Telerobotic gastrointestinal surgery: phase 2--safety and efficacy

Impact of innovative technologies on quality and safety in surgery

Technological advancements gradually lead to the revision and transformation of healthcare, training, and research. Surgery is a field of medicine where the collaboration of human resources and the application of innovative technologies could elevate faithfulness and efficiency. The article, exploring the technologies and analyzing them in terms of their reliability, the benefits of performing precision surgeries, the effectiveness in the outcome of surgery with less psychosomatic fatigue, and the improvements in the training process for surgeons, emphasizes the safety and quality that can be achieved. The study was conducted by searching the relevant papers mainly from 2016-2024 using different online databases such as Web of Science, Google Scholar, and PubMed to examine the impact of adopting new technologies in medicine. This paper highlights that the use of innovative technologies in a wide range of surgical procedures could, by adapting interdisciplinary procedures, provide significant results in issues related to safety, quality, reliability, and training.

Transition from open to robotic distal pancreatectomy in a low volume pancreatic surgery country: a single Australian centre experience

BACKGROUND

Advances in technology and techniques have allowed for robotic distal pancreatectomies to be readily performed in patients at high volume centres. This study describes the experience of a single surgeon during the learning curve and transition from open to robotic distal pancreatectomy in Australia, a traditionally low volume pancreatic surgery country.

METHODS

All patients undergoing distal pancreatectomy at an Australian-based tertiary referral centre between 2010 and 2021 were reviewed retrospectively. Demographic, clinicopathologic and survival data were analysed to compare perioperative and oncological outcomes between patients who underwent open, laparoscopic and robotic distal pancreatectomies.

RESULTS

A total of 178 distal pancreatectomies were identified for analysis during the study period. Ninety-one open distal pancreatectomies (ODP), 48 laparoscopic distal pancreatectomies (LDP), and 39 robotic distal pancreatectomies (RDP) were performed. Robotic distal pancreatectomy was non-inferior with respect to perioperative outcomes and yielded statistically non-significant advantages over LDP and ODP.

CONCLUSION

RDP is feasible and can be performed safely in well-selected patients during the learning phase at large pancreatic centres in a traditionally low-volume country like Australia. Referral to large pancreatic centres where access to the robotic platform and surgeon experience is not a barrier, and where a robust multidisciplinary team meeting can take place, remains pivotal in the introduction and transition toward the robotic approach for management of patients with pancreatic body or tail lesions.

Short-term outcomes of intracorporeal and extracorporeal anastomosis in robotic right colectomy: a systematic review and meta-analysis

Ileocolic anastomosis is performed via extracorporeal or intracorporeal techniques in robotic right hemicolectomy. The aim of this meta-analysis was to compare the short-term outcomes of intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) for robotic right colectomy. The EMBASE, PubMed, and Cochrane Library databases were searched systematically (from inception until March 1, 2020) for randomized and non-randomized control trials reporting the short-term outcomes of IA and EA for robotic right colectomy. Five observational cohort studies involving 585 participants were included in our meta-analysis. Compared to the EA group, the IA group showed significantly longer operation time [weighted mean difference (WMD): 28.88, 95% confidence interval (CI) 13.88-43.89, p = 0.0002], lower rate of anastomotic leak (odds ratio: 0.26, 95% CI 0.08-0.85, p = 0.03), and shorter time to first flatus (WMD: - 0.57, 95% CI - 0.95 to 0.19, p = 0.003). However, pooled results revealed no difference in blood loss, complications, wound infection, incisional hernia, length of incision, and hospital stay between the IA and EA groups (p < 0.05). This meta-analysis indicated that IA was superior to EA in terms of anastomotic leak and time to first flatus, but inferior in terms of operation time. Large-scale, multicenter, randomized studies are needed to confirm our findings.

Comparison of pathologic outcomes of robotic and open resections for rectal cancer: A systematic review and meta-analysis

Objective

The application of robotic surgery for rectal cancer is increasing steadily. The purpose of this meta-analysis is to compare pathologic outcomes among patients with rectal cancer who underwent open rectal surgery (ORS) versus robotic rectal surgery (RRS).

Methods

We systematically searched the literature of EMBASE, PubMed, the Cochrane Library of randomized controlled trials (RCTs) and nonrandomized controlled trials (nRCTs) comparing ORS with RRS.

Results

Fourteen nRCTs, including 2711 patients met the predetermined inclusion criteria and were included in the meta-analysis. Circumferential resection margin (CRM) positivity (OR: 0.58, 95% CI, 0.29 to 1.16, P = 0.13), number of harvested lymph nodes (WMD: −0.31, 95% CI, −2.16 to 1.53, P = 0.74), complete total mesorectal excision (TME) rates (OR: 0.93, 95% CI, 0.48 to 1.78, P = 0.83) and the length of distal resection margins (DRM) (WMD: −0.01, 95% CI, −0.26 to 0.25, P = 0.96) did not differ significantly between the RRS and ORS groups.

Conclusion

Based on the current evidence, robotic resection for rectal cancer provided equivalent pathological outcomes to ORS in terms of CRM positivity, number of harvested lymph nodes and complete TME rates and DRM.

