Advantages of advanced laparoscopic systems

A systematic review of the Da Vinci® Single-Port system (DVSP) in the context of colorectal surgery

PURPOSE

The purpose of this study is to review the application of the da Vinci® Single-Port system (DVSP) in colorectal surgery, with a view to assessing its safety and feasibility, and investigating its clinical and oncological outcomes.

METHODS

A comprehensive search of the scientific literature was conducted across three major databases (PubMed, Web of Science, and Cochrane) up to November 2024. The study was registered in PROSPERO (CRD42024612762) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies pertained to the utilisation of DVSP in the domain of colorectal surgery.

RESULTS

Eleven articles were included in the final analysis. No randomized controlled trials were identified. A total of 396 patients (199 men, 197 women) underwent robotic colorectal surgery using the DVSP. Surgical resections were indicated for benign pathology in 56 patients, colon carcinoma in 194 cases, and rectal carcinoma in 146 cases. The median incision length for Uniport placement was 4 cm. The median docking time was 5.96 min (IQR, 9.33 min), and the median console time was 105 min (IQR, 62.51 min). The mean operative time was 186.3 min (IQR, 77.65 min). Intraoperative complications were rare, with only two cases reported (0.47%). Postoperative complications occurred in 12.47% of patients, with ileus being the most common. No patients were readmitted for complications within 30 days. Short-term oncological outcomes seemed promising, with a median of 24.59 lymph nodes retrieved. There were no reported deaths within 30 days. The median follow up time was 11.4 months (IQR, 11.76 months).

CONCLUSION

This study shows that the use of DVSP in colorectal surgery is both feasible and safe. Short-term clinical and oncological outcomes seem promising. However, longer follow-up data and larger patient cohorts are needed to fully assess the long-term efficacy of this novel technique.

PROSPERO REGISTRY

Registration number CRD42024612762.

Comparison of surgical outcomes between single-layer and double-layer pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most severe complication after pancreaticoduodenectomy (PD), and this study investigates the effects of single-layer and double-layer pancreaticojejunostomy (PJ) on POPF.

EVIDENCE ACQUISITION

Four electronic databases were systematically searched until March 2024: PubMed, Web of Science, Embase, and Cochrane Library. Statistical analysis was performed using Review Manager (RevMan) software. Mean difference (MD) or odds ratios (OR) with 95% confidence intervals (CI) were used to indicate continuous or dichotomous variables, respectively. Ten studies were included, comprising 1811 patients.

EVIDENCE SYNTHESIS

Compared to the double-layer PJ group, the single-layer PJ group had a similar POPF rate (OR=0.73; P=0.28) and grade C POPF rate (OR=0.55; P=0.12), but a lower grade B POPF rate (OR=0.50; 95% CI: 0.31-0.81; P=0.005). The clinically relevant POPF (CR-POPF) rate was lower in the single-layer PJ group (OR=0.47; 95% CI: 0.31-0.73; P<0.001), especially in the 2017 International Study Group of Pancreatic Surgery (ISGPS) criteria subgroup (OR=0.44; 95% CI: 0.27-0.73; P=0.001), the China subgroup (OR=0.41; 95% CI: 0.26-0.64; P<0.001), and the minimally invasive subgroup (OR=0.40; 95% CI: 0.22-0.74; P=0.003).

CONCLUSIONS

Compared with double-layer PJ, single-layer PJ after PD might reduce the incidence of CR-POPF.

A review of ergonomic positions to improve musculoskeletal distress in hepatobiliary pancreatic surgeons according to open, laparoscopic, and robotic surgeries

Advances in surgical ergonomics are essential for the performance, health, and career longevity of surgeons. Many surgeons experience work-related musculoskeletal disorders (WMSDs) resulting from various surgical modalities, including open, laparoscopic, and robotic surgeries. To prevent WMSDs, individual differences may exist depending on the surgical method; however, the key is to maintain a neutral posture, and avoid static postures. This review aims to summarize the concepts of ergonomics and WMSDs; identify the ergonomic challenges of open, laparoscopic, and robotic surgeries; and discuss ergonomic recommendations to improve them.

Open versus laparoscopic completion cholecystectomy in patients with previous open partial cholecystectomy: a retrospective comparative study

Background

Some patients report recurrence or persistence of their manifestations after cholecystectomy, and retained gallstones may be a relevant etiology for their complaint. Completion cholecystectomy is advised for these cases to alleviate their manifestations. No previous studies have compared the outcomes of open versus laparoscopic outcomes in these patients, especially in patients who had initial open partial procedures. That is why we performed this study to report the perioperative outcomes of the two approaches in such patients.

Methodology

This is a retrospective analysis of 80 patients who had a completion cholecystectomy in the authors' center (40 open and 40 laparoscopic cases) after initial open partial cholecystectomy.

Results

The duration elapsed since the primary procedure had an average of 18 months in the open group and 21 months in the laparoscopic group. Abdominal pain and dyspepsia were the most common presentations. Some patients had stump cholecystitis or jaundice. The intraoperative assessment revealed either the residual gallbladder or a long cystic duct stump. Laparoscopy yielded shorter operative time, earlier oral intake, and shorter hospitalization periods compared to the open approach (P<0.05). The latter was associated with a 20% wound infection rate that was never encountered after laparoscopy (P =0.003).

Conclusion

Previous open partial cholecystectomy does not hinder subsequent laparoscopic completion cholecystectomy. Additionally, laparoscopy is associated with better perioperative outcomes than the open approach.

Laparoscopy training of novices with complex curved instruments using 2D- and 3D-visualization

PURPOSE

Beside many advantages, disadvantages such as reduced degrees of freedom and poorer depth perception are still apparent in laparoscopic surgery. 3D visualization and the development of complex instruments are intended to counteract the disadvantages. We want to find out whether the use of complex instruments and 3D visualization has an influence on the performance of novices.

METHODS

48 medical students with no experience in laparoscopic surgery or simulator-based laparoscopy training were included. They were randomized in four groups according to a stratification assessment. During a structured training period they completed the FLS-Tasks "PEG Transfer", "Pattern Cut" and "Intracorporeal Suture" and a transfer task based on these three. Two groups used conventional laparoscopic instruments with 3D or 2D visualization, two groups used complex curved instruments. The groups were compared in terms of their performance.

