Telesurgery. Remote monitoring and assistance during laparoscopy

Comparison of Mortality and Postoperative Complications Between Open and Laparoscopic Repair of Perforated Peptic Ulcer: An Umbrella Review

Background: Perforated peptic ulcer (PPU) is one of the common complications of peptic ulcers. Open repair (OR) is the traditional surgical treatment for this condition, but with advances in laparoscopic and minimally invasive surgery, laparoscopic repair (LR) has gained popularity. Many studies have compared the effectiveness of OR vs. LR for PPU. However, the superiority of one method over the other remains a topic of debate. We conducted this review to investigate the advantages and disadvantages of LR over OR. Methods: PubMed, Scopus, Google Scholar, and Web of Science were searched from 2000 to 2022 for systematic reviews and meta-analyses comparing OR and LR for PPU. Previous studies included seven postoperative outcomes, including mortality, reoperation, postoperative ileus, intra-abdominal abscess, leakage, pneumonia, and wound infection. Two researchers independently extracted data and assessed the quality of the eligible studies using the AMSTAR 2 tool. Results: Five systematic reviews and meta-analyses were included, involving 36 studies. The pooled estimate showed that the risks for mortality, postoperative ileus, and wound infection were significantly lower with LR. In comparison, the risks for reoperation and leakage were less with OR. Based on the pooled estimate, no significant relationship was noted between the surgical method and intraabdominal abscess or postoperative pneumonia. Conclusion: Evidence suggests that in stable patients with PPU, LR is better than OR in terms of mortality. However, more high-quality evidence is needed to determine which is more appropriate for different circumstances (e.g., unstable or high-risk patients).

Narrative review of telemedicine consultation in medical practice

BACKGROUND

The use of telemedicine has grown across several medical fields, due to the increasing number of "e-patients".

OBJECTIVE

This narrative review gives an overview of the growing use of telemedicine in different medical specialties, showing how its use can improve medical care.

METHODS

A PubMed/Medline, Embase, Web of Science, and Scopus search was performed using the following keywords: telemedicine, teleconsultation, telehealth, e-health, and e-medicine. Selected papers from 1996 to 2014 were chosen on the basis of their content (quality and novelty).

RESULTS

Telemedicine has already been applied to different areas of medical practice, and it is as effective as face-to-face medical care, at least for the diagnosis and treatment of some pathological conditions.

CONCLUSION

Telemedicine is time- and cost-effective for both patients and health care professionals, encouraging its use on a larger scale. Telemedicine provides specialist medical care to patients who have poor access to hospitals, and ensures continuity of care and optimal use of available health resources. The use of telemedicine opens new perspectives for patients seeking a medical second opinion for their pathology, since they can have remote access to medical resources that would otherwise require enormous costs and time.

Pediatric robotic surgery: early assessment

OBJECTIVES

This article reviews the evidence regarding the feasibility, safety, benefits, limitations, and costs of robotically assisted surgery in children, evaluates how the technology compares with other pediatric surgical techniques, and provides insights about the near and more-distant future of the technology.

METHODS

The peer-reviewed medical pediatric literature was searched for studies that provided evidence of the feasibility and safety of robotic surgery in children and for studies that compared pediatric robotic surgery with conventional laparoscopic surgery or open surgery.

RESULTS

A total of 8 case series and 5 studies comparing robotic surgery with open or conventional laparoscopic surgery met the selection criteria for review. A few small studies that focused on rare complex surgical procedures also were reviewed. All studies were designed to evaluate the feasibility and safety of robotic surgery in children. None of the studies was randomized, and some studies had a retrospective design. These studies demonstrated that a number of routine, robotically assisted, laparoscopic and thoracic procedures were feasible and safe when performed by surgeons experienced in the technique, although robotic surgery did not provide superior outcomes, compared with traditional laparoscopic and open surgery. The advantages of the robotic system were best seen in complex procedures that involved areas that were difficult to access and in procedures in which dissection of delicate, anatomic structures was required.

