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

Robotic surgery - advance or gimmick?

Robotic surgery is increasingly implemented as a minimally invasive approach to a variety of gynaecological procedures. The use of conventional laparoscopy by a broad range of surgeons, especially in complex procedures, is hampered by several drawbacks. Robotic surgery was created with the aim of overcoming some of the limitations. Although robotic surgery has many advantages, it is also associated with clear disadvantages. At present, the proof of superiority over access by laparotomy or laparoscopy through large randomised- controlled trials is still lacking. Until results of such trials are present, a firm conclusion about the usefulness of robotic surgery cannot be drawn. Robotic surgery is promising, making the advantages of minimally invasive surgery potentially available to a large number of surgeons and patients in the future.

Impact of robotic assistance on precision of vitreoretinal surgical procedures

PURPOSE

To elucidate the merits of robotic application for vitreoretinal maneuver in comparison to conventional manual performance using an in-vitro eye model constructed for the present study.

METHODS

Capability to accurately approach the target on the fundus, to stabilize the manipulator tip just above the fundus, and to perceive the contact of the manipulator tip with the fundus were tested. The accuracies were compared between the robotic and manual control, as well as between ophthalmologists and engineering students.

RESULTS

In case of manual control, ophthalmologists were superior to engineering students in all the 3 test procedures. Robotic assistance significantly improved accuracy of all the test procedures performed by engineering students. For the ophthalmologists including a specialist of vitreoretinal surgery, robotic assistance enhanced the accuracy in the stabilization of manipulator tip (from 90.9 µm to 14.9 µm, P = 0.0006) and the perception of contact with the fundus (from 20.0 mN to 7.84 mN, P = 0.046), while robotic assistance did not improve pointing accuracy.

CONCLUSIONS

It was confirmed that telerobotic assistance has a potential to significantly improve precision in vitreoretinal procedures in both experienced and inexperienced hands.

Robotic gastric resection of large gastrointestinal stromal tumors

BACKGROUND

The stomach is the most common site for gastrointestinal stromal tumors (GIST) development. Surgical treatment consists of excision of the entire neoplastic mass, with sufficient surgical margins within healthy tissue. This can be achieved with different techniques ranging from wedge resections, typical gastric resections, right up to total gastrectomy. There aren't clear guidelines for the use of minimally invasive approach.

MATERIALS AND METHODS

From January 2011 to April 2012, 5 patients with presumed preoperative diagnosis of GIST were treated by robotic surgery at the Unit of Surgery and Advanced Oncologic Therapies, Forlì Hospital, Forlì, Italy. We report operative techniques, perioperative outcomes and follow-up.

RESULTS

Lesions were localized at anterior wall of gastric antrum (N = 2) and near pyloric area (N = 3). Mean tumor size was 5 cm (range 4-7 cm). Surgical procedures were 5 distal gastrectomy. None intervention was converted to open surgery and there weren't major intraoperative complications. Median operative time was 240 min (range 210-300 min) and mean intraoperative blood loss was 96 ml (80-120 ml). All lesions had microscopically negative resection margins. Median follow-up was 13.5 months (range 12-15 months) with a disease-free survival rate of 100%.

CONCLUSIONS

Surgical robotic approach for large GISTs is feasibility and new evidences are needed to clarify the effective role of different surgical strategies.

Minimally invasive liver resection: robotic versus laparoscopic left lateral sectionectomy

BACKGROUND

The purpose of this study was to compare the clinical and economic outcomes of robotic versus laparoscopic left lateral sectionectomy (LLS).

METHODS

A retrospective analysis was made comparing robotic (n = 11) and laparoscopic (n = 18) LLS performed at the University of Pittsburgh Medical Center between January 2009 and July 2011. Demographic data, operative, and postoperative outcomes were collected.

RESULTS

Demographic and tumor characteristics of robotic and laparoscopic LLS were similar. There were also no significant differences in operative outcomes including estimated blood loss and operating room time. Patients undergoing robotic LLS had more admissions to the ICU (46 versus 6 %), increased rate of minor complications (27 versus 0 %), and longer lengths of stay (4 versus 3 days). There were no significant differences in major complication rates or 90-day mortality. The cost of robotic and laparoscopic LLS was not significantly different when only considering direct costs ($5,130 versus $4,408, p = 0.401). However, robotic LLS costs were significantly greater when including indirect costs, which were estimated to be $1,423 per robotic case ($6,553 versus $4,408, p = 0.021).

DISCUSSION

Robotic LLS yields slightly inferior clinical outcomes and increased cost compared to the laparoscopic approach.

Robotic thyroidectomy versus endoscopic thyroidectomy: a meta-analysis

Background

To conduct a meta-analysis to determine the relative merits of robotic thyroidectomy (RT) and endoscopic thyroidectomy (ET).