RESULTS

In 2D laparoscopy there was a better performance with straight instruments vs. curved instruments in PEG Transfer and Intracorporeal Suture. In the transfer task, fewer errors were made with straight instruments. In 2D vs. 3D laparoscopy when using complex curved instruments there was an advantage in Intracorporeal Suture and PEG Transfer for 3D visualization. Regarding the transfer exercise, a better performance was observed and fewer errors were made in 3D group.

CONCLUSION

We could show that learning laparoscopic techniques with complex curved instruments is more difficult with standard 2D visualization and can be overcome using 3D optics. The use of curved instruments under 3D vision seems to be advantageous when working on more difficult tasks.

A Medium-Term Comparison of Quality of Life and Pain After Robotic or Laparoscopic Cholecystectomy

INTRODUCTION

We sought to compare medium-term outcomes between robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC) using validated quality of life (QoL) and pain assessments.

MATERIALS AND METHODS

Patients who underwent RC or LC between 2012 and 2017 at a single academic institution were examined. Cases converted to open were excluded. Patients were contacted by telephone in 2019 and completed two standardized surveys to rate their QoL and pain.

RESULTS

Of those screened, 122 (35.8%) completed both surveys. Ninety three (76.2%) underwent RC and 29 (23.8%) underwent LC. The groups (RC versus LC) were similar based on mean age (47.9 versus 45.5 y, P = 0.48), gender (66.7% versus 72.4% female, P = 0.56), race (86.0% White/5.4% Black versus 72.4% White/13.8% Black, P = 0.2), insurance status (98.9% versus 100.0% insured, P = 0.58), median body mass index (31.8 versus 31.3, P = 0.43), and median Charlson Comorbidity Index (1 versus 0, P = 0.14). Fewer RC patients had a history of steroid use compared to LC (16.1% versus 34.5%, P = 0.03). No overall significant difference in QoL was demonstrated. LC group had higher severity of "tiring-exhausting pain" (P = 0.04), "electric-shock pain" (P = 0.003), and "shooting pain" (P = 0.05). The "overall intensity" of pain in the "gallbladder region" between the groups was similar at the time of follow-up (P = 0.31).

CONCLUSIONS

QoL over 2-7 y following time of surgery is comparable for robotic-assisted versus conventional laparoscopic cholecystectomies. The laparoscopic approach may be associated with a higher severity of subset categories of pain, but overall pain between the two approaches is comparable.

Compatibility effects with touchless gestures

Human actions are suspect to various compatibility phenomena. For example, responding is faster to the side where a stimulus appears than to the opposite side, referred to as stimulus-response (S-R) compatibility. This is even true, if the response is given to a different stimulus feature, while location itself is irrelevant (Simon compatibility). In addition, responses typically produce perceivable effects on the environment. If they do so in a predictable way, responses are faster if they produce a (e.g., spatially) compatible effect on the same side than on the other side. That it, a left response is produced faster if it results predictably in a left effect than in a right effect. This effect is called response-effect (R-E) compatibility. Finally, compatibility could also exist between stimuli and the effects, which is accordingly called stimulus-effect (S-E) compatibility. Such compatibility phenomena are also relevant for applied purposes, be it in laparoscopic surgery or aviation. The present study investigates Simon and R-E compatibility for touchless gesture interactions. In line with a recent study, no effect of R-E compatibility was observed, yet irrelevant stimulus location yielded a large Simon effect. Touchless gestures thus seem to behave differently with regard to compatibility phenomena than interactions via (other) tools such as levers.

Three-dimensional vision versus two-dimensional vision on laparoscopic performance of trainee surgeons: a systematic review and meta-analysis

Laparoscopic surgery underwent great improvements during the last few years. This review aims to compare the performance of Trainee Surgeons using 2D versus 3D/4 K laparoscopy. A systematic review of the literature was done on Pubmed, Embase, Cochrane's Library and Scopus. The following words and key phrases have been searched: "Two-dimensional vision", "Three-dimensional vision", "2D and 3D laparoscopy", "Trainee surgeons". This systematic review was reported according to the PRISMA statement 2020. PROSPERO registration No. CRD42022328045. Twenty-two randomized controlled trials (RCTs) and two observational studies were included in the systematic review. Two trials were carried out in a clinical setting, and twenty-two trials were performed in a simulated setting. In studies involving the use of a box trainer, the number of errors in the 2D laparoscopic group was significantly higher than in the 3D laparoscopic group during the performance of FLS skill tasks: peg transfer (MD: -0.82; 95% CI - 1.17 to - 0.47; p < 0.00001), cutting (MD: - 1.09; 95% CI - 1.50 to - 0.69 p < 0.00001), suturing (MD: - 0.48; 95% CI - 0.83 to - 0.13 p = 0.007), However, in clinical studies, there was no significant difference in the time taken for laparoscopic total hysterectomy (MD: 8.71; 95% CI - 13.55 to 30.98; p = 0.44) and vaginal cuff closure (MD: 2.00; 95% CI - 0.72 to - 4.72; p = 0.15) between 2D group and 3D group. 3D laparoscopy facilitates learning for novice surgeons and shows improvements in their laparoscopic performance.

Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb): short-term clinical outcomes of over 1400 colorectal resections

INTRODUCTION

The Serbian National Training Programme for minimally invasive colorectal surgery (LapSerb) was introduced to implement laparoscopic colorectal surgery across Serbia. The programme aimed to accelerate training of established colorectal surgeons through a competency-based programme. This involved knowledge assessment, workshops, live operating, and competency-based assessment of unedited videos. The aim of this study is to report the outcomes of laparoscopic colorectal resection performed by LapSerb certified surgeons.

METHODS

LapSerb prospectively maintained multicentred database was analysed for laparoscopic colorectal resections from January 2015 to February 2021. Data collected included patient demographics, indications for surgery, perioperative data, and 30-day outcomes.