Short-term efficacy of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy via Huang's three-step maneuver for advanced upper gastric cancer: Results from a propensity score-matched study

BACKGROUND

Robotic surgery has been considered to be significantly better than laparoscopic surgery for complicated procedures.

AIM

To explore the short-term effect of robotic and laparoscopic spleen-preserving splenic hilar lymphadenectomy (SPSHL) for advanced gastric cancer (GC) by Huang's three-step maneuver.

METHODS

A total of 643 patients who underwent SPSHL were recruited from April 2012 to July 2017, including 35 patients who underwent robotic SPSHL (RSPSHL) and 608 who underwent laparoscopic SPSHL (LSPSHL). One-to-four propensity score matching was used to analyze the differences in clinical data between patients who underwent robotic SPSHL and those who underwent laparoscopic SPSHL.

RESULTS

In all, 175 patients were matched, including 35 patients who underwent RSPSHL and 140 who underwent LSPSHL. After matching, there were no significant differences detected in the baseline characteristics between the two groups. Significant differences in total operative time, estimated blood loss (EBL), splenic hilar blood loss (SHBL), splenic hilar dissection time (SHDT), and splenic trunk dissection time were evident between these groups (P < 0.05). Furthermore, no significant differences were observed between the two groups in the overall noncompliance rate of lymph node (LN) dissection (62.9% vs 60%, P = 0.757), number of retrieved No. 10 LNs (3.1 ± 1.4 vs 3.3 ± 2.5, P = 0.650), total number of examined LNs (37.8 ± 13.1 vs 40.6 ± 13.6, P = 0.274), and postoperative complications (14.3% vs 17.9%, P = 0.616). A stratified analysis that divided the patients receiving RSPSHL into an early group (EG) and a late group (LG) revealed that the LG experienced obvious improvements in SHDT and length of stay compared with the EG (P < 0.05). Logistic regression showed that robotic surgery was a significantly protective factor against both SHBL and SHDT (P < 0.05).

CONCLUSION

RSPSHL is safe and feasible, especially after overcoming the early learning curve, as this procedure results in a radical curative effect equivalent to that of LSPSHL.

Aggregation properties of triamcinolone acetonide injection in human serum: considerations when performing epidural steroid injections

Background

Morbidity has been reported as a sequelae of crystalline steroid epidural steroid injections (ESIs), and particulate steroid size, aggregation, and embolization in brain and spinal cord may be the mechanism related to these neurologic effects.

Objective

The objective of the study was to examine the aggregation properties of triamcinolone acetonide in commonly used local anesthetics with and without human serum.

Setting

This study was conducted in an academic tertiary care center.

Hypothesis

Triamcinolone acetonide shows different aggregation characteristics in serum compared to a non-physiologic solution.

Design

Triamcinolone acetonide was mixed with lidocaine 1% (first group) and bupivacaine 0.5% (second group) in a 1:1 ratio and then mixed with either distilled water (control group) or serum ex vivo. A pathologist blinded to our hypothesis inspected all solutions under light microscopy with 100× and 400× magnifications. Total number of particulate steroid aggregates and the number of particles forming each aggregate (recorded as single,1 double,2 triple,3 quadruple,4 or large [>4} crystals) were counted. Particle size and aggregate size were measured (in μm). The ratios of quadruple to total aggregates, large to total, and quadruple with large to total aggregates were calculated. Steroid-serum solutions and steroid-sterile water were then compared.

Results

Triamcinolone aggregates showed an increased crystal and aggregate size when compared with other steroids. Within the triamcinolone subgroup, the mixture of lidocaine 1% and serum resulted in the largest crystal aggregates.

Limitations

Whole blood analysis may have provided a more physiologically accurate model but was not chosen due to poor microscopic analysis. Serum donor variability may also have affected particle characteristics.

Conclusion

Fewer large triamcinolone aggregates were noted in the presence of serum when compared to the non-serum control groups. However, when compared to previously studied particulate steroids, it had the largest aggregates when added to serum.

Minimally Invasive Approaches for Surgical Management of Primary Liver Cancers

The benefits of minimally invasive approaches in oncologic surgery are increasingly recognized, and laparoscopic liver surgery has become increasingly widespread. In light of the complexity and technical challenges of hepatobiliary procedures, robotic approaches are also employed. The utility, safety, and oncologic integrity of these methods in the management of primary liver cancers are reported. PubMed was used to search the medical literature for studies and articles pertaining to laparoscopic and robotic liver surgery. Studies that particularly addressed hepatocellular carcinoma and cholangiocarcinoma were identified and reviewed. Laparoscopic liver surgery, including for major resections, has been shown to be safe in experienced hands without any compromise of oncologic outcomes for either hepatocellular carcinoma or intrahepatic cholangiocarcinoma. Some studies show improved clinical outcomes including shorter hospital stays and lower complication rates when compared to open surgery, particularly for patients with cirrhosis. Robotic liver surgeries seem to have equally acceptable clinical outcomes; however, there is limited data regarding oncologic integrity and considerable additional expense. Laparoscopic and robotic liver resections are both feasible and safe for the management of primary liver tumors. Future studies should aim to clarify specific indications and optimize applications of these approaches.

