital stay was shorter (5.6 ± 1.9 vs. 6.7 ± 1.9 days, P = 0.021), and postoperative restoration of bowel function was earlier (2.6 ± 1.1 vs. 3.1 ± 1.2 days, P = 0.028).

CONCLUSION

Full robotic gastrectomy with intracorporeal robot-sewn anastomosis for gastric cancer is safe and does not increase the complication risk during or after surgery. J. Surg. Oncol. 2016;113:397-404. © 2016 Wiley Periodicals, Inc.

Laparoscopic surgery: A qualified systematic review

AIM: To review current applications of the laparoscopic surgery while highlighting the standard procedures across different fields.

METHODS: A comprehensive search was undertaken using the PubMed Advanced Search Builder. A total of 321 articles were found in this search. The following criteria had to be met for the publication to be selected: Review article, randomized controlled trials, or meta-analyses discussing the subject of laparoscopic surgery. In addition, publications were hand-searched in the Cochrane database and the high-impact journals. A total of 82 of the findings were included according to matching the inclusion criteria. Overall, 403 full-text articles were reviewed. Of these, 218 were excluded due to not matching the inclusion criteria.

RESULTS: A total of 185 relevant articles were identified matching the search criteria for an overview of the current literature on the laparoscopic surgery. Articles covered the period from the first laparoscopic application through its tremendous advancement over the last several years. Overall, the biggest advantage of the procedure has been minimizing trauma to the abdominal wall compared with open surgery. In the case of cholecystectomy, fundoplication, and adrenalectomy, the procedure has become the gold standard without being proven as a superior technique over the open surgery in randomized controlled trials. Faster recovery, reduced hospital stay, and a quicker return to normal activities are the most evident advantages of the laparoscopic surgery. Positive outcomes, efficiency, a lower rate of wound infections, and reduction in the perioperative morbidity of minimally invasive procedures have been shown in most indications.

CONCLUSION: Improvements in surgical training and developments in instruments, imaging, and surgical techniques have greatly increased safety and feasibility of the laparoscopic surgical procedures.

Robotic versus laparoscopic surgery for mid or low rectal cancer in male patients after neoadjuvant chemoradiation therapy: comparison of short-term outcomes

The aim of our study was to compare short-term outcomes of robotic and laparoscopic sphincter-saving total mesorectal excision (TME) in male patients with mid-low rectal cancer (RC) after neadjuvant chemoradiotherapy (NCRT). The study was conducted as a retrospective review of a prospectively maintained database, and we analyzed 14 robotic and 65 laparoscopic sphincter saving TME (R-TME and L-TME, respectively) performed by one surgeon between 2005 and 2013. Patient characteristics, perioperative recovery, postoperative complications and and pathology results were compared between the two groups. The patient characteristics did not differ significantly between the two groups. Median operating time was longer in the R-TME than in the L-TME group (182 min versus 140 min). Only two conversions occurred in the L-TME group. No difference was found between groups regarding perioperative recovery and postoperative complication rates. The median number of harvested lymph nodes was higher in the RTME than in the L-TME group (32 versus 23, p = 0.008). The median circumferential margin (CRM) was 10 mm in the R-TME group, 6.5 mm in the L-TME group (p = 0.047. The median distal resection margin (DRM) was 27.5 mm in the R-TME, 15 mm in the L-TME group (p = 0.014). Macroscopic grading of the specimen in the R-TME group was complete in all patients. In the L-TME group, grading was complete in 52 (80%) and incomplete in 13 (20%) cases (p = 0.109). R-TME is a safe and feasible procedure that facilitates performing of TME in male patients with mid-low RC after NCRT.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Robotic video-assisted thoracoscopic lung resection for lung tumors: a community tertiary care center experience over four years

INTRODUCTION/BACKGROUND

After its initial description in 1990, video-assisted thoracoscopic surgery (VATS) has emerged as the minimally invasive approach for lung resection in early lung cancer.