RESULTS

A total of 1456 laparoscopic colectomies by 24 certified surgeons were included in the final analysis. Mean age was 67 (± 12) years old and male to female ratio was 1:1.5. 83.1% of the colectomies were malignant, mainly due to adenocarcinoma. Anterior resection was the most common procedure with 699 (48%) cases, followed by right and left colectomies with 357 (24.5%) and 303 (21%) procedure respectively. 4.8% of patients required conversion to open surgery. Thirty-day readmission and reoperation rates were 2.3% and 4.7%, respectively. Overall mortality in all cases was 1.1% and R0 resections were achieved in 97.8% of malignant colectomies.

CONCLUSION

The LapSerb programme successfully and safely established laparoscopic colorectal surgery across the country with comparable and acceptable short-term clinical outcomes.

A dual-view multi-resolution laparoscope for safer and more efficient minimally invasive surgery

Minimally invasive surgery (MIS) is limited in safety and efficiency by the hand-held nature and narrow fields of view of traditional laparoscopes. A multi-resolution foveated laparoscope (MRFL) was invented to address these concerns. The MRFL is a stationary dual-view imaging device with optical panning and zooming capabilities. It is designed to simultaneously capture and display a zoomed view and supplemental wide view of the surgical field. Optical zooming and panning capabilities facilitate repositioning of the zoomed view without physically moving the system. Additional MRFL features designed to improve safety and efficiency include its snub-nosed endoscope, tool-tip auto tracking, programmable focus profiles, unique selectable display modalities, foot pedal controls, and independently controlled surgeon and assistant displays. An MRFL prototype was constructed to demonstrate and test these features. Testing of the prototype validates its design architecture and confirms the functionality of its features. The current MRFL prototype functions adequately as a proof of concept, but the system features and performance require further improvement to be practical for clinical use.

High-throughput multi-resolution foveated laparoscope for minimally invasive surgery

Feasibility and clinical utility of a multi-resolution foveated laparoscope (MRFL) was previously tested in a porcine surgical study. The study revealed several clinical limitations of the system including moisture proofing, working distance, image quality, low light performance, color accuracy, size, and weight. In this paper, we discuss the root causes of these limitations and strategies to correct them, present the design and prototyping of a new high throughput multi resolution foveated laparoscope (HT-MRFL), and demonstrate the HT-MRFL prototype performance in comparison to the MRFL and simulated performance metrics.

Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy

BACKGROUND

Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract.

METHODS

A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review.

RESULTS

The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing.

CONCLUSIONS

This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.

Minimally invasive pancreatic surgery—will robotic surgery be the future?

Due to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.

[Minimally invasive and robot-assisted surgery for chronic inflammatory bowel disease : Current status and evidence situation]

The majority of cases of inflammatory bowel disease (IBD) can be treated by minimally invasive surgery. The advantages of standard laparoscopic approaches compared to open surgery with respect to short-term and long-term outcome parameters have been adequately proven with evidence level 1 for ileocecal resection in Crohn's disease. For many other indications there are at least several larger registry or case-control studies that have shown advantages for laparoscopy. For robot-assisted surgery the feasibility has principally been demonstrated for IBD, whereby at least for ulcerative colitis limited data suggest comparable results to the standard laparoscopic approach. Single port approaches have so far not been able to demonstrate any relevant advantages in IBD surgery. Major advantages for transanal minimally invasive surgery (TAMIS) for performing restorative proctocolectomy could not be demonstrated in two larger case-controlled studies but it was at least shown to be a comparable alternative to standard laparoscopy. Overall, it seems unlikely that the recently described new laparoscopic approaches will result in measurable advantages for the patient in comparison to standard laparoscopy as the access trauma is not significantly changed. In general, the indications to perform minimally invasive surgery must always be based on the basic principles of IBD surgery and contraindications have to be considered in individual cases as the advantages of laparoscopic approaches are levelled out in the long run.

Outcomes of robotic and laparoscopic cholecystectomy for benign gallbladder disease in Veteran patients

The robotic platform for cholecystectomy has been extensively studied in comparison to its laparoscopic counterpart with acceptable outcomes. However, wide acceptance of a robotic approach to cholecystectomy has been limited by increased operative room (OR) times and substantially higher cost. This is a single-institution retrospective review of Veteran patients presenting for elective laparoscopic (LC) and robotic (RC) cholecystectomies for benign biliary disease at the Dallas VA Medical Center. The primary goal was to interrogate 30-day morbidity as well as operative room times, estimated blood loss (EBL), hospital length of stay (LOS), and conversion rates. The entire cohort included 612 patients (age = 55.1 ± 12.9 years, men = 77.9%, BMI = 31.2 ± 6.3 kg/m²) undergoing elective cholecystectomy (LC = 441 and RC = 171) for benign biliary disease (biliary colic = 78.8%, history of biliary pancreatitis = 7.8%, history of cholecystitis = 5.7%). Univariate analysis comparing LC and RC showed the two groups to be of similar age (55.4 ± 12.4 vs. 54.4 ± 14.2 years; p = 0.4), male gender (79.4% vs. 74.3%, p = 0.2), and BMI (31.1 ± 6.4 vs. 31.5 ± 6.3 kg/m²; p = 0.5). Except for dyslipidemia (LC = 48.3% vs. RC = 36.8%; p = 0.01), both groups had the same rate of co-morbid conditions. ASA level III and IV (LC = 60.1 vs. RC = 69.0%, p = 0.04) was higher in the RC group. Both groups underwent surgical intervention for similar indications (biliary colic LC = 80.5% vs. RC = 74.3; p = 0.1). Hospital LOS (1.7 ± 3.2 vs. 0.3 ± 0.9 days, p < 0.001), EBL (32.3 ± 52.3 vs. 17.0 ± 43.1; p = 0.001), and conversion to open (6.6% vs. 0.6%, p = 0.001) were all superior with the robotic platform. Thirty-day overall morbidity (9.8% vs. 12.3%, p = 0.4), skin-to-skin OR time (84.5 ± 33.5 vs. 88.0 ± 35.3 min, p = 0.2), and total OR time (129.2 ± 36.8 vs. 129.7 ± 39.7, p = 0.9) were similar between the LC and RC groups. Despite being older and having more comorbidities, Veteran patients undergoing robotic cholecystectomy experienced equivalent OR time and a moderate improvement in conversion rate, EBL, and hospital LOS compared to those undergoing conventional laparoscopy, therein demonstrating the safety and efficacy of the robotic platform for this patient population.

