A performance study comparing manual and robotically assisted laparoscopic surgery using the da Vinci system

The Role and Future of Artificial Intelligence in Robotic Image-Guided Interventions

Artificial intelligence and robotics are transforming interventional radiology, driven by advancements in computer vision, robotics and procedural automation. Historically focused on diagnostics, AI now also enhances procedural capabilities in IR, enabling future robotic systems to handle complex tasks such as catheter manipulation or needle placement with increasing precision and reliability. Early robotic systems in IR demonstrated improved accuracy in both vascular and percutaneous interventions, though none were equipped with automatic decision-making. This review tends to show the potential in improving procedural outcomes with AI for robotics, though challenges remain. Techniques like reinforcement learning and haptic vision are under investigation to address several issues, training robots to adapt based on real-time feedback from the environment. As AI-driven robotics evolve, IR could shift towards a model where human expertise oversees the technology rather than performs the intervention itself.

Robotic-assisted unicompartmental knee arthroplasty: historical perspectives and current innovations

Robotic assisted unicompartmental knee arthroplasty (RAUKA) has emerged as a successful approach for optimizing implant positioning accuracy, minimizing soft tissue injury, and improving patient-reported outcomes. The application of RAUKA is expected to increase because of its advantages over conventional unicompartmental knee arthroplasty. This review article provides an overview of RAUKA, encompassing the historical development of the procedure, the features of the robotic arm and navigation systems, and the characteristics of contemporary RAUKA. The article also includes a comparison between conventional unicompartmental arthroplasty and RAUKA, as well as a discussion of current challenges and future advancements in the field of RAUKA.

3D Da Vinci robotic surgery: is it a risk to the surgeon's eye health?

Da Vinci three-dimensional (3D) system has been increasingly used in customary surgical settings, gaining fundamental relevance for abdominal, urological, and gynecological laparoscopic surgery. The aim of this research is to evaluate the degree of discomfort and potential changes in the binocular vision and ocular motility of surgical operators, who employ 3D vision systems during Da Vinci robotic surgery. Twenty-four surgeons were enrolled in the study, including twelve who typically use the 3D Da Vinci system and twelve who routinely employ 2D system. Routine general ophthalmological and orthoptic examinations were conducted at baseline (T0), the day before surgery, and 30 min after the 3D or 2D surgery (T1). In addition, surgeons were interviewed using a questionnaire of 18 symptoms, with each item containing three questions regarding the frequency, severity, and bothersomeness of the symptoms, in order to evaluate the degree of discomfort. Mean age at evaluation was 45.28 ± 8.71 years (range 33-63 years). Cover test, uncover test, and fusional amplitude showed no statistically significant difference. After surgery, no statistical difference was observed in the Da Vinci group on the TNO stereotest (p > 0.9999). However, the difference in the 2D group resulted statistically significant (p = 0.0156). Comparing participants (p 0.0001) and time (T0-T1; p = 0.0137), the difference between the two groups was statistically significant. Surgeons using 2D systems reported more discomfort than those using 3D systems. The absence of short-term consequences following surgery with the Da Vinci 3D system is a promising conclusion, considering the numerous advantages of this technology. Nonetheless, multicenter investigations and more studies are required to verify and interpret our findings.

Robotic-assisted surgery in the pediatric surgeons' world: Current situation and future prospectives

Robotic-assisted surgery has been fully embraced by surgeons for the adult population; however, its acceptance is too slow in the world of pediatric surgeons. It is largely due to the technical limitations and the inherent high cost associated with it. In the past two decades, indeed, there has been considerable advancement in pediatric robotic surgery. A large number of surgical procedures were performed on children with the assistance of robots, even with comparative success rates to standard laparoscopy. As a newly developing field, it still has many challenges and obstacles. This work is centered on the current status and progression of pediatric robotic surgery as well as the future perspectives in the field of pediatric surgery.

Patient-Related Functional Outcomes After Robotic-Assisted Rectal Surgery Compared With a Laparoscopic Approach: A Systematic Review and Meta-analysis

BACKGROUND

Robotic surgery has gained significant momentum in rectal cancer surgery. Most studies focus on short-term and oncological outcomes, showing similar outcomes to laparoscopic surgery. Increasing survivorship mandates greater emphasis on quality of life and long-term function.

OBJECTIVE

This study aimed to compare quality of life and urinary, sexual, and lower GI functions between robotic and laparoscopic rectal surgeries.