Methods

A literature search was performed to identify comparative studies reporting peri-operative outcomes for RT and ET. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence interval (95% CI) were calculated using either a fixed-effects or a random-effects model.

Results

Six studies matched the selection criteria, which reported on 2048 subjects, of whom 978 underwent RT and 1070 underwent ET. Comparing the outcomes of RT with ET, this meta-analysis indicated that RT was associated with more complications (WMD = 1.51, 95% CI 1.18 to 1.94) and greater amount of drainage fluid (WMD = 17.10, 95% CI 5.69 to 28.51). Meanwhile, operating time (WMD = 1.50, 95% CI −39.59 to 42.58), conversion (WMD = 0.63, 95% CI 0.07 to 6.17), post-operative hospital stay (WMD = −0.05; 95% CI −0.18 to 0.08), and the number of lymph nodes harvested (WMD = 0.62, 95% CI −0.29 to 1.53) were similar for both procedures.

Conclusion

The results of this meta-analysis indicated that RT is associated with an increased risk of complications and a greater amount of drainage fluid. Therefore, RT does not appear to have any advantage over ET. Further studies are required to confirm these results.

Robot-assisted versus conventional laparoscopic surgery for colorectal disease, focusing on rectal cancer: a meta-analysis

BACKGROUND

Robotic colorectal surgery may solve some of the problems inherent to conventional laparoscopic surgery (CLS). We sought to evaluate the advantages of robot-assisted laparoscopic surgery (RALS) using the da Vinci Surgical System over CLS in patients with benign and malignant colorectal diseases.

METHODS

PubMed and Embase databases were searched for relevant studies published before July 2011. Studies clearly documenting a comparison of RALS with CLS for benign and malignant colorectal diseases were selected. Operative and postoperative measures, resection margins, complications, and related outcomes were evaluated. Weighted mean differences, relative risks, and hazard ratios were calculated using a random-effects model.

RESULTS

The meta-analysis included 16 studies comparing RALS and CLS in patients with colorectal diseases and 7 studies in rectal cancer. RALS was associated with lower estimated blood loss in colorectal diseases (P = 0.04) and rectal cancer (P < 0.001) and lower rates of intraoperative conversion in colorectal diseases (P = 0.03) and rectal cancer (P < 0.001) than CLS. In patients with colorectal diseases, however, operating time (P < 0.001) and total hospitalization cost (P = 0.06) were higher for RALS than for CLS.

CONCLUSIONS

RALS was associated with reduced estimated blood loss and a lower intraoperative conversion rate than CLS, with no differences in complication rates and surrogate markers of successful surgery. Robotic colorectal surgery is a promising tool, especially for patients with rectal cancer.

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.

Current status of validation for robotic surgery simulators - a systematic review

To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE(®), EMBASE(®) and PsycINFO(®) databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; 'expert' and 'novice'. Experts ranged in experience from 21-2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer(®), ProMIS(®), SimSurgery Educational Platform(®) (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial. Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

Laparoscopic versus robotic subtotal splenectomy in hereditary spherocytosis. Potential advantages and limits of an expensive approach

BACKGROUND

This study was designed to compare the laparoscopic subtotal splenectomy with the robotic approach in patients with hereditary spherocytosis.

METHODS

Thirty-two consecutive subtotal splenectomies by minimal approach in patients with hereditary spherocytosis were analyzed (10 robotic vs. 22 laparoscopic subtotal splenectomies).

RESULTS

A significant difference was found for the robotic approach regarding blood loss, vascular dissection duration, and splenic remnant size. Follow-up for 4-103 months was available.

CONCLUSIONS

Subtotal splenectomy seems to be a suitable candidate for robotic surgery, requiring a delicate dissection of the splenic vessels and a correct intraoperative evaluation of the splenic remnant. Robotic subtotal splenectomy is comparable to laparoscopy in terms of hospital stay and complication. The main benefits are lower blood loss rate, vascular dissection time, and a better evaluation of the splenic remnant volume.

Magnetic tracking in the operation room using the da Vinci(®) telemanipulator is feasible

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

Robotic assistance may reduce conversion to open in rectal carcinoma laparoscopic surgery: systematic review and meta-analysis

BACKGROUND

We hypothesized that robotic assistance (RARS) could provide better intraoperative and short-term outcomes than a traditional laparoscopic approach (LARS) to rectal cancer surgery.

METHODS

Systematic review of the literature, including electronic searches and communications to international robotic meetings.

INCLUSION CRITERIA

studies involving rectal cancer patients and comparing outcomes of robotic surgery vs laparoscopic surgery. Primary end-points: conversion and postoperative short-term complications. Meta-analysis performed using Review Manager 5.0 software.