Acquiring Advanced Laparoscopic Colectomy Skills - The Issues

Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England's Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves pre-clinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.

Further Comparison of 4 Display Modes for a Multi-Resolution Foveated Laparoscope

Background. To overcome field of view and ergonomic limitations of standard laparoscopes, we are developing a multi-resolution foveated laparoscope (MRFL), which can simultaneously obtain both wide- and zoomed-in-view images. To facilitate the effectiveness of our MRFL, we have been investigating various ways of organizing and visualizing dual-view multi-resolution images acquired by the MRFL. In our prior study, we implemented and compared 6 display modes for the MRFL, assuming a typical clinical environment where a standard (but limited) resolution monitor is available. To take full advantage of our MRFL, displays having sufficient screen resolutions might be advantageous. The present study aims to further understand the effects of view configurations through displays with a standard high-definition (HD) resolution and a 4K resolution. In this study, we compare 3 display modes for limited-resolution displays against a new mode for sufficient-resolution displays. Methods. Twenty subjects performed 3 evaluation trials of a touching task with each display mode in an emulated MRFL environment. Various objective measurements including task completion time and the number of collisions, and subjective preference were recorded. Results. The new mode showed a better task completion time than the other modes, while it maintained a low number of collisions similar to the others. Moreover, the majority of participants selected the new mode as their most preferred one. Conclusions. With a sufficient display resolution, the co-registration between the unblocked and unwarped wide context view and the high-resolution zoomed-in view offered by the new mode was highly effective on both task performance and user preference.

First robot-assisted radical prostatectomy in a client-owned Bernese mountain dog with prostatic adenocarcinoma

OBJECTIVE

To describe robot-assisted radical prostatectomy (RARP) and report the short-term outcome of a dog with prostatic cancer treated with RARP.

STUDY DESIGN

Case report ANIMALS: Client-owned 6-year-old male-neutered Bernese mountain dog.

METHODS

Robot-assisted radical prostatectomy was performed with a daVinci Si Surgical System through a transperitoneal approach. An interfascial nerve-sparing approach was used to preserve the neurovascular bundles and increase the likelihood of postoperative urinary continence. Urinary continence was assessed by placing white cloth bedding in the kennel during hospitalization and by owners' observation at home.

RESULTS

The console time was 120 minutes, and the estimated intraoperative blood loss was 30 mL. No intraoperative complications were observed. The urinary catheter was removed after 7 days, at which point the dog urinated normally. Peritoneal carcinomatosis was diagnosed 43 days after surgery, and the dog was euthanized.

CONCLUSION

Robot-assisted radical prostatectomy was successfully completed in a dog with prostatic neoplasia and led to postoperative urinary continence.

CLINICAL SIGNIFICANCE

This single-case report provides evidence to justify further evaluation of RARP in dogs with prostatic neoplasms.

A comparative analysis of outcomes of open, laparoscopic, and robotic elective (procto-) colectomies for benign and malignant disease

Laparoscopy has emerged as a common alternative to the open approach for colorectal operations. Robotic surgery has many advantages, but cost and outcomes are an area of study. There are no randomized-controlled trials of all techniques. The present study evaluated a cohort of veterans undergoing (procto-) colectomy for benign or malignant colorectal disease. This is a single-institution retrospective review. We compared open, laparoscopic, and robotic colectomies. The primary outcome was 30-day mortality. The secondary endpoints included morbidity, operative times, estimated blood loss (EBL), length of stay (LOS), conversion rate, and the learning curve (LC). Subgroup analyses were undertaken for: (1) right hemicolectomies (RHC) and (2) by specific surgeons most familiar with each approach. The cohort included 390 patients (men = 95%, White = 70.8%, BMI = 29.3 ± 6.4 kg/m², age = 63.7 ± 10.2 years) undergoing (open = 117, laparoscopic = 168, and robotic = 105), colorectal operations for colorectal adenocarcinoma (52.8%) and benign disease. Thirty-day morbidity was similar across all techniques (open = 46.2%, laparoscopic = 42.9%, and robotic = 38.1%; NS). EBL and LOS were decreased with minimally invasive techniques compared to open. Operative time was longer in robotic, but equalized to laparoscopic after 90 cases. The learning curve was reduced to 20 when performed by the surgeon most familiar with the robot. EBL and operative time independently predicted complications for the entire cohort. The best technique for colorectal operations rests on the surgeon's experience, but minimally invasive techniques are gaining momentum over open colectomies. Robotic colectomy is emerging as a non-inferior approach to laparoscopy in terms of outcomes, while maintaining all its technical advantages.

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.

Essential advances in surgical and adjuvant therapies for colorectal cancer 2018-2019

Surgical resection and adjuvant chemotherapy are the only treatment modalities for localized colorectal cancer that can obtain a "cure." The goal in surgically treating primary colorectal cancer is complete tumor removal along with dissection of systematic D3 lymph nodes. Adjuvant treatment controls recurrence and improves the prognosis of patients after they undergo R0 resection. Various clinical studies have promoted the gradual spread and clinical use of new surgical approaches such as laparoscopic surgery, robotic surgery, and transanal total mesorectal excision (TaTME). Additionally, the significance of adjuvant chemotherapy has been established and it is now recommended in the JSCCR (the Japanese Society for Cancer of the Colon and Rectum) guideline as a standard treatment. Herein, we review and summarize current surgical treatment and adjuvant chemotherapy for localized colorectal cancer and discuss recent advances in personalized medicine related to adjuvant chemotherapy.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Cost-analysis and quality of life after laparoscopic and robotic ventral mesh rectopexy for posterior compartment prolapse: a randomized trial

Background

The aim of this study was to assess, whether robotic-assistance in ventral mesh rectopexy adds benefit to laparoscopy in terms of health-related quality of life (HRQoL), cost-effectiveness and anatomical and functional outcome.