DATA SOURCES

A systematic search of Medline, PubMed, Embase, Clinical Trials Register, and Cochrane Library-identified articles comparing robotic with laparoscopic rectal resections was performed.

MAIN OUTCOME MEASURES

The outcome measures were quality of life and urinary, sexual, and GI functions between robotic and laparoscopic rectal resection patient groups. Where comparable data were available, results were pooled for analysis.

RESULTS

The initial search revealed 1777 papers; 101 were reviewed in full, and 14 studies were included for review. Eleven assessed male sexual function; 7 favored robotic surgery, and the remaining studies showed no significant difference. Pooled analysis of 5 studies reporting rates of male sexual dysfunction at 12 months showed significantly lower rates after robotic surgery (OR, 0.51; p = 0.043). Twelve studies compared urinary function. Six favored robotic surgery, but in 2 studies, a difference was seen at 6 months but not sustained at 12 months. Pooled analysis of 4 studies demonstrated significantly better urinary function scores at 12 months after robotic surgery (OR, 0.26; p = 0.016). Quality of life and GI function were equivalent, but very little data exist for these parameters.

LIMITATIONS

A small number of studies compare outcomes between these groups; only 2 are randomized. Different scoring systems limit comparisons and pooling of data.

CONCLUSIONS

The limited available data suggest that robotic rectal cancer resection improves male sexual and urinary functions when compared with laparoscopy, but there is no difference in quality of life or GI function. Future studies should report all facets of functional outcomes using standardized scoring systems.

Rise of pediatric robotic surgery in Italy: a multicenter observational retrospective study

Background

The minimally invasive surgery (MIS) in term of robot-assisted surgery changed in a dramatic way the surgical approach either in adults or children. For many specialties (urology, gynecology, general surgery) robotic surgery rapidly became the gold standard for some procedures, while the experience in pediatric population is not wide for some reasons. The aim of this study is to retrospective analyze trends of application of robotic surgery in pediatric patients across the country, focusing on indications, limitations, development, and training acquired by national experience and in comparison to the literature.

Methods

We made a retrospective multicenter study on behalf of Italian Society of Pediatric Surgery. We performed a census among all pediatric surgery units in the country to enroll those performing robotic surgery on children between 2013 and 2019.

Results

We enrolled 7 pediatric surgery referral Centers (Ancona, Bologna, Brescia, Genova, Pavia, Pescara, Siena). A total of 303 patients were included in the study, 164 males (54%) and 139 females (46%). The most commonly performed interventions for each anatomic area were respectively atypical pulmonary resection (38%), pyeloplasty (49%), and fundoplication (30%).

Conclusions

Since its first application in Italy, about 10 years ago, several considerations were made about application and feasibility of robotics in children.

The learning curve in robotic colorectal surgery compared with laparoscopic colorectal surgery: a systematic review

AIM

The learning curve has implications for efficient surgical training. Robotic surgery is perceived to have a shorter learning curve than laparoscopy; however, detailed analysis is lacking. The aim of this work was to analyse studies comparing robotic and laparoscopic colorectal learning curves. Simulation studies comparing novices' learning curves were analysed in order to surmise applicability to colorectal surgery.

METHOD

A systematic search of Medline, PubMed, Embase and the Cochrane Library identified colorectal papers (from 1 January 2000 to 3 March 2021) comparing robotic and laparoscopic learning curves where surgeons lacked laparoscopic colorectal experience. Simulation studies comparing learning curves were also included. The learning curve was defined as the period of ongoing improvement in speed and/or accuracy.

RESULTS

From 576 abstracts reviewed, three operative and 16 simulation studies were included. The robotic learning curve for right colectomy was significantly faster in one study (16 vs. 25 cases) and equal for anterior resection in two studies (44 vs. 41 cases and 55 vs. 55). One study showed fewer complications for robotic patients (14.6% vs. 0%, p = 0.013). Ten simulation studies reported faster times and eight recorded error rates favouring robotic surgery. Seven studies measured the learning curve. Four favoured laparoscopic surgery, but operating times were faster using the robotic platform.

CONCLUSION

Operating times for robotic surgery may be faster than laparoscopy when surgeons are inexperienced with both platforms. This may be related to a superior baseline performance rather than a shorter learning curve. Whether a shorter learning curve on the laparoscopic platform will persist for long enough to enable skills to overtake robotic ability needs further investigation.

