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

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Minimally invasive surgery for gastric cancer treatment: current status and future perspectives

Minimally invasive surgery, which has been extensively used to treat gastric adenocarcinoma, is now regarded as one of the standard treatments for early gastric cancer, and its suitability for advanced gastric cancer is being investigated. The use of cutting-edge techniques for minimally invasive surgery enables surgeons to deliver various treatment options to minimize a patient's distress and to maintain oncologic safety. Ongoing multicenter prospective studies aim to validate the efficacy of these surgical techniques and to expand the indications of minimally invasive surgery for the treatment of gastric cancer. In this review, we summarize the current status and issues regarding minimally invasive surgery for the treatment of gastric cancer.

Uncontrolled manifold analysis of arm joint angle variability during robotic teleoperation and freehand movement of surgeons and novices

Teleoperated robot-assisted surgery (RAS) is used to perform a wide variety of minimally invasive procedures. However, current understanding of the effect of robotic manipulation on the motor coordination of surgeons is limited. Recent studies in human motor control suggest that we optimize hand movement stability and task performance while minimizing control effort and improving robustness to unpredicted disturbances. To achieve this, the variability of joint angles and muscle activations is structured to reduce task-relevant variability and increase task-irrelevant variability. In this study, we determine whether teleoperation of a da Vinci Si surgical system in a nonclinical task of simple planar movements changes this structure of variability in experienced surgeons and novices. To answer this question, we employ the UnControlled manifold analysis that partitions users' joint angle variability into task-irrelevant and task-relevant manifolds. We show that experienced surgeons coordinate their joint angles to stabilize hand movements more than novices, and that the effect of teleoperation depends on experience--experts increase teleoperated stabilization relative to freehand whereas novices decrease it. We suggest that examining users' exploitation of the task-irrelevant manifold for stabilization of hand movements may be applied to: (1) evaluation and optimization of teleoperator design and control parameters, and (2) skill assessment and optimization of training in RAS.

Emerging technology in surgical education: combining real-time augmented reality and wearable computing devices

The authors describe the first surgical case adopting the combination of real-time augmented reality and wearable computing devices such as Google Glass (Google Inc, Mountain View, California). A 66-year-old man presented to their institution for a total shoulder replacement after 5 years of progressive right shoulder pain and decreased range of motion. Throughout the surgical procedure, Google Glass was integrated with the Virtual Interactive Presence and Augmented Reality system (University of Alabama at Birmingham, Birmingham, Alabama), enabling the local surgeon to interact with the remote surgeon within the local surgical field. Surgery was well tolerated by the patient and early surgical results were encouraging, with an improvement of shoulder pain and greater range of motion. The combination of real-time augmented reality and wearable computing devices such as Google Glass holds much promise in the field of surgery.

Development and testing of a robotic surgical training curriculum for novice surgeons

A robotics practice curriculum was developed utilizing dry lab skills and testing parameters based upon the objective structured assessment of surgical tasks (OSATS) to determine its effectiveness in training novice surgeons. We recruited 20 medical students who were oriented to the DaVinci S console and instrumentation. They were pre-tested with four dry lab skills including manipulation, transection, suturing and knot tying. A control group was instructed to practice once weekly to attain proficiency and the intervention group was provided specific instructions regarding practice goals. Each subject was post-tested after a 6-week time. There were 17 students who completed the post-testing. All participants showed significant improvement in pre-test and post-test scores for manipulation (6.6-11.2, p < 0.0005), transection (3.5-6.9, p < 0.0005), knot tying (0.4-1.7, p = 0.003), and suturing (2.0-3.5, p = 0.001). There was no significant difference in pre-test and post-test scores between the control and intervention groups in manipulation, transection, knot tying, and suturing (p = 0.700, 0.782, 0.682, 0.605, respectively). Our study shows that novice surgeons such as medical students can improve dry lab robotics skills with instruction and practice.

Single-site robotic cholecystectomy in a broadly inclusive patient population: a prospective study

OBJECTIVES

To describe our initial experience with single-site robotic cholecystectomy (SSRC) and its applicability to a broad segment of patients.

BACKGROUND

At the initiation of our study, there were only 3 published reports on SSRC. These initial studies had limited inclusion criteria. We present our experience with the technical aspects and patient outcomes of SSRC in a broadly inclusive patient population.

METHODS

Prospective cohort study from January 2012 to January 2013, in which 95 patients underwent SSRC. Procedural times, postoperative complications, delayed hospital discharges, and re-admissions were evaluated.

