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Karikis I, Pachos N, Mela E, Saliaris K, Kitsou E, Linardoutsos D, Triantafyllou S, Theodorou D. Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes. Hernia 2024:10.1007/s10029-024-03126-5. [PMID: 39123086 DOI: 10.1007/s10029-024-03126-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques. METHODS We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis. RESULTS Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196 min for robotic compared to 145 min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88 min for robotic versus 102 min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20 ml for robotic versus 50 ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%). CONCLUSIONS Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.
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Affiliation(s)
- I Karikis
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece.
| | - N Pachos
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - E Mela
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - K Saliaris
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - E Kitsou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - D Linardoutsos
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - S Triantafyllou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
| | - D Theodorou
- First Propedeutic Department of Surgery, National and Kapodistrian University of Athens, Hippocration General Hospital, Athens, Greece
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Delgado-Miguel C, Camps JI. Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study. Int J Med Robot 2023; 19:e2541. [PMID: 37317669 DOI: 10.1002/rcs.2541] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/21/2023] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Robotic-assisted redo fundoplication has some advantages compared to the laparoscopic approach in adults, although to date there are no studies in children. METHODS A retrospective case-control study was performed among consecutive children who underwent redo antireflux surgery between 2004 and 2020, divided into two groups: LAF group (laparoscopic redo-fundoplication) and RAF group (robotic-assisted redo-fundoplication). Demographics, clinical, intraoperative, postoperative and economic data were compared. RESULTS A total of 24 patients were included (10 LAF group; 14 RAF group) without demographic or clinical differences. The RAF group presented lower intraoperative blood loss (52 ± 19 vs. 145 ± 69 mL; p < 0.021), shorter surgery time (135 ± 39 vs. 179 ± 68 min; p = 0.009) and shorter length of hospital stay (median 3 days [2-4] vs. 5 days [3-7]; p = 0.002). The RAF group presented a higher rate of symptom improvement (85.7% vs. 60%; p = 0.192) and lower overall associated economic costs (25 800$ vs. 45 500$; p = 0.012). CONCLUSION Robotic-assisted redo antireflux surgery may offer several benefits over the laparoscopic approach. Prospective studies are still needed.
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Affiliation(s)
- Carlos Delgado-Miguel
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
- Institute for Health Research IdiPAZ, La Paz University Hospital, Madrid, Spain
| | - Juan I Camps
- Department of Pediatric Surgery, Prisma Health Children's Hospital, Columbia, South Carolina, USA
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Straatman J, Rahman SA, Carter NC, Mercer SJ, Knight BC, van Boxel GI, Pucher PH. Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre. Surg Endosc 2023; 37:7608-7615. [PMID: 37474827 PMCID: PMC10520141 DOI: 10.1007/s00464-023-10210-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 06/12/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring. METHODS The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases. RESULTS Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B). CONCLUSION The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.
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Affiliation(s)
- Jennifer Straatman
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.
| | - Saqib A Rahman
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Nicholas C Carter
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Stuart J Mercer
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Benjamin C Knight
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Gijsbert I van Boxel
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Philip H Pucher
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
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Kawka M, Fong Y, Gall TMH. Laparoscopic versus robotic abdominal and pelvic surgery: a systematic review of randomised controlled trials. Surg Endosc 2023; 37:6672-6681. [PMID: 37442833 PMCID: PMC10462573 DOI: 10.1007/s00464-023-10275-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND The current evidence is inconclusive on whether robotic or laparoscopic surgery is the optimal platform for minimally invasive surgery. Existing comparisons techniques focus on short-term outcomes only, while potentially being confounded by a lack of standardisation in robotic procedures. There is a pertinent need for an up-to-date comparison between minimally invasive surgical techniques. We aimed to systematically review randomised controlled trials comparing robotic and laparoscopic techniques in major surgery. METHODS Embase, Medline and Cochrane Library were searched from their inception to 13th September 2022. Included studies were randomised controlled trials comparing robotic and laparoscopic techniques in abdominal and pelvic surgery. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Short-term, health-related quality of life, and long-term, outcomes were analysed. RESULTS Forty-five studies, across thirteen procedures, involving 7364 patients were included. All of the studies reported non-significant differences in mortality between robotic and laparoscopic surgery. In majority of studies, there was no significant difference in complication rate (n = 31/35, 85.6%), length of postoperative stay (n = 27/32, 84.4%), and conversion rate (n = 15/18, 83.3%). Laparoscopic surgery was associated with shorter operative time (n = 16/31, 51.6%) and lower total cost (n = 11/13, 84.6%). Twenty three studies reported on quality of life outcomes; majority (n = 14/23, 60.9%) found no significant differences. CONCLUSION There were no significant differences between robotic surgery and laparoscopic surgery with regards to mortality and morbidity outcomes in the majority of studies. Robotic surgery was frequently associated with longer operative times and higher overall cost. Selected studies found potential benefits in post-operative recovery time, and patient-reported outcomes; however, these were not consistent across procedures and trials, with most studies being underpowered to detect differences in secondary outcomes. Future research should focus on assessing quality of life, and long-term outcomes to further elucidate where the robotic platform could lead to patient benefits, as the technology evolves.
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Affiliation(s)
- Michal Kawka
- Department of Medicine, Imperial College London, London, UK
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA, 91010, USA
| | - Tamara M H Gall
- Department of HPB Surgery, The Mater Misericordiae Hospital, Dublin, Ireland.
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Vertaldi S, D’Amore A, Manigrasso M, Anoldo P, Chini A, Maione F, Pesce M, Sarnelli G, De Palma GD, Milone M. Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis. J Pers Med 2023; 13:jpm13020231. [PMID: 36836465 PMCID: PMC9966072 DOI: 10.3390/jpm13020231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/07/2023] [Accepted: 01/22/2023] [Indexed: 01/31/2023] Open
Abstract
The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.
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Affiliation(s)
- Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-340-86-03-360
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Marcella Pesce
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
| | | | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy
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Mohr C, Ciomperlik H, Dhanani N, Olavarria OA, Hannon C, Hope W, Roth S, Liang MK, Holihan JL. Review of SAGES GERD guidelines and recommendations. Surg Endosc 2022; 36:9345-9354. [PMID: 35414134 DOI: 10.1007/s00464-022-09209-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 02/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed evidence-based guidelines for the management of patients with gastroesophageal reflux disease (GERD). The aim of this study is to evaluate guidelines lacking agreement among experts (grades B-D) or lacking support from randomized controlled trials (levels II-III). METHODS Six guidelines were chosen for evaluation. A retrospective review of a multicenter database of patients undergoing fundoplication surgery for treatment of GERD between 2015 and 2020 was performed. Patients that underwent a concurrent gastrectomy or were diagnosed with pre-operative achalasia were excluded. Demographics, pre-operative, intra-operative, and post-operative variables were collected. Post-operative outcomes were evaluated based on selected SAGES guidelines. Outcomes were assessed using multivariable regression or stratified analysis for each guideline. RESULTS A total of 444 patients from four institutions underwent surgery for the management of GERD with a median (interquartile range) follow-up of 16 (13) months. Guidelines supported by our data were (1) robotic repair has similar short-term outcomes to laparoscopic repair, (2) outcomes in older patients are similar to outcomes of younger patients undergoing antireflux surgery, and (3) following laparoscopic antireflux surgery, dysphagia has been reported to significantly improve from pre-operative values. Guidelines that were not supported were (1) mesh reinforcement may be beneficial in decreasing the incidence of wrap herniation, (2) a bougie has been found to be effective, and (3) the long-term effectiveness of fundoplication in obese individuals (BMI > 30) has been questioned due to higher failure rates. CONCLUSION Many SAGES GERD guidelines not receiving Grade A or Level I recommendation are supported by large, multicenter database findings. However, further studies at low risk for bias are needed to further refine these guidelines.