Time-Driven activity-based costing identifies opportunities for process efficiency and cost optimization for robot-assisted laparoscopic pyeloplasty

BACKGROUND

Robot-assisted laparoscopic pyeloplasty (RALP) is a commonly performed procedure in children, but its actual cost implications on the healthcare ecosystem have not been adequately defined. Time-driven activity-based costing (TDABC) is a novel cost accounting method derived from value based healthcare systems that may offer one pathway to assess institutional costs.

OBJECTIVE

To determine the true cost of a robot-assisted laparoscopic pyeloplasty (RALP) in the pediatric population using TDABC, and compare it to traditional cost accounting. And to utilize TDABC to minimize cost and improve time-flow efficiency.

SUBJECTS/PATIENTS AND METHODS

The RALP care pathway was defined from patient arrival to the pre-operative suite to discharge from the post-anesthesia care unit (PACU). Process maps were created with an interdisciplinary team to survey RALP activities. Retrospective time stamps were obtained from the electronic medical record for fiscal year 2016 (FY16) RALP cases, and were validated by prospectively stopwatch timing additional RALP cases. Male and female pediatric patients undergoing a unilateral RALP during FY16 and during the prospective study period (June 2017-October 2017) were included. Procedure costs were calculated using TDABC after determining the capacity cost rate for all personnel and assets, and multiplying them with the time stamps.

RESULTS

25 RALP cases were analyzed for FY16. TDABC determined a total cost of $15 319/case, when direct, indirect and capital robot cost are included. Traditional cost accounting amounted to a total of $16 158/case. The current robot utilization rate is 22% of total capacity, effectively increasing the total RALP cost by 16%. Time stamps with the most variance were pre-operative services (115 ± 27.5 min), robotic console (142 min ±30.7 min) and PACU times (145 ± 101.1 min) (Figure) DISCUSSION: This study represents the first TDABC implementation in robot-assisted pediatric procedures. Previous TDABC in other areas of urology similarly revealed discrepancies between traditional cost accounting and TDABC. The present study demonstrates a higher total cost than previous cost accounting studies for the RALP, however, this is the first effort to include indirect costs in the final calculations. This study does convey the limitations of a retrospective analysis and those inherent to a single institution study.

CONCLUSION

TDABC defined the magnitude of cost variation based on robot utilization of a RALP. Traditional cost accounting overestimates the actual costs of a RALP. TDABC also identified high-cost and high variability loci in the RALP process map that will be targeted for process and quality improvement while further reducing assessed costs.

Laparoscopic Versus Robotic-assisted Suturing Performance Among Novice Surgeons: A Blinded, Cross-Over Study

Robotic-assisted laparoscopy (RAL) presents several advantages over 3-dimensional conventional laparoscopy (3D-CL) that may facilitate laparoscopic suturing especially with novice surgeons. This study compares novice surgeons' suturing performance by 3D-CL and RAL using Objective Structured Assessment of Technical Skill (OSATS), an objective, validated scoring tool. Twenty-two surgeons with no robotic experience completed a standardized suturing task in an experimental setup by both 3D-CL and RAL in a randomized, cross-over design. Two experienced surgeons blindly assessed their performance using OSATS. Median (interquartile range) OSATS scores for 3D-CL and RAL were, respectively, 22.8 (17.4 to 25.8) versus 25.0 (21.9 to 26.5), P=0.032. There was no association between laparoscopic experience and robotic-assisted suturing performance. Thus, this study is, to our knowledge, the first to compare novice surgeons' suturing performance by 3D-CL and RAL using an objective, validated scoring tool and to show better suturing performance when assisted by the robot regardless of experience level.

Electrically-Evoked Proximity Sensation Can Enhance Fine Finger Control in Telerobotic Pinch

For teleoperation tasks requiring high control accuracy, it is essential to provide teleoperators with information on the interaction between the end effector and the remote environment. Real-time imaging devices have been widely adopted, but it delivers limited information, especially when the end effectors approach the target following the line-of-sight. In such situations, teleoperators rely on the perspective at the screen and can apply high force unintentionally at the initial contact. This research proposes to deliver the distance information at teleoperation to the fingertips of teleoperators, i.e., proximity sensation. Transcutaneous electrical stimulation was applied onto the fingertips of teleoperators, with the pulsing frequency inversely proportional to the distance. The efficacy of the proximity sensation was evaluated by the initial contact force during telerobotic pinch in three sensory conditions: vision only, vision + visual assistance (distance on the screen), and vision + proximity sensation. The experiments were repeated at two viewing angles: 30–60° and line-of-sight, for eleven healthy human subjects. For both cases, the initial contact force could be significantly reduced by either visual assistance (20–30%) or the proximity sensation (60–70%), without additional processing time. The proximity sensation is two-to-three times more effective than visual assistance regarding the amount of force reduction.