RESULTS

Five case-control studies involving 486 patients (203 RARS-283 LARS) were finally included. Conversion to open rate (RR = 0.31; 95% CI 0.12,0.78) was lower for RARS. No differences were found in oncological outcomes, hospital stay or anastomotic leakage.

CONCLUSIONS

This meta-analysis of available non-randomized studies suggests that conversion to open rate may be reduced when using RARS instead of LARS for rectal cancer.

Robot-assisted transhiatal esophagectomy: a 3-year single-center experience

Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high-grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0-16), and median length of hospital stay was 9 days (range, 6-36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30-day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3-38). In 33 patients with known lymph node locations, median of four (range, 0-12) nodes was obtained from the mediastinum, and median of 15 (range, 1-26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow-up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow-up. For patients with EC, median disease-free survival was 20 months (range, 3-45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high-volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.

Robotic surgery for rectal cancer: initial experience from 30 consecutive patients

BACKGROUND

Robotic surgery offers 3D visualization and the advantage of the usage of multi-articulated instruments with superior dexterity. Theoretically, it can overcome many limitations of laparoscopic rectal surgery in the narrow pelvis.

MATERIALS AND METHODS

Between January 2010 and January 2011, the patients who underwent robotic rectal resection for cancer were retrospectively evaluated in terms of demographics, operative data, complications, the duration of hospital stay, and histopathological data.

RESULTS

Thirty consecutive patients made up of 13 female and 17 male patients underwent robotic rectal resection. Sphincter-saving mesorectal excision was performed in 27 patients. Of these, there were 19 total and 8 partial mesorectal excisions. The mean operative time was 270 min (175-480 min). The median postoperative hospital stay was 4 days (4-20 days). No operation was converted. The complication rate was 13.3%. One patient died due to colonic necrosis caused by Drummond artery deficiency (3.3%). The median number of harvested lymph nodes was 15 (3-38), and the distal resection margin was 4 cm (2-8). Histopathological evaluation revealed that the mesorectum resection was complete in all patients.

CONCLUSION

Robotic rectal surgery (hybrid or totally robotic) is a safe and feasible procedure when performed by experienced laparoscopic surgeons.

Robotic Neuro-Endoscope with Concentric Tube Augmentation

Surgical robots are gaining favor in part due to their capacity to reach remote locations within the body. Continuum robots are especially well suited for accessing deep spaces such as cerebral ventricles within the brain. Due to the entry point constraints and complicated structure, current techniques do not allow surgeons to access the full volume of the ventricles. The ability to access the ventricles with a dexterous robot would have significant clinical implications. This paper presents a concentric tube manipulator mated to a robotically controlled flexible endoscope. The device adds three degrees of freedom to the standard neuroendoscope and roboticizes the entire package allowing the operator to conveniently manipulate the device. To demonstrate the improved functionality, we use an in-silica virtual model as well as an ex-vivo anatomic model of a patient with a treatable form of hydrocephalus. In these experiments we demonstrate that the augmented and roboticized endoscope can efficiently reach critical regions that a manual scope cannot.

Medical Robots: Current Systems and Research Directions

First used medically in 1985, robots now make an impact in laparoscopy, neurosurgery, orthopedic surgery, emergency response, and various other medical disciplines. This paper provides a review of medical robot history and surveys the capabilities of current medical robot systems, primarily focusing on commercially available systems while covering a few prominent research projects. By examining robotic systems across time and disciplines, trends are discernible that imply future capabilities of medical robots, for example, increased usage of intraoperative images, improved robot arm design, and haptic feedback to guide the surgeon.

Conventional versus robot-assisted laparoscopic Nissen fundoplication: a comparison of postoperative acid reflux parameters

BACKGROUND

Laparoscopic Nissen fundoplication (LNF) is a technically demanding surgical procedure designed to cure gastroesophageal reflux disease (GERD). It represents an alternative to life-long medical therapy and the only recommended treatment modality to overcome refractoriness to proton pump inhibitor (PPI) therapy. The recent development of robotic systems prompted evaluation of their use in antireflux surgery. Between 1997 and 2000, in a PPI-responsive series we found postoperative normalization of esophageal acid exposure time (EAET) in most but not all cases. Between 2007 and 2009, in a PPI-refractory series we found postoperative normalization of EAET in all cases. We decided to analyze retrospectively our prospectively collected data to evaluate whether differences other than the conventional or robot-assisted technique could justify postoperative differences in acid reflux parameters.

METHODS

Baseline demographic, endoscopic, and manometric parameters were compared between the two series of patients, as well as postoperative manometric and acid reflux parameters.