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Affiliation(s)
- Cassandra Mohr
- Department of Surgery, McGovern Medical School, Houston, TX, USA.
- Department of Surgery, Lyndon B. Johnson Hospital, 5656 Kelley St, Houston, TX, 77026, USA.
| | | | - Naila Dhanani
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | | | - Craig Hannon
- Department of Surgery, McGovern Medical School, Houston, TX, USA
| | - William Hope
- Department of Surgery, New Hanover Regional Medical Center, Wilmington, NC, USA
| | - Scott Roth
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - Mike K Liang
- Department of Surgery, HCA Healthcare Kingwood, University of Houston, Kingwood, TX, USA
| | - Julie L Holihan
- Department of Surgery, McGovern Medical School, Houston, TX, USA
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Huttman MM, Robertson HF, Smith AN, Biggs SE, Dewi F, Dixon LK, Kirkham EN, Jones CS, Ramirez J, Scroggie DL, Zucker BE, Pathak S, Blencowe NS. A systematic review of robot-assisted anti-reflux surgery to examine reporting standards. J Robot Surg 2022; 17:313-324. [PMID: 36074220 PMCID: PMC10076351 DOI: 10.1007/s11701-022-01453-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/11/2022] [Indexed: 12/01/2022]
Abstract
Robot-assisted anti-reflux surgery (RA-ARS) is increasingly being used to treat refractory gastro-oesophageal reflux disease. The IDEAL (Idea, Development, Exploration, Assessment, Long-term follow up) Collaboration's framework aims to improve the evaluation of surgical innovation, but the extent to which the evolution of RA-ARS has followed this model is unclear. This study aims to evaluate the standard to which RA-ARS has been reported during its evolution, in relation to the IDEAL framework. A systematic review from inception to June 2020 was undertaken to identify all primary English language studies pertaining to RA-ARS. Studies of paraoesophageal or giant hernias were excluded. Data extraction was informed by IDEAL guidelines and summarised by narrative synthesis. Twenty-three studies were included: two case reports, five case series, ten cohort studies and six randomised controlled trials. The majority were single-centre studies comparing RA-ARS and laparoscopic Nissen fundoplication. Eleven (48%) studies reported patient selection criteria, with high variability between studies. Few studies reported conflicts of interest (30%), funding arrangements (26%), or surgeons' prior robotic experience (13%). Outcome reporting was heterogeneous; 157 distinct outcomes were identified. No single outcome was reported in all studies.The under-reporting of important aspects of study design and high degree of outcome heterogeneity impedes the ability to draw meaningful conclusions from the body of evidence. There is a need for further well-designed prospective studies and randomised trials, alongside agreement about outcome selection, measurement and reporting for future RA-ARS studies.
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Affiliation(s)
- Marc M Huttman
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University College Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Harry F Robertson
- St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Sarah E Biggs
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Ffion Dewi
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lauren K Dixon
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Emily N Kirkham
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | - Conor S Jones
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Jozel Ramirez
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Darren L Scroggie
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Benjamin E Zucker
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Samir Pathak
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.,St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Natalie S Blencowe
- Centre for Surgical Research, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
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Bai F, Li M, Han J, Qin Y, Yao L, Yan W, Liu Y, He G, Zhou Y, Ma X, Aboudou T, Guan L, Lu M, Wei Z, Li X, Yang K. More work is needed on cost-utility analyses of robotic-assisted surgery. J Evid Based Med 2022; 15:77-96. [PMID: 35715999 DOI: 10.1111/jebm.12475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/19/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To comprehensively analyze the cost-utility of robotic surgery in clinical practice and to investigate the reporting and methodological quality of the related evidence. METHODS Data on cost-utility analyses (CUAs) of robotic surgery were collected in seven electronic databases from the inception to July 2021. The quality of the included studies was assessed using the CHEERs and QHES checklists. A systematic review was performed with the incremental cost-effectiveness ratio as the outcome of interest. RESULTS Thirty-one CUAs of robotic surgery were eligible. Overall, the identified CUAs were fair to high quality, and 63% of the CUAs ranked the cost-utility of robotic surgery as "favored," 32% categorized as "reject," and the remaining 5% ranked as "unclear." Although a high heterogeneity was present in terms of the study design among the included CUAs, most studies (81.25%) consistently found that robotic surgery was more cost-utility than open surgery for prostatectomy (ICER: $6905.31/QALY to $26240.75/QALY; time horizon: 10 years or lifetime), colectomy (dominated by robotic surgery; time horizon: 1 year), knee arthroplasty (ICER: $1134.22/QALY to $1232.27/QALY; time horizon: lifetime), gastrectomy (dominated by robotic surgery; time horizon: 1 year), spine surgery (ICER: $17707.27/QALY; time horizon: 1 year), and cystectomy (ICER: $3154.46/QALY; time horizon: 3 months). However, inconsistent evidence was found for the cost-utility of robotic surgery versus laparoscopic surgery and (chemo)radiotherapy. CONCLUSIONS Fair or high-quality evidence indicated that robotic surgery is more cost-utility than open surgery, while it remains inconclusive whether robotic surgery is more cost-utility than laparoscopic surgery and (chemo)radiotherapy. Thus, an additional evaluation is required.
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Affiliation(s)
- Fei Bai
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- National Center for Medical Service Administration, National Health Commission of the People's Republic of China, Beijing, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Jiani Han
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Yu Qin
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Wenlong Yan
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Yujun Liu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Gege He
- The Second School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Yinjuan Zhou
- The Second School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Xiaoya Ma
- The Second School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Taslim Aboudou
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Ling Guan
- School/Hospital of Stomatology, Lanzhou University, Lanzhou, China
| | - Mengying Lu
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Zhipeng Wei
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Xiuxia Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Health Technology Assessment Center, Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
- WHO Collaborating Centre for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China
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9
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Dhanani NH, Olavarria OA, Bernardi K, Lyons NB, Holihan JL, Loor M, Haynes AB, Liang MK. The Evidence Behind Robot-Assisted Abdominopelvic Surgery : A Systematic Review. Ann Intern Med 2021; 174:1110-1117. [PMID: 34181448 DOI: 10.7326/m20-7006] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Use of robot-assisted surgery has increased dramatically since its advent in the 1980s, and nearly all surgical subspecialties have adopted it. However, whether it has advantages compared with laparoscopy or open surgery is unknown. PURPOSE To assess the quality of evidence and outcomes of robot-assisted surgery compared with laparoscopy and open surgery in adults. DATA SOURCES PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials were searched from inception to April 2021. STUDY SELECTION Randomized controlled trials that compared robot-assisted abdominopelvic surgery with laparoscopy, open surgery, or both. DATA EXTRACTION Two reviewers independently extracted study data and risk of bias. DATA SYNTHESIS A total of 50 studies with 4898 patients were included. Of the 39 studies that reported incidence of Clavien-Dindo complications, 4 (10%) showed fewer complications with robot-assisted surgery. The majority of studies showed no difference in intraoperative complications, conversion rates, and long-term outcomes. Overall, robot-assisted surgery had longer operative duration than laparoscopy, but no obvious difference was seen versus open surgery. LIMITATIONS Heterogeneity was present among and within the included surgical subspecialties, which precluded meta-analysis. Several trials may not have been powered to assess relevant differences in outcomes. CONCLUSION There is currently no clear advantage with existing robotic platforms, which are costly and increase operative duration. With refinement, competition, and cost reduction, future versions have the potential to improve clinical outcomes without the existing disadvantages. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42020182027).
