Computer-assisted cardiac surgery

Right minithoracotomy and resternotomy approach in patients undergoing a redo mitral valve procedure

OBJECTIVES

A minimally invasive approach via a thoracotomy is an alternative in challenging redo cardiac procedures. Our goal was to present our early postoperative experience with minimally invasive cardiac surgery via a right minithoracotomy (minimally invasive) and resternotomy in patients undergoing a mitral valve procedure as a reoperation.

METHODS

From 2017 until 2020, reoperation of the mitral valve was performed through a right-sided minithoracotomy in 27 patients and via a resternotomy in 26 patients. Patients with femoral vessels suitable for cannulation underwent a minimally invasive technique. Patients requiring concomitant procedures regarding the aortic valve were operated on via a resternotomy.

RESULTS

The mean age was 66 ± 12 years in the minimally invasive group and 65 ± 12 years in the whole cohort. The average Society of Thoracic Surgeons score was 11 ± 10% in the minimally invasive group and 13 ± 9% in all patients. The majority of the patients underwent reoperation because of severe mitral valve insufficiency (48% and 55%, respectively). The mean time to reoperation was 7 ± 9 years (minimally invasive group). The 30-day mortality was 4% in the minimally invasive group and 11% in the whole cohort. The blood loss was 566 ± 359 ml in the minimally invasive group and 793 ± 410 ml totally. There were no postoperative neurological complications in the minimally invasive group and 1 (2%) in the whole cohort. Postoperative echocardiography revealed competent mitral valve/prosthesis function in all patients.

CONCLUSIONS

A minimally invasive approach for a mitral valve reoperation in selected patients is a safe alternative to resternotomy with a low transfusion requirement. Both surgical techniques are associated with good postoperative outcomes.

Development status of telesurgery robotic system

As an emerging field, telesurgery robotic system is changing the traditional medical mode and can delivery remote surgical treatment anywhere in the world. Advances in telesurgery robotic technology achieve the remote control beyond the current limitation of distance and special medical environment. This review introduces the development history, the current status and the potential in future of the telesurgery robotic system. In addition, it presents the construction of control platform and the application, especially in trauma treatment, as well as the challenge in clinic.

Right mini-thoracotomy approach in patients undergoing redo mitral valve procedure

Aim

A minimally invasive technique is an attractive option in cardiac surgery. In this study, we present our experience with minimally invasive cardiac surgery (MICS) via right mini-thoracotomy on patients undergoing mitral valve procedure as reoperation.

Methods

From 2017 until 2019, 20 patients underwent reoperation of the mitral valve through a right-sided mini-thoracotomy. Cardiopulmonary bypass was established through cannulation of the femoral vessels. All patients requiring isolated re-operative mitral valve surgery with suitable femoral vessels for cannulation were included in the study. Patients requiring concomitant coronary artery bypass grafting (CABG) or with peripheral artery disease were excluded.

Results

The mean age was 65 ± 12 years. The average log. EuroSCORE was 9 ± 5%. Ten patients with severe mitral valve regurgitation (MR) underwent re-repair of the mitral valve. Seven of them were post mitral valve repair (MVR), one was post aortic valve replacement (AVR), one had tricuspid valve repair, and one other patient had CABG before. Ten patients underwent mitral valve replacement due to mixed mitral valve disease (n = 9) or mitral valve endocarditis (n = 1). Eight patients were post MVR and 2 had AVR before. The mean time to reoperation was 7.5 ± 8 years. In-hospital mortality was 5% (n = 1). The mean cross clamp time was 54 ± 26 min. Postoperative echocardiography revealed competent valve function in all cases with mean ejection fraction of 55 ± 9%. The Kaplan-Meier 1- and 2-year survival was 95%.

Conclusion

The MICS approach for mitral valve reoperation in selected patients seems to be safe and feasible. It is also a surgical option for high-risk patients.