RESULTS

Patients were predominantly female (71.6%) had mean age of 45.2 ± 6.1 years and mean body mass index (BMI) of 30.1 ± 7.1 kg/m. Overall, mean total operative time (TOT) for all patients (n = 95) was 88.63 ± 32.0 (range: 49-220) minutes. SSRC was not completed in 8 (8.42%) patients: 6 conversions to laparoscopy, 1 conversion to open, and 1 aborted case. The group of patients who were able to complete SSRC (n = 87) had a mean TOT of 83.5 ± 24.5 minutes and mean operative robotic time (RT) of 39.6 ± 15.2 minutes. RT was longer in patients with intra-abdominal adhesions (P = 0.0139) and higher BMI (P = 0.03). A minority of patients required hospital admission (11.6%), readmission (6.3%), or reoperation (1.1%). No bile duct injury or death occurred.

CONCLUSIONS

SSRC is safe and has a manageable learning curve. Patient factors, such as obesity, did not significantly affect conversion rates or TOTs. SSRC is a promising new technique, which can be offered to a wide array of patients.

Current concepts of laparoscopic splenectomy in elective patients

Formerly, open splenectomy represented the conventional surgical treatment for many hematologic diseases. Currently, thanks to permanent technical development and improved skills, also laparoscopic splenectomy (LS) has become a recognized procedure in the treatment of spleen diseases, even in case of splenomegaly. A systematic review was performed with the aim of recalling the proved concepts of this surgical treatment and to browse new devices and techniques and their impact on the surgical outcome. The literature search was initially conducted in PubMed by entering general queries related to LS. The record identified through PubMed searching (n = 1599) was then screened by applying several criteria (study published in English from 1991 to 2013 with abstract available, by excluding systematic/non-systematic reviews, meta-analysis, practice guidelines, case reports, and study involving animals). The articles assessed for eligibility (n = 160) were primarily evaluated by excluding studies that did not report operative time and conversion to open surgery. For articles that treated multiport LS we included only clinical trials with patients > 20. The studies included in qualitative synthesis were 23. The search strategy carried out in PubMed does not allow to obtain an overview of the items returned by the main queries. With this aim we replicated the search in the Web of Science^TM database, only including the studies published in English in the period 1991-2013 with no other filter/selection criteria. The full records (n = 1141) and cited references returned by Web of Science^TM were analyzed with the visualization of similarities (VOS) mapping technique. Maps of title/abstract text corpus and bibliographic coupling of authors obtained by applying the VOS approach were presented. If in normal-size or moderately enlarged spleens the laparoscopic approach is unquestionable, in massive splenomegaly the optimal technique remain to be determined. In this setting, prospective randomized trials to compare open vs LS are needed. Between the new techniques of LS the robotic single port splenectomy has the ability to join all the positive aspects of both techniques. Data about this topic are too initial and need to be confirmed with further studies.

Robot-assisted oesophageal and gastric surgery for benign disease: antireflux operations and Heller's myotomy

BACKGROUND

Robot-assisted general surgery operations are being performed more frequently. This review investigates whether robotic assistance results in significant advantages or disadvantages for the operative treatment of gastro-oesophageal reflux disease and achalasia.

METHODS

The electronic databases (Medline, Embase, PubMed) were searched for original English language publications for antireflux surgery and Heller's myotomy between January 1990 and December 2013.

RESULTS

Thirty-three publications included antireflux operations and 20 included Heller's myotomy. The publications indicate that the safety and effectiveness of robotic surgery is similar to that of conventional minimally invasive surgery for both operations. The six randomized trials of robot-assisted versus laparoscopic antireflux surgery showed no significant advantages but significantly higher costs for the robotic method. Gastric perforation during non-redo robotic fundoplication occurred in four trials.

CONCLUSIONS

No consistent advantage for robot-assisted antireflux surgery has been demonstrated, and there is an increased cost with current robotic technology. A reported advantage for robotic in reducing the perforation rate during Heller's myotomy for achalasia remains unproven. Gastric perforation during robotic fundoplication may be due to the lack of haptic feedback combined with the superhuman strength of the robot.