Robotic-assisted spleen preserving distal pancreatectomy: a technical review

Minimally-invasive spleen-preserving distal pancreatectomy is indicated for benign or borderline malignant lesions confined to the pancreatic body and tail. With the introduction of the da Vinci robotic system, preliminary case series have suggested an improved spleen preservation rate, higher rate of margin negative resections and improved lymph node yield versus the standard laparoscopic approach. In this article, we described our approach to robotic-assisted distal pancreatectomy with both vessel-conserving (Kimura) and vessel-sacrificing (Warshaw) variations.

Comparison of Perioperative Outcomes between Open, Laparoscopic, and Robotic Distal Pancreatectomy: an Analysis of 1815 Patients from the ACS-NSQIP Procedure-Targeted Pancreatectomy Database

BACKGROUND

Robotic surgery is gaining acceptance for distal pancreatectomy (DP). Nevertheless, no multi-institutional data exist to demonstrate the ideal clinical circumstances for use and the efficacy of the robot compared to the open or laparoscopic techniques, in terms of perioperative outcomes.

METHODS

The 2014 ACS-NSQIP procedure-targeted pancreatectomy data for patients undergoing DP were analyzed. Demographics and clinicopathological and perioperative variables were compared between the three approaches. Univariate and multivariable analyses were used to evaluate outcomes.

RESULTS

One thousand eight hundred fifteen DPs comprised 921 open distal pancreatectomies (ODPs), 694 laparoscopic distal pancreatectomies (LDPs), and 200 robotic distal pancreatectomies (RDPs). The three groups were comparable with respect to demographics, ASA score, relevant comorbidities, and malignant histology subtype. Compared to the ODP group, patients undergoing RDP had lower T-stages of disease (P = 0.0192), longer operations (P = 0.0030), shorter hospital stays (P < 0.0001), and lower postoperative 30-day morbidity (P = 0.0476). Compared to the LDP group, RDPs were longer operations (P < 0.0001) but required fewer concomitant vascular resections (P = 0.0487) and conversions to open surgery (P = 0.0068). On multivariable analysis, neoadjuvant therapy (P = 0.0236), malignant histology (P = 0.0124), pancreatic reconstruction (P = 0.0006), and vascular resection (P = 0.0008) were the strongest predictors of performing an ODP.

CONCLUSIONS

The open, laparoscopic, and robotic approaches to distal pancreatectomy offer particular advantages for well-selected patients and specific clinicopathological contexts; therefore, clearly demonstrating the most suitable use and superiority of one technique over another remains challenging.

Robot-assisted surgery in elderly and very elderly population: our experience in oncologic and general surgery with literature review

BACKGROUND

Although there is no agreement on a definition of elderly, commonly an age cutoff of ≥65 or 75 years is used. Nowadays most of malignancies requiring surgical treatment are diagnosed in old population. Comorbidities and frailty represent well-known problems during and after surgery in elderly patients. Minimally invasive surgery offers earlier postoperative mobilization, less blood loss, lower morbidity as well as reduction in hospital stay and as such represents an interesting and validated option for elderly population. Robot-assisted surgery is a recent improvement of conventional minimally invasive surgery.

AIMS

We provided a complete review of old and very old patients undergoing robot-assisted surgery for oncologic and general surgery interventions.

PATIENTS AND METHODS

A retrospective review of all patients undergoing robot-assisted surgery in our General Surgery Unit from September 2012 to June 2016 was conducted. Analysis was performed for the entire cohort and in particular for three of the most performed surgeries (gastric resections, right colectomy, and liver resections) classifying patients into three age groups: ≤64, 65-79, and ≥80. Data from these three different age groups were compared and examined in respect of different outcomes: ASA score, comorbidities, oncologic outcomes, conversion rate, estimated blood loss, hospital stay, geriatric events, mortality, etc.

RESULTS

Using our in-patient robotic surgery database, we retrospectively examined 363 patients, who underwent robot-assisted surgery for different diseases (402 different robotic procedures): colorectal surgery, upper GI, HPB, etc.; the oncologic procedures were 81%. Male were 56%. The mean age was 65.63 years (18-89). Patients aged ≥65 years represented 61% and ≥80 years 13%. Overall conversion rate was of 6%, most in the group 65-79 years (59% of all conversions). The more frequent diseases treated were colorectal surgery 43%, followed by hepatobilopancreatic surgery 23.4%, upper gastro-intestinal 23.2%, and others 10.4%.

DISCUSSION

Robot-assisted surgery is a safe and effective technique in aging patient population too. There was no increased risk of death or morbidity compared to younger patients in the three groups examined. A higher conversion rate was observed in our experience for patients aged 65-79. Prolonged operative time and in any cases steep positions (Trendelenburg) have not represented a problem for the majority of patients.

CONCLUSIONS

In any case, considering the high direct costs, minimally invasive robot-assisted surgery should be performed on a case-by-case basis, tailored to each patient with their specific histories and comorbidities.

SAGES TAVAC safety and effectiveness analysis: da Vinci ® Surgical System (Intuitive Surgical, Sunnyvale, CA)

BACKGROUND

The da Vinci(®) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is a computer-assisted (robotic) surgical system designed to enable and enhance minimally invasive surgery. The Food and Drug Administration (FDA) has cleared computer-assisted surgical systems for use by trained physicians in an operating room environment for laparoscopic surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic and urologic surgical procedures. There are substantial numbers of peer-reviewed papers regarding the da Vinci(®) Surgical System, and a thoughtful assessment of evidence framed by clinical opinion is warranted.