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Affiliation(s)
- Naila H Dhanani
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Oscar A Olavarria
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Karla Bernardi
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Nicole B Lyons
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Julie L Holihan
- McGovern Medical School at UTHealth, Houston, Texas (N.H.D., O.A.O., K.B., N.B.L., J.L.H.)
| | - Michele Loor
- Baylor College of Medicine, Houston, Texas (M.L.)
| | - Alex B Haynes
- Dell Medical School at the University of Texas, Austin, Texas (A.B.H.)
| | - Mike K Liang
- University of Houston, HCA Kingwood, Kingwood, Texas (M.K.L.)
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Association between Functional Brain Network Metrics and Surgeon Performance and Distraction in the Operating Room. Brain Sci 2021; 11:brainsci11040468. [PMID: 33917719 PMCID: PMC8068138 DOI: 10.3390/brainsci11040468] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The aim of this work was to examine (electroencephalogram) EEG features that represent dynamic changes in the functional brain network of a surgical trainee and whether these features can be used to evaluate a robot assisted surgeon's (RAS) performance and distraction level in the operating room. MATERIALS AND METHODS Electroencephalogram (EEG) data were collected from three robotic surgeons in an operating room (OR) via a 128-channel EEG headset with a frequency of 500 samples/second. Signal processing and network neuroscience algorithms were applied to the data to extract EEG features. The SURG-TLX and NASA-TLX metrics were subjectively evaluated by a surgeon and mentor at the end of each task. The scores given to performance and distraction metrics were used in the analyses here. Statistical test data were utilized to select EEG features that have a significant relationship with surgeon performance and distraction while carrying out a RAS surgical task in the OR. RESULTS RAS surgeon performance and distraction had a relationship with the surgeon's functional brain network metrics as recorded throughout OR surgery. We also found a significant negative Pearson correlation between performance and the distraction level (-0.37, p-value < 0.0001). CONCLUSIONS The method proposed in this study has potential for evaluating RAS surgeon performance and the level of distraction. This has possible applications in improving patient safety, surgical mentorship, and training.
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McKinley SK, Dirks RC, Walsh D, Hollands C, Arthur LE, Rodriguez N, Jhang J, Abou-Setta A, Pryor A, Stefanidis D, Slater BJ. Surgical treatment of GERD: systematic review and meta-analysis. Surg Endosc 2021; 35:4095-4123. [PMID: 33651167 DOI: 10.1007/s00464-021-08358-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients. METHODS PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale. RESULTS From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference = - 0.51, 95%CI - 0.63, - 0.40, I2 = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I2 = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I2 = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I2 = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I2 = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67). CONCLUSIONS The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
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Affiliation(s)
| | - Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, USA
| | - Danielle Walsh
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Lauren E Arthur
- Walsh - Department of Surgery, East Carolina University, Greenville, USA
| | - Noe Rodriguez
- Department of Surgery, Florida Atlantic University, Boca Raton, USA
| | - Joyce Jhang
- University of Nebraska Medical Center, Omaha, USA
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | - Aurora Pryor
- Department of Surgery, Stony Brook University, Stony Brook, USA
| | | | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.
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12
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Bjelović M, Harsányi L, Altorjay Á, Kincses Z, Forsell P. Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark. BMC Surg 2020; 20:159. [PMID: 32689979 PMCID: PMC7370422 DOI: 10.1186/s12893-020-00794-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/09/2020] [Indexed: 01/29/2023] Open
Abstract
Background RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected. Methods In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction. Results There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects. Conclusion The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced. Trial registration ClinicalTrials.gov, NCT02759094. Registered 3 May, 2016,
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, University Hospital for Digestive Surgery - First Surgical Hospital, Clinical Center of Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia.
| | - László Harsányi
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Áron Altorjay
- Surgical Department, Fejér County Szent György University Teaching Hospital, Székesfehérvár, Hungary
| | - Zsolt Kincses
- General Surgery Department, University of Debrecen Kenézy Gyula Teaching Hospital, Debrecen, Hungary
| | - Peter Forsell
- Inventor of RefluxStop™, Seehof 4b, 6072, Sachseln, Switzerland
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13
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Favorable peri-operative outcomes observed in paraesophageal hernia repair with robotic approach. Surg Endosc 2020; 35:3085-3089. [DOI: 10.1007/s00464-020-07700-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/09/2020] [Indexed: 12/31/2022]
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15
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Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT. Robotic Fundoplication for Large Paraesophageal Hiatal Hernias. JSLS 2020; 24:JSLS.2019.00054. [PMID: 32206010 PMCID: PMC7065729 DOI: 10.4293/jsls.2019.00054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Purpose: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique. Methods: Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus. Results: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically. Conclusions: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.
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Affiliation(s)
- Massimo Arcerito
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Martin G Perez
- Riverside Medical Clinic Inc., University of California Riverside School of Medicine, Riverside, California
| | - Harpreet Kaur
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - Kenneth M Annoreno
- Division of General and Vascular Surgery, Riverside Community Hospital, Riverside, California
| | - John T Moon
- Shawnee Mission Medical Center, Shawnee Mission, Kansas
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16
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Sowards KJ, Holton NF, Elliott EG, Hall J, Bajwa KS, Snyder BE, Wilson TD, Mehta SS, Walker PA, Chandwani KD, Klein CL, Rivera AR, Wilson EB, Shah SK, Felinski MM. Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience. Surg Endosc 2019; 34:2560-2566. [PMID: 31811451 DOI: 10.1007/s00464-019-07291-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 11/28/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs. METHODS Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables. RESULTS There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks. CONCLUSIONS Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.
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Affiliation(s)
- Kendell J Sowards
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Nicholas F Holton
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Ekatarina G Elliott
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - John Hall
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Brad E Snyder
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Todd D Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | | | | | - Kavita D Chandwani
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Connie L Klein
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Angielyn R Rivera
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA. .,Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA.
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 4.156, Houston, TX, 77030, USA
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17
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Abdelmoaty WF, Dunst CM, Neighorn C, Swanstrom LL, Hammill CW. Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis. Surg Endosc 2018; 33:3436-3443. [PMID: 30535936 DOI: 10.1007/s00464-018-06606-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 11/28/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States. METHODS Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ2 test for categorical variables. A p-value < 0.05 was considered significant. RESULTS A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results. CONCLUSIONS Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.
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Affiliation(s)
- Walaa F Abdelmoaty
- Providence St. Joseph Health, Portland, OR, USA.,The Foundation for Surgical Innovation and Education, Portland, OR, USA
| | - Christy M Dunst
- The Foundation for Surgical Innovation and Education, Portland, OR, USA.,The Oregon Clinic, Portland, OR, USA
| | | | - Lee L Swanstrom
- The Foundation for Surgical Innovation and Education, Portland, OR, USA.,The Oregon Clinic, Portland, OR, USA
| | - Chet W Hammill
- Washington University School of Medicine, Box 8109, St. Louis, MO, 63110, USA.
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18
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Roh HF, Nam SH, Kim JM. Robot-assisted laparoscopic surgery versus conventional laparoscopic surgery in randomized controlled trials: A systematic review and meta-analysis. PLoS One 2018; 13:e0191628. [PMID: 29360840 PMCID: PMC5779699 DOI: 10.1371/journal.pone.0191628] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 12/14/2017] [Indexed: 12/22/2022] Open
Abstract
Importance This review provides a comprehensive comparison of treatment outcomes between robot-assisted laparoscopic surgery (RLS) and conventional laparoscopic surgery (CLS) based on randomly-controlled trials (RCTs). Objectives We employed RCTs to provide a systematic review that will enable the relevant community to weigh the effectiveness and efficacy of surgical robotics in controversial fields on surgical procedures both overall and on each individual surgical procedure. Evidence review A search was conducted for RCTs in PubMed, EMBASE, and Cochrane databases from 1981 to 2016. Among a total of 1,517 articles, 27 clinical reports with a mean sample size of 65 patients per report (32.7 patients who underwent RLS and 32.5 who underwent CLS), met the inclusion criteria. Findings CLS shows significant advantages in total operative time, net operative time, total complication rate, and operative cost (p < 0.05 in all cases), whereas the estimated blood loss was less in RLS (p < 0.05). As subgroup analyses, conversion rate on colectomy and length of hospital stay on hysterectomy statistically favors RLS (p < 0.05). Conclusions Despite higher operative cost, RLS does not result in statistically better treatment outcomes, with the exception of lower estimated blood loss. Operative time and total complication rate are significantly more favorable with CLS.