The impact of marketing language on patient preference for robot-assisted surgery

Robot-assisted surgery is gaining momentum as a new trend in minimally invasive surgery. With limited evidence supporting its use in place of the far less expensive conventional laparoscopic surgery, it has been suggested that marketing pressure is partly responsible for its widespread adoption. The impact of phrases that promote the novelty of robot-assisted surgery on patient decision making has not been investigated. We conducted a discrete choice experiment to elicit preference of partial colectomy technique for a hypothetical diagnosis of colon cancer. A convenience sample of 38 participants in an ambulatory general surgery clinic consented to participate. Each participant made 2 treatment decisions between robot-assisted surgery and conventional laparoscopic surgery, with robot-assisted surgery described as "innovative" and "state-of-the-art" in one of the decisions (marketing frame), and by a disclosure of the uncertainty of available evidence in the other (evidence-based frame). The magnitude of the framing effect was large with 12 of 38 subjects (31.6%, P = .005) selecting robot-assisted surgery in the marketing frame and not the evidence-based frame. This is the first study to our knowledge to demonstrate that words that highlight novelty have an important influence on patient preference for robot-assisted surgery and that use of more neutral language can mitigate this effect.

Robotic vs. Standard Laparoscopic Technique - What is Better?

Introduction: Laparoscopic surgery is subject to certain limitations that can be a problem when performing complex minimally invasive operations. Robotic surgery was developed precisely to overcome such technical limitations. The question therefore arises whether robotic surgery leads to significantly better results compared with standard laparoscopic surgery.

Methods: Based on comparative systematic reviews and meta-analyses, this paper examines whether the robotic technique when used for abdominal and visceral surgery procedures confers advantages on the patient compared with the standard laparoscopic technique.

Results: Even for demanding visceral surgery procedures, the perioperative complication rate for robotic surgery is not higher than for open or laparoscopic surgical procedures. In cancer cases, the oncological accuracy of robotic resection for gastric, pancreatic, and rectal resection is seen to be adequate. Only the operating time is generally longer than for standard laparoscopic and open procedures. But, on the other hand, in some procedures blood loss is less, conversion rates are lower and hospital stay shorter.

Conclusion: To evaluate the future role of the robotic technique for visceral surgery, high-quality prospective randomized trials are urgently needed.

Robotics in general surgery: an evidence-based review

Since its introduction, robotic surgery has been rapidly adopted to the extent that it has already assumed an important position in the field of general surgery. This rapid progress is quantitative as well as qualitative. In this review, we focus on the relatively common procedures to which robotic surgery has been applied in several fields of general surgery, including gastric, colorectal, hepato-biliary-pancreatic, and endocrine surgery, and we discuss the results to date and future possibilities. In addition, the advantages and limitations of the current robotic system are reviewed, and the advanced technologies and instruments to be applied in the near future are introduced. Such progress is expected to facilitate the widespread introduction of robotic surgery in additional fields and to solve existing problems.

Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials

Background

Robotic-assisted laparoscopy is popularly performed for colorectal disease. The objective of this meta-analysis was to compare the safety and efficacy of robotic-assisted colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) for colorectal disease based on randomized controlled trial studies.

Methods

Literature searches of electronic databases (Pubmed, Web of Science, and Cochrane Library) were performed to identify randomized controlled trial studies that compared the clinical or oncologic outcomes of RCS and LCS. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were mean differences and odds ratios for continuous and dichotomous variables, respectively. Fixed-effects or random-effects models were adopted according to heterogeneity.

Results

Four randomized controlled trial studies were identified for this meta-analysis. In total, 110 patients underwent RCS, and 116 patients underwent LCS. The results revealed that estimated blood losses (EBLs), conversion rates and times to the recovery of bowel function were significantly reduced following RCS compared with LCS. There were no significant differences in complication rates, lengths of hospital stays, proximal margins, distal margins or harvested lymph nodes between the two techniques.

Conclusions

RCS is a promising technique and is a safe and effective alternative to LCS for colorectal surgery. The advantages of RCS include reduced EBLs, lower conversion rates and shorter times to the recovery of bowel function. Further studies are required to define the financial effects of RCS and the effects of RCS on long-term oncologic outcomes.

Advances in bio-tactile sensors for minimally invasive surgery using the fibre Bragg grating force sensor technique: a survey

The large interest in utilising fibre Bragg grating (FBG) strain sensors for minimally invasive surgery (MIS) applications to replace conventional electrical tactile sensors has grown in the past few years. FBG strain sensors offer the advantages of optical fibre sensors, such as high sensitivity, immunity to electromagnetic noise, electrical passivity and chemical inertness, but are not limited by phase discontinuity or intensity fluctuations. FBG sensors feature a wavelength-encoding sensing signal that enables distributed sensing that utilises fewer connections. In addition, their flexibility and lightness allow easy insertion into needles and catheters, thus enabling localised measurements inside tissues and blood. Two types of FBG tactile sensors have been emphasised in the literature: single-point and array FBG tactile sensors. This paper describes the current design, development and research of the optical fibre tactile techniques that are based on FBGs to enhance the performance of MIS procedures in general. Providing MIS or microsurgery surgeons with accurate and precise measurements and control of the contact forces during tissues manipulation will benefit both surgeons and patients.