METHODS

The SAGES da Vinci(®) TAVAC sub-committee performed a literature review of the da Vinci(®) Surgical System regarding gastrointestinal surgery. Conclusions by the sub-committee were vetted by the SAGES TAVAC Committee and SAGES Executive Board. Following revisions, the document was evaluated by the TAVAC Committee and Executive Board again for final approval.

RESULTS

Several conclusions were drawn based on expert opinion organized by safety, efficacy, and cost for robotic foregut, bariatric, hepatobiliary/pancreatic, colorectal surgery, and single-incision cholecystectomy.

CONCLUSIONS

Gastrointestinal surgery with the da Vinci(®) Surgical System is safe and comparable, but not superior to standard laparoscopic approaches. Although clinically acceptable, its use may be costly for select gastrointestinal procedures. Current data are limited to the da Vinci(®) Surgical System; further analyses are needed.

Robotic gastrectomy for gastric cancer

Robotic surgery for gastric cancer overcomes technical difficulties with laparoscopic gastrectomy. Its benefits include reduced intraoperative bleeding and shorter hospital stays; it is also easier to learn. Because accuracy increases during lymphadenectomy, a larger number of lymph nodes is likely to be retrieved using robotic gastrectomy. Higher costs and longer operation times have hindered the widespread adaptation and use of robotic surgery. In this review, we summarize the current status and issues regarding robotic gastrectomy.

State of the art of robotic pancreatic surgery

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

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

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

Distal pancreatectomy: a single institution's experience in open, laparoscopic, and robotic approaches

BACKGROUND

The indications for minimally invasive (MIS) pancreatectomy have slowly increased as experience, techniques, and technology have improved and evolved to manage malignant lesions in selected patients without compromising safety and oncologic principles. There are sparse data comparing laparoscopic, robotic, and open distal pancreatectomy (DP).

STUDY DESIGN

All patients undergoing DP at Memorial Sloan Kettering Cancer Center between 2000 and 2013 were analyzed from a prospective database. Clinicopathologic and survival data were analyzed to compare perioperative and oncologic outcomes in patients who underwent DP via open, laparoscopic, and robotic approaches.

RESULTS

Eight hundred five DP were performed during the study period, comprising 37 robotic distal pancreatectomies (RDP), 131 laparoscopic distal pancreatectomies (LDP), and 637 open distal pancreatectomies (ODP). The 3 groups were similar with respect to American Society of Anesthesiologists (ASA) score, sex ratio, body mass index, pancreatic fistula rate, and 90-day morbidity and mortality. Patients in the ODP group were generally older (p = 0.001), had significantly higher intraoperative blood loss (p < 0.001), and had a trend toward a longer hospital stay (p = 0.05). Of the significant preoperative variables, visceral fat was predictive of conversion on multivariate analysis (p = 0.003). Oncologic outcomes in the adenocarcinoma cases were similar for the 3 groups, with high rates of R0 resection (88% to 100%). The ODP group had a higher lymph node yield than the LDP and RDP groups (15.4, [SD 8.7] vs 10.4 [SD 8.0] vs 12[SD 7.2], p = 0.04).

CONCLUSIONS

The RDP and LDP were comparable with respect to most perioperative outcomes, with no clear advantage of one approach over the other. Both of these MIS techniques may have advantages over ODP in well-selected patients. All approaches achieved a similarly high rate of R0 resection for patients with adenocarcinoma.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Robotic versus open total mesorectal excision for rectal cancer: comparative study of short and long-term outcomes

BACKGROUND

Despite the several series in which the short-term outcomes of robotic-assisted surgery were investigated, data concerning the long-term outcomes are still scarce.

METHODS

The prospectively collected records of 65 consecutive patients with extraperitoneal rectal cancer who underwent robotic total mesorectal excision (RTME) were compared with those of 109 consecutive patients treated with open surgery (OTME). Patient characteristics, pathological findings, local and systemic recurrence rates and 5-year survival rates were compared.

RESULTS

There were no statistically significant differences in postoperative complications, reoperation and 30-day mortality. There were significant differences comparing groups: number of lymph nodes harvested (RTME: 20.1 vs. OTME: 14.1, P < 0.001), estimated blood loss (RTME: 0 vs. OTME: 150 ml, P = 0.003), operation time (RTME: 299.0 vs. OTME: 207.5 min, P < 0.001) and length of postoperative stay (RTME: 6 vs. OTME: 9 days, P < 0.001). The rate of circumferential resection margin involvement and distal resection margin were not statistically different between groups. There were no statistically significant differences at the 5-year follow-up: overall survival, disease-free survival and cancer-specific survival. The cumulative local recurrence rate was statistically lower in the robotic group (RTME: 3.4% vs. OTME: 16.1%, P = 0.024).

CONCLUSION

RTME showed a significant reduction in local recurrence rate and a higher, although not statistically significant, long-term cancer-specific survival with respect to OTME. Prospective randomized studies are needed to confirm or deny significantly better local control rates with robotic surgery.