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Affiliation(s)
- Hyunsuk Frank Roh
- Department of Biomedical Science, Hanyang University College of Medicine and Graduate School of Biomedical Science and Engineering, Seoul, Korea
- Department of Microbiology and Biomedical Science, Hanyang University College of Medicine and Graduate School of Biomedical Science and Engineering, Seoul, Korea
| | - Seung Hyuk Nam
- Department of Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Guri, Gyunggi, Korea
| | - Jung Mogg Kim
- Department of Microbiology and Biomedical Science, Hanyang University College of Medicine and Graduate School of Biomedical Science and Engineering, Seoul, Korea
- * E-mail:
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Two years of experience with robot-assisted anti-reflux surgery: A retrospective cohort study. Int J Surg 2017; 39:260-266. [PMID: 28216290 DOI: 10.1016/j.ijsu.2017.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 02/05/2017] [Accepted: 02/08/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Robot-assisted anti-reflux surgery (RAAS) is an alternative to conventional laparoscopic anti-reflux surgery (CLAS). The purpose of this study was to evaluate initial Danish experiences with robot-assisted anti-reflux surgery compared to conventional laparoscopic anti-reflux surgery incorporating follow-up and evaluation of possible learning curve. MATERIAL AND METHODS Patients undergoing primary RAAS or CLAS at The Department of Surgery A, Odense University Hospital and The Department of General Surgery, Kolding Hospital from April 2013 to April 2015 was included. Demographic data, comorbidity, docking time, length of procedure, type of fundic wrap as well as perioperative complications and postoperative complications, need for reoperation or any upper gastrointestinal endoscopy from surgery to final follow-up was retrospectively extracted from patient records. RESULTS 103 patients were included in this study. 39 patients underwent RAAS and 64 patients underwent CLAS. There were no statistically significant differences in demographic data or comorbidities except distribution of heart disease (RAAS: 5.1% vs. CLAS: 18.8%, p = 0.05) and previous abdominal surgery (RAAS: 28.2% vs. CLAS: 48.4%, p = 0.04). Duration of surgery was significantly increased in patients undergoing RAAS (RAAS: 135 ± 27 min vs. CLAS: 86 ± 19 min, p < 0.01). There was no statistical significant difference in intraoperative complications (p = 0.20), 30-day postoperative complication rate (p = 0.20) or mortality (p = 1.00). At follow-up in April 2016, there were no statistically significant differences in patients having undergone upper endoscopy postoperatively (p = 0.92), the use of anti-secretory drugs (p = 0.46) or patients having undergone reoperation (p = 0.60). Reasons for reoperation were significantly dependent on type of fundic wrap with reoperation of Nissen fundoplication being dysphagia and reoperation of Toupet being recurrent reflux (p = 0.008). There was no clearly determined learning curve. CONCLUSIONS RAAS was safe, feasible and with equal efficacy to CLAS. There were however no particular advantages to performing antireflux surgery as robot-assisted procedures neither intra-operatively nor at follow-up.
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Rebecchi F, Allaix ME, Morino M. Robotic technological aids in esophageal surgery. J Vis Surg 2017; 3:7. [PMID: 29078570 DOI: 10.21037/jovs.2017.01.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 12/18/2016] [Indexed: 12/13/2022]
Abstract
Robotic technology is an emerging technology that has been developed in order to overcome some limitations of the standard laparoscopic approach, offering a stereoscopic three-dimensional visualization of the surgical field, increased maneuverability of the surgical tools with consequent increased movement accuracy and precision and improved ergonomics. It has been used for the surgical treatment of most benign esophageal disorders. More recently, it has been proposed also for patients with operable esophageal cancer. The current evidence shows that there are no real benefits of the robotic technology over conventional laparoscopy in patients undergoing a fundoplication for gastroesophageal reflux disease (GERD), hiatal closure for giant hiatal hernia, or Heller myotomy for achalasia. A few small studies suggest potential advantages in patients undergoing redo surgery for failed fundoplication or Heller myotomy, but large comparative studies are needed to better clarify the role of the robotic technology in these patients. Robot-assisted esophagectomy seems to be safe and effective in selected patients; however, there are no data showing superiority of this approach over both conventional laparoscopic and open surgery. The short-term and long-term oncologic results of ongoing randomized controlled trials (RCTs) are awaited to validate this approach for the treatment of esophageal cancer.
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Affiliation(s)
- Fabrizio Rebecchi
- Department of Surgical Sciences, University of Torino, Corso A. M. Dogliotti, Torino, Italy
| | - Marco E Allaix
- Department of Surgical Sciences, University of Torino, Corso A. M. Dogliotti, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso A. M. Dogliotti, Torino, Italy
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Limited Evidence for Robot-assisted Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Surg Laparosc Endosc Percutan Tech 2017; 26:117-23. [PMID: 26766316 DOI: 10.1097/sle.0000000000000248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate available evidence on robot-assisted surgery compared with open and laparoscopic surgery. METHOD The databases Medline, Embase, and Cochrane Library were systematically searched for randomized controlled trials comparing robot-assisted surgery with open and laparoscopic surgery regardless of surgical procedure. Meta-analyses were performed on each outcome with appropriate data material available. Cochrane Collaboration's tool for assessing risk of bias was used to evaluate risk of bias on a study level. The GRADE approach was used to evaluate the quality of evidence of the meta-analyses. RESULTS This review included 20 studies comprising 981 patients. The meta-analyses found no significant differences between robot-assisted and laparoscopic surgery regarding blood loss, complication rates, and hospital stay. A significantly longer operative time was found for robot-assisted surgery. Open versus robot-assisted surgery was investigated in 3 studies. A lower blood loss and a longer operative time were found after robot-assisted surgery. No other difference was detected. CONCLUSIONS At this point there is not enough evidence to support the significantly higher costs with the implementation of robot-assisted surgery.
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Gkegkes ID, Mamais IA, Iavazzo C. Robotics in general surgery: A systematic cost assessment. J Minim Access Surg 2017; 13:243-255. [PMID: 28000648 PMCID: PMC5607789 DOI: 10.4103/0972-9941.195565] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The utilisation of robotic-assisted techniques is a novelty in the field of general surgery. Our intention was to examine the up to date available literature on the cost assessment of robotic surgery of diverse operations in general surgery. PubMed and Scopus databases were searched in a systematic way to retrieve the included studies in our review. Thirty-one studies were retrieved, referring on a vast range of surgical operations. The mean cost for robotic, open and laparoscopic ranged from 2539 to 57,002, 7888 to 16,851 and 1799 to 50,408 Euros, respectively. The mean operative charges ranged from 273.74 to 13,670 Euros. More specifically, for the robotic and laparoscopic gastric fundoplication, the cost ranged from 1534 to 2257 and 657 to 763 Euros, respectively. For the robotic and laparoscopic colectomy, it ranged from 3739 to 17,080 and 3109 to 33,865 Euros, respectively. For the robotic and laparoscopic cholecystectomy, ranged from 1163.75 to 1291 and from 273.74 to 1223 Euros, respectively. The mean non-operative costs ranged from 900 to 48,796 from 8347 to 8800 and from 870 to 42,055 Euros, for robotic, open and laparoscopic technique, respectively. Conversions to laparotomy were present in 34/18,620 (0.18%) cases of laparoscopic and in 22/1488 (1.5%) cases of robotic technique. Duration of surgery robotic, open and laparoscopic ranged from 54.6 to 328.7, 129 to 234, and from 50.2 to 260 min, respectively. The present evidence reveals that robotic surgery, under specific conditions, has the potential to become cost-effective. Large number of cases, presence of industry competition and multidisciplinary team utilisation are some of the factors that could make more reasonable and cost-effective the robotic-assisted technique.