The Financial Burden of Setting up a Pediatric Robotic Surgery Program

Background and Objectives: Robotic surgery is currently at the forefront of both adult and pediatric treatment. The main limit in the wide adoption of this technology is the high cost of purchasing and running the robotic system. This report will focus on the costs assessment of running a robotic program in a pediatric surgery center in Romania. Materials and Methods: In 12 months we performed 40 robot-assisted procedures in children. We recorded and analyzed data regarding their age, gender, pathological condition and comorbidities, surgical procedure, time of surgery, complications, hospital stay and related costs, medication, robotic instruments and consumables, additional cost, and income per case received from the National Insurance Company (NIC). Results: Mean cost per case was €3260.63 (€1880.07 to €9851.78) and was influenced by type of the procedure, intraoperative incidents, postoperative complication, and non-scheduled reinterventions (p < 0.05). The direct costs for operating the surgical robot were relatively constant, regardless of the surgical procedure (mean €1579.81). The reimbursement from the NIC ranged from 5% to 56% (mean 16.9%) of the total cost per case. Conclusion: In Romania, a pediatric surgery robotic program is not cost-efficient and cannot operate relying solely onto the health insurance system.

Impact of laparoscopic experience on virtual robotic simulator dexterity

BACKGROUND:

Different skills are required for robotic surgery and laparoscopic surgery. We hypothesized that the laparoscopic experience would not affect the performance with the da Vinci^® system. A virtual robotic simulator was used to estimate the operator's robotic dexterity.

MATERIALS AND METHODS:

The performance of 11 surgical fellows with laparoscopic experience and 14 medical students were compared using the dV-trainer^®. Each subject completed three virtual endo-wrist modules (“Pick and Place,” “Peg Board,“ and “Match Board”). Performance was recorded using a built-in scoring algorithm.

RESULTS:

In the Peg Board module, the performance of surgical fellows was better in terms of the number of instrument collisions and number of drops (P < 0.05). However, no significant differences were found in the percentage scores of the three endo-wrist modules between the groups.

CONCLUSION:

Robotic dexterity was not significantly affected by laparoscopic experience in this study. Laparoscopic experience is not an important factor for learning robotic skills.

Robotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy

Technical surgical skills are said to be acquired quicker on a robotic rather than laparoscopic platform. However, research examining this proposition is scarce. Thus, this study aimed to compare the performance and learning curves of novices acquiring skills using a robotic or laparoscopic system, and to examine if any learning advantages were maintained over time and transferred to more difficult and stressful tasks. Forty novice participants were randomly assigned to either a robotic- or laparoscopic-trained group. Following one baseline trial on a ball pick-and-drop task, participants performed 50 learning trials. Participants then completed an immediate retention trial and a transfer trial on a two-instrument rope-threading task. One month later, participants performed a delayed retention trial and a stressful multi-tasking trial. The results revealed that the robotic-trained group completed the ball pick-and-drop task more quickly and accurately than the laparoscopic-trained group across baseline, immediate retention, and delayed retention trials. Furthermore, the robotic-trained group displayed a shorter learning curve for accuracy. The robotic-trained group also performed the more complex rope-threading and stressful multi-tasking transfer trials better. Finally, in the multi-tasking trial, the robotic-trained group made fewer tone counting errors. The results highlight the benefits of using robotic technology for the acquisition of technical surgical skills.

Smart tissue anastomosis robot (STAR): a vision-guided robotics system for laparoscopic suturing

This paper introduces the smart tissue anastomosis robot (STAR). Currently, the STAR is a proof-of-concept for a vision-guided robotic system featuring an actuated laparoscopic suturing tool capable of executing running sutures from image-based commands. The STAR tool is designed around a commercially available laparoscopic suturing tool that is attached to a custom-made motor stage and the STAR supervisory control architecture that enables a surgeon to select and track incisions and the placement of stitches. The STAR supervisory-control interface provides two modes: A manual mode that enables a surgeon to specify the placement of each stitch and an automatic mode that automatically computes equally-spaced stitches based on an incision contour. Our experiments on planar phantoms demonstrate that the STAR in either mode is more accurate, up to four times more consistent and five times faster than surgeons using state-of-the-art robotic surgical system, four times faster than surgeons using manual Endo360(°)®, and nine times faster than surgeons using manual laparoscopic tools.