Robotic abdominal surgery: a Brazilian initial experience

BACKGROUND

Robotic brought to laparoscopy the enrichment of movements, the easy to perform maneuvers and procedures, visualization in three dimensions, and ergonomics for the surgeon.

AIM

To describe Brazilian experience with robotically-assisted abdominal surgery.

METHODS

From July 2008 to April 2010, patients were admitted for abdominal surgery and agreed to being operated with the help of the robot by a trained medical staff. All patients were operated by the same surgical robotic approach. Time required for complete surgery, and console time, were recorded.

RESULTS

Forty-four patients were operated, most for hernial hiatal correction or bariatric surgery. All patients, except one, were discharged in the day after surgery. The only complication was a fistula due to a videolaparoscopic clamping procedure during bariatric surgery. There was no hemorrhage. No re-operation was necessary, neither conversion to laparoscopic or open surgery. Mean surgery time for the whole sample was 249.7 minutes (4.1 hours) and console time was 153.4 minutes (2.5 hours). Patients' blood lost was minimal.

CONCLUSIONS

Robotically assisted abdominal surgery is safe for the patients, with reduced bleeding and acceptable surgical time, and also ergonomic for the surgeons.

Robotic versus open pancreatectomy: a systematic review and meta-analysis

BACKGROUND

Robotic surgery is gaining momentum with advantages for minimally invasive management of pancreatic diseases. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of robotic versus open pancreatectomy.

METHODS

A systematic review of the literature was performed to identify studies comparing robotic pancreatectomy and open pancreatectomy. Postoperative outcomes, intraoperative outcomes, and oncologic safety were evaluated. Meta-analysis was performed using a random-effect model.

RESULTS

Seven studies matched the selection criteria, including 137 (40 %) cases of robotic pancreatectomy and 203 (60 %) cases of open pancreatectomy. None of the included studies were randomized. Overall complication rate was significantly lower in robotic group [risk difference (RD) = -0.12, 95 % confidence interval (CI) -0.22 to -0.01, P = 0.03], as well as reoperation rate (RD = -0.12; CI -0.2 to -0.03, P = 0.006) and margin positivity (RD = -0.18; 95 % CI -0.3 to -0.06, P = 0.003). There was no significant difference in postoperative pancreatic fistula (POPF) incidence and mortality. The median (range) conversion rate was 10 % (0-12 %).

CONCLUSIONS

The results of this meta-analysis suggest that robotic pancreatectomy is as safe and efficient as, if not superior to, open surgery for patients with benign or malignant pancreatic diseases. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.

Robot-assisted spleen-preserving distal pancreatectomy: a single surgeon's experiences and proposal of clinical application

BACKGROUND

Advanced and delicate laparoscopic techniques are usually required for safe and successful laparoscopic spleen-preserving distal pancreatectomy. The unique characteristics of robotic surgical system are thought to be useful for this minimally invasive procedure.

METHODS

From September 2007 to May 2011, patients who underwent robot-assisted, spleen-preserving, distal pancreatectomy for benign and borderline malignant tumors of the pancreas were retrospectively reviewed. Perioperative clinicopathologic surgical outcomes were evaluated.

RESULTS

Twenty-two patients were attempted for robot-assisted, spleen-preserving, distal pancreatectomy, and in 21 patients (95.5 %), the spleen was saved either by splenic vessels conservation (SVC; n = 17, 81 %) or by splenic vessels sacrifice (SVS; n = 4, 19 %). Seven patients were male and 15 were female with a mean age of 43.2 ± 15.2 years. Pathologic diagnosis included MCT in five patients, SCT in five, SPT in four, IPMT in three, NET in three, and other benign conditions in two. The mean operation time was 398.9 ± 166.3 min, but it gradually decreased as experiences were accumulated (Rsq = 0.223, p = 0.023). Intraoperative blood loss was 361.3 ± 360.1 ml, and intraoperative transfusion was required in four patients (18.1 %). A soft diet was given for 1.2 ± 0.4 days, and the length of hospital stay was 7.0 ± 2.4 days postoperatively. Clinically relevant pancreatic fistula was noted in two patients (9.1 %) but was successfully managed conservatively. Most patients (87.5 %) showed patency in conserved both splenic vessels, and only two patients (12.5 %) had partially or completely obliterated in splenic veins in the SVC-SpDP group. Partially impaired splenic perfusion was observed in one patient in the SVS-SpDP group. The perfusion defect area decreased without any clinical symptom after 4 months.

CONCLUSIONS

The robotic surgical system is thought to be beneficial for improving the spleen-preservation rate in laparoscopic distal pancreatectomy. Robot-assisted approach can be chosen for patients who require spleen-preserving distal pancreatectomy.

[Robot technology in the Italian Health-CARE system: cost-efficacy economic analysis]

BACKGROUND

Robotic technology is used in multiple fields of surgery, especially radical prostatectomy in patients with prostate cancer. The purpose of this study was to evaluate the introduction of robotic technology in the Italian Public Heath-care context, from the perspective of the Health Technology Assessment (HTA). An economic analysis that compares the costs and effectiveness of the method was developed. Data were compared with those of the most important international literature, analyzing structural and organizational problems related to the method.

MATERIALS AND METHODS

A systematic review of literature on tertiary literature (Health Technology Assessment reports) and secondary (systematic reviews) published since 2002 was conducted. The review was also conducted on more recent primary literature regarding the clinical effectiveness and the economic analysis in the fields of surgery where Da Vinci robot is most promising.