Robotic spleen-preserving total gastrectomy for gastric cancer: comparison with conventional laparoscopic procedure

BACKGROUND

Robotic systems recently have been introduced to overcome technical limitations of conventional laparoscopic surgery, especially for complex procedures. Laparoscopic spleen-preserving total gastrectomy with D2 lymph node (LN) dissection (LTGD2) is one of the most complicated procedures. We hypothesized that robotic LN dissection would be more thorough and accurate. We compared robotic spleen-preserving total gastrectomy with D2 LN dissection (RTGD2) with LTGD2 to investigate the impact of robotics.

METHODS

Clinicopathologic characteristics and short-term and long-term outcomes of RTGD2 (n = 51) versus LTGD2 (n = 58) in gastric adenocarcinoma patients were extracted from a prospectively designed database and analyzed retrospectively.

RESULTS

There was no difference of patients' characteristics between groups. Mean operation time of RTGD2 was longer than LTGD2 (p < 0.001), and no differences in tumor histology, size, location, and TNM stage were seen. Total retrieved LNs from RTGD2 was similar to LTGD2 (mean 47.2 vs. 42.8, respectively), as were retrieved LNs at splenic hilum (1.3 vs. 0.8). However, mean numbers of retrieved LNs along the splenic artery from RTGD2 was higher than LTGD2 (2.3 vs. 1.0, respectively; p = 0.013), as was also the case at the splenic hilum and artery (3.6 vs. 1.9, p = 0.014). Postoperative complication (16 vs. 22 %, p = 0.374) and overall and disease-free survival between the two groups were not significantly different (p = 0.767 and p = 0.666, respectively).

CONCLUSIONS

Robotic spleen-preserving total gastrectomy with D2 LN dissection is feasible. Operation time and retrieved total LNs and splenic hilar LNs in the robotic procedure are acceptable.

Novel application of simultaneous multi-image display during complex robotic abdominal procedures

Background

The surgical robot offers the potential to integrate multiple views into the surgical console screen, and for the assistant’s monitors to provide real-time views of both fields of operation. This function has the potential to increase patient safety and surgical efficiency during an operation. Herein, we present a novel application of the multi-image display system for simultaneous visualization of endoscopic views during various complex robotic gastrointestinal operations.

All operations were performed using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) with the assistance of Tilepro, multi-input display software, during employment of the intraoperative scopes. Three robotic operations, left hepatectomy with intraoperative common bile duct exploration, low anterior resection, and radical distal subtotal gastrectomy with intracorporeal gastrojejunostomy, were performed by three different surgeons at a tertiary academic medical center.

Results

The three complex robotic abdominal operations were successfully completed without difficulty or intraoperative complications. The use of the Tilepro to simultaneously visualize the images from the colonoscope, gastroscope, and choledochoscope made it possible to perform additional intraoperative endoscopic procedures without extra monitors or interference with the operations.

Conclusion

We present a novel use of the multi-input display program on the da Vinci Surgical System to facilitate the performance of intraoperative endoscopies during complex robotic operations. Our study offers another potentially beneficial application of the robotic surgery platform toward integration and simplification of combining additional procedures with complex minimally invasive operations.

Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution

BACKGROUND/AIM

Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy.

METHODS

A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case.

RESULTS

No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively.

CONCLUSIONS

ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

What have we gained by performing robotic rectal resection? Evaluation of 64 consecutive patients who underwent laparoscopic or robotic low anterior resection for rectal adenocarcinoma

BACKGROUND

Robotic surgery is thought to be a solution to overcome the limitations of laparoscopy in sphincter-saving resections. In this study, we present our results on patients undergoing robotic and laparoscopic low anterior resection (LAR) consecutively for rectal adenocarcinoma.

MATERIALS AND METHODS

Between February 2008 and June 2011, consecutive patients who underwent laparoscopic or robotic LAR by a single surgical team for rectal cancer were evaluated. The patients' demographic, operative, postoperative short-term follow-up, and histopathologic data were analyzed.

RESULTS

Twenty-seven patients underwent robotic LAR, whereas 37 patients underwent laparoscopic LAR. The operation time of the laparoscopy group was significantly shorter than that of the robotic group (P=0.02). The complete total mesorectal excision rate was significantly higher in the robotic group (P=0.02). The overall complication rates were 11.11% and 21.62% in the robotic and laparoscopy groups, respectively (P=0.45).