RESULTS

There were no significant differences in the baseline demographic, endoscopic, and manometric characteristics between the two groups of patients. The median lower esophageal sphincter tone increased significantly, and the median EAET decreased significantly after conventional as well as after robot-assisted LNF. The median postoperative EAET was significantly lower in the robot-assisted (0.2%) than in the conventional LNF group (1%; P = 0.001). Abnormal EAET values were found in 6 of 44 (14%) and in 0 of 44 cases after conventional and robot-assisted LNF, respectively (P = 0.026).

CONCLUSIONS

Robot-assisted LNF provided a significant gain in postoperative acid reflux parameters compared with the conventional technique. In a challenging clinical setting, such as PPI-refractoriness, in which the efficacy of endoscopic or pharmacological treatment modalities is only moderate, even a small therapeutic gain can be clinically relevant. In centers where robot-assisted LNF is available, it should be preferred to conventional LNF in PPI-refractory GERD.

Robotic hepatobiliary and pancreatic surgery: a cohort study

BACKGROUND

Robotic surgery has emerged as one of the most promising surgical advances since its launch at the turn of the millennium. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary and pancreatic (HBP) surgery remains relatively unexplored. This article aims to evaluate the efficacy and outcomes of robotic HBP surgery in a single surgical center.

METHODS

Between May 2009 and December 2010, all patients admitted to our unit for robotic HBP surgery were evaluated. A retrospective analysis of a prospectively maintained database on clinical outcomes was performed.

RESULTS

There were 55 robotic HBP operations performed during the study period. There were 27 robotic liver resections (left lateral sectionectomies n = 17, left hepatectomy n = 1, other segmentectomies n = 2 and wedge resections n = 7), 12 robotic pancreatic procedures (Whipple's operations n = 8, spleen-preserving distal pancreatectomies n = 2, double bypass n = 1 and cystojejunostomy n = 1) and 16 biliary procedures (biliary enteric bypass n = 9, bile duct exploration and related procedures n = 7). The median postoperative hospital stays for robotic liver resections, biliary procedures and pancreatic operations were 5.5 days (range 3-11 days), 6 days (range 4-11 days) and 12 days (range 6-21 days), respectively. Morbidities for liver resection, biliary procedures and pancreatic operations were 7.4, 18 and 33%, respectively. There was no mortality in our series.

CONCLUSIONS

Robotic surgery is feasible and can be safely performed in patients with complicated HBP pathologies. Further evaluation with clinical trials is required to validate its real benefits.

Our initial experience with robotic hepato-biliary-pancreatic surgery

BACKGROUND

The authors performed Asia's first robotic surgery in March 2000 and a clinical trial was launched in the following year in order to obtain governmental approval for the da Vinci(®) Surgical System.

METHODS

Fifty-two robotic surgeries were performed at Keio University Hospital, of which the authors performed 28 hepato-biliary-pancreatic surgeries.

RESULTS

In robotic laparoscopic cholecystectomy, articulated monopolar electrocautery scalpels are flexible, enabling precise dissection around the gall bladder and clipless ligation of the cystic artery and cystic ducts. For laparoscopic hepatectomy, hepatic parenchyma was safely resected without hemorrhage by Glisson's pedicles ligation and bipolar hemostatic forceps.

CONCLUSIONS

We review robotic laparoscopic cholecystectomy and hepatectomy and discuss the potential and future outlook for robotic hepato-biliary-pancreatic surgery.

Robotic surgery in gynecology: an updated systematic review

The introduction of da Vinci Robotic Surgery to the field of Gynecology has resulted in large changes in surgical management. The robotic platform allows less experienced laparoscopic surgeons to perform more complex procedures. In general gynecology and reproductive gynecology, the robot is being increasingly used for procedures such as hysterectomies, myomectomies, adnexal surgery, and tubal anastomosis. Among urogynecology the robot is being utilized for sacrocolopexies. In the field of gynecologic oncology, the robot is being increasingly used for hysterectomies and lymphadenectomies in oncologic diseases. Despite the rapid and widespread adoption of robotic surgery in gynecology, there are no randomized trials comparing its efficacy and safety to other traditional surgical approaches. Our aim is to update previously published reviews with a focus on only comparative observational studies. We determined that, with the right amount of training and skill, along with appropriate patient selection, robotic surgery can be highly advantageous. Patients will likely have less blood loss, less post-operative pain, faster recoveries, and fewer complications compared to open surgery and potentially even laparoscopy. However, until larger, well-designed observational studies or randomized control trials are completed which report long-term outcomes, we cannot definitively state the superiority of robotic surgery over other surgical methods.