CONCLUSIONS

Robotic surgery is feasible and safe for a number of pediatric surgical procedures, but evidence that it offers better clinical outcomes than conventional open or laparoscopic techniques is lacking.

Telementoring for minimally invasive surgical training by wireless robot

Hands-on training courses with local mentoring are excellent educational tools in laparoscopic surgery; however, the need for the physical presence of specialized instructors represents a limitation because of costs, time, and geographic constraints. Remote robotic telementoring using a wireless videoconferencing mobile robot could represent an alternative to local instruction. The authors compare local active and passive mentoring with remote robotic telementoring using the wireless RP-6 Robot that worked through a WiFi 802.11b connection during a hands-on laparoscopic training session. Surgeons were mentored once in France from the United States. Robot mentoring was well received and appreciated (assessment score of 2.65; scale, 0 to 4). There was no statistical difference in the different mentoring sessions (active, passive, and remote). Mobile wireless robot is a valuable tool in laparoscopic telementoring. Robotic-assisted telementoring may not replace onsite mentoring, but it may enhance educational opportunities and the quality of hands-on training courses by implementing tutoring with expert assistance from remote locations.

Robotics in urologic surgery: an evolving new technology

Rapid technological developments in the past two decades have produced new inventions such as robots and incorporated them into our daily lives. Today, robots perform vital functions in homes, outer space, hospitals and on military instillations. The development of robotic surgery has given hospitals and health care providers a valuable tool that is making a profound impact on highly technical surgical procedures. The field of urology is one area of medicine that has adopted and incorporated robotic surgery into its armamentarium. Innovative robotic urologic surgical applications and techniques are being developed and reported everyday. Increased utilization and development will ultimately fuel the discovery of newer applications of robotic systems in urologic surgery. Herein we provide an overview of the history, development, and applications of robotics in surgery with a focus on urologic surgery.

New Technology for Imaging and Documenting Urologic Procedures

Recent advances in fiber optics and digital technology have dramatically improved the ability of the urologic surgeon to accurately image and document endoscopic and laparoscopic procedures. In addition, the development of digital endoscopes has expanded the armamentarium of the endoscopic surgeon greatly. Finally, new virtual reality technology has allowed increased visualization during surgery and provides excellent training for surgeons. This article details new imaging and documentation technology currently utilized during urologic procedures.

A randomized controlled trial of human versus robotic and telerobotic access to the kidney as the first step in percutaneous nephrolithotomy

OBJECTIVE

We present results from the first randomized controlled trial of human vs. telerobotic access to the kidney during percutaneous nephrolithotomy.

METHODS

To compare (a) human with robotic percutaneous needle access and (b) local robotic with trans-Atlantic robotic percutaneous needle access, we used a validated kidney model into which a needle was inserted 304 times. Half the insertions were performed by a robotic arm and the other half by urological surgeons. Order was decided randomly except for a sub-group of 30 trans-Atlantic robotic procedures that were controlled by a team at Johns Hopkins, Baltimore, via four ISDN lines.

RESULTS

All attempts were successful within three passes with a median time of 35 s for human attempts compared with a median of 57 s for robotic attempts. The robot was slower than the human to complete insertions (p < 0.001, Mann-Whitney U test), but was more accurate when compared with human operators as it made fewer attempts (88% robotic vs. 79% human first attempt success; p = 0.046, chi-squared test). Times for trans-Atlantic robotic needle insertion (median = 59 s) were comparable to times taken for local robotic needle insertion (median = 56 s) with no difference in accuracy.

CONCLUSION

Telerobotics is an accurate and feasible tool for future minimally invasive surgery.

The impact of latency on surgical precision and task completion during robotic-assisted remote telepresence surgery

OBJECTIVE

It has been suggested that robotic-assisted remote telepresence surgery with a signal transmission latency of greater than 300 ms may not be possible.

METHODS

We evaluated the impact of four different latencies of up to 500 ms on task completion and error rate in five surgeons after completion of three different surgical tasks.