METHODS

A retrospective review of prospectively collected data on patients who underwent robotic pulmonary resection for cancer by a single surgeon, between years 2009 and 2013, was performed. Age, gender, type and duration of surgery, length of stay, estimated blood loss, early and late complications, follow-up time, and local recurrence were reviewed and analyzed descriptively.

RESULTS

Three hundred and thirty-one patients underwent the procedure for pulmonary neoplasm. Two hundred and fifty-nine (79%) patients underwent anatomic lobectomies, 56 (17%) patients had wedge resection, while five (1.5%) patients underwent pneumonectomy. In 11 patients, no pulmonary resection was performed for different reasons. Most common neoplasm was adenocarcinoma (185, 56%). All procedures involved a systematic mediastinal and hilar lymph node exploration and removal of suspicious nodes. Twenty-six (6.9%) procedures were converted to open thoracotomy. Mean duration of surgery was 185.63 min. Mean length of hospital stay was 5.52 days. Mean estimated blood loss (EBL) was 47.85 ml. Mean follow-up was 249.41 days (20-1550 days), and five (1.5%) patients developed local recurrence. Early complications were seen in 29 patients (8.8%), most commonly cardiac arrhythmias (20, 6%).

CONCLUSION

Robotic video-assisted thoracoscopic surgery is feasible in lung lesions, with all the advantages of VATS in terms of decreased length of stay and decreased blood loss with local recurrence rate and complication rate comparable to open procedures. There is a clear need for more studies comparing the apparent advantages of robotic-assisted surgery with increased cost of technology.

Robotic surgery for rectal cancer can overcome difficulties associated with pelvic anatomy

INTRODUCTION

Total mesorectal excision (TME) for rectal cancer can be challenging to perform in the presence of difficult pelvic anatomy. In our previous studies based on open and laparoscopic TME, we found that pelvic MRI-based pelvimetry could well reflect anatomical difficulty of the pelvis and operative time increased in direct proportion to the difficulty. We explored different outcomes of robotic surgery for TME based on classifications of difficult pelvic anatomies to determine whether this method can overcome these challenges.

METHODS

We reviewed data from 182 patients who underwent robotic surgery for rectal cancer between January 2008 and August 2010. Patient demographics, pathologic outcomes, pelvimetric results, and operative and postoperative outcomes were assessed. The data were compared between easy, moderate, and difficult groups classified by MRI-based pelvimetry.

RESULTS

Comparing the three groups, there was no difference between the groups in terms of operative and pathologic outcomes, including operation time. High BMI, history of preoperative chemoradiotherapy, and lower tumor levels were significantly associated with longer operation time (p < 0.001, p < 0.001, p = 0.009), but the pelvimetric parameter was not.

CONCLUSION

There was no difference between the easy, moderate, and difficult groups in terms of surgical outcomes, such as operation time, for robotic rectal surgery. The robot system can provide more comfort during surgery for the surgeon, and may overcome challenges associated with difficult pelvic anatomy.

Robotic versus conventional laparoscopic colorectal operations: a-single center experience

OBJECTIVE

Robotic surgery was first introduced in 2000 especially to overcome the limitations of low rectum cancer surgery. There is still no consensus regarding the standard method for colorectal surgery. The aim of this study was to compare robotic surgery with laparoscopic colorectal surgery.

MATERIAL AND METHODS

This is a retrospective study. Data of patients with a diagnosis of colon or rectal cancer were analyzed for robotic colorectal surgery and laparoscopic colorectal surgery.

RESULTS

The cost of robotic surgery group was statistically higher than the laparoscopic surgery group (p=0.032). The average operation duration was 178 minutes in the laparoscopic surgery group and 228 minutes in the robotic surgery group, and this difference was statistically significant (p=0.044). There was no statistically significant difference between the groups regarding other parameters.

DISCUSSION

Disadvantages of robotic surgery seem to be its higher cost and longer operation duration as compared to laparoscopic surgery. We claim that an increase in the number of cases and experience may shorten the operation time while the increase in commercial interest may decrease the cost disadvantage of robotic surgery.