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Affiliation(s)
- Ioannis D Gkegkes
- Department of Surgery, General Hospital of Attica "KAT", Athens, Greece
| | - Ioannis A Mamais
- Department of Medicine, Medical School of Athens, University of Athens, Athens, Greece
| | - Christos Iavazzo
- Department of Gynaecological Oncology, Christie Hospital, Manchester, United Kingdom
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Frosini F, Miniati R, Grillone S, Dori F, Gentili GB, Belardinelli A. Integrated HTA-FMEA/FMECA methodology for the evaluation of robotic system in urology and general surgery. Technol Health Care 2016; 24:873-887. [DOI: 10.3233/thc-161236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Francesco Frosini
- Department of Information Engineering, School of Engineering, University of Florence, Florence, Italy
| | - Roberto Miniati
- Department of Information Engineering, School of Engineering, University of Florence, Florence, Italy
| | - Saverio Grillone
- Department of Information Engineering, School of Engineering, University of Florence, Florence, Italy
| | - Fabrizio Dori
- Department of Information Engineering, School of Engineering, University of Florence, Florence, Italy
| | - Guido Biffi Gentili
- Department of Information Engineering, School of Engineering, University of Florence, Florence, Italy
| | - Andrea Belardinelli
- Innovation and Planning Area, Head Management, Florence Teaching Hospital AOU-Careggi, Florence, Italy
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Bhatia P, Bindal V, Singh R, Gonzalez-Heredia R, Kalhan S, Khetan M, John S. Robot-assisted sleeve gastrectomy in morbidly obese versus super obese patients. JSLS 2016; 18:JSLS-D-14-00099. [PMID: 25392663 PMCID: PMC4208899 DOI: 10.4293/jsls.2014.00099] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background and Objectives: This study evaluates our technique for robot-assisted sleeve gastrectomy for morbidly obese and super obese patients and our outcomes. Methods: A retrospective analysis of patients who underwent robot-assisted sleeve gastrectomy at a single center was performed. The procedure was performed with the da Vinci Si HD Surgical System (Intuitive Surgical, Sunnyvale, California). The staple line was imbricated with No. 2-0 polydioxanone in all cases. The super obese (body mass index ≥50 kg/m2) subset of patients was compared with the morbidly obese group in terms of demographic characteristics, comorbidities, operative times, perioperative complications, and excess body weight loss. Results: A total of 35 patients (15 female and 20 male patients) with a mean body mass index of 48.17 ± 11.7 kg/m2 underwent robot-assisted sleeve gastrectomy. Of these patients, 11 were super obese and 24 were morbidly obese. The mean operative time was 116.3 ± 24.7 minutes, and the mean docking time was 8.9 ± 5.4 minutes. Mean blood loss was 19.36 ± 4.62 mL, and there were no complications, conversions, or perioperative deaths. When compared with the morbidly obese patients, the super obese patients showed no significant difference in operative time, blood loss, and length of hospital stay. There was a steep decline in operating room times after 10 cases of robot-assisted sleeve gastrectomy. Conclusion: This study shows the feasibility and safety of robot-assisted sleeve gastrectomy. Robotic assistance might help overcome the operative difficulties encountered in super obese patients. It shows a rapid reduction in operative times with the growing experience of the entire operative team. Robot-assisted sleeve gastrectomy can be a good procedure by which to introduce robotics in a bariatric surgery center before going on to perform Roux-en-Y gastric bypass and revision procedures.
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Affiliation(s)
- Parveen Bhatia
- Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Vivek Bindal
- Division of General, Minimally Invasive & Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Rahul Singh
- Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Raquel Gonzalez-Heredia
- Division of General, Minimally Invasive & Robotic Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sudhir Kalhan
- Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Mukund Khetan
- Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Suviraj John
- Institute of Minimal Access, Metabolic & Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Tan A, Ashrafian H, Scott AJ, Mason SE, Harling L, Athanasiou T, Darzi A. Robotic surgery: disruptive innovation or unfulfilled promise? A systematic review and meta-analysis of the first 30 years. Surg Endosc 2016; 30:4330-52. [PMID: 26895896 PMCID: PMC5009165 DOI: 10.1007/s00464-016-4752-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/11/2016] [Indexed: 12/14/2022]
Abstract
Background Robotic surgery has been in existence for 30 years. This study aimed to evaluate the overall perioperative outcomes of robotic surgery compared with open surgery (OS) and conventional minimally invasive surgery (MIS) across various surgical procedures. Methods MEDLINE, EMBASE, PsycINFO, and ClinicalTrials.gov were searched from 1990 up to October 2013 with no language restriction. Relevant review articles were hand-searched for remaining studies. Randomised controlled trials (RCTs) and prospective comparative studies (PROs) on perioperative outcomes, regardless of patient age and sex, were included. Primary outcomes were blood loss, blood transfusion rate, operative time, length of hospital stay, and 30-day overall complication rate. Results We identified 99 relevant articles (108 studies, 14,448 patients). For robotic versus OS, 50 studies (11 RCTs, 39 PROs) demonstrated reduction in blood loss [ratio of means (RoM) 0.505, 95 % confidence interval (CI) 0.408–0.602], transfusion rate [risk ratio (RR) 0.272, 95 % CI 0.165–0.449], length of hospital stay (RoM 0.695, 0.615–0.774), and 30-day overall complication rate (RR 0.637, 0.483–0.838) in favour of robotic surgery. For robotic versus MIS, 58 studies (21 RCTs, 37 PROs) demonstrated reduced blood loss (RoM 0.853, 0.736–0.969) and transfusion rate (RR 0.621, 0.390–0.988) in favour of robotic surgery but similar length of hospital stay (RoM 0.982, 0.936–1.027) and 30-day overall complication rate (RR 0.988, 0.822–1.188). In both comparisons, robotic surgery prolonged operative time (OS: RoM 1.073, 1.022–1.124; MIS: RoM 1.135, 1.096–1.173). The benefits of robotic surgery lacked robustness on RCT-sensitivity analyses. However, many studies, including the relatively few available RCTs, suffered from high risk of bias and inadequate statistical power. Conclusions Our results showed that robotic surgery contributed positively to some perioperative outcomes but longer operative times remained a shortcoming. Better quality evidence is needed to guide surgical decision making regarding the precise clinical targets of this innovation in the next generation of its use.