RESULTS

18 studies were selected out of a total of 65 evaluated. The "Break-Even Point" (BEP) is the minimum number of cases needed to be treated in order to achieve a balance between costs and revenues, below which the system is losing money. It was calculated that the total fixed costs are € 378,000 and variable costs are € 3,810 per surgery. Considering that the current value of DRG (Diagnosis-Related Group) refunded by the public Health-care system is actually € 4,553, the BEP would be achieved performing 508 surgeries, so that the robotic technology does not generate neither profit nor loss.

CONCLUSIONS

It is not possible to demonstrate the superiority of robotic surgery in terms of efficacy. The robotic surgery is safe and effective only if performed by surgical teams with relevant experience. Considering the reported case of an Italian University Hospital with public Health-care system refund, the BEP target of 508 radical prostatectomies could be achieved after a few years. The use of the robot in multiple fields on one hand shortens recovery time costs, but on the other hand increases costs due to organizational issues. The value of the DRG refund does not appear adequate to new robotic technology.

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

BACKGROUND

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

METHODS

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

INCLUSION CRITERIA

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

RESULTS

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

CONCLUSIONS

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

Conservation of Information (COI)

The authors review telemedicine and e-health from an organizational perspective. To evaluate their effectiveness, they review organizational and system theory along with field and laboratory results. Theory of the conservation of information (COI) provides the means to study tradeoffs across space and over time as telemedicine and e-health management make operational decisions for virtual communities users. With the authors’ three case studies, they evaluate COI for telemedicine and e-health networks operating in the state of Georgia. After analyzing the case studies with COI, the authors close with a review of future trends that includes an interaction rate equation, an agent-based model (ABM) using natural selection (machine learning), and a Monte Carlo simulation of return on investments (ROI).

Current status of robot-assisted gastric surgery

In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.

Comparison of surgical performance and short-term clinical outcomes between laparoscopic and robotic surgery in distal gastric cancer

AIMS

The authors aimed to compare the surgical performance and the short-term clinical outcomes of robotic assisted laparoscopic distal gastrectomy (RADG) with laparoscopy-assisted distal gastrectomy (LADG) in distal gastric cancer patients.

METHOD

From April 2009 to August 2010, 62 patients underwent LADG and 30 patients underwent RADG for preoperative stage I distal gastric cancer by one surgeon at the National Cancer Center, Korea. Surgical performance was measured using lymph node (LN) dissection time and number of retrieved LNs, which were viewed as surrogates of technical ease and oncologic quality.

RESULTS

In clinicopathologic characteristics, mean age, depth of invasion and stage were significantly different between the LADG and RADG group. Mean dissection time at each LN station was greater in the RADG group, but no significant intergroup difference was found for numbers of retrieved LNs. Furthermore, proximal resection margins were smaller, and hospital costs were higher in the RADG group. In terms of the RADG learning curve, mean LN dissection time was smaller in the late RADG group (n = 15) than in the early RADG group (n = 15) for 4sb/4d, 5, 7-12a stations, but numbers of retrieved LNs per station were similar.

CONCLUSION

With the exception of operating time and cost, the numbers of retrieved LNs and the short-term clinical outcomes of RADG were found to be comparable to those of LADG, despite the surgeon's familiarity with LADG and lack of RADG experience. Further studies are needed to evaluate objectively ergonomic comfort and to quantify the patient benefits conferred by robotic surgery.

Conventional laparoscopic and robot-assisted spleen-preserving pancreatectomy: does da Vinci have clinical advantages?

BACKGROUND

Function-preserving minimally invasive pancreatectomy is thought to be an ideal approach for pancreatic benign and borderline malignant lesions requiring pancreatectomy. However, it is not that easy to accomplish this goal with the conventional laparoscopic approach. It requires extensive surgeon experience and learned techniques. A robot surgical system was recently introduced to overcome these limitations and it may potentially provide precise and safe laparoscopic surgery.

METHODS

Between March 2006 and July 2010, a total of 45 patients underwent laparoscopic or robot-assisted pancreatectomy performed by a single pancreatic surgeon to preserve the spleen. Twenty-five patients underwent the conventional laparoscopic approach (Lap group) and the other 20 patients underwent robot-assisted surgery (Robot group). The perioperative clinicopathologic variables (age, gender, length of resected pancreas, tumor size, tumor location, amount of bleeding, operation time, length of hospital stay, complications, mortality, and cost) were compared between the two groups, as well as the spleen preservation rate.

RESULTS

Younger patients preferred robot-assisted surgery to conventional laparoscopic surgery (44.5±15.9 vs. 56.7±13.9 years, p=0.010), and the mean operation time was longer in the Robot group (258.2±118.6 vs. 348.7±121.8 min, p=0.016). The spleen-preserving rate of the Robot group was considerably superior to that of the Lap group (fail/success, 9/16 vs. 1/19, p=0.027). However, robot surgery cost the patients about USD 8,300 (USD 8,304.8±870.0), which was more than twice the amount for the Lap group (USD 3,861.7±1,724.3). There were no significant differences in other clinicopathologic variables.