CONCLUSIONS

Good quality of resected specimens could be achieved with robotic LAR. Further prospective studies including long-term oncologic outcomes and costs with higher patient number are definitely needed to assess the benefits of robotic resection in rectal cancer treatment.

Effects of robotic manipulators on movements of novices and surgeons

BACKGROUND

Robot-assisted surgery is widely adopted for many procedures but has not realized its full potential to date. Based on human motor control theories, the authors hypothesized that the dynamics of the master manipulators impose challenges on the motor system of the user and may impair performance and slow down learning. Although studies have shown that robotic outcomes are correlated with the case experience of the surgeon, the relative contribution of cognitive versus motor skill is unknown. This study quantified the effects of da Vinci Si master manipulator dynamics on movements of novice users and experienced surgeons and suggests possible implications for training and robot design.

METHODS

In the reported study, six experienced robotic surgeons and ten novice nonmedical users performed movements under two conditions: teleoperation of a da Vinci Si Surgical system and freehand. A linear mixed model was applied to nine kinematic metrics (including endpoint error, movement time, peak speed, initial jerk, and deviation from a straight line) to assess the effects of teleoperation and expertise. To assess learning effects, t tests between the first and last movements of each type were used.

RESULTS

All the users moved slower during teleoperation than during freehand movements (F(1,9343) = 345; p < 0.001). The experienced surgeons had smaller errors than the novices (F(1,14) = 36.8; p < 0.001). The straightness of movements depended on their direction (F(7,9343) = 117; p < 0.001). Learning effects were observed in all conditions. Novice users first learned the task and then the dynamics of the manipulator.

CONCLUSIONS

The findings showed differences between the novices and the experienced surgeons for extremely simple point-to-point movements. The study demonstrated that manipulator dynamics affect user movements, suggesting that these dynamics could be improved in future robot designs. The authors showed the partial adaptation of novice users to the dynamics. Future studies are needed to evaluate whether it will be beneficial to include early training sessions dedicated to learning the dynamics of the manipulator.

Laparoscopic surgery for gastro-esophageal acid reflux disease

Gastro-esophageal reflux disease is a troublesome disease for many patients, severely affecting their quality of life. Choice of treatment depends on a combination of patient characteristics and preferences, esophageal motility and damage of reflux, symptom severity and symptom correlation to acid reflux and physician preferences. Success of treatment depends on tailoring treatment modalities to the individual patient and adequate selection of treatment choice. PubMed, Embase, The Cochrane Database of Systematic Reviews, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for systematic reviews with an abstract, publication date within the last five years, in humans only, on key terms (laparosc* OR laparoscopy*) AND (fundoplication OR reflux* OR GORD OR GERD OR nissen OR toupet) NOT (achal* OR pediat*). Last search was performed on July 23nd and in total 54 articles were evaluated as relevant from this search. The laparoscopic Toupet fundoplication is the therapy of choice for normal-weight GERD patients qualifying for laparoscopic surgery. No better pharmaceutical, endoluminal or surgical alternatives are present to date. No firm conclusion can be stated on its cost-effectiveness. Results have to be awaited comparing the laparoscopic 180-degree anterior fundoplication with the Toupet fundoplication to be a possible better surgical alternative. Division of the short gastric vessels is not to be recommended, nor is the use of a bougie or a mesh in the vast majority of GERD patients undergoing surgery. The use of a robot is not recommended. Anti-reflux surgery is to be considered expert surgery, but there is no clear consensus what is to be called an 'expert surgeon'. As for setting, ambulatory settings seem promising although high-level evidence is lacking.

Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

BACKGROUND

The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma.

MATERIALS AND METHODS

All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up).

RESULTS

Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced.

CONCLUSIONS

In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.

Systematic review and meta-analysis of robotic surgery compared with conventional laparoscopic and open resections for gastric carcinoma

BACKGROUND

Robot-assisted gastrectomy (RAG) has been developed in the hope of improving surgical quality and overcoming the limitations of conventional laparoscopically assisted gastrectomy (LAG) and open gastrectomy (OG) for gastric cancer. The aim of this study was to determine the extent of evidence in support of these ideals.

METHODS

A systematic review of the three operation types (RAG, LAG and OG) was carried out to evaluate short-term outcomes including duration of operation, retrieved lymph nodes, estimated blood loss, resection margin status, technical postoperative complications and hospital stay.