Methods

A prospective randomized study was conducted on patients who underwent robot-assisted ventral mesh rectopexy (RVMR) or laparoscopic ventral mesh rectopexy (LVMR) for internal or external rectal prolapse at Oulu University Hospital, Finland, recruited in February–May 2012. The primary outcomes were health care costs from the hospital perspective and HRQoL measured by the 15D-instrument. Secondary outcomes included anatomical outcome assessed by pelvic organ prolapse quantification method and functional outcome by symptom questionnaires at 24 months follow-up.

Results

There were 30 females (mean age 62.5 years, SD 11.2), 16 in the RVMR group and 14 in the LVMR group. The surgery-related costs of the RVMR were 1.5 times higher than the cost of the LVMR. At 3 months the changes in HRQoL were ‘much better’ (RVMR) and ‘slightly better’ (LVMR) but declined in both groups at 2 years (RVMR vs. LVMR, p > 0.05). The cost-effectiveness was poor at 2 years for both techniques, but if the outcomes were assumed to last for 5 years, it improved significantly. The incremental cost-effectiveness ratio for the RVMR compared to LVMR was €39,982/quality-adjusted life years (QALYs) at 2 years and improved to €16,707/QALYs at 5 years. Posterior wall anatomy was restored similarly in both groups. The subjective satisfaction rate was 87% in the RVMR group and 69% in the LVMR group (p = 0.83).

Conclusions

Although more expensive than LVMR in the short term, RVMR is cost-effective in long-term. The minimally invasive VMR improves pelvic floor function, sexual function and restores posterior compartment anatomy. The effect on HRQoL is minor, with no differences between techniques.

Is the Human Brain Capable of Controlling Seven Degrees of Freedom?

BACKGROUND

Conventional rigid laparoscopic instruments offer five degrees of freedom (DOF). Robotic instruments add two independent DOFs allowing unconstrained directional steering. Several nonrobotic instruments have been developed with the additional DOFs, but with these devices, surgeon's wrist movements are not intuitively transmitted into tip movements. In this study, a new articulated instrument has been evaluated. The aim of the study was to compare learning curves and performances of conventional laparoscopic instruments, the da Vinci system and Steerable devices in a crossover study.

MATERIALS AND METHODS

A total of 16 medical students without any laparoscopic experience were trained for 27 h to operate all of a rigid, a robotic, and a new Steerable instrument in a random order. Learning curves and ultimate experience scores were determined for each instrument. Strain in wrist and shoulders was assessed with a visual analog score.

RESULTS

Performing the suturing task with rigid and robot instruments required 4 h of training, compared with 6 h to master the Steerable instrument. After 9 h of training with each instrument, completing the complex suturing pattern required 662 ± 308 s with rigid instruments, 279 ± 90 s with the da Vinci system, and 279 ± 53 s with the Steerable instrument. Pain scores were significantly higher after using the rigid instruments compared with the Steerable instruments.

CONCLUSIONS

Transmission of torque and the presence of additional two DOFs in combination with reduced crosstalk significantly improved the instrument dexterity where the Steerable platform is concerned. Although the learning curve is longer, once mastered, it provides enhanced surgical freedom.

Comparison of six display modes for a multi-resolution foveated laparoscope

BACKGROUND

To overcome the field of view and ergonomic limitations of standard laparoscopes, we are developing a multi-resolution foveated laparoscope that can simultaneously obtain both wide- and zoomed-in-view images through a single scope. To facilitate the effective access to the dual views of images with different resolution and field coverage acquired by our laparoscope, six different display modes have been developed. Each of the six display modes has inherent advantages and disadvantages. This study compares the six display modes through a human-subject experiment, which was conducted with an emulated laparoscope using a 4K camera.

METHODS

Twenty-four subjects without medicine background performed three evaluation trials of a touching task with each of the display modes. Various objective measurements including task completion time, the number of collisions, gaze position, and tooltip position, and subjective preference for the display modes were recorded.

RESULTS

For all the measurements except for task completion time and moving speed of tooltip, there were statistically significant differences among the display modes. Although the focus plus warped context view mode was selected as one of the least preferred modes, it showed the best task performance.

CONCLUSIONS

The unblocked wide context view was useful to provide a situational awareness even when it was severely distorted in some of the display modes, and information continuity played an important role in improving task performance. Moreover, the position change of viewing window coupled to the location of region of interest helped improve task performance, by providing an additional cue for spatial awareness.

Robotic ventral mesh rectopexy for rectal prolapse: a single-institution experience

BACKGROUND

Robotic ventral mesh rectopexy (RVMR) is an appealing approach for the treatment of rectal prolapse and other conditions. The aim of this study was to evaluate the outcomes of RVMR for rectal prolapse.

METHODS

We performed a retrospective chart review for patients who underwent RVMR for rectal prolapse at our institution between July 2012 and May 2016. Any patient who underwent RVMR during this time frame was included in our analysis. Any cases involving colorectal resection or other rectopexy techniques were excluded.

RESULTS

Of the 24 patients who underwent RVMR, 95.8% of patients were female. Median age was 67.5 years old (IQR 51.5-73.3), and 79.2% of patients were American Society of Anesthesiologists class III or IV. Median operative time was 191 min (IQR 164.3-242.5), and median length of stay was 3 days (IQR 2-3). There were no conversions, RVMR-related complications or mortality. Patients were followed for a median of 3.8 (IQR 1.2-15.9) months. Full-thickness recurrence occurred in 3 (12.4%) patients. Rates of fecal incontinence improved after surgery (62.5 vs. 41.5%, respectively) as did constipation (45.8 vs. 33.3%, respectively). No patients reported worsening symptoms postoperatively. Only one (4.2%) patient reported de novo constipation postoperatively.

CONCLUSIONS

RVMR is a feasible, safe and effective option for the treatment of rectal prolapse, with low short-term morbidity and mortality. Multicenter and long-term studies are needed to better assess the benefits of this procedure.