CONCLUSION

Robot-assisted pancreatic surgery could provide an increased chance for spleen preservation in spite of higher cost and longer operation time. More experiences are needed to specifically address the role of robot surgery in the advanced laparoscopic era.

Initial experience with robot-assisted modified radical neck dissection for the management of thyroid carcinoma with lateral neck node metastasis

BACKGROUND

Since the introduction of endoscopic techniques in thyroid surgery, several trials of endoscopic lateral neck dissection have been conducted with the aim of avoiding a long cervical scar, but these endoscopic procedures require more effort than open surgery, mainly because of the relatively nonsophisticated instruments used. However, the recent introduction of surgical robotic systems has simplified the operations and increased the precision of endoscopic techniques. We have described our initial experience with robot-assisted modified radical neck dissection (MRND) in thyroid cancer using the da Vinci S system.

METHODS

From October 2007 to October 2009, 33 patients with thyroid cancer with lateral neck lymph node (LN) metastases underwent robot-assisted thyroidectomy and additional robotic MRND using a gasless, transaxillary approach. Clinicopathologic data were analyzed retrospectively.

RESULTS

Mean patient age was 37 ± 9 years and the gender ratio (male to female) was 7:26. The mean operating time was 281 ± 41 minutes and mean postoperative hospital stay was 5.4 ± 1.6 days. The mean tumor size was 1.1 ± 0.5 cm and 20 cases (61%) had papillary thyroid microcarcinoma. The mean number of retrieved LNs was 6.1 ± 4.4 in the central neck compartment and 27.7 ± 11.0 in the lateral compartment. No serious postoperative complications, such as Horner's syndrome or major nerve injury, occurred.

CONCLUSION

Robot-assisted MRND is technically feasible, safe, and produces excellent cosmetic results. Based on our initial experience, robot-assisted MRND should be viewed as an acceptable alternative method in patients with low-risk, well-differentiated thyroid cancer with lateral neck node metastasis.

Robotic versus laparoscopic resection of liver tumours

BACKGROUND

There are scant data in the literature regarding the role of robotic liver surgery. The aim of the present study was to develop techniques for robotic liver tumour resection and to draw a comparison with laparoscopic resection.

METHODS

Over a 1-year period, nine patients underwent robotic resection of peripherally located malignant lesions measuring <5 cm. These patients were compared prospectively with 23 patients who underwent laparoscopic resection of similar tumours at the same institution. Statistical analyses were performed using Student's t-test, χ(2) -test and Kaplan-Meier survival. All data are expressed as mean ± SEM.

RESULTS

The groups were similar with regards to age, gender and tumour type (P= NS). Tumour size was similar in both groups (robotic -3.2 ± 1.3 cm vs. laparoscopic -2.9 ± 1.3 cm, P= 0.6). Skin-to-skin operative time was 259 ± 28 min in the robotic vs. 234 ± 17 min in the laparoscopic group (P= 0.4). There was no difference between the two groups regarding estimated blood loss (EBL) and resection margin status. Conversion to an open operation was only necessary in one patient in the robotic group. Complications were observed in one patient in the robotic and four patients in the laparoscopic groups. The patients were followed up for a mean of 14 months and disease-free survival (DFS) was equivalent in both groups (P= 0.6).

CONCLUSION

The results of this initial study suggest that, for selected liver lesions, a robotic approach provides similar peri-operative outcomes compared with laparoscopic liver resection (LLR).

The evolution of robotic general surgery

Surgical robotics in general surgery has a relatively short but very interesting evolution. Just as minimally invasive and laparoscopic techniques have radically changed general surgery and fractionated it into subspecialization, robotic technology is likely to repeat the process of fractionation even further. Though it appears that robotics is growing more quickly in other specialties, the changes digital platforms are causing in the general surgical arena are likely to permanently alter general surgery. This review examines the evolution of robotics in minimally invasive general surgery looking forward to a time where robotics platforms will be fundamental to elective general surgery. Learning curves and adoption techniques are explored. Foregut, hepatobiliary, endocrine, colorectal, and bariatric surgery will be examined as growth areas for robotics, as well as revealing the current uses of this technology.

Robotic thyroid surgery using a gasless, transaxillary approach and the da Vinci S system: the operative outcomes of 338 consecutive patients

BACKGROUND

Recently, robotic technology in the surgical area has gained wide popularity. However, in the filed of head and neck surgery, the applications of robotic instruments are problematic owing to spatial and technical limitations. The authors performed robot-assisted endoscopic thyroid operations in consecutive thyroid tumor patients using the newly introduced da Vinci S surgical system. Herein the authors describe the technique used and its utility for the operative management of thyroid tumors.

METHODS

From October 2007 to November 2008, 338 patients underwent robot-assisted endoscopic thyroid operations using a gasless, transaxillary approach. All procedures were successfully completed without conversion to an open procedure. Patient's clinicopathologic characteristics, operation types, operation times, the learning curve, and postoperative hospital stays and complications were evaluated.

RESULTS

The mean patient age was 40 years (range, 16-69) and the male to female ratio was 1:16.8. Two hundred and thirty-four patients underwent less than total and 104 underwent bilateral total thyroidectomy. Ipsilateral central compartment node dissection was conducted in all malignant cases. Mean operation time was 144.0 minutes (range, 69-347) and mean postoperative hospital stay was 3.3 days (range, 2-7). No serious postoperative complication occurred; there were 3 cases of recurrent laryngeal nerve injury and 1 of Horner's syndrome.