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Affiliation(s)
- Alan Tan
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
| | - Hutan Ashrafian
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK.
| | - Alasdair J Scott
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
| | - Sam E Mason
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
| | - Leanne Harling
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary's Hospital, London, W2 1NY, UK
- Institute of Global Health Innovation, Imperial College London, London, SW7 2NA, UK
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Enayati N, De Momi E, Ferrigno G. Haptics in Robot-Assisted Surgery: Challenges and Benefits. IEEE Rev Biomed Eng 2016; 9:49-65. [DOI: 10.1109/rbme.2016.2538080] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kassahun Y, Yu B, Tibebu AT, Stoyanov D, Giannarou S, Metzen JH, Vander Poorten E. Surgical robotics beyond enhanced dexterity instrumentation: a survey of machine learning techniques and their role in intelligent and autonomous surgical actions. Int J Comput Assist Radiol Surg 2015; 11:553-68. [PMID: 26450107 DOI: 10.1007/s11548-015-1305-z] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 09/21/2015] [Indexed: 02/06/2023]
Abstract
PURPOSE Advances in technology and computing play an increasingly important role in the evolution of modern surgical techniques and paradigms. This article reviews the current role of machine learning (ML) techniques in the context of surgery with a focus on surgical robotics (SR). Also, we provide a perspective on the future possibilities for enhancing the effectiveness of procedures by integrating ML in the operating room. METHODS The review is focused on ML techniques directly applied to surgery, surgical robotics, surgical training and assessment. The widespread use of ML methods in diagnosis and medical image computing is beyond the scope of the review. Searches were performed on PubMed and IEEE Explore using combinations of keywords: ML, surgery, robotics, surgical and medical robotics, skill learning, skill analysis and learning to perceive. RESULTS Studies making use of ML methods in the context of surgery are increasingly being reported. In particular, there is an increasing interest in using ML for developing tools to understand and model surgical skill and competence or to extract surgical workflow. Many researchers begin to integrate this understanding into the control of recent surgical robots and devices. CONCLUSION ML is an expanding field. It is popular as it allows efficient processing of vast amounts of data for interpreting and real-time decision making. Already widely used in imaging and diagnosis, it is believed that ML will also play an important role in surgery and interventional treatments. In particular, ML could become a game changer into the conception of cognitive surgical robots. Such robots endowed with cognitive skills would assist the surgical team also on a cognitive level, such as possibly lowering the mental load of the team. For example, ML could help extracting surgical skill, learned through demonstration by human experts, and could transfer this to robotic skills. Such intelligent surgical assistance would significantly surpass the state of the art in surgical robotics. Current devices possess no intelligence whatsoever and are merely advanced and expensive instruments.
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Affiliation(s)
- Yohannes Kassahun
- Robotics Innovation Center, German Research Center for Artificial Intelligence, Robert-Hooke-Str. 1, 28359, Bremen, Germany.
| | - Bingbin Yu
- Faculty 3 - Mathematics and Computer Science, University of Bremen, Robert-Hooke-Str. 1, 28359, Bremen, Germany
| | - Abraham Temesgen Tibebu
- Faculty 3 - Mathematics and Computer Science, University of Bremen, Robert-Hooke-Str. 1, 28359, Bremen, Germany
| | - Danail Stoyanov
- Centre for Medical Image Computing, Department of Computer Science, University College London, London, UK
| | | | - Jan Hendrik Metzen
- Faculty 3 - Mathematics and Computer Science, University of Bremen, Robert-Hooke-Str. 1, 28359, Bremen, Germany
| | - Emmanuel Vander Poorten
- Department of Mechanical Engineering, University of Leuven, Celestijnenlaan 300B, 3001, Heverlee, Belgium
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SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA). Surg Endosc 2015. [PMID: 26205559 DOI: 10.1007/s00464-015-4428-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted. METHODS The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval. RESULTS Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy. CONCLUSIONS Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.
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Tolboom R, Broeders I, Draaisma W. Robot-assisted laparoscopic hiatal hernia and antireflux surgery. J Surg Oncol 2015; 112:266-70. [DOI: 10.1002/jso.23912] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 03/08/2015] [Indexed: 12/22/2022]
Affiliation(s)
- R.C. Tolboom
- Meander Medical Centre; Department of Surgery; Amersfoort The Netherlands
- University of Twente; Robotics and Minimal Invasive Surgery; Enschede The Netherlands
| | - I.A.M.J. Broeders
- Meander Medical Centre; Department of Surgery; Amersfoort The Netherlands
- University of Twente; Robotics and Minimal Invasive Surgery; Enschede The Netherlands
| | - W.A. Draaisma
- Meander Medical Centre; Department of Surgery; Amersfoort The Netherlands
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Lu WS, Xu WY, Pan F, Liu D, Tian ZM, Zeng Y. Clinical application of a vascular interventional robot in cerebral angiography. Int J Med Robot 2015; 12:132-6. [PMID: 25782077 DOI: 10.1002/rcs.1650] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 01/31/2015] [Accepted: 02/10/2015] [Indexed: 01/14/2023]
Affiliation(s)
- Wang-sheng Lu
- Department of Neurosurgery; Navy General Hospital of PLA; 6 Fucheng, Road Beijing 100048 China
| | - Wu-yi Xu
- Department of Neurosurgery; Navy General Hospital of PLA; 6 Fucheng, Road Beijing 100048 China
| | - Feng Pan
- Department of Neurosurgery; The First People's Hospital of Tancheng; Shandong 276199 China
| | - Da Liu
- Robotics Institute; Beijing University of Aeronautics and Astronautics; Beijing 100022 China
| | - Zeng-min Tian
- Department of Neurosurgery; Navy General Hospital of PLA; 6 Fucheng, Road Beijing 100048 China
| | - Yanjun Zeng
- Beijing University of Technology; 100 Pingleyuan, Chaoyang District Beijing 100022 China
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Robotic general surgery: current practice, evidence, and perspective. Langenbecks Arch Surg 2015; 400:283-92. [PMID: 25854502 DOI: 10.1007/s00423-015-1278-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 01/27/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Robotic technology commenced to be adopted for the field of general surgery in the 1990s. Since then, the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, CA, USA) has remained by far the most commonly used system in this domain. The da Vinci surgical system is a master-slave machine that offers three-dimensional vision, articulated instruments with seven degrees of freedom, and additional software features such as motion scaling and tremor filtration. The specific design allows hand-eye alignment with intuitive control of the minimally invasive instruments. As such, robotic surgery appears technologically superior when compared with laparoscopy by overcoming some of the technical limitations that are imposed on the surgeon by the conventional approach. PURPOSE This article reviews the current literature and the perspective of robotic general surgery. CONCLUSIONS While robotics has been applied to a wide range of general surgery procedures, its precise role in this field remains a subject of further research. Until now, only limited clinical evidence that could establish the use of robotics as the gold standard for procedures of general surgery has been created. While surgical robotics is still in its infancy with multiple novel systems currently under development and clinical trials in progress, the opportunities for this technology appear endless, and robotics should have a lasting impact to the field of general surgery.
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Bindal V, Bhatia P, Dudeja U, Kalhan S, Khetan M, John S, Wadhera S. Review of contemporary role of robotics in bariatric surgery. J Minim Access Surg 2015; 11:16-21. [PMID: 25598594 PMCID: PMC4290112 DOI: 10.4103/0972-9941.147673] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 01/07/2023] Open
Abstract
With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery.
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Affiliation(s)
- Vivek Bindal
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Parveen Bhatia
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Usha Dudeja
- Department of Biochemistry, University College of Medical Sciences, New Delhi, India
| | - Sudhir Kalhan
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Mukund Khetan
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Suviraj John
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sushant Wadhera
- Institute of Minimal Access, Metabolic and Bariatric Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Technique Evolution, Learning Curve, and Outcomes of 200 Robot-Assisted Gastric Bypass Procedures: a 5-Year Experience. Obes Surg 2014; 25:997-1002. [DOI: 10.1007/s11695-014-1502-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Szold A, Bergamaschi R, Broeders I, Dankelman J, Forgione A, Langø T, Melzer A, Mintz Y, Morales-Conde S, Rhodes M, Satava R, Tang CN, Vilallonga R. European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery. Surg Endosc 2014; 29:253-88. [PMID: 25380708 DOI: 10.1007/s00464-014-3916-9] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/19/2014] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Amir Szold
- Technology Committee, EAES, Assia Medical Group, P.O. Box 58048, Tel Aviv, 61580, Israel,
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Ismail I, Wolff S, Gronfier A, Mutter D, Swanström LL. A cost evaluation methodology for surgical technologies. Surg Endosc 2014; 29:2423-32. [PMID: 25318371 DOI: 10.1007/s00464-014-3929-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 09/27/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To create and validate a micro-costing methodology that surgeons and hospital administrators can use to evaluate the cost of implementing innovative surgical technologies. METHODS Our analysis is broken down into several elements of fixed and variable costs which are used to effectively and easily calculate the cost of surgical operations. As an example of application, we use data from 86 robot assisted gastric bypass operations made in our hospital. To validate our methodology, we discuss the cost reporting approaches used in 16 surgical publications with respect to 7 predefined criteria. RESULTS Four formulas are created which allow users to import data from their health system or particular situation and derive the total cost. We have established that the robotic surgical system represents 97.53 % of our operating room's medical device costs which amounts to $4320.11. With a mean surgery time of 303 min, personnel cost per operation amounts to $1244.73, whereas reusable instruments and disposable costs are, respectively, $1539.69 and $3629.55 per case. The literature survey demonstrates that the cost of surgery is rarely reported or emphasized, and authors who do cover this concept do so with variable methodologies which make their findings difficult to interpret. CONCLUSION Using a micro-costing methodology, it is possible to identify the cost of any new surgical procedure/technology using formulas that can be adapted to a variety of operations and healthcare systems. We hope that this paper will provide guidance for decision makers and a means for surgeons to harmonise cost reporting in the literature.