Robotics in cardiac surgery

A summary of its uses in mitral valve surgery and coronary artery revascularisation.

Endomicroscopy for Computer and Robot Assisted Intervention

Endomicroscopy is a new technique that allows human tissue to be characterized in vivo and in situ, circumventing the need for conventional biopsy and histology. Despite increased application and growing research interests in this area, the clinical application of endomicroscopy, however, is limited by difficulties in ergonomic control, consistent probe-tissue contact, large area surveillance, and retargeting. Recently, advances in high-speed imaging, mosaicing, and robotics have aimed to address these difficulties. The development of robot-assisted devices in particular has shown great promises in extending the clinical potential of endomicroscopy. Issues related to miniaturization, adaptation to tissue deformation, control stability, force and position compensation, cost, and sterility are being pursued by both research and commercial communities. In this review, recent clinical and technical developments in different aspects of computer and robotic assisted endomicroscopy interventions including instrumentation, multiscale integration, and high-speed imaging techniques are presented. We further address emerging trends and new research opportunities toward more widespread clinical acceptance of robotically assisted endomicroscopy technologies.

The state of robotic cardiac surgery in Europe

BACKGROUND

In the past two decades, the introduction of robotic technology has facilitated minimally invasive cardiac surgery, allowing surgeons to operate endoscopically rather than through a median sternotomy. This approach has facilitated procedures for several structural heart conditions, including mitral valve repair, atrial septal defect closure and multivessel minimally invasive coronary artery bypass grafting. In this rapidly evolving field, we review the status of robotic cardiac surgery in Europe with a focus on mitral valve surgery and coronary revascularization.

METHODS

Structured searches of MEDLINE, Embase, and Cochrane databases were performed from their dates of inception to June 2016. All original studies, except case-reports, were included in this qualitative review. Studies performed in Europe were presented quantitatively. Data provided from Intuitive Surgical Inc. are also presented.

RESULTS

Fourteen papers on coronary surgery were included in the analysis and reported a mortality rate ranging between 0-1%, revision for bleeding between 2-7%, conversion to a larger incision between 2-15%, and patency rate between 92-98%. The number of procedures ranged between 23 and 170 per year. There were only a small number of published reports for robotic mitral valve surgery from European centers.

CONCLUSIONS

Coronary robotic surgery in Europe has been performed safely and effectively with very few perioperative complications in the last 15 years. On the other hand, mitral surgery has been developed later with increasing applications of this technology only in the last 5-6 years.

VATS-based approach for robotic lobectomy

Lobectomy with systematic lymph node sampling or dissection remains the mainstay of treatment of early stage non-small cell lung cancer. The use of video-assisted thoracic surgery (VATS) to perform lobectomy was first reported in 1992. Advantages of VATS include less trauma and pain, shorter chest drainage duration, decreased hospital stay, and preservation of short-term pulmonary function. However, VATS is characterized by loss of binocular vision and a limited maneuverability of thoracoscopic instruments, an unstable camera platform, and poor ergonomics for the surgeon. To overcome these limitations, robotic systems were developed during the last decades. This article reviews the technical aspects of robotic lobectomy using a VATS-based approach.

From passive tool holders to microsurgeons: safer, smaller, smarter surgical robots

Within only a few decades from its initial introduction, the field of surgical robotics has evolved into a dynamic and rapidly growing research area with increasing clinical uptake worldwide. Initially introduced for stereotaxic neurosurgery, surgical robots are now involved in an increasing number of procedures, demonstrating their practical clinical potential while propelling further advances in surgical innovations. Emerging platforms are also able to perform complex interventions through only a single-entry incision, and navigate through natural anatomical pathways in a tethered or wireless fashion. New devices facilitate superhuman dexterity and enable the performance of surgical steps that are otherwise impossible. They also allow seamless integration of microimaging techniques at the cellular level, significantly expanding the capabilities of surgeons. This paper provides an overview of the significant achievements in surgical robotics and identifies the current trends and future research directions of the field in making surgical robots safer, smaller, and smarter.