Robotic vs. laparoscopic colorectal surgery: an institutional experience

BACKGROUND

Robotic colorectal surgery is gaining interest in general and colorectal surgery. The use of the da Vinci(®) Robotic system has been postulated to improve outcomes, primarily by increasing the dexterity and facility with which complex dissections can be performed. We report a large, single institution, comparative study of laparoscopic and robotic colectomies, attempting to better elucidate the benefits of robotic surgery in patients with colorectal disease.

METHODS

We conducted a retrospective review of 171 patients who underwent robotic and laparoscopic colectomies (79 and 92, respectively) at our institution between November 2004 and November 2009. Patients in both groups had well-matched preoperative parameters. All cases were further subdivided by their anatomical location into right-sided and left-sided colectomy, and analysis was performed within these two subgroups. Perioperative outcomes reported include operative time, operative blood loss, time to return of bowel function, time to discontinuation of patient controlled analgesia, length of stay, and intraoperative or postoperative complications.

RESULTS

Our results indicate that there is no statistical difference in length of stay, time to return of bowel function, and time to discontinuation of patient-controlled analgesia between robotic and laparoscopic left and right colectomies. Interestingly, the total procedure time difference between the laparoscopic and robotic colectomies was much smaller than previously published accounts (mean 140 min vs. 135 min for right colectomy; mean 168 min vs. 203 min for left colectomy).

CONCLUSIONS

Our study is one of the largest reviews of robotic colorectal surgery to date. We believe that our results further demonstrate the equivalence of robotic surgery to laparoscopic surgery in colorectal procedures. Future research should focus on surgeon-specific variables, such as comfort, ergonomics, distractibility, and ease of use, as other ways to potentially distinguish robotic from laparoscopic colorectal surgery.

Global financial crisis and surgical practice: the Greek paradigm

Apart from the significant implications of recent financial crisis in overall health indices and mortality rates, the direct effect of health resources redistribution in everyday clinical practice is barely recognized. In the case of Greece, health sector reform and health spending cuts have already had a major impact on costly interventions, particularly in surgical practice. An increase in utilization of public health resources, lack of basic and advanced surgical supplies, salary deductions, and emerging issues in patient management have contributed to serious dysfunction of a public health system unable to sustain current needs. In this context, significant implications arise for the surgeons and patients as proper perioperative management is directly affected by reduced public health funding. The surgical community has expressed concerns about the quality of surgical care and the future of surgical progress in the era of the European Union. Greek surgeons are expected to support reform while maintaining a high level of surgical care to the public. The challenge of cost control in surgical practice provides, nevertheless, an excellent opportunity to reconsider health economics while innovation through a more traditional approach to the surgical patient should not be precluded. A Greek case study on the extent of the current situation is presented with reference to health policy reform, serving as an alarming paradigm for the global community under the pressure of a profound financial recession.

Transanal specimen extraction in robotic rectal cancer surgery

BACKGROUND

The aim of this study was to identify the benefits of robotic transanal specimen extraction (RTSE) compared with minilaparotomy specimen extraction (MSE).

METHODS

Patients who underwent totally robotic surgery with curative intent for treatment of adenocarcinoma of the rectum below 12 cm from the anal verge were selected from the authors' database. Patients were divided into RTSE and MSE groups according to the method of specimen delivery. Clinicopathological features and perioperative surgical outcomes were compared between the two groups.

RESULTS

There were 53 patients in the RTSE group and 66 in the MSE group. No differences were observed in overall complications. Postoperative recovery was faster in the RTSE group in terms of resumption of a soft diet (mean(s.d.) 3·5(1·5) versus 4·6(1·7) days; P < 0·001) and length of hospital stay (9·0(4·8) versus 11·3(5·3) days; P = 0·016). Pain scores on a visual analogue scale were significantly lower in the RTSE group than in the MSE group from day 2 to day 5 after surgery (P = 0·021 to P < 0·001).

CONCLUSION

RTSE in robotic rectal cancer surgery was associated with less pain and a faster recovery than MSE.

How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia

BACKGROUND

Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy.

METHODS

This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed.

RESULTS

2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001).

CONCLUSIONS

The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies.

How does the robot affect outcomes? A retrospective review of open, laparoscopic, and robotic Heller myotomy for achalasia

BACKGROUND

Robotic techniques are routinely used in urological and gynecological procedures; however, their role in general surgical procedures is limited. A robotic technique has been successfully adopted for a minimally invasive Heller myotomy procedure for achalasia. This study aims to compare perioperative outcomes following open, laparoscopic, and robotic Heller myotomy.