RESULTS

Nine non-randomized observational clinical studies involving 7200 patients satisfied the eligibility criteria. RAG was associated with longer operating times than LAG and OG (weighted mean difference 61.99 and 65.73 min respectively; P ≤ 0.001). The number of retrieved lymph nodes and the resection margin length in RAG were comparable with those of LAG and OG. Estimated blood loss as significantly less in RAG than in OG (P = 0.002), but not LAG. Mean hospital stay for RAG was similar to that for LAG (P = 0.14). In contrast, hospital stay was significantly shorter, by a mean of 2.18 days, for RAG compared with OG (P < 0.001). Postoperative complications were similar for all three operative approaches.

CONCLUSION

Short-term oncological outcomes of RAG were comparable with those of the other approaches. LAG was a shorter procedure and less expensive than RAG. Future studies involving RAG should focus on minimizing duration of operation and reducing cost.

Robotic cholecystectomy and resident education: the UC Davis experience

INTRODUCTION

The popularity of robotic surgery highlights the need for strategies to integrate this technique into surgical education. We present 5 year data for robotic cholecystectomy (RC) as a model for training residents.

METHODS

Data were collected on all RC over 66 months. Duration for docking the robot (S2) and performing RC (S3), and surgical outcomes, were recorded. We used a linear mixed effects model to investigate learning curves.

RESULTS

Thirty-eight trainees performed 160 RCs, with most performing more than four. One case was aborted due to haemodynamic instability, and two were converted to open surgery due to adhesions. There were no technical complications. The duration of S2 (mean = 6.2 ± 3.6 min) decreased considerably (p = 0.027). Trainees also demonstrated decrease in duration of S3 (mean = 38.4 ± 15.4 min), indicating improvement in technique (p = 0.008).

CONCLUSIONS

RC is an effective model for teaching residents. Significant and reproducible improvement can be realized with low risk of adverse outcomes.

Robotic surgery: colon and rectum

Although robotic technology aims to obviate some of the limitations of conventional laparoscopic surgery, the role of robotics in colorectal surgery is still largely undefined and different with respect to its application in abdominal versus pelvic surgery. This review aims to elucidate current developments in colorectal robotic surgery.In colon surgery, robotic techniques are associated with longer operative times and higher costs compared with laparoscopic surgery. However, robotics provides a stable camera platform and articulated instruments that are not subject to human tremors. Because of these advantages, robotic systems can play a role in complex procedures such as the dissection of lymph nodes around major vessels. In addition robot-assisted hand-sewn intracorporeal anastomoses can be easily performed by the surgeon, without a substantial need for a competent assistant. At present, although the short-term outcomes and oncological adequacy of robotic colon resection have been observed to be acceptable, the long-term outcomes of robotic colon resection remain unknown.In rectal surgery, robotic-assisted surgery for rectal cancer can be carried out safely and in accordance with current oncological principles. However, to date, the impact of robotic rectal surgery on the long-term oncological outcomes of minimally invasive total mesorectal excision remains undetermined. Robotic total mesorectal excision may allow for better preservation of urinary and sexual functions, and robotic surgery may attenuate the learning curve for laparoscopic rectal resection. However, a major drawback to robotic rectal surgery is the high cost involved.Large-scale prospective randomized clinical trials such as the international randomized trial ROLARR are required to establish the benefits of robotic rectal surgery.

Comparative effectiveness of laparoscopic versus robot-assisted colorectal resection

BACKGROUND

During the past 20 years, laparoscopy has revolutionized colorectal surgery. With proven benefits in patient outcomes and healthcare utilization, laparoscopic colorectal surgery has steadily increased in use. Robotic surgery, a new addition to colorectal surgery, has been suggested to facilitate and overcome limitations of laparoscopic surgery. Our objective was to compare the outcomes of robot-assisted laparoscopic resection (RALR) to laparoscopic resections (LAP) in colorectal surgery.

METHODS

A national inpatient database was evaluated for colorectal resections performed over a 30-month period. Cases were divided into traditional LAP and RALR resection groups. Cost of robot acquisition and servicing were not measured. Main outcome measures were hospital length of stay (LOS), operative time, complications, and costs between groups.

RESULTS

A total of 17,265 LAP and 744 RARL procedures were identified. The RALR cases had significantly higher total cost ($5,272 increase, p < 0.001) and direct cost ($4,432 increase, p < 0.001), significantly longer operating time (39 min, p < 0.001), and were more likely to develop postoperative bleeding (odds ratio 1.6; p = 0.014) than traditional laparoscopic patients. LOS, complications, and discharge disposition were comparable. Similar findings were noted for both laparoscopic colonic and rectal surgery.

CONCLUSIONS

RALR had significantly higher costs and operative time than traditional LAP without a measurable benefit.