Development of a robotic system with six-degrees-of-freedom robotic tool manipulators for single-port surgery

BACKGROUND

Current robotic systems have limitations for single-port surgery (SPS) because the instruments are large, the arms collide and the field of vision requires manual readjustment. We have developed an SPS robotic system that manipulates the vision field.

METHODS

The master-slave system included a six degrees of freedom (DOFs) tool manipulator, an easy set-up mechanism, a flexible shaft drive with sufficient DOFs and a vertical arrangement for improved vision. The robot manipulates an endoscope within the body. After assembly, the system was tested in vitro and in vivo.

RESULTS

In vitro testing showed that the tool manipulators resected tissue precisely, with the range of motion required. In vivo testing indicated that an abdominal organ is accurately approached and diseased tissue removed by combined endoscopy and robotics.

CONCLUSIONS

Our robotics allowed the operator to adjust the vision field intuitively. The tool manipulator approached and resected diseased tissue precisely.

Robot-assisted ramicotomy: evaluation in a swine model

BACKGROUND

To evaluate the feasibility of robot-assisted thoracoscopic T2-T5 ramicotomy.

METHODS

In 5 pigs, a robot-assisted thoracoscopic T2-T5 ramicotomy was performed, followed by T2-T5 sympathectomy 10 min later. Ramicotomy and sympathectomy times, and core (esophageal) and surface (left front foot) temperatures, were monitored and recorded.

RESULTS

The procedure was successfully completed in all 5 animals. In all cases, the sympathetic chain remained intact. No major hemorrhage occurred. The mean operating time for T2-T5 ramicotomy from incision until transsection of the last efferent ramus was 34 min (32-40). After completion of the ramicotomy, a total T2-T5 sympathectomy was performed, with a mean duration of 7 min (4-12). Mean core temperature before the operation was 37.6°C (36.7-38.0). Mean surface temperature before the operation was 34.2°C (33.3-35.5). Ten minutes after completion of the ramicotomy, temperatures stabilized. Mean postramicotomy core temperature was 37.4°C (36.3-38) and mean postramicotomy surface temperature was 35.4°C (33.9-37). Mean postsympathectomy temperatures were: core 37.3°C (36.1-38) and surface 35.8°C (33.8-37.1).

CONCLUSION

Robot-assisted thoracoscopic T2-T5 ramicotomy is feasible and effective in a porcine model.

In vivo experiments of a surgical robot with vision field control for Single Port Endoscopic Surgery

Recently, robotics systems are focused to assist in Single Port Endoscopic Surgery (SPS). However, the existing system required a manual operation of vision and viewpoint, hindering the surgical task. We proposed a surgical endoscopic robot for SPS with dynamic vision control, the endoscopic view being manipulated by a master controller. The prototype robot consists of a manipulator for vision control, and dual tool tissue manipulators (gripping: 5DOFs, cautery: 3DOFs) can be attached at the tip of sheath manipulator. In particular, this paper focuses on an in vivo experiment. We showed that vision control in the stomach and a cautery task by a cautery tool could be effectively achieved.

Three-dimensional vision enhances task performance independently of the surgical method

BACKGROUND

Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance.

METHODS

In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system.

RESULTS

Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P < 0.0001-0.02). Simple tasks took 25 % to 30 % longer to complete and more complex tasks took 75 % longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P = 0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P < 0.001-0.015).

CONCLUSIONS

The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical method.

A novel approach to the design of a needle driver with multiple DOFs for pediatric laparoscopic surgery

INTRODUCTION

The objective of our research was to design and develop a novel needle driver with multiple degrees of freedom (DOFs) for pediatric laparoscopic surgery. Pediatric laparoscopic surgery has many advantages for patients, but the difficulty of the operation is increased due to many restrictions. For example, the motion of the needle driver is restricted by the insertion points, and the operation workspace is smaller in children than in adults.

MATERIAL AND METHODS

A needle driver with 3 DOFs and a 3.5-mm diameter is proposed and implemented in this study. Grasping DOF is achieved using a piston mechanism actuated by a wire. Deflection and rotation DOFs are actuated by gears.