METHODS

This study is a multicenter, retrospective analysis utilizing a large administrative database. The University Health System Consortium (UHC) is an alliance between academic medical centers and affiliate hospitals. The UHC database was accessed using International Classification of Diseases, Ninth Revision, Clinical Modification codes and analyzed.

RESULTS

2,683 patients with achalasia underwent Heller myotomy between October 2007 and June 2011. Myotomy was performed by open surgery (OM) in 418 patients, by laparoscopic approach (LM) in 2,116, and by robotic approach (RM) in 149. Comparison between LM and RM groups demonstrated no significant difference in mortality (0.14 vs. 0.0%; P = 1), morbidity (5.19 vs. 4.02%; P = 0.7), intensive care unit (ICU) admission (6.62 vs. 3.36%; P = 0.12), length of stay (LOS) (2.70 ± 3.87 days vs. 2.42 ± 2.69 days; P = 0.34), or 30-day readmission (1.41 vs. 2.84%; P = 0.27). However, hospital costs were significantly lower for the LM group (US $7,441 ± 7,897 vs. US $9,415 ± 5,515; P = 0.0028). Comparison between OM and RM demonstrated significant lower morbidity (9.08 vs. 4.02%; P = 0.02), ICU admission rate (14.01 vs. 3.36%, P = 0.0002), and LOS (4.42 ± 5.25 days vs. 2.42 ± 2.69 days; P = 0.0001).

CONCLUSIONS

The perioperative outcomes are superior in LM and RM groups when compared with OM. The outcomes for the LM and RM group are comparable, with the robotic group having slightly improved results, although with increased costs. We conclude that robotic surgery is equivalent in safety and efficacy to laparoscopic Heller myotomy, and feel that the increased cost should come down as surgeons and manufacturers work together on cost reduction strategies.

Laparoscopic versus robotic right colectomy: a single surgeon's experience

There is increased interest in robotic techniques for colon resection, but the role of robotics in colorectal surgery has not yet been defined. The purpose of this study was to compare our recent experience with robotic right colectomy to that with laparoscopic right colectomy. From November 2008 to June 2011, a total of 47 consecutive patients underwent elective, right colectomy: 25 laparoscopic right colectomies (LRC) and 22 robotic right colectomies (RRC). All procedures in this study were performed by a single, board-certified colon and rectal surgeon (H.J.L.). Main outcomes recorded included conversion rate, operative time (OT), estimated blood loss (EBL), length of extraction sites, length of stay (LOS), and complications. Data studied were prospectively recorded in a database and were retrospectively reviewed. Mean OT for LRC was 107 ± 36.7 min (median 98, range 48-207) and for RRC was 189.1 ± 38.1 min (median 185, range 123-288, P < 0.001). Mean total operating room time (TORT) for LRC was 158.6 ± 38.1 min (median 149, range 104-274) and for RRC was 258.3 ± 40.9 (median 251, range 182-372, P < 0.001). The tendency lines for both OT and TORT decreased over time for RRC. EBL for LRC was 70.2 ± 52.9 ml (median 50, range 10-200) and for RRC was 60.8 ± 71.3 ml (median 40, range 10-300, P = 0.037). The mean extraction site length for the laparoscopic group was 5.3 ± 1.3 cm (median 5, range 4-11) and for the robotic group was 4.6 ± 0.7 cm (median 4.5, range 3.5-6, p = 0.008). LOS was similar for both groups, as were complications. No cases were converted to open. No leaks occurred and there was no 30-day mortality. RRC is safe and feasible, with similar outcomes to LRC. Operative times were longer for RRC; however, they compare favorably with times for LRC published in the literature. Extraction site length and EBL were less for RRC. However, further study is necessary to demonstrate the clinical relevance of these findings. We are optimistic that OT and TORT will continue to improve.

Assessing appropriateness for elective colorectal cancer surgery: clinical, oncological, and quality-of-life short-term outcomes employing different treatment approaches

PURPOSE

In recent years, colorectal cancer surgery has benefitted from new techniques such as laparoscopy and robotic surgery. However, many treatment disparities exist among different centers for patients affected by the same kind of tumors.

METHODS

Forty-five (41%) open (OCO) vs. 30 (28%) laparoscopic (LCO) vs. 34 (31%) robotic-assisted (RCO) colectomies and 34 (40%) open (ORR) vs. 52 (60%) robotic (ROR) rectal resections performed during a 15-month period, in elective setting, were compared. Patients presenting contraindications for minimally invasive procedures were excluded from the study, so that all the enrolled patients were suitable for either of the surgical procedures.