Changing the Learning Curve in Novice Laparoscopists: Incorporating Direct Visualization into the Simulation Training Program

OBJECTIVE

A major challenge in laparoscopic surgery is the lack of depth perception. With the development and continued improvement of 3D video technology, the potential benefit of restoring 3D vision to laparoscopy has received substantial attention from the surgical community. Despite this, procedures conducted under 2D vision remain the standard of care, and trainees must become proficient in 2D laparoscopy. This study aims to determine whether incorporating 3D vision into a 2D laparoscopic simulation curriculum accelerates skill acquisition in novices.

DESIGN

Postgraduate year-1 surgical specialty residents (n = 15) at the Schulich School of Medicine and Dentistry, at Western University were randomized into 1 of 2 groups. The control group practiced the Fundamentals of Laparoscopic Surgery peg-transfer task to proficiency exclusively under standard 2D laparoscopy conditions. The experimental group first practiced peg transfer under 3D direct visualization, with direct visualization of the working field. Upon reaching proficiency, this group underwent a perceptual switch, changing to standard 2D laparoscopy conditions, and once again trained to proficiency.

RESULTS

Incorporating 3D direct visualization before training under standard 2D conditions significantly (p < 0.0.5) reduced the total training time to proficiency by 10.9 minutes or 32.4%. There was no difference in total number of repetitions to proficiency. Data were also used to generate learning curves for each respective training protocol.

CONCLUSIONS

An adaptive learning approach, which incorporates 3D direct visualization into a 2D laparoscopic simulation curriculum, accelerates skill acquisition. This is in contrast to previous work, possibly owing to the proficiency-based methodology employed, and has implications for resource savings in surgical training.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

3D Laparoscopy in Neonates and Infants

BACKGROUND

This study focuses on the successful application of three-dimensional (3D) laparoscopic surgeries in the treatment of congenital anomalies and acquired diseases in the young pediatric population. The purpose of this scientific work consists in highlighting the spectrum, indications, applicability, and effectiveness of 3D endosurgery in children.

METHODS

Our experience is based on 110 endosurgical procedures performed in neonates and infants in the 3D format between January 2014 and May 2015. Depending on the type of operations, all patients were divided into the following groups: (1) inguinal herniorrhaphy (IH)-63 patients; (2) Nissen fundoplication (NF)-22 patients; (3) pyeloureteral anastomosis (PUA)-15 patients; (4) nephrectomy (NE)-5 patients; and (5) ovarian cystectomy (OC)-5 patients. The patients of the first three groups were compared with babies who underwent standard laparoscopic surgery, performed in the two-dimensional (2D) format during the same time period. The groups were organized according to patient demographics, operative report, and postoperative parameters.

RESULTS

The patients were similar in terms of demographics and other preoperative parameters. There were significant differences in mean operative time between 3D and 2D procedures in the groups of patients with hydronephrosis and gastroesophageal reflux, which used manipulation with internal sutures (NF-37.95 minutes versus 48.42 minutes, P = .014; PUA-61.31 minutes versus 78.75 minutes, P = .019), but not in group after IH (15.88 minutes versus 15.57 minutes, P = .681). Postoperative parameters such as length of hospital stay and the number of complications were equivalent between groups.

CONCLUSION

In this study, we demonstrated the success of 3D laparoscopy in small babies with inguinal hernia, gastroesophageal reflux, hydronephrosis, ovarian cyst, and multicystic kidney. Laparoscopy in 3D format lessens the duration of complex procedures, which utilize the use of the suture technique into the abdominal cavity. The perception of depth and the presence of tactile feedback make 3D laparoscopic surgery more acceptable when compared to traditional laparoscopy.

Robot-like dexterity without computers and motors: a review of hand-held laparoscopic instruments with wrist-like tip articulation

INTRODUCTION

Conventional manual laparoscopic instruments for minimally invasive surgery have limited dexterity within the patient, making procedures challenging. Surgical robotic systems offer enhanced articulation, but at substantial financial costs. This has motivated the development of high-dexterity, low-cost laparoscopic instruments.

AREAS COVERED

This article reviews both commercial and academic results on creating fully mechanical (i.e. non-robotic) laparoscopic instruments that provide wrists or wrist-like dexterity within the patient. We review the state of the art in the development of these mechanical instruments, focusing on the surgeon interface, wrist mechanism, and the kinematic mapping between the two. Expert commentary: Current articulated mechanical laparoscopic instruments exhibit a wide range of designs, with no clear consensus on what makes such devices easy to use. As these technologies mature, user studies are needed to determine surgeon preferences. Articulated, low-cost instruments have the potential to impact the minimally invasive surgery market if they provide compelling benefits to surgeons.

Optical design and system engineering of a multiresolution foveated laparoscope

The trade-off between the spatial resolution and field of view is one major limitation of state-of-the-art laparoscopes. In order to address this limitation, we demonstrated a multiresolution foveated laparoscope (MRFL) which is capable of simultaneously capturing both a wide-angle overview for situational awareness and a high-resolution zoomed-in view for accurate surgical operation. In this paper, we focus on presenting the optical design and system engineering process for developing the MRFL prototype. More specifically, the first-order specifications and properties of the optical system are discussed, followed by a detailed discussion on the optical design strategy and procedures of each subsystem. The optical performance of the final system, including diffraction efficiency, tolerance analysis, stray light and ghost image, is fully analyzed. Finally, the prototype assembly process and the final prototype are demonstrated.

Continuously zoom imaging probe for the multi-resolution foveated laparoscope

In modern minimally invasive surgeries (MIS), standard laparoscopes suffer from the tradeoff between the spatial resolution and field of view (FOV). The inability of simultaneously acquiring high-resolution images for accurate operation and wide-angle overviews for situational awareness limits the efficiency and outcome of the MIS. A dual view multi-resolution foveated laparoscope (MRFL) which can simultaneously provide the surgeon with a high-resolution view as well as a wide-angle overview was proposed and demonstrated to have great potential for improving the MIS. Although experiment results demonstrated the high-magnification probe has an adequate magnification for viewing surgical details, the dual-view MRFL is limited to two fixed levels of magnifications. A fine adjustment of the magnification is highly desired for obtaining high resolution images with desired field coverage. In this paper, a high magnification probe with continuous zooming capability without any mechanical moving parts is demonstrated. By taking the advantages of two electrically tunable lenses, one for optical zoom and the other for image focus compensation, the optical magnification of the high-magnification probe varies from 2 × to 3 × compared with that of the wide-angle probe, while the focused object position stays the same as the wide-angle probe. The optical design and the tunable lens analysis are presented, followed by prototype demonstration.