Robotic oncologic complexity score - a new tool for predicting complications in computer-enhanced oncologic surgery

BACKGROUND

While there is little doubt that robotic interventions have already opened new horizons in surgery due to its inherent complexity, there is still an unmet need for tools allowing center-to-center performance comparisons. A complexity score could be a valuable instrument for further research.

METHODS

The items of the robotic oncologic complexity score (ROCS) were based on risk factors identified in previous studies. We attempt to build the score and validate it on 400 consecutive cases of robotic oncologic surgery. The primary endpoint is to assess the value of ROCS in predicting major complications.

RESULTS

The mean ROCS in the group was 3.3(+/-1.4). Different correlations were calculated: the score and the complications (r=0.38), the major complications (r=0.42), Clavien grade (r=0.5), the operating time (r=0.35), and the length of stay (r=0.47). On the ROC-curve a score >4 has the best specificity and sensibility for predicting major complications (P<0.05).

CONCLUSION

ROCS has potential in predicting complications and hospital length of stay, as well as a role in classifying oncologic robotic surgical interventions. Copyright © 2015 John Wiley & Sons, Ltd.

Current status of randomized controlled trials for laparoscopic gastric surgery for gastric cancer in Korea

Laparoscopic gastrectomy for gastric cancer has rapidly gained popularity as a result of the increased incidence of early gastric cancer in Korea. Although laparoscopic gastrectomy has been considered as an investigational treatment because of the lack of solid evidence of efficacy and safety, it is increasingly regarded as a standard treatment for early gastric cancer. Moreover, solid evidence is anticipated from two studies in Korea, KLASS 01 and KLASS 02, the latter of which examines the suitability of laparoscopic gastrectomy for advanced gastric cancer. The use of cutting-edge techniques for laparoscopic gastrectomy enables surgeons to deliver various treatment options that offer the best possible quality of life after gastrectomy. In this review, we summarize the current status of clinical trials on laparoscopic gastrectomy in Korea and examine future perspectives regarding laparoscopic gastrectomy for the treatment of gastric cancer.

State of the art in robotic hepatobiliary surgery

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

Robotic-assisted colorectal surgery in the United States: a nationwide analysis of trends and outcomes

BACKGROUND

While robotic-assisted colorectal surgery (RACS) is becoming increasingly popular, data comparing its outcomes to other established techniques remain limited to small case series. Moreover, there are no large studies evaluating the trends of RACS at the national level.

METHODS

The Nationwide Inpatient Sample 2009-2010 was retrospectively reviewed for robotic-assisted and laparoscopic colorectal procedures performed for cancer, benign polyps, and diverticular disease. Trends in different settings, indications, and demographics were analyzed. Multivariate regression analysis was used to compare selected outcomes between RACS and conventional laparoscopic surgery (CLS).

RESULTS

An estimated 128,288 colorectal procedures were performed through minimally invasive techniques over the study period, and RACS was used in 2.78 % of cases. From 2009 to 2010, the use of robotics increased in all hospital settings but was still more common in large, urban, and teaching hospitals. Rectal cancer was the most common indication for RACS, with a tendency toward its selective use in male patients. On multivariate analysis, robotic surgery was associated with higher hospital charges in colonic ($11,601.39; 95 % CI 6,921.82-16,280.97) and rectal cases ($12,964.90; 95 % CI 6,534.79-19,395.01), and higher rates of postoperative bleeding in colonic cases (OR = 2.15; 95 % CI 1.27- 3.65). RACS was similar to CLS with respect to length of hospital stay, morbidity, anastomotic leak, and ileus. Conversion to open surgery was significantly lower in robotic colonic and rectal procedures (0.41; 95 % CI 0.25-0.67) and (0.10; 95 % CI 0.06-0.16), respectively.

CONCLUSIONS

The use of RACS is still limited in the United States. However, its use increased over the study period despite higher associated charges and no real advantages over laparoscopy in terms of outcome. The one advantage is lower conversion rates.

Robotic single-site versus laparoscopic cholecystectomy: Which is cheaper? A cost report and analysis

OBJECTIVE

There is a need for a comparison of costs of robotic single-site cholecystectomy (RSSC) and laparoscopic cholecystectomy (LC) in the US healthcare model. Cholecystectomy is one of the most common procedures in general surgery. Single-incision laparoscopic surgery is beneficial but cumbersome. Robotic surgery is ergonomic but expensive. Costs of RSSC and LC have not been compared within the US healthcare model.