RESULTS

Overall morbidity rates were similar among groups. Perioperative mortality was nil. No significant differences were noted as for total number of lymph nodes harvested between arms. Mean time (days) to first bowel movement to gas was 3.3 vs. 2.3 vs. 2.6 for OCO, LCO, and RCO, respectively (p < 0.001), and 3.3 vs. 2.0 for ORR and ROR, respectively (p = 0.003). Among several European Organization in Research and Treatment of Cancer QLQ-C30 functional scales considered only physical functioning was significantly better at 30 days for RCO vs. OCO (96.3 ± 10 RCO vs. 85.5 ± 12.6 OCO; p = 0.015). Robotic surgery was much more expensive in comparison to open as well as laparoscopic procedures.

CONCLUSIONS

Laparoscopic and robotic surgeries for colorectal cancer present both the same advantages in comparison to open procedures in terms of faster recovery. However, our data do not seem to support the routine use of RCO as a cost-effective procedure.

Robotic-assisted laparoscopic wedge resection of a gastric leiomyoma with intraoperative ultrasound localization

Gastric leiomyoma is a rare gastric neoplasm that traditionally has been resected for negative margins using an open approach. The laparoscopic approach may also treat various gastric tumors without opening the gastric cavity. Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Herein, we describe a case of robotic-assisted laparoscopic wedge resection of a gastric leiomyoma. A 63-year-old male complaining of abdominal pain was found to have an incidental 3 cm antral mass on an abdominal CT. Endoscopy with endoscopic ultrasound (EUS) confirmed a submucosal mass. Biopsy of the lesion was consistent with a leiomyoma. The DaVinci robotic system was used for partial gastrectomy and reconstruction, with the addition of intraoperative ultrasound to localize the lesion intraoperatively. Pathological examination of the resected mass confirmed a diagnosis of leiomyoma with negative margins. There were no intraoperative or postoperative complications. The patient was discharged home on the second postoperative day. Intraoperative endoscopic ultrasound is a safe technique that may improve the success rate of surgery by confirming the location of the lesion. Robotic assistance in gastric resection offers an easy minimally invasive approach to such tumors. This approach can achieve adequate surgical margins and lead to short hospital stays.

The use of robotics in pediatric surgery: my initial experience

Robotic assisted minimal invasive surgery (RMIS) is a new resource popular in some surgical specialties but not yet in pediatric surgery. There are numerous advantages of robotic surgical technology in adult patients well documented in the literature. The purpose of this study is to define the feasibility, safety, and benefits of RMIS in pediatric patients in my initial learning experience. In a period of 24 months, all consecutive abdominal RMIS were reviewed. Chart revision was conducted retrospectively. Demographic data were collected in each patient. Other data reviewed were indications for surgery, surgical procedures, complication rate, and conversion rate to open procedure. Four arms robotic equipment was used in all cases with 3 (5 mm) reusable robotic ports and a single (12 mm) disposable port. A total of 102 consecutive abdominal RMIS were performed in 77 pediatric patients. All cases were performed by the same pediatric surgeon in a teaching institution. The average patient age was 6.2 years (ranged from 4 months to 18 years) with 16 patients <1 year of age. The smallest patient was 4 kg. No cases required conversion to open technique. However, one case was converted to laparoscopy because of mesenteric bleeding. There were five intraoperative complications in three patients: minor bleeding (2), suture orogastric tube (1), and gastric opening (2) with repair. Postoperative complications were noted in four patients: mild dysphagia (2) and Nissen wrap breakdown (2). Although the use of RMIS in pediatric patients is still controversial, it is feasible and safe to perform robotic surgery in children with a low complication rate. In addition, excellent visualization with outstanding maneuverability of instruments is of great benefit. These benefits may offset the increased cost of robotic technology especially in technically complex surgical cases.

Totally robotic right colectomy: a preliminary case series and an overview of the literature

BACKGROUND

Since the introduction of robotics, relatively few series have been published evaluating its role for right colectomy. The aim of this study was to report our preliminary experience with totally robotic right colectomy (TRRC).

METHODS

Between 2009 and 2010 we performed three TRRCs, using a hand-sewn intracorporeal anastomosis. Data were retrospectively reviewed.

RESULTS

Two women and one man underwent a TRRC. Mean operative time was 270 min. Mean blood loss was 30 ml. There was no conversion. Mean number of lymph nodes harvested was 18. There were no complications. Median hospital stay was 10 days. After a median follow-up of 10 months, there was no tumoural recurrence.

CONCLUSION

TRRC is not only safe and feasible but also oncologically effective. Although preliminary and small, this experience confirmed the results from previous series using a hand-sewn intracorporeal anastomosis. Larger series are required to draw firm conclusions concerning the possible indications for TRRC.