RESULTS

Experiments were conducted to evaluate the workspace and ligation force, and the results confirmed that the needle driver meets all the necessary requirements. Finally, a first reaction of a pediatric surgeon on the suturing and ligaturing capabilities of the prototype is reported.

CONCLUSION

A multi-DOF needle driver with a new mechanism was proposed for pediatric laparoscopic surgery and a first prototype was developed. It is expected that further elaboration of the developed first prototype of the needle driver may contribute to the advancement of pediatric laparoscopic surgery.

Remote ultrasound palpation for robotic interventions using absolute elastography

Although robotic surgery has addressed many of the challenges presented by minimally invasive surgery, haptic feedback and the lack of knowledge of tissue stiffness is an unsolved problem. This paper presents a system for finding the absolute elastic properties of tissue using a freehand ultrasound scanning technique, which utilizes the da Vinci Surgical robot and a custom 2D ultrasound transducer for intraoperative use. An external exciter creates shear waves in the tissue, and a local frequency estimation method computes the shear modulus. Results are reported for both phantom and in vivo models. This system can be extended to any 6 degree-of-freedom tracking method and any 2D transducer to provide real-time absolute elastic properties of tissue.

Development of a Tool Manipulator Driven by a Flexible Shaft for Single-Port Endoscopic Surgery

Recently, a robotic system was developed to assist in Single-Port Endoscopic Surgery (SPS). However, the existing system required a manual operation of vision and viewpoint, hindering the surgical task. We proposed a surgical endoscopic robot for SPS with a dynamic vision control, the endoscopic view being manipulated by a master controller. The prototype robot consists of a manipulator for vision control, and dual tool tissue manipulators (gripping: five DOFs; cautery: three DOFs) can be attached at the tip of the sheath manipulator. In particular, this paper focuses on the details of the mechanism and control scheme of the tool manipulator. The experimental results show that our manipulator exhibits a response with a precision of less than 0.15 mm and a time delay of less than 31 ms, when the input frequency is 1.0 Hz.

Status of robotic assistance--a less traumatic and more accurate minimally invasive surgery?

PURPOSE

Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy, such as limited degree of freedom, 2D vision, fulcrum, and pivoting effect. Robotic systems provide corresponding solutions as 3D view, intuitive motion and enable additional degrees of freedom. This review provides an overview of the history of medical robotics, experimental studies, clinical state-of-the-art and economic impact.

METHODS

The Medline database was searched for the terms "robot, telemanipulat, and laparoscop." A total of 2,573 references were found. All references were considered for information on robotic assistance in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work.

RESULTS

In experimental studies, current robotic systems showed superior handling and ergonomics compared to conventional laparoscopic techniques. In gynecology especially for hysterectomy and in urology especially for prostatectomy, two procedures formerly performed via an open approach, the robot enables a laparoscopic approach. This results in reduced need for pain medication, less blood loss, and shorter hospital stay. Within abdominal surgery, clinical studies were generally unable to prove a benefit of the robot. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.

CONCLUSION

Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. The most promising procedures are those in which the robot enables a laparoscopic approach where open surgery is usually required.

Autostereoscopic three-dimensional viewer evaluation through comparison with conventional interfaces in laparoscopic surgery

In the near future, it is likely that 3-dimensional (3D) surgical endoscopes will replace current 2D imaging systems given the rapid spreading of stereoscopy in the consumer market. In this evaluation study, an emerging technology, the autostereoscopic monitor, is compared with the visualization systems mainly used in laparoscopic surgery: a binocular visor, technically equivalent from the viewer's point of view to the da Vinci 3D console, and a standard 2D monitor. A total of 16 physicians with no experience in 3D interfaces performed 5 different tasks, and the execution time and accuracy of the tasks were evaluated. Moreover, subjective preferences were recorded to qualitatively evaluate the different technologies at the end of each trial. This study demonstrated that the autostereoscopic display is equally effective as the binocular visor for both low- and high-complexity tasks and that it guarantees better performance in terms of execution time than the standard 2D monitor. Moreover, an unconventional task, included to provide the same conditions to the surgeons regardless of their experience, was performed 22% faster when using the autostereoscopic monitor than the binocular visor. However, the final questionnaires demonstrated that 60% of participants preferred the user-friendliness of the binocular visor. These results are greatly heartening because autostereoscopic technology is still in its early stages and offers potential improvement. As a consequence, the authors expect that the increasing interest in autostereoscopy could improve its friendliness in the future and allow the technology to be widely accepted in surgery.