RESULTS

The surgeons were able to complete all tasks with a latency of 500 ms. However, higher latency was associated with higher error rates and task completion time (TCT). There were significant variations between surgeons and different tasks.

CONCLUSION

Surgeons are able to complete tasks with a signal transmission latency of up to 500 ms. The clinical impact of slower TCT and increased error rates encountered at higher latency needs to be established.

Robotic Assistant for Laparoscopy

BACKGROUND

With the advent of technologies allowing for wider application of minimally invasive surgeries, the integration of telerobotics for mentoring by a surgeon at a remote site will make it possible to include a wider audience in surgical consultations and collaboration.

MATERIALS AND METHODS

Two surgery research fellows performed 8 laparoscopic cholecystectomies each in a swine model, as the animate portion of the study. Using the Zeus robotic system, a senior surgeon participated as a robotic assistant and consulted remotely. Teleconsultation was achieved using Hermes voice-activated software to display an on-screen pointer highlighting significant anatomic structures. To clarify the workspace space constraints on the robotic arms, an inanimate study was conducted to carry out retrieval, delivery, and complex object movement.

RESULTS

All the laparoscopic cholecystectomies were completed successfully, with minimal blood loss and no complications. The robotic assistant surgeon participated in all surgeries and instructed on anatomical landmarks. The robotic tools were at a disadvantage due to the radius of movement. The simpler tasks were easier to complete than the complex movement, which required bimanual coordination.

CONCLUSION

This study confirms the feasibility of integrating robotics as a surgical assistant and to consult distant audiences by a single senior surgeon. Incorporating remote access assistance and education capacities extends the limits of physical restrictions in completing surgical procedures safely.

Prospective evaluation of remote, interactive videoconferencing to enhance urology resident education: the genitourinary teleteaching initiative

PURPOSE

Changes in referral patterns and resource allocation into Centers of Excellence affect the educational experience of urology trainees by altering resident exposure to patients and clinicians, especially at sites where subspecialty deficiencies exist. Access to educators at Centers of Excellence using interactive videoconferencing technology may facilitate residency training objectives and enhance trainees' overall educational experience. We prospectively evaluated the implementation of this technology at tertiary care teaching centers to enhance urology resident education.

MATERIALS AND METHODS

Using videoconferencing technology, urology residents at the University of Western Ontario (London, Canada) participated in a series of didactic, interactive pediatric urology teleteaching seminars. These were presented by an expert pediatric urologist from the Hospital for Sick Children, Toronto, Canada. Using a 5-point Likert scale (1-strongly disagree, 5-strongly agree), participants responded to statements pertaining to seminar content, technology and ease of use at the completion of each session. The results were subsequently tabulated and evaluated to determine the effectiveness and accessibility of the program in providing expert pediatric urological education to residents at a remote urology training program.

RESULTS

The entire urology resident staff from postgraduate year 1 to 5 participated in the seminar program. The overall acceptance of this medium was high (mean score 4.5). The quality of presentation, as well as picture and sound quality, all received mean scores greater than 4. Participants indicated that their ability to interact with the presenter was not inhibited by using this medium. All participants agreed that they would use this technology in the future (mean score 4.5) and that the presentation would not be improved if the presenter were on-site. Due to preexisting technology at both centers, no direct cost was incurred throughout the study.

CONCLUSIONS

Our experience suggests that interactive teleteaching using readily available, existing technology, is a cost-effective and accepted method of providing trainees with an appropriate educational experience. In centers where subspecialty deficiencies exist, this medium may provide residents with the necessary education requirements of their respective programs without the need for costly teacher (or student) travel. Continual improvements in technology as well as the addition of multiple sites will increased this medium's impact in the future.