A virtual surgical training system that simulates cutting of soft tissue using a modified pre-computed elastic model

This work presents a surgical training system that incorporates cutting operation of soft tissue simulated based on a modified pre-computed linear elastic model in the Simulation Open Framework Architecture (SOFA) environment. A precomputed linear elastic model used for the simulation of soft tissue deformation involves computing the compliance matrix a priori based on the topological information of the mesh. While this process may require a few minutes to several hours, based on the number of vertices in the mesh, it needs only to be computed once and allows real-time computation of the subsequent soft tissue deformation. However, as the compliance matrix is based on the initial topology of the mesh, it does not allow any topological changes during simulation, such as cutting or tearing of the mesh. This work proposes a way to modify the pre-computed data by correcting the topological connectivity in the compliance matrix, without re-computing the compliance matrix which is computationally expensive.

Preliminary design of an actuated imaging probe for generation of additional visual cues in a robotic surgery

BACKGROUND

The aim of this study was to enhance the visual feedback of surgeons, during robotic surgeries, by designing and developing an actuated 2D imaging probe, which is used in conjunction with the traditional stereoscopic camera of the da Vinci surgical system. The probe provides the surgeon with additional visual cues, overcoming visualization constraints encountered during certain scenarios of robot-assisted minimally invasive surgery.

METHODS

The actuated imaging probe is implemented as a master-slave tele-manipulated system, and it is designed to be compatible with the da Vinci surgical system. The detachable probe design enables it to be mounted on any of the EndoWrist(®) instruments of the robot and is controlled by the surgeon using a custom-made pedal system. The image from the 2D probe is rendered along with the stereoscopic view on the surgeon's console.

RESULTS

The experimental results demonstrate the effectiveness of the proposed actuated imaging probe when used as an additional visualization channel and in surgical scenarios presenting visual problems due to tissue occlusion.

CONCLUSION

The study shows the potential benefits of an additional actuated imaging probe when used in conjunction with traditional surgical instruments to perform surgical tasks requiring visualization from multiple orientations and workspaces.

Outcomes of Open, Laparoscopic, and Robotic Abdominoperineal Resections in Patients With Rectal Cancer

BACKGROUND

There are limited available data comparing open, laparoscopic, and robotic approaches for rectal cancer surgery.

OBJECTIVE

We sought to investigate outcomes of different surgical approaches to abdominoperineal resection in patients with rectal cancer.

DESIGN

The nationwide inpatient sample database was used to examine the clinical data of patients with rectal cancer who underwent elective abdominoperineal resection between 2009 and 2012 in the United States. Multivariate regression analysis was performed to compare outcomes of different surgical approaches.

SETTINGS

A retrospective review according to the national inpatient sample database was designed.

PATIENTS

We included patients with rectal cancer who underwent elective abdominoperineal resection between 2009 and 2012.

MAIN OUTCOME MEASURES

Outcomes of different surgical approaches to abdominoperineal resection were investigated.

RESULTS

We sampled 18,359 patients with rectal cancer who underwent elective abdominoperineal resections. Of these, 69.5% had open surgery, 25.8% had laparoscopic surgery, and 4.7% had robotic surgery. The rate of robotic procedures increased >4-fold, from 2.1% to 8.1%, from 2009 to 2012. The conversion rate in robotic surgery was significantly lower compared with laparoscopic surgery (5.7% vs 13.4%; p < 0.01). After risk adjustment, patients who underwent laparoscopic and robotic approaches had lower morbidity risks compared with those who underwent the open approach (adjusted OR = 0.77 (95% CI, 0.65-0.92), 0.57 (95% CI, 0.40-0.80); p < 0. 01). There were no significant differences in the morbidity rate of patients who underwent laparoscopic or robotic approaches (adjusted OR = 0.79 (95% CI, 0.55-1.14); p = 0.21). However, patients who underwent the robotic approach had significantly higher total hospital charges compared with those who underwent the laparoscopic approach (mean difference, $24,890; p < 0.01).

LIMITATIONS

We could not adjust the results with some important factors, such as the tumor stage and BMI.

CONCLUSIONS

The use of robotic and laparoscopic approaches to abdominoperineal resection have increased between 2009 and 2012. Both minimally invasive approaches decrease morbidity rates of patients undergoing abdominoperineal resection. The robotic approach has a significantly lower conversion rate compared with the laparoscopic approach. However, it had significantly higher total hospital charges compared with the laparoscopic approach.

Need for simulation in laparoscopic colorectal surgery training

The dissemination of laparoscopic colorectal surgery (LCS) has been slow despite increasing evidence for the clinical benefits, with a prolonged learning curve being one of the main restrictions for a prompt uptake. Performing advanced laparoscopic procedures requires dedicated surgical skills and new simulation methods designed precisely for LCS have been established: These include virtual reality simulators, box trainers, animal and human tissue and synthetic materials. Studies have even demonstrated an improvement in trainees’ laparoscopic skills in the actual operating room and a staged approach to surgical simulation with a combination of various training methods should be mandatory in every colorectal training program. The learning curve for LCS could be reduced through practice and skills development in a riskfree setting.

Interactive Instrument-Driven Image Display in Laparoscopic Surgery

BACKGROUND

A significant limitation of minimally invasive surgery is dependence of the entire surgical team on a single endoscopic viewpoint. An individualized, instrument-driven image display system that allows all operators to simultaneously define their viewing frame of the surgical field may be the solution. We tested the efficacy of such a system using a modified Fundamentals of Laparoscopic Surgery™ (Society of American Gastrointestinal and Endoscopic Surgeons, Los Angeles, CA) bead transfer task.