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Affiliation(s)
- Imad Ismail
- University of Strasbourg, BETA, Strasbourg Cedex, France,
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Elayaperumal S, Bae JH, Daniel BL, Cutkosky MR. Detection of Membrane Puncture with Haptic Feedback using a Tip-Force Sensing Needle. PROCEEDINGS OF THE ... IEEE/RSJ INTERNATIONAL CONFERENCE ON INTELLIGENT ROBOTS AND SYSTEMS. IEEE/RSJ INTERNATIONAL CONFERENCE ON INTELLIGENT ROBOTS AND SYSTEMS 2014; 2014:3975-3981. [PMID: 26509101 DOI: 10.1109/iros.2014.6943121] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This paper presents calibration and user test results of a 3-D tip-force sensing needle with haptic feedback. The needle is a modified MRI-compatible biopsy needle with embedded fiber Bragg grating (FBG) sensors for strain detection. After calibration, the needle is interrogated at 2 kHz, and dynamic forces are displayed remotely with a voice coil actuator. The needle is tested in a single-axis master/slave system, with the voice coil haptic display at the master, and the needle at the slave end. Tissue phantoms with embedded membranes were used to determine the ability of the tip-force sensors to provide real-time haptic feedback as compared to external sensors at the needle base during needle insertion via the master/slave system. Subjects were able to determine the position of the embedded membranes with significantly better accuracy using FBG tip feedback than with base feedback using a commercial force/torque sensor (p = 0.045) or with no added haptic feedback (p = 0.0024).
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Affiliation(s)
- Santhi Elayaperumal
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305
| | - Jung Hwa Bae
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305
| | - Bruce L Daniel
- Department of Radiology, Stanford University, Stanford, CA 94305
| | - Mark R Cutkosky
- Department of Mechanical Engineering, Stanford University, Stanford, CA 94305
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Falkenback D, Lehane CW, Lord RVN. Robot-assisted oesophageal and gastric surgery for benign disease: antireflux operations and Heller's myotomy. ANZ J Surg 2014; 85:113-20. [PMID: 25039924 DOI: 10.1111/ans.12731] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2014] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Dan Falkenback
- Department of Surgery, St Vincent's Hospital, University of Notre Dame Medical School, Sydney, New South Wales, Australia; Department of Surgery, Lund University and Lund University Hospital (Skane University Hospital), Lund, Sweden
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Abstract
The overall advantages of thoracoscopy over thoracotomy in terms of patient recovery have been fairly well established. The use of robotics, however, is a newer and less proven modality in the realm of thoracic surgery. Robotics offers distinct advantages and disadvantages in comparison with video-assisted thoracoscopic surgery. Robotic technology is now used for a variety of complex cardiac, urologic, and gynecologic procedures including mitral valve repair and microsurgical treatment of male infertility. This article addresses the potential benefits and limitations of using the robotic platform for the performance of a variety of thoracic operations.
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Robotic Nissen fundoplication for gastroesophageal reflux disease: a meta-analysis of prospective randomized controlled trials. Surg Today 2014; 44:1415-23. [PMID: 24909497 DOI: 10.1007/s00595-014-0948-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/13/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE Since its introduction, the Da Vinci surgical system for the treatment of gastroesophageal reflux disease (GERD) has been the subject of much controversy. Several prospective randomized controlled trials, conducted to assess its effectiveness and safety, have revealed differences. We performed this meta-analysis to evaluate the efficiency and safety of robotic Nissen fundoplication for GERD. METHODS We performed a comprehensive search of PubMed, Embase, and OVID-MEDLINE, from 1950 to the present, with daily updates generated by a computer, to identify all published papers on robotic Nissen fundoplication for the treatment of GERD. The meta-analysis was performed by Review Manager Version 5.0. Differences of the overall effect were considered significant at P < 0.05 with a 95 % confidence interval (95 % CI). RESULTS Five studies with a collective total of 160 patients were included. Apart from intra-operative and post-operative complications, which were excluded because of incomplete primary data, there were no significant differences in outcomes, including of total operation interval (P = 0.16), effective operation interval (P = 0.95), post-operative dysphagia (P = 0.94), intra-operative conversion (P = 0.94), re-operation (P = 0.43), hospital stay (P = 0.97) and in-hospital costs (P = 0.08). CONCLUSIONS As current data do not clarify the advantages of the Da Vinci surgical system in Nissen fundoplication for GERD, we believe that a large a multi-center controlled trial is warranted.
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Abstract
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.
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Affiliation(s)
- Se-Jin Baek
- Department of Surgery; Yonsei University College of Medicine; Seoul South Korea
| | - Seon-Hahn Kim
- Department of Surgery; Korea University College of Medicine; Seoul South Korea
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Huerta-Iga F, Tamayo-de la Cuesta JL, Noble-Lugo A, Hernández-Guerrero A, Torres-Villalobos G, Ramos-de la Medina A, Pantoja-Millán JP. [The Mexican consensus on gastroesophageal reflux disease. Part II]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:231-9. [PMID: 24290724 DOI: 10.1016/j.rgmx.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/14/2013] [Accepted: 05/27/2013] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To update the themes of endoscopic and surgical treatment of Gastroesophageal Reflux Disease (GERD) from the Mexican Consensus published in 2002. METHODS Part I of the 2011 Consensus dealt with the general concepts, diagnosis, and medical treatment of this disease. Part II covers the topics of the endoscopic and surgical treatment of GERD. In this second part, an expert in endoscopy and an expert in GERD surgery, along with the three general coordinators of the consensus, carried out an extensive bibliographic review using the Embase, Cochrane, and Medline databases. Statements referring to the main aspects of endoscopic and surgical treatment of this disease were elaborated and submitted to specialists for their consideration and vote, utilizing the modified Delphi method. The statements were accepted into the consensus if the level of agreement was 67% or higher. RESULTS Twenty-five statements corresponding to the endoscopic and surgical treatment of GERD resulted from the voting process, and they are presented herein as Part II of the consensus. The majority of the statements had an average level of agreement approaching 90%. CONCLUSION Currently, endoscopic treatment of GERD should not be regarded as an option, given that the clinical results at 3 and 5 years have not demonstrated durability or sustained symptom remission. The surgical indications for GERD are well established; only those patients meeting the full criteria should be candidates and their surgery should be performed by experts.