METHODS

Cost categories were compared between RSSC and LC in consecutive outpatient-elective cases during the same period. Cost efficiency of outpatient-elective cases before and after the first 50 institutional RSSC cases (including outpatients, inpatients, emergent, and elective) were compared to investigate for a learning curve that would subsequently affect cost.

RESULTS

A total of 458 cases included 177 RSSCs and 281 LCs. Non-emergent non-admitted cases included in cost analysis were 46 RSSCs and 175 LCs. Costs were less with RSSC: median total ($1319 vs. $1710, p < 0.001), driven mainly by cost category "Supplies" ($913 vs. $1244, p < 0.001), and to a lesser extent "Operating room" ($196 vs. $232, p < 0.001), and "Anesthesiology" ($127 vs. $168, p < 0.001). Supplies were responsible for 87% of median total cost reduction. Other cost categories were not significantly different. There were 11 and 9% drops (p < 0.006) in RSSC OR times and costs, respectively, after our 50th institutional case.

CONCLUSION

In a hospital that has already acquired infrastructure for robotic surgery, we observed procedural costs for RSSC that were lower than LC. This decreased cost was mainly driven by cutting down on supplies (87% of median total cost reduced), and to a lesser extent OR time. A steep learning curve exists after which RSSC OR times can be significantly shortened. A randomized study is needed.

Robotic versus laparoscopic surgery for colonic disease: a meta-analysis of postoperative variables

INTRODUCTION

An increasing number of studies have been published since the introduction of robotic technology into general surgery. Gastrointestinal surgery is an area of special interest for the robotic surgeon. Colonic surgery can be challenging depending on the disease and the operative approach. We seek to perform a meta-analysis comparing robotic surgery against laparoscopic surgery in this particular field.

MATERIALS AND METHODS

We performed a systematic search of MEDLINE database from January 2001 to July 2013 supplemented by manual searches of bibliographies of key relevant articles. Randomized controlled trials and cohort studies were selected for review and for collection of postoperative data (length of stay, time to first flatus and complications).

RESULTS

After careful review, nine studies were considered for analysis. Non-pooled data showed a slight trend toward laparoscopy with increased number of events without statistical significance. Pooled data demonstrated a statistical significance for return to bowel function in the right and mixed robotic colectomy arm (WSMD -0.33, 95 % CI -0.5, -0.1; p < 0.005 and WSMD -0.26, 95 % CI -0.51, 0.0; p = 0.05). Pooled data of length of stay and complications showed no statistical significance between robotic and laparoscopic colonic surgery.

DISCUSSION

Robotic surgery is a comparable option when dealing with colonic disease, either benign or malignant. No difference in complication rate or length of stay was found when comparing the two. Robotic surgery appears to have an advantage over laparoscopy in regards to return of bowel function when dealing with right colectomies.

Robotic-assisted Heller myotomy: a modern technique and review of outcomes

Achalasia is a debilitating esophageal motility disorder characterized by incomplete relaxation of the lower esophageal sphincter and lack of peristalsis. Manometry is the gold standard for diagnosis and laparoscopic Heller myotomy has been the gold standard for definitive therapy. However, current advances in surgical technology have introduced the robotic platform as a viable approach for this procedure. The safety and efficacy has been clearly established with comparable operative times to laparoscopy in experienced hands. Importantly, the rate of resolution of dysphagia postoperatively is over 80% which is comparable to laparoscopic outcomes. Moreover, some literature suggests lower esophageal perforation rates utilizing the robotic platform. Nevertheless, costs remain one of the largest barriers to widespread use of the robotic platform and future studies should aim to identify strategies in cost reduction.

Robotic general surgery: current practice, evidence, and perspective

BACKGROUND

Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach.

PURPOSE

This article reviews the current literature and the perspective of robotic general surgery.

CONCLUSIONS

While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.