Pilot study on effectiveness of simulation for surgical robot design using manipulability

Medical technology has advanced with the introduction of robot technology, which facilitates some traditional medical treatments that previously were very difficult. However, at present, surgical robots are used in limited medical domains because these robots are designed using only data obtained from adult patients and are not suitable for targets having different properties, such as children. Therefore, surgical robots are required to perform specific functions for each clinical case. In addition, the robots must exhibit sufficiently high movability and operability for each case. In the present study, we focused on evaluation of the mechanism and configuration of a surgical robot by a simulation based on movability and operability during an operation. We previously proposed the development of a simulator system that reproduces the conditions of a robot and a target in a virtual patient body to evaluate the operability of the surgeon during an operation. In the present paper, we describe a simple experiment to verify the condition of the surgical assisting robot during an operation. In this experiment, the operation imitating suturing motion was carried out in a virtual workspace, and the surgical robot was evaluated based on manipulability as an indicator of movability. As the result, it was confirmed that the robot was controlled with low manipulability of the left side manipulator during the suturing. This simulation system can verify the less movable condition of a robot before developing an actual robot. Our results show the effectiveness of this proposed simulation system.

Robotic anatomic segmentectomy of the lung: technical aspects and initial results

BACKGROUND

Robotic lobectomy with radical lymph node dissection is a new frontier of minimally invasive thoracic surgery. Series of sublobar anatomic resection for primary initial lung cancers or for metastasis using video-assisted thoracic surgery have been reported but no cases have been so far reported using the robot-assisted approach. We present the technique and surgical outcome of our initial experience.

METHODS

Clinical data of patients undergoing robotic lung anatomic segmentectomy were retrospectively reviewed. All cases were done using the DaVinci System. A 3- or 4-incision strategy with a 3-cm utility incision in the anterior fourth or fifth intercostal space was performed. Individual ligation and division of the hilar structures was performed using Hem-o-Lok (Teleflex Medical, Research Triangle Park, NC) or endoscopic staplers. The parenchyma was transected with endovascular staplers introduced by the bedside assistant mainly through the utility incision. Systematic mediastinal lymph node dissection or sampling was performed.

RESULTS

From 2008 to 2010, 17 patients underwent a robot-assisted lung anatomic segmentectomy in two centers. There were 10 women and 7 men with a mean age of 68.2 years (range, 32 to 82). Mean duration of surgery was 189 minutes. There were no major intraoperative complications. Conversion to open procedure was never required. Postoperative morbidity rate was 17.6% with pneumonia in 1 case and prolonged air leaks in 2 patients. Median postoperative stay was 5 days (range, 2 to 14), and postoperative mortality was 0%. Final pathology was non-small cell lung cancer in 8 patient, typical carcinoids in 2, and lung metastases in 7.

CONCLUSIONS

Robotic anatomic lung segmentectomy is feasible and safe procedure. Robotic system, by improving ergonomic, surgeon view and precise movements, may make minimally invasive segmentectomy easier to adopt and perform.

Embracing a Revolution - Telemedicine

The recent advances in information and communication technologies offer real and practical opportunities to health professionals to share expertise and resources in health care over distances. For a country like India with pockets of medical excellence surrounded by a vast number of badly equipped hospitals with limited specialists, telemedicine could revolutionize health care. The potential of telemedicine seem to be vital in avoiding the frame of travel, in timely getting specialist advise to remote areas, minimizing the cost and of course an opportunity to learn from each other. In developed countries the technological advancement and research aims primarily to satiate the needs of their armed forces and to ensure tactical and technical supremacy. The medical community in the Indian Armed Forces should harness the technologies and embrace this revolution of the information age to provide world class combat casualty care.