[Robotic hepatobiliary and gastric surgery]

Hepatobiliary 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 hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary 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, allow for 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 hepatobiliary 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 hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).

Robotic-assisted cystogastrostomy for a patient with a pancreatic pseudocyst

Pancreatic pseudocysts are generally treated by endoscopic cystogastrostomy. However, difficult cases involving abscess, necrosis, or risk of hemorrhage often require surgical intervention. Here, we report a case of a robotically assisted cystogastrostomy. The patient presented with an infected pseudocyst with adjacent varices. Use of the da Vinci Surgical System allowed us to create a widely patent anastomosis between the pseudocyst and the stomach. The patient tolerated the procedure well without any complications. This report demonstrates the feasibility of robotic cystogastrostomy.

Minimally invasive splenectomy: an update and review

Laparoscopic splenectomy (LS) has become an established standard of care in the management of surgical diseases of the spleen. The present article is an update and review of current procedures and controversies regarding minimally invasive splenectomy. We review the indications and contraindications for LS as well as preoperative considerations. An individual assessment of the procedures and outcomes of multiport laparoscopic splenectomy, hand-assisted laparoscopic splenectomy, robotic splenectomy, natural orifice transluminal endoscopic splenectomy and single-port splenectomy is included. Furthermore, this review examines postoperative considerations after LS, including the postoperative course of uncomplicated patients, postoperative portal vein thrombosis, infections and malignancy.

Robotic-assisted and laparoscopic ventral rectopexy in the treatment of rectal prolapse: a matched-pairs study of operative details and complications

BACKGROUND

Laparoscopic ventral rectopexy has been proven to be safe and effective in the treatment of rectal prolapse or intussusception. Robotic-assisted surgery may offer potential benefits to this operation. This study describes the comparison of robotic-assisted and conventional laparoscopic ventral rectopexy in terms of clinical parameters, operative details, postoperative complications and short-term outcomes.

METHODS

Twenty patients operated on for rectal prolapse or intussusception using the Da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale CA, USA) were prospectively followed for 3 months. The cases were pair-matched with laparoscopically operated controls from registry files.

RESULTS

Mean operating time was 159 min (standard deviation; ±37 SD) and 153 min (±33 SD) and mean total time in the operating theatre 231 min (±39 SD) and 234 min (±41 SD) for robotic-assisted and laparoscopic operations, respectively. Mean blood loss was 25 ml (±49 SD) in robotic-assisted and 37 ml (±50 SD) in laparoscopic procedures. There was one (5 %) significant complication in each group. Mean length of hospital stay was 3.1 (±2 SD) and 3.3 (±1.3 SD) days for the robotic-assisted and laparoscopic groups, respectively. The subjective benefit rate was the same in both groups: 16/20 (80 %). One patient in the robotic-assisted group continued to have symptoms of obstructed defecation, and there was one recurrence of prolapse in the laparoscopic group.

CONCLUSIONS

Robotic-assisted laparoscopic ventral rectopexy is safe, feasible and not more time consuming than the laparoscopic technique even at the beginning of the learning curve. The short-term results are comparable with those of laparoscopy. We found no arguments to support the routine use of robotic assistance in rectopexy operations.

Early experience with robotic rectopexy

BACKGROUND

The introduction of robotics in colorectal surgery has been gaining increasing acceptance. However, experience remains still limited for pelvic floor disorders. We report herein our first cases of fully robotic rectopexy and promontofixation for rectal prolapse.

METHODS

From October 2011 to June 2012, five female patients underwent a robotic rectopexy at our institution. The patients were selected according to their primary pathology and their medical history for this preliminary experience. Four of them presented a rectal prolapse associated or not with a vaginal prolapse and the last patient presented a recurrent rectal prolapse 5 years after a laparoscopic repair. The study was approved by our local ethics committee. The robot da Vinci Si (Intuitive Surgical Inc, Sunnyvale, CA) was used with a 4-port setting in all cases.

RESULTS

The mean operative time was 170 minutes (range: 120-270). There was no conversion. The blood loss was minimal. One patient presented a retrorectal hematoma, treated conservatively with success. There was no other complication. The mean hospital stay was 3.6 days (range: 2-7). At 2 months, there was neither recurrence nor readmission. In comparison with the laparoscopic approach, there were no statistically significant differences.

CONCLUSIONS

Robotic rectopexy and promontofixation are feasible and safe. The outcomes are encouraging, but functional results and long-term outcomes are required to evaluate the exact role of robotics for rectal prolapse.