Laparoscopic splenectomy: conventional versus robotic approach--a comparative study

BACKGROUND

Laparoscopic splenectomy is accepted as a safe approach in the surgical treatment of blood disorders worldwide. Compared with the laparotomic technique, it is associated with a lower risk of intraoperative bleeding, less postoperative pain, and faster discharge times. The advent of robotic surgery (RS) has changed the concept of minimally invasive surgery because, in addition to allowing a three-dimensional view, it permits greater freedom of movement and higher levels of accuracy than laparoscopic surgery (LS). The aim of this study was to comparatively evaluate whether RS presents advantages over LS in spleen surgery.

METHODS

In two Surgical Units with experience in laparoscopic splenectomy, over a 7-year period, two groups of 45 patients underwent LS and RS. The two groups were well matched for demographic characteristics, indications, and spleen size.

RESULTS

No statistically significant differences were found regarding intraoperative blood loss, conversion rate to laparotomy, food intake, drain removal, postoperative complications, and median time to discharge. On the contrary, statistically increased differences were observed in median operative time and costs. In both groups, the transfusion and mortality rate was 0%. At the 6-month follow-up no surgical complications were observed.

CONCLUSIONS

Although RS offers a three-dimensional view, greater freedom of movement, and higher levels of accuracy, it is associated with longer operative times and higher costs. It can consequently be concluded that with the intrinsic limits of the study design used, at the current time, RS does not have any significant advantage over LS in splenectomy.

Robotic surgery for gastric cancer: a technical review

Minimally invasive gastric cancer surgery is gaining acceptance, especially in the treatment of patients with early gastric cancer. While offering patients the benefits of minimally invasive surgery, laparoscopic surgery is limited by several disadvantages such as altered operating view and lack of versatility in surgical instrumentation. Robotic surgery offers the surgeon the benefit of superior 3D visualization, the freedom of the EndoWrist function, and the tremble-filtered control of the four robotic arms. Due to the technical advantages of the robotic surgical system, robotic surgery may facilitate the expansion of minimally invasive surgery over laparoscopy. The application of robotic surgery for gastric cancer is increasing in experienced centers. Most reports of the robotic operating methods are only slightly modified from the laparoscopic technique. Robotic gastric cancer surgery including radical subtotal gastrectomy with D2 lymph node dissection is technically feasible and safe and results in similar short-term postoperative outcomes when compared to laparoscopic surgery. The role of robotic surgery in gastric cancer is promising but awaits further comparative studies of long-term results and cost-effectiveness.

Totally robotic gastric bypass: approach and technique

Despite the advantages of the da Vinci robotic system in the performance of abdominal surgery (Maeso et al. Ann Surg 252:254-262, 2010), there has been limited application of this technology to bariatric surgery. The robotic platform may be ideal for performance of Roux-en-Y gastric bypass (RYGB), providing significant ergonomic advantage and greater ability to maneuver more precisely in limited spaces. However, there has been slow adoption of robotic technology for the performance of the RYGB procedure due, in part, to the perceived difficulty of conversion from laparoscopic to totally robotic procedures and the associated initial increase in operative time. In this report, we describe our approach to developing a standardized totally robotic technique with focus on patient safety and attention to operative times, the technique itself, and surgery outcomes of nearly 300 RYGB cases. Our findings show that totally robotic RYGB can be safely approached through systematic stepwise progression with minimal complications and comparable operative times.

Optimal Total Mesorectal Excision for Rectal Cancer: the Role of Robotic Surgery from an Expert's View

Total mesorectal excision (TME) has gained worldwide acceptance as a standard surgical technique in the treatment of rectal cancer. Ever since laparoscopic surgery was first applied to TME for rectal cancer, with increasing penetration rates, especially in Asia, an unstable camera platform, the limited mobility of straight laparoscopic instruments, the two-dimensional imaging, and a poor ergonomic position for surgeons have been regarded as limitations. Robotic technology was developed in an attempt to reduce the limitations of laparoscopic surgery. The robotic system has many advantages, including a more ergonomic position, stable camera platform and stereoscopic view, as well as elimination of tremor and subsequent improved dexterity. Current comparison data between robotic and laparoscopic rectal cancer surgery show similar intraoperative results and morbidity, postoperative recovery, and short-term oncologic outcomes. Potential benefits of a robotic system include reduction of surgeon's fatigue during surgery, improved performance and safety for intracorporeal suture, reduction of postoperative complications, sharper and more meticulous dissection, and completion of autonomic nerve preservation techniques. However, the higher cost for a robotic system still remains an obstacle to wide application, and many socioeconomic issues remain to be solved in the future. In addition, we need more concrete evidence regarding the merits for both patients and surgeons, as well as the merits compared to conventional laparoscopic techniques. Therefore, we need large-scale prospective randomized clinical trials to prove the potential benefits of robot TME for the treatment of rectal cancer.