Remote presence proctoring by using a wireless remote-control videoconferencing system

Remote presence in an operating room to allow an experienced surgeon to proctor a surgeon has been promised through robotics and telesurgery solutions. Although several such systems have been developed and commercialized, little progress has been made using telesurgery for anything more than live demonstrations of surgery. This pilot project explored the use of a new videoconferencing capability to determine if it offers advantages over existing systems. The video conferencing system used is a PC-based system with a flat screen monitor and an attached camera that is then mounted on a remotely controlled platform. This device is controlled from a remotely placed PC-based videoconferencing system computer outfitted with a joystick. Using the public Internet and a wireless router at the client site, a surgeon at the control station can manipulate the videoconferencing system. Controls include navigating the unit around the room and moving the flat screen/camera portion like a head looking up/down and right/left. This system (InTouch Medical, Santa Barbara, CA) was used to proctor medical students during an anatomy class cadaver dissection. The ability of the remote surgeon to effectively monitor the students' dissections and direct their activities was assessed subjectively by students and surgeon. This device was very effective at providing a controllable and interactive presence in the anatomy lab. Students felt they were interacting with a person rather than a video screen and quickly forgot that the surgeon was not in the room. The ability to move the device within the environment rather than just observe the environment from multiple fixed camera angles gave the surgeon a similar feel of true presence. A remote-controlled videoconferencing system provides a more real experience for both student and proctor. Future development of such a device could greatly facilitate progress in implementation of remote presence proctoring.

Establishment of the world's first telerobotic remote surgical service: for provision of advanced laparoscopic surgery in a rural community

OBJECTIVE

To establish a telerobotic surgical service between a teaching hospital and a rural hospital for provision of telerobotic surgery and assistance to aid rural surgeons in providing a variety of advanced laparoscopic surgery to their community patients.

SUMMARY BACKGROUND DATA

The above service was established between St. Joseph's Hospital in Hamilton and North Bay General Hospital 400 km north of Hamilton on February 28, 2003. The service uses an IP-VPN (15 Mbps of bandwidth) commercially available network to connect the robotic console in Hamilton with 3 arms of the Zeus-TS surgical system in North Bay.

RESULTS

To date, 21 telerobotic laparoscopic surgeries have taken place between North Bay and Hamilton, including 13 fundoplications, 3 sigmoid resections, 2 right hemicolectomies, 1 anterior resection, and 2 inguinal hernia repairs. The 2 surgeons were able to operate together using the same surgical footprint and interchange roles seamlessly when desired. There have been no serious intraoperative complications and no cases have had to be converted to open surgeries. The mean hospital stays were equivalent to mean laparoscopic LOS in the tertiary institution.

CONCLUSIONS

Telerobotic remote surgery is now in routine use, providing high-quality laparoscopic surgical services to patients in a rural community and providing a superior degree of collaboration between surgeons in teaching hospitals and rural hospitals. Further refinement of the robotic and telecommunication technology should ensure its wider application in the near future.

Overview and fundamentals of urologic robot-integrated systems

Advances in technology have revolutionized urology. Minimally invasive tools now form the core of the urologist's armamentarium. Laparoscopic surgery has become the favored approach for treating many complicated urologic ailments. Surgical robots represent the next evolutionary step in the fruitful man-machine partnership. The introduction of robotic technology in urology changes how urologists learn, teach, plan, and operate. As technology evolves, robots not only will improve performance in minimally invasive procedures, but also enhance other procedures or enable new kinds of operations.

Effects of latency on telesurgery: an experimental study

The paper is concerned with determining the feasibility of performing telesurgery over long communication links. It describes an experimental testbed for telesurgery that is currently available in our laboratory. The tesbed is capable of supporting both wired and satellite connections as well as simulated network environments. The feasibility of performing telesurgery over a satellite link with approximately 600 ms delay is shown through a number of dry and wet lab experiments. Quantative results of these experiments are also discussed.

Telerounding and patient satisfaction after surgery

BACKGROUND

Technologic advances in communications have facilitated the development and diffusion of telemedicine. Most applications have focused on remote outpatient management of medical conditions. We assessed the impact of introducing remote video conferencing during the immediate postoperative period (telerounds) on patient-reported satisfaction with their hospitalization.