CONCLUSION

Our technique of robotic thyroid surgery using a gasless, transaxillary approach is feasible and safe in selected patients with a benign or malignant thyroid tumor.

Current status of robotic assisted pelvic surgery and future developments

AIMS

The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems.

MATERIALS AND METHODS

We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery.

RESULTS

During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome.

CONCLUSIONS

Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.

Robot-assisted endoscopic surgery for thyroid cancer: experience with the first 100 patients

BACKGROUND

Various robotic surgical procedures have been performed in recent years, and most reports have proved that the application of robotic technology for surgery is technically feasible and safe. This study aimed to introduce the authors' technique of robot-assisted endoscopic thyroid surgery and to demonstrate its applicability in the surgical management of thyroid cancer.

METHODS

From 4 October 2007 through 14 March 2008, 100 patients with papillary thyroid cancer underwent robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach. This novel robotic surgical approach allowed adequate endoscopic access for thyroid surgeries. All the procedures were completed successfully using the da Vinci S surgical robot system. Four robotic arms were used with this system: a 12-mm telescope and three 8-mm instruments. The three-dimensional magnified visualization obtained by the dual-channel endoscope and the tremor-free instruments controlled by the robotic systems allowed surgeons to perform sharp and precise endoscopic dissections.

RESULTS

Ipsilateral central compartment node dissection was used for 84 less-than-total and 16 total thyroidectomies. The mean operation time was 136.5 min (range, 79-267 min). The actual time for thyroidectomy with lymphadenectomy (console time) was 60 min (range, 25-157 min). The average number of lymph nodes resected was 5.3 (range, 1-28). No serious complications occurred. Most of the patients could return home within 3 days after surgery.

CONCLUSIONS

The technique of robot-assisted endoscopic thyroid surgery using a gasless transaxillary approach is a feasible, safe, and effective method for selected patients with thyroid cancer. The authors suggest that application of robotic technology for endoscopic thyroid surgeries could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid cancer.

Robot-assisted laparoscopic total and partial gastric resection with D2 lymph node dissection for adenocarcinoma

BACKGROUND

Lymph node dissection and esophageal anastomosis, considered the more demanding steps of laparoscopic gastrectomy for gastric adenocarcinoma, can be performed with the use of a remote-controlled robot.

METHODS

Thirteen patients with a histologically proved gastric cancer (six stage I, six stage II, and one stage III) were enrolled in a prospective study to assess feasibility and safety of the Da Vinci surgical system in total and partial gastrectomy with extended lymph node dissection. Outcome measures were conversion rate, intra- and postoperative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested, and macroscopic and microscopic evaluation of resection margins.

RESULTS

Eight distal, four total, and one proximal laparoscopic gastrectomies were completed without conversion. Extended lymph node dissection, and esophagojejunal and esophagogastric anastomoses were successfully carried out using the da Vinci System. Mean operative time was 286 +/- 32.6 min and blood loss was 103 +/- 87.5 ml. Mean number of nodes retrieved was 28.1 +/- 8.3 and all resection margins were negative. There was no mortality. Trocar bleeding requiring laparoscopy was the only major complication encountered. No recurrence occurred during a mean follow-up time of 12.2 +/- 4.5 months.

CONCLUSIONS

Robot-assisted laparoscopic lymph node dissection and esophageal anastomosis are feasible and safe. Longer follow-up time and randomized studies are needed to evaluate long-term outcome and clinical advantages of this new technology.

Laparoscopic robotic-assisted gastrointestinal surgery: the Geneva experience

The continuing development of robotic surgery supports its use in laparoscopic gastrointestinal surgery. Our study retrospectively reviewed the surgical outcome and patient's satisfaction of gastrointestinal laparoscopic robotic procedures. From January 2003 to September 2007, 94 patients (27 women, 67 men) with a mean age of 53 years (range 19-84 years) underwent laparoscopic surgery with a da Vinci robotic system. There were 40 colorectal cases (43%), 31 anti-reflux surgery cases (33%) and 14 obesity surgery cases (15%); the remaining cases consisted of gastric and gallbladder surgery, intra-abdominal tumour excisions, and hepatic cyst resections. The majority of the cases (88, 94%) were performed for benign disease. The mean operative time was 153 min (range 60-330 min). One patient needed a blood transfusion. The mean body mass index was 25 (range 16-47). No death occurred. Five cases (5.3%) were converted to conventional laparoscopic surgery (n = 3) or to laparotomy (n = 2). Morbidity consisted of one Nissen redo surgery to loosen a tight anti-reflux valve 6 days after robotic surgery, a robotic left ureter repair and pelvic haemorrhage following proctectomy requiring re-operation to control haemostasis and to remove pelvic haematoma. Mean follow-up time was 11 months (range 15 days to 34 months). One case of incisional trocar hernia needed re-operation. Overall patient's satisfaction was high: few scars were cheloïd, while functional surgical outcome was rated high by most of the patients. Our preliminary experience was encouraging, with minimal morbidity and very high acceptance by patients.