Standardized surgical technique and dedicated operating room environment can reduce the operative time during robotic-assisted surgery for pelvic floor disorders

Robotic-assisted surgery for pelvic floor disorders (PFD) meets the accepted standards for laparoscopic surgery. The aim of this study was to describe the technique and the impact of this standardized surgical technique and dedicated operating teams on the operative time for robotic-assisted laparoscopic ventral mesh rectopexy (RALVMR). Data from a prospective database were extracted for all patients who underwent RALVMR between January 2008 and May 2012 for multi-compartment PFD. Patient pre-, intra- and early postoperative data were analysed. To evaluate the impact of both the surgical technique and operating room team on operative time over successive years, we divided the total operation time (TOT) into robot set-up time (RST) and surgeon console time (SCT) including disembarking robotic arms and closure of wounds. A total of 51 patients (3 male) with a mean age of 61.1 [±11, standard deviation (SD)] years were included for analysis. There were no major complications or deaths. Median TOT fell significantly by 23 % from 2008 (270 min) to 2012 (179 min) (p < 0.0001). The largest reduction (>60 %) was seen in RST, from 55 (SD ±3) to 21 (SD ±2) min (p < 0.0001). Similarly, SCT was reduced by 36 % from 216 (SD ±12) to 138 (SD ±8) min (p < 0.0001). Decreased operative time and efficiency were facilitated by a devoted, well-trained and consistent team. A standardized surgical technique for PFD helps to reduce the duration of the surgical procedure.

Perioperative outcomes after totally robotic gastric bypass: a prospective nonrandomized controlled study

BACKGROUND

Perioperative short-term outcomes could be improved after totally robotic Roux-en-Y gastric bypass (TR-RYGBP) compared with conventional laparoscopic gastric bypass.

METHODS

This is a nonrandomized controlled prospective study (N = 200) to evaluate perioperative short-term outcomes. The primary endpoint was to investigate risk factors for 30-day surgical complications.

RESULTS

Mean total operative time was shorter in patients who underwent TR-RYGBP (130 vs 147 minutes; P < .0001). However, postoperative surgical complications rate (13% vs 1%; P = .001), and mean overall hospital stay (9.3 vs 6.7 days; P < .0001) were higher after TR-RYGBP. By multivariate analysis, robotic surgery (hazard ratio [HR] = 15.1; 95% confidence interval [CI], 2.8 to 280; P = .01), and conversion to laparotomy (HR = 18.8; 95% CI, 1.7 to 250.8; P = .014) were independent risk factors for 30-day surgical complications.

CONCLUSIONS

Although robotic gastric bypass reduces mean operative time, TR-RYGBP is associated with an increased postoperative surgical complications rate and longer hospitalization.

Force feedback facilitates multisensory integration during robotic tool use

The present study investigated the effects of force feedback in relation to tool use on the multisensory integration of visuo-tactile information. Participants learned to control a robotic tool through a surgical robotic interface. Following tool-use training, participants performed a crossmodal congruency task, by responding to tactile vibrations applied to their hands, while ignoring visual distractors superimposed on the robotic tools. In the first experiment it was found that tool-use training with force feedback facilitates multisensory integration of signals from the tool, as reflected in a stronger crossmodal congruency effect with the force feedback training compared to training without force feedback and to no training. The second experiment extends these findings by showing that training with realistic online force feedback resulted in a stronger crossmodal congruency effect compared to training in which force feedback was delayed. The present study highlights the importance of haptic information for multisensory integration and extends findings from classical tool-use studies to the domain of robotic tools. We argue that such crossmodal congruency effects are an objective measure of robotic tool integration and propose some potential applications in surgical robotics, robotic tools, and human-tool interaction.

The economic evaluation of medical devices: challenges ahead

The economic evaluation of medical technology has evolved as a key element in supporting health budget allocation decisions. Among suppliers of innovation, the medical device industry is one of the most dynamic fields of medical progress with thousands of new products marketed every year. Accordingly, the broad variety of technologies covered by the umbrella term 'medical devices' have come under increasing scrutiny regarding their cost effectiveness. In the process, a number of device-specific factors have become apparent, each of which can complicate a thorough economic evaluation and limit its informative value. Some of these factors relate to specific characteristics of device functioning. Examples of such factors include the fact that most technologies require, or form part of, a procedure and that many devices have multiple indications or purposes. Others in turn reflect external conditions and are more general in character, such as the regulatory framework that a medical device manufacturer faces prior to market approval and the structure of the medical device industry. Drawing on the available literature, these complicating factors and their practical implications are discussed and used as a basis to elaborate on the emerging challenges for the economic evaluation of medical devices.