Robotic surgery: India is not ready yet

Robotic surgery is one of the most significant advances in urology in recent years. It promises to make urological surgeries safer with far superior results as compared to laparoscopic or open surgeries. It holds great promise for the surgeons and patients alike. However like any other technological advance, it too comes with a heavy price tag. Aggressive marketing by the manufacturers and urologists may lead to unethical practices. This article analyses the applicability of robotics to urology and India in particular taking into consideration the financial aspects involved. At present, the scope for robotics in India is limited because of cost considerations. The future of robotic surgery in India also will depend on the same factor.

Minimally invasive robotic mitral valve surgery

Over the past two decades, significant advances have been made in mitral valve surgery. Cardiac surgeons have successfully repaired degenerative and ischemic regurgitant mitral valves via a traditional midline sternotomy. In recent years, alternate incisions have yielded minimally invasive approaches to the mitral valve. Technological advances have made robotically assisted minimally invasive mitral valve surgery feasible. Decreased pain, more rapid return to work, diminished blood loss and reduced length of hospitalization have been witnessed following robotic mitral valve surgery when compared with a traditional sternotomy. Equivalent long-term mortality and freedom from recurrent mitral regurgitation are evident between mitral valve repair performed via a traditional sternotomy and minimally invasive and robotic techniques. As a result, an increasing number of patients and referring cardiologists are seeking minimally invasive approaches to mitral valve surgery.

Failure and malfunction of da Vinci Surgical systems during various robotic surgeries: experience from six departments at a single institute

OBJECTIVES

To analyze the mechanical failures and malfunctions of the da Vinci Surgical (S) System during various robotic surgeries in 6 different departments at our institute and also evaluated the solutions for the failures and malfunctions.

METHODS

From July 2005 to December 2008, a total of 1797 robotic surgeries were performed at our institute. The surgeries were performed using 4 da Vinci surgical systems (1 standard da Vinci system from July 2005 to July 2007 and 3 da Vinci S systems from July 2007 to December 2008). Mechanical failures or malfunctions occurred in 43 cases. We evaluated the robotic surgeries according to the type of surgery and the department. We analyzed the cases involving conversion to open or laparoscopic surgeries and those in which there was a malfunction with the instrument.

RESULTS

There were 43 cases (2.4%) of mechanical failure with the da Vinci system from a total of 1797 robotic surgeries. This included 24 (1.3%) cases of mechanical failure or malfunction and 19 cases (1.1%) of instrument malfunction. The mechanical malfunction included 1 on/off failure, 5 console malfunctions, 6 robotic arm malfunctions, 2 optic system malfunctions, and 10 system errors. One open and 2 laparoscopic conversions (3 cases; 0.17%) were performed.

CONCLUSIONS

Mechanical failure or malfunction occurred during robotic surgery in 43 cases (2.4%), and the open or laparoscopic conversion rate during surgery was very low (0.17%). We found the mechanical failure or malfunction to be rare.

The revolution of computer-aided surgery – the dawn of robotic surgery

Endoscopic surgery has rapidly changed the performance of surgical procedures in a wide range of surgical specialities, but difficulties with endoscopic manipulation remain. The next step in the revolution initiated by the introduction of endoscopic surgery will be achieved by the introduction of robotics, tele-mentoring systems and telepresence surgery. Primary capabilities brought to surgery by robotic manipulators can be summarised as surgical assistance, image-guided therapy and dexterity enhancement. Using computer-aided systems, such as robotics and image-guided surgery, the next generation of surgical systems will be more sophisticated, and will permit surgeons to perform surgical procedures beyond the current limitation of human performance — on the microscale, or on moving organs. Industry is focusing currently on developing manipulators for endoscopic microsurgery, and several devices have already entered clinical use. Taking advantage of one such robotic system, we have developed a new method of endoscopic cholecystectomy, which is performed without leaving foreign bodies and using a procedure that prevents adhesions after surgery. Some new endoscopic procedures have also become feasible, although these are currently performed only by open surgery, without this system. It seems to be highly probable that master–slave manipulators will soon be in routine surgical use for selected indications.