Long-term outcomes of robotic-assisted laparoscopic sacrocolpopexy with a minimum of three years follow-up

We describe efficacy and safety of robotic-assisted laparoscopic vaginal vault prolapse repair with long-term follow-up. We reviewed the records of 40 consecutive patients with posthysterectomy vaginal vault prolapse who underwent a robotic-assisted laparoscopic sacrocolpopexy at our institution between September 2002 and September 2006. Patient analysis focused on complications, patient satisfaction, and morbidity, with a minimum of 36 months' follow-up. Median follow-up was 62 months (range 36-84) and mean age was 67 (43-83) years. Mean operating time was 3.1 (2.15-5) h with a median operating time of 2.9 h. All but four were discharged home on postoperative day one; three patients left on postoperative day two and one left on postoperative day seven. Three developed recurrent grade 3-4 rectoceles and two vaginal extrusion of mesh. Thirty-eight of the 40 patients (95%) were satisfied with their outcome. Robotic-assisted laparoscopic sacrocolpopexy is a minimally invasive technique for vaginal vault prolapse repair, combining the advantages of open sacrocolpopexy with the decreased morbidity of laparoscopy. We found a short hospital stay, low complication rates, and high patient satisfaction with a minimum of 3 years' follow-up.

Robot-assisted anterior lumbar interbody fusion (ALIF) using retroperitoneal approach

BACKGROUND

Over the past few years, robot-assisted surgery has become increasingly popular, affecting virtually all surgical fields. It has been proven to overcome pitfalls of laparoscopic procedures, such as high complication rates and steep learning curve. We have, therefore, performed experimental anterior lumbar interbody fusion (ALIF) using retroperitoneal approach in swine model to test the feasibility of robot-assisted surgery in spinal surgery.

METHOD

In this report, we describe the setup with the da Vinci surgical system, operative method, result and discuss technical aspects and the future of robot-assisted ALIF.

FINDINGS

Experimental retroperitoneal dissection using robotic surgical system was successfully performed with great visual cue, minimal retraction and minimal bleeding.

CONCLUSION

Although retroperitoneal approach for spinal fusion has never been attempted with robotic surgical system, we could demonstrate the possibility with swine model. Further studies and development of appropriate instruments will bring minimally invasive spine surgery to a new era.

Influence of 2D and 3D view on performance and time estimation in minimal invasive surgery

This study aimed to evaluate the impact of two-dimensional (2D) and three-dimensional (3D) images on time performance and time estimation during a surgical motor task. A total of 60 subjects without any surgical experience (nurses) and 20 expert surgeons performed a fine surgical task with a new laparoscopic technology (da Vinci robotic system). The 80 subjects were divided into two groups, one using 3D view option and the other using 2D view option. We measured time performance and asked subjects to verbally estimate their time performance. Our results showed faster performance in 3D than in 2D view for novice subjects while the performance in 2D and 3D was similar in the expert group. We obtained a significant interaction between time performance and time evaluation: in 2D condition, all subjects accurately estimated their time performance while they overestimated it in the 3D condition. Our results emphasise the role of 3D in improving performance and the contradictory feeling about time evaluation in 2D and 3D. This finding is discussed in regard with the retrospective paradigm and suggests that 2D and 3D images are differently processed and memorised.

A Mental Workload Study on the 2d and 3d Viewing Conditions of the da Vinci Surgical Robot

Fifteen medical students performed a standard training task using the da Vinci Surgical robot's 2d and 3d viewing conditions. Measures of mental workload associated with both viewing conditions were assessed using a secondary interval production task as well as the NASA Task Load Index (NASA-TLX) and the Multiple Resources Questionnaire (MRQ). The Results of the NASA-TLX indicated that the 3d viewing condition results in lower scores of mental workload when compared to the 2d condition. The MRQ data provided diagnostic information regarding which information processing pools were stressed in both the 2d and 3d viewing conditions.

Vaginal vault prolapse

Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women's quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised, taking into consideration the surgeon's experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCall's culdoplasty under direct visualisation to be superior. Vault prolapse repair rely on either the use of patient's tissue or synthetic materials and can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%. Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which are equally effective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using the mesh needs to be studied further. The later may well be the way forward in future.