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Affiliation(s)
- F Huerta-Iga
- Encargado del Servicio de Endoscopia, Hospital Ángeles Torreón, Coahuila, México.
| | | | - A Noble-Lugo
- Departamento de Enseñanza, Hospital Español de México, México D.F., México
| | - A Hernández-Guerrero
- Jefe del Servicio de Endoscopia, Instituto Nacional de Cancerología, México D.F., México
| | - G Torres-Villalobos
- Servicio de Cirugía, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, México D.F., México
| | | | - J P Pantoja-Millán
- Cirugía del Aparato Digestivo, Hospital Ángeles del Pedregal, México D.F., México
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Huerta-Iga F, Tamayo-de la Cuesta J, Noble-Lugo A, Hernández-Guerrero A, Torres-Villalobos G, Ramos-de la Medina A, Pantoja-Millán J. The Mexican consensus on gastroesophageal reflux disease. Part II. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2013. [DOI: 10.1016/j.rgmxen.2014.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Abstract
Rudolph Nissen firstly implemented the idea of surgical treatment of gastroesophageal reflux more than 55 years ago. Today, laparoscopic fundoplication has become the surgical "golden standard" for the treatment of GERD. However, the initial enthusiasm and increasing number of performed procedures in the early 1990s declined dramatically between 2000 and 2006. Despite its excellent outcome, laparoscopic fundoplication is only offered to a minority of patients who are suffering from GERD. In this article we review the current indications for antireflux surgery, technical and intraoperative aspects of fundoplication, perioperative complications as well as short and long-term outcome. The focus is on the laparoscopic approach as the current surgical procedure of choice.
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Affiliation(s)
- Stefan Niebisch
- Department of Surgery, University of Rochester Medical Center, Rochester, NY 14642, USA.
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Robotic Applications in the Treatment of Diseases of the Esophagus. Surg Laparosc Endosc Percutan Tech 2012; 22:304-9. [DOI: 10.1097/sle.0b013e318258340a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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[Robot technology in the Italian Health-CARE system: cost-efficacy economic analysis]. Urologia 2012; 79:69-80. [PMID: 22388991 DOI: 10.5301/ru.2012.9098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND Robotic technology is used in multiple fields of surgery, especially radical prostatectomy in patients with prostate cancer. The purpose of this study was to evaluate the introduction of robotic technology in the Italian Public Heath-care context, from the perspective of the Health Technology Assessment (HTA). An economic analysis that compares the costs and effectiveness of the method was developed. Data were compared with those of the most important international literature, analyzing structural and organizational problems related to the method. MATERIALS AND METHODS A systematic review of literature on tertiary literature (Health Technology Assessment reports) and secondary (systematic reviews) published since 2002 was conducted. The review was also conducted on more recent primary literature regarding the clinical effectiveness and the economic analysis in the fields of surgery where Da Vinci robot is most promising. RESULTS 18 studies were selected out of a total of 65 evaluated. The "Break-Even Point" (BEP) is the minimum number of cases needed to be treated in order to achieve a balance between costs and revenues, below which the system is losing money. It was calculated that the total fixed costs are € 378,000 and variable costs are € 3,810 per surgery. Considering that the current value of DRG (Diagnosis-Related Group) refunded by the public Health-care system is actually € 4,553, the BEP would be achieved performing 508 surgeries, so that the robotic technology does not generate neither profit nor loss. CONCLUSIONS It is not possible to demonstrate the superiority of robotic surgery in terms of efficacy. The robotic surgery is safe and effective only if performed by surgical teams with relevant experience. Considering the reported case of an Italian University Hospital with public Health-care system refund, the BEP target of 508 radical prostatectomies could be achieved after a few years. The use of the robot in multiple fields on one hand shortens recovery time costs, but on the other hand increases costs due to organizational issues. The value of the DRG refund does not appear adequate to new robotic technology.
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Wang Z, Zheng Q, Jin Z. Meta-analysis of robot-assisted versus conventional laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease. ANZ J Surg 2012; 82:112-7. [PMID: 22510118 DOI: 10.1111/j.1445-2197.2011.05964.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Conventional laparoscopic Nissen fundoplication (CLF) is generally considered the surgical approach of choice for gastro-oesophageal reflux disease. Robotic-assisted laparoscopic fundoplication (RALF) has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance by eliminating tremors and fatigue. A meta-analysis of randomized clinical trials (RCTs) was performed to compare RALF and CLF. METHODS Medline, Embase, ISI Web of Knowledge CPCI-S and The Cochrane Library were searched and the methodological quality of included trials was evaluated. Outcomes evaluated were intraoperative, dysphagia, flatulence, antisecretory medication, satisfaction with intervention, operation time, hospital stay and total cost. Results were pooled in meta-analyses as risk ratios and weighted mean differences (WMD). RESULTS Of 221 patients in six RCTs, 111 were allocated to CLF and 110 to RALF. RALF prolonged total time necessary to carry out fundoplication (WMD 3.17 (95% confidence interval. 2.33-4.00) min; P < 0.00001, χ(2) P = 0.25, I(2) = 24%). Operation complication, antisecretory medication, satisfaction with intervention, the time needed for hiatal dissection, the time from incision to completion of sutures, the total operation time and total cost were similar in both groups. CONCLUSION Clinical outcomes from RALF were comparable to CLF approach, but RALF prolonged the operation time. Currently, CLF should be routinely used as costs are lower.
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Affiliation(s)
- Zhanhui Wang
- Shanghai Jiaotong University Affiliated Sixth People's Hospital, China
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Dennis T, de Mendonça C, Phalippou J, Collinet P, Boulanger L, Weingertner F, Leblanc E, Narducci F. [Study of surplus cost of robotic assistance for radical hysterectomy, versus laparotomy and standard laparoscopy]. ACTA ACUST UNITED AC 2012; 40:77-83. [PMID: 22252053 DOI: 10.1016/j.gyobfe.2011.09.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Accepted: 09/02/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The study purpose was to compare the costs among robotic, laparoscopic and open radical hysterectomy for cervical cancer. PATIENTS AND METHODS Thirty-seven patients underwent robotic radical hysterectomy for cervical cancer. Cases were performed by three surgeons, at two institutions, and were retrospectively reviewed to perform a cost comparison between all three modalities. We included costs for edible materials in anesthesia and surgery, but costs for staff and indirect financial expenses were excluded. Those data are compared to open and laparoscopic radical hysterectomy data. RESULTS The average cost for robotic assistance presented a surplus of 1796 euros compare to laparotomy and 1313 euros compare to standard laparoscopy in 2008, and 1320 and 837 euros respectively. DISCUSSION AND CONCLUSION The average cost for radical hysterectomy was highest for robotic, followed by standard laparoscopy, and least for laparotomy. However, over only 2 years of use, this difference tends to decrease. Medico-economic impact is the main restraint for robotic assistance development, and needs to be assessed permanently.
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Affiliation(s)
- T Dennis
- Clinique de gynécologie, hôpital Jeanne-de-Flandre, centre hospitalier régional et universitaire (CHRU) de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France.
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Huettner F, Alley RA, Doubet JL, Ryan MJ, Dynda DI, Crawford DL. Robotic Foregut Surgery: One Surgeon’s Experience with Nissen Fundoplication, Esophagomyotomy, and Hiatal Hernia Repair. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ss.2012.31001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
The first laparoscopic Nissen fundoplication was performed 20 years ago. Surgical management of gastroesophageal reflux disease (GERD) should be offered only to appropriately studied and selected patients, with the ultimate aim of improving the well-being of the individual, the "quality of life." The choice of fundoplication should be dictated by the surgeon's preference and experience.
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Affiliation(s)
- Bernard Dallemagne
- Department of Digestive and Endocrine Surgery, and Institut de Recherche contre les Cancers de l'Appareil Digestif (IRCAD), University Hospital of Strasbourg, IRCAD-EITS, 1 Place de l'Hôpital, 67091, Strasbourg, France.
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