MATERIALS AND METHODS

A program was custom-written to allow zooming and centering of the image window on specific color signals, each attached near the tip of a different laparoscopic instrument. Two controls were used for the bead transfer task: (1) a static, wide-angle view and (2) a single moving camera allowing close-up and tracking of the bead as it was transferred. Time to task completion and number of bead drops were recorded.

RESULTS

Thirty-six sessions were performed by surgical residents. Average time for bead transfer was 127.3±21.3 seconds in the Experimental group, 139.1±27.8 seconds in the Control 1 group, and 186.2±18.5 seconds in the Control 2 group (P=.034, by analysis of variance). Paired analysis (the Wilcoxon Signed-Rank Test) showed that the Experimental group was significantly faster than the Control 1 group (P=.035) and the Control 2 group (P=.028).

CONCLUSIONS

We have developed an image navigation system that allows intuitive and efficient laparoscopic performance compared with two controls. It offers high-resolution images and ability for multitasking. The tracking system centers close-up images on the laparoscopic target. Further development of robust prototypes will help transition this in vitro system into clinical application.

Surgical management of rectal prolapse: The role of robotic surgery

The robotic technique as a safe approach in treatment of rectal prolapse has been widely reported during the last decade. Although there is limited clinical data regarding the benefits of robotic surgery, the safety of robotic surgery in rectal prolapse treatment has been cited by several authors. Also, the robotic approach helps overcome some of the laparoscopic approach challenges with purported advantages including improved visualization, more precise dissection, easier suturing, accurate identification of anatomic structures and fewer conversions to open surgery which can facilitate the conduct of technically challenging cases. These advantages can make robotic surgery ideally suited for minimally invasive ventral rectopexy. Currently, with greater surgeon experience in robotic surgery, the length of the procedure and the recurrence rate with the robotic approach are decreasing and short term outcomes for robotic rectal prolapse seem on par with laparoscopic and open techniques in recent studies. However, the high cost of robotic procedures is still an important issue. The benefits of a robotic approach must be weighed against the higher cost. More research is needed to better understand if the increased cost is justified by an improvement in outcomes. Also, published articles comparing long term outcomes of the robotic approach with other approaches are very limited at this time and further clinical trials are indicated to affirm the role of robotic surgery in the treatment of rectal prolapse.

Characterization and in-vivo evaluation of a multi-resolution foveated laparoscope for minimally invasive surgery

The state-of-the-art laparoscope lacks the ability to capture high-magnification and wide-angle images simultaneously, which introduces challenges when both close- up views for details and wide-angle overviews for orientation are required in clinical practice. A multi-resolution foveated laparoscope (MRFL) which can provide the surgeon both high-magnification close-up and wide-angle images was proposed to address the limitations of the state-of-art surgical laparoscopes. In this paper, we present the overall system design from both clinical and optical system perspectives along with a set of experiments to characterize the optical performances of our prototype system and describe our preliminary in-vivo evaluation of the prototype with a pig model. The experimental results demonstrate that at the optimum working distance of 120mm, the high-magnification probe has a resolution of 6.35lp/mm and image a surgical area of 53 × 40mm(2); the wide-angle probe provides a surgical area coverage of 160 × 120mm(2) with a resolution of 2.83lp/mm. The in-vivo evaluation demonstrates that MRFL has great potential in clinical applications for improving the safety and efficiency of the laparoscopic surgery.

Evaluation of the impact of three-dimensional vision on laparoscopic performance

INTRODUCTION

Recent technological advancements have led to the introduction of new three-dimensional (3D) cameras in laparoscopic surgery. The 3D view has been touted as useful during robotic surgery, however, there has been limited investigation into the utility of 3D in laparoscopy.

MATERIALS AND METHODS

We performed a prospective, randomized crossover trial comparing a 0° 3D camera with a conventional 0° two-dimensional (2D) camera using a high definition monitor (Karl Storz, Tuttlingen, Germany). All participants completed six standardized basic skills tasks. Quality testing scores were measured by the number of drops, grasping attempts, and precision of needle entry and exiting. Additionally, resolution, color distribution, depth of field and distortion were measured using optical test targets.

RESULTS

In this pilot study, we evaluated 10 medical students, 7 residents, and 7 expert surgeons. There was a significant difference in the performance in all the six skill tasks, for the three levels of surgical expertise and training levels in 2D vs 3D except for the cut the line quality score and the peg transfer quality score. Adjusting for the training level, 3D camera image results were superior for the number of rings left (p=0.041), ring transfer quality score (p=0.046), thread the rings (no. of rings) (p=0.0004), and thread the rings quality score (p=0.0002). The 3D camera image was also superior for knot tying (quality score) (p=0.004), peg transfer (time in seconds) (p=0.047), peg transfer pegs left (p=0.012), and for peg transfer quality score (p=0.001). The 3D camera system showed significantly less distortion (p=0.0008), a higher depth of field (p=0.0004) compared with the 2D camera system.

CONCLUSION

3D laparoscopic camera equipment results in a significant improvement in depth perception, spatial location, and precision of surgical performance compared with the conventional 2D camera equipment. With this improved quality of vision, even expert laparoscopic surgeons may benefit from 3D imaging.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multiresolution foveated laparoscope with high resolvability

A key limitation of the state-of-the-art laparoscopes for minimally invasive surgery is the tradeoff between the field of view and spatial resolution in a single-view camera system. As such, surgical procedures are usually performed at a zoomed-in view, which limits the surgeon's ability to see much outside the immediate focus of interest and causes a situational awareness challenge. We proposed a multiresolution foveated laparoscope (MRFL) aiming to address this limitation. The MRFL is able to simultaneously capture wide-angle overview and high-resolution images in real time; it can scan and engage the high-resolution images to any subregion of the entire surgical field in analogy to the fovea of human eye. The MRFL is able to render equivalently 10 million pixel resolution with a low data bandwidth requirement. The system has a large working distance (WD) from 80 to 180 mm. The spatial resolvability is about 45 μm in the object space at an 80 mm WD, while the resolvability of a conventional laparoscope is about 250 μm at a typically 50 mm surgical distance.