Grand Espoir: Robotics in Regenerative Medicine

Here, we overlook the brief history of regenerative medicine, and summarize the expectation to breakthroughs achieved by robotics in the field. One expected application of robotics is an automatic cell culture system, which can dramatically reduce the cost for manufacturing bioengineered tissues conventionally requiring GMP (Good Manufacturing Practice) facility for Cell Processing Center. The other is a robotic surgery system for less invasive transplantation of cells and fabricated tissues. To show the feasibility of robotic surgery-assisted transplantation, we have shown the success of cell sheet transplantation to luminal surface of living canine esophagus by endoscopy. Thus, the contribution of robotics to regenerative medicine has been wanted to realize the greatest success of tissue engineering and cell-based medicine.

A new mechatronic assistance system for the neurosurgical operating theatre: implementation, assessment of accuracy and application concepts

OBJECTIVE

To introduce a new robotic system to the field of neurosurgery and report on a preliminary assessment of accuracy as well as on envisioned application concepts. Based on experience with another system (Evolution 1, URS Inc., Schwerin, Germany), technical advancements are discussed.

MATERIAL/METHODS

The basic module is an industrial 6 degrees of freedom robotic arm with a modified control element. The system combines frameless stereotaxy, robotics, and endoscopy. The robotic reproducibility error and the overall error were evaluated. For accuracy testing CT markers were placed on a cadaveric head and pinpointed with the robot's tool tip, both fully automated and telemanipulatory. Applicability in a clinical setting, user friendliness, safety and flexibility were assessed.

RESULTS

The new system is suitable for use in the neurosurgical operating theatre. Hard- and software are user-friendly and flexible. The mean reproducibility error was 0.052-0.062 mm, the mean overall error was 0.816 mm. The system is less cumbersome and much easier to use than the Evolution 1.

CONCLUSIONS

With its user-friendly interface and reliable safety features, its high application accuracy and flexibility, the new system is a versatile robotic platform for various neurosurgical applications. Adaptations for different applications are currently being realized.

Historia de la robótica: de Arquitas de Tarento al Robot da Vinci. (Parte II)

Robotic surgery is a reality. In order to to understand how new robots work is interesting to know the history of ancient (see part i) and modern robotics. The desire to design automatic machines imitating humans continued for more than 4000 years. Archytas of Tarentum (at around 400 a.C.), Heron of Alexandria, Hsieh-Fec, Al-Jazari, Bacon, Turriano, Leonardo da Vinci, Vaucanson o von Kempelen were robot inventors. At 1942 Asimov published the three robotics laws. Mechanics, electronics and informatics advances at XXth century developed robots to be able to do very complex self governing works. At 1985 the robot PUMA 560 was employed to introduce a needle inside the brain. Later on, they were designed surgical robots like World First, Robodoc, Gaspar o Acrobot, Zeus, AESOP, Probot o PAKI-RCP. At 2000 the FDA approved the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, CA, USA), a very sophisticated robot to assist surgeons. Currently urological procedures like prostatectomy, cystectomy and nephrectomy are performed with the da Vinci, so urology has become a very suitable speciality to robotic surgery.

[Da Vinci advanced robotic laparoscopic surgery: origin and current clinical application in urology, and comparison with open and laparoscopic surgery]

Over the last decade, open surgery, which is able to perform large extirpations and repairs of fragile tissues, is gradually being substituted with laparoscopic surgery due to the high benefits the latter entails for the patients, an also due to the learning difficulties for surgeons who must make up for such deficiencies applying higher efforts and a larger amount of stress. Robotic surgery stands in for the limitations of conventional laparoscopic surgery by means of performing more ergonomic and more accurate surgeries, particularly in the case of the most complex and difficult to access operations, such as radical prostatectomy. This review will perform a reminder of the history and clinical applications of new advanced and robotic technologies, and also a comparison with open surgery and conventional laparoscopy.