STUDY DESIGN

Between October 2002 and June 2003,85 patients undergoing elective laparoscopic or percutaneous urologic procedures were enrolled in a trial testing the impact of telerounds on patients' satisfaction with their hospitalization. Participants were entered into one of three postoperative care arms: standard once-daily attending bedside rounds; standard once-daily attending level bedside rounds plus one afternoon telerounding visit; or a substitution of one daily bedside round with a robotic telerounding visit. Participants completed a validated patient satisfaction survey 2 weeks after hospital discharge.

RESULTS

Eighty-five individuals (100% response rate) completed the questionnaire. With responses dichotomized to "excellent" or "other," patients in the telerounding arm demonstrated statistically substantial improvements in ratings of examination thoroughness, quality of discussions about medical information, postoperative care coordination, and attending physician availability. Patients in the robotic telerounding arm indicated considerably higher satisfaction with regard to physician availability. After adjusting for age differences, ratings of each of the previously listed aspects of care remained notably improved in the telerounding arm.

CONCLUSIONS

Telerounding either as an additional visit or as a substituted bedside visit is associated with increased patient satisfaction in postoperative care. This type of interaction appears to acceptably facilitate physician communication with hospitalized patients.

Role of robotics in laparoscopic urologic surgery

Robotic surgery is in its infancy. Small series of cases are emerging from various centers that indicate a strong role for robotics in the future of urology, surgery, and general medicine. Robotic technology is progressing on every level and will continue to be a driving force in the progress of science and medicine.

Robot-assisted laparoscopic cholecystectomy: initial Mayo Clinic Scottsdale experience

OBJECTIVE

To review a single institution's experience with robot-assisted laparoscopic cholecystectomy.

PATIENTS AND METHODS

We reviewed retrospectively all cholecystectomies performed with the assistance of a surgical robot at the Mayo Clinic in Scottsdale, Ariz, from October 2002 to July 2003. Cholanglograms were obtained intraoperatively for patients with elevated results on liver function tests. The gallbladder was removed by the surgeon with the use of the robot. A surgical assistant at the operating table exchanged instruments in the robot arms and applied clips when needed. Total operating time, assembly time of the robot, complications, and postoperative course were evaluated.

RESULTS

Nineteen patients underwent robot-assisted laparoscopic cholecystectomy; 16 had symptomatic cholelithiasis, 2 had gallbladder polyps, and 1 had acute cholecystitis. Of the 19 surgeries, 16 were completed successfully with robotic assistance. In 3 consecutive patients, a mechanical problem occurred with the robot; however, all procedures were completed laparoscopically. The mean set-up time, including patient positioning and preparation and robotic installation, was 28.1 minutes. The mean +/- SD operating time was 82.3+/-17.9 minutes without a cholanglogram and 102+/-20.9 minutes with a cholanglogram. There were no complications and no conversions to an open procedure.

CONCLUSION

Robotic surgery offers many potential advantages, including surgeon comfort, elimination of surgeon tremor, improved imaging, and increased degrees of freedom of the operative Instruments, compared with conventional laparoscopic surgery. However, patient outcomes and operative costs need to be evaluated further.

Hand assisted laparoscopic training for postgraduate urologists: the role of mentoring

PURPOSE

Hand assisted laparoscopy (HAL) has recently been accepted as a safe alternative for nephrectomy. HAL courses have been offered at several institutions to train novice laparoscopic surgeons in this minimally invasive surgical procedure. Mentoring by a course instructor or an experienced laparoscopist provides assistance to surgeons with their initial operation. However, to our knowledge the impact of mentoring on the clinical practice of HAL is not known. Therefore, we evaluated the clinical practice patterns of urologists following a postgraduate HAL course, comparing course graduates who underwent subsequent mentoring with those who were not mentored.

MATERIALS AND METHODS

A total of 71 urologists attended a postgraduate training course in HAL at our institution between March 2002 and October 2002. Graduates were given the opportunity for one of the instructors to travel to their home institution and mentor them during their initial case(s). Followup surveys were mailed to the graduates in March 2003 to evaluate their practice patterns. Responses from returned surveys were entered into a dedicated database and data analysis was performed.

RESULTS

Of the 71 surveys mailed 56 were returned (79%). The majority of respondents (91%) described themselves as community based general urologists. Respondents were categorized into 1 of 2 groups, namely group 1-those who had mentoring by a course instructor (23.2%) or another experienced laparoscopist (30.4%) and group 2-those who were not mentored (46.4%). The majority of group 1 respondents (93%) reported that they were still performing laparoscopic procedures at 6 months of followup. However, only 44% of the surgeons in group 2 were performing laparoscopy at 6 months. The majority of surgeons in group 1 (72%) reported that their laparoscopic experience had been sufficient to maintain their expertise compared to only 42% in group 2.

CONCLUSIONS

Mentoring provides a useful adjunct to postgraduate urological training and the integration of laparoscopic techniques into the community based practice of urology.

The telecommunication revolution in the medical field: present applications and future perspective

In the present review, we analyze the achievements of telecommunication innovations in the medical field focusing on patient care and medical-education aspects. In this regard, the telecommunication revolution has offered medical professionals the possibility to transmit information of any sort zeroing transmission time latency and annihilating spatial distances. Although telemedicine is still in its infancy, multiple applications of this science have already been successfully tested. As an example, robotically mediated telesurgery has it made possible for surgeons to operate standing at a considerable distance from the operating table without even touching or directly seeing the surgical field. Moreover, medical education and medical consulting have acquired new and wider ranges of applicability thanks to the introduction of teleproctoring, telementoring, and teleconsulting. Finally, in the very near future, telepresence surgery will permit "virtual" operations on patients where surgeons can project their manual dexterity, psychomotor skills, and problem-solving ability to remote locations. In this context, telemedicine will support a more equal distribution of medical knowledge and promote excellence in patients' care even in the most disadvantaged environments.

Robotic surgery update

BACKGROUND

Minimally invasive surgical techniques have revolutionized the field of surgery. Telesurgical manipulators (robots) and new information technologies strive to improve upon currently available minimally invasive techniques and create new possibilities.

METHODS

A retrospective review of all robotic cases at a single academic medical center from August 2000 until November 2002 was conducted. A comprehensive literature evaluation on robotic surgical technology was also performed.

RESULTS

Robotic technology is safely and effectively being applied at our institution. Robotic and information technologies have improved upon minimally invasive surgical techniques and created new opportunities not attainable in open surgery.

CONCLUSIONS

Robotic technology offers many benefits over traditional minimal access techniques and has been proven safe and effective. Further research is needed to better define the optimal application of this technology. Credentialing and educational requirements also need to be delineated.

Initial Evaluation of Robotic Technology for Microsurgical Vasovasostomy

PURPOSE

Conventional microscope assisted vasovasostomy (MAVV) is a technically difficult procedure that is most successful in the hands of well-trained microsurgeons. Robotics may help surgeons overcome the microsurgical challenges of tremor, limited dexterity, miniaturized instrumentation and use of fine suture. We determine the feasibility of a robotic assisted vasovasostomy (RAVV) and compare performance measures with those of conventional MAVV.

MATERIALS AND METHODS

One surgeon performed 10 vasovasostomies with a modified 1-layer technique and 9-zero suture on fresh human vas specimens using the robot in 5 RAVV cases and standard microsurgical instrumentation in 5 MAVV cases. Pre-specified performance measures and adverse haptic events (broken sutures, bent needles or loose stitches) were recorded. Patency was evaluated by instilling saline through the anastomoses.

RESULTS

Mean operating time and number of adverse haptic events were higher for RAVV than for MAVV (84 vs 38 minutes, p = 0.01; 2.4 vs 0.0 events, p = 0.03). The number of needle passes required for the 6 full-thickness stitches was similar in both groups (16.8 vs 15.2 passes, p = 0.55). Although no tremor occurred during RAVV, minimal to moderate amounts occurred during MAVV. Minimal fatigue was noted for both groups. Patency was confirmed in all 10 operations.