In touch with robotics: neurosurgery for the future

The introduction of multiple front-end technologies during the past quarter century has generated an emerging futurism for the discipline of neurological surgery. Driven primarily by synergistic developments in science and engineering, neurosurgery has always managed to harness the potential of the latest technical developments. Robotics represents one such technology. Progress in development of this technology has resulted in new uses for robotic devices in our discipline, which are accompanied by new potential dangers and inherent risks. The recent surge in robot-assisted interventions in other disciplines suggests that this technology may be considered one of a spectrum of frontier technologies poised to fuel the development of neurosurgery and consolidate the era of minimalism. On a more practical level, if the introduction of robotics in neurosurgery proves beneficial, neurosurgeons will need to become facile with this technology and learn to harness its potential so that the best surgical results may be achieved in the least invasive manner. This article reviews the role of robotic technology in the context of neurosurgery.

Robotic long-distance telementoring in neurosurgery

OBJECTIVE

To test the feasibility of long-distance telementoring in neurosurgery by providing subspecialized expertise in real time to another neurosurgeon performing a surgical procedure in a remote location.

METHODS

A robotic telecollaboration system (Socrates; Computer Motion, Inc., Santa Barbara, CA) capable of controlling the movements of a robotic arm, of handling two-way video, and of audio communication as well as transmission of neuronavigational data from the remote operating room was used for the telementoring procedures. Four integrated services digital network lines with a total speed of transmission of 512 kilobytes per second provided telecommunications between a large academic center (Halifax, Nova Scotia) and a community-based center (Saint John, New Brunswick) located 400 km away.

RESULTS

Long-distance telementoring was used in three craniotomies for brain tumors, a craniotomy for an arteriovenous malformation, a carotid endarterectomy, and a lumbar laminectomy. There were no surgical complications during the procedures, and all patients had uneventful outcomes. The neurosurgeons in the remote location believed that the input from the mentors was useful in all of the cases and was crucial in the removal of a mesial temporal lobe glioma and resection of an occipital arteriovenous malformation.

CONCLUSION

Our initial experience with long-distance robotic-assisted telementoring in six cases indicates that telementoring is feasible, reliable, and safe. Although still in its infancy, telementoring has the potential to improve surgical care, to enhance neurosurgical training, and to have a major impact on the delivery of neurosurgical services throughout the world.

Telerobotic-assisted laparoscopic hysterectomy for benign and oncologic pathologies: initial clinical experience with 30 patients

BACKGROUND

Telerobotic-assisted laparoscopic attempts to provide technological solutions to the inherent limitations of traditional laparoscopic surgery. The aim of this study is to report the first experience of two teams concerning telerobotic-assisted laparoscopic hysterectomy for benign and malignant pathologies.

METHODS

This study included 14 patients at the University Hospital Saint Pierre of Brussels (Belgium) and 16 patients at the Cancer Center of Nancy (France) from September 1999 to July 2003.

RESULTS

The indications for surgery were uterine malignant diseases in 12 cases (stade I) (41%), and benign pathologies of the uterus in 18 cases (59%). Five postoperative complications (17%) occurred, none related to the robotic system.

CONCLUSION

Robotic surgery can be safely performed in gynecologic and gynecologic-oncologic surgery with no increase in complication rates. A significant advance is represented by the surgeon's ergonomic improvement.

The PAKY, HERMES, AESOP, ZEUS, and da Vinci robotic systems

In 1965 Gordon Moore, cofounder of Intel Corporation, made his famous observation now known as Moore's law. He predicted that computing capacity will double every 18 to 24 months. Since then, Moore's law has held true; the number of transistors per integrated computer circuit has doubled every couple of years. This relentless advance in computer technology ensures future advances in robotic technology. The ultimate goal of robotics is to allow surgeons to perform difficult procedures with a level of precision and improved clinical outcomes not possible by conventional methods. Robotics has the potential to enable surgeons with various levels of surgical skill to achieve a uniform outcome. As long as urologists continue to embrace technological advances and incorporate beneficial technology into their practice, the outlook for patients remains bright.

Robotics technology: a journey into the future

Some major technologic improvements are needed for robotic technology to reach its ultimate potential, which includes better visualization, tactile sensing, diagnostic sensing, and miniaturization. This article gives a vision of the future of robotic technology with respect to these improvements.

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.

Robotics and neurosurgery

Ultimately, neurosurgery performed via a robotic interface will serve to improve the standard of a neurosurgeon's skills, thus making a good surgeon a better surgeon. In fact, computer and robotic instrumentation will become allies to the neurosurgeon through the use of these technologies in training, diagnostic, and surgical events. Nonetheless, these technologies are still in an early stage of development, and each device developed will entail its own set of challenges and limitations for use in clinical settings. The future operating room should be regarded as an integrated information system incorporating robotic surgical navigators and telecontrolled micromanipulators, with the capabilities of all principal neurosurgical concepts, sharing information, and under the control of a single person, the neurosurgeon. The eventual integration of robotic technology into mainstream clinical neurosurgery offers the promise of a future of safer, more accurate, and less invasive surgery that will result in improved patient outcome.

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.

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.

Transcontinental robot-assisted remote telesurgery: feasibility and potential applications

OBJECTIVE

To show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology.

SUMMARY BACKGROUND DATA

Technical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances.

METHODS

To verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service).

RESULTS

The operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery.

CONCLUSIONS

Remote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide.

The evolution of and early experience with robot-assisted mitral valve surgery

Cardiac surgeons have embraced minimally invasive surgery with warranted enthusiasm. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, efficient minimally invasive cardiac procedures. In this article we review the evolution of and early experience with robot-assisted mitral valve surgery. Articles by leaders in the field of minimally invasive cardiac surgery, both American and European, are reviewed to describe the development of cardiac robotic surgery. The current state of robotic mitral surgery is described.

The evolution and early experience with robot-assisted mitral valve surgery

Cardiac surgeons, with a warranted enthusiasm, have embraced minimally invasive surgery. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, and efficient minimally invasive cardiac procedures. In this Technology Focus section, we review the evolution and early experience with robot-assisted mitral valve surgery. The articles of leading minimally invasive cardiac surgeons, both American and European, are reviewed to define the development toward cardiac robotic surgery. The current state of robotic mitral surgery is described.

Robotically assisted laparoscopic hysterectomy and adnexal surgery

BACKGROUND

In this pilot study, we tested the feasibility and safety of using a robotic device to perform complex gynecologic surgery.

METHODS

Ten female pigs underwent adnexal surgery (n = 5) or hysterectomy (n = 5) using the "Zeus" robotic device. The surgeon operates while sitting at the console away from the surgical table on which the robotic arms are fixed. Both procedures were performed solely with the robotic arms. After 1 week of observation the animals were sacrificed and the surgical site was explored.

RESULTS

The procedure was completed successfully in all cases. No animal required conversion to laparotomy or nonrobotic laparoscopic assistance. The mean operative time (+/- SD) was 170 +/- 44 min for adnexal surgery and 200 +/- 57 min for hysterectomy. No complications occurred. No ureteral injuries were found on necropsy.

CONCLUSION

Although designed for laparoscopic microsuturing, this robotic technology has the potential to be used for more complex gynecologic procedures.

Totally endoscopic coronary artery bypass on the beating heart

Our aim was to develop a technique for totally endoscopic coronary artery bypass on the beating heart for patients with coronary artery disease. For this procedure, operations were performed through four thoracoports. The left internal thoracic artery (LITA) was harvested thoracoscopically. The pericardium was