CONCLUSIONS

Use of RAVV in this human ex vivo vas model was feasible. While RAVV took longer to perform and was associated with adverse haptic events, elimination of tremor and comparable patency rates suggest that it may be a viable surgical alternative for microsurgical vasovasostomy.

Telemedicine in surgery

BACKGROUND

Telemedicine is influencing surgical training, allows mentoring, proctoring and teleconferencing, and is increasingly being applied to carry out remote surgical procedures. A systematic review of the telemedicine systems available, along with a critical appraisal of their application, potential and limitations in the surgical field, has been undertaken.

METHOD

Medline, Ovid and internet searches were carried out using the keywords 'telesurgery', 'telepresence surgery' and 'telemedicine and surgery', along with hand searches of the two peer-reviewed telesurgery journals.

RESULTS

Telementoring and teleconferencing have been used widely for surgical teaching and training. Two clinical telesurgery systems are currently available and have been a trial in patients undergoing a variety of operations including cholecystectomy, coronary artery bypass, prostatectomy and gastroplasty. Most studies have reported successful outcomes but with prolonged operating times. In 2002 the first long-distance telesurgery procedure was successfully performed.

CONCLUSION

Telemedicine has huge potential to alter surgical practice but improvements are required in telesurgical technology with respect to tactile feedback, instrumentation, telecommunication speed and availability. Issues of liability, legislation, cost and benefit require clarification. The future of telemedicine in surgery may lie in facilitating complex minimally invasive techniques.

Telesurgery, telementoring, virtual surgery, and telerobotics

With the advent of laparoscopic surgery, a method characterized by a surgeon's lack of direct contact with the patient's organs and tissue and the availability of magnified video images, it has become possible to incorporate computer and robotic technologies into surgical procedures. Computer technology has the ability to enhance, compress, and transmit video signals and other information over long distances. These technical advances have had a profound effect on surgical procedures and on the surgeons themselves because they are changing the way surgery is taught and learned. This article provides an overview of the most important advances and issues developing from the use of computer and robotic technologies in surgery.

Laparoscopic gastrointestinal surgery

In the short time since LC was first performed in humans, minimal-access surgical techniques have been applied to the full spectrum of surgical therapy of gastrointestinal diseases. For many gastrointestinal diseases, [figure: see text] laparoscopy seems to offer advantages over traditional open surgery. The long-term results of laparoscopic surgery for cancer await the results of prospective clinical trials currently underway and caution is urged when laparoscopic curative resection is performed. On the horizon are significant improvements in technology that should lead to further applications and advances in laparoscopic gastrointestinal surgery.

Robotically driven interventions: a method of using CT fluoroscopy without radiation exposure to the physician

Radiation exposure to physicians' hands during interventional procedures with computed tomography (CT) fluoroscopic guidance may be high. A robot was developed that could hold, orient, and advance a needle, with CT fluoroscopic guidance. This robot could be either computer or joystick controlled. Twenty-three robotically guided percutaneous interventions were performed without complication. Physician radiation exposure was negligible during the CT fluoroscopy-guided procedures.

Robotically assisted gynaecological surgery

Industry has used robots successfully for fine, delicate, repetitive tasks for decades. Recently, robots have been introduced into clinical medicine and specifically into the surgical suite. Voice algorithms have been developed that allow voice activation of some types of equipment in the operating room, such as the laparoscope or the light source. Advances in computer software have allowed a computer controller to translate a surgeon's movements from the handles located in a console to the robotic arms that hold the surgical instruments. This console is placed away from the surgical table. Clinical experience is limited and there are few published clinical trials. The initial trials have focused on laparoscopic microsuturing such as that performed during coronary bypass surgery or tubal anastomosis. Preliminary results have demonstrated that laparoscopic coronary bypass surgery with the internal mammary artery can be achieved. In gynaecological surgery, laparoscopic tubal reanastomosis can be performed using the same technique that has been used traditionally at laparotomy. Future clinical trials will assess whether other gynaecological procedures can be performed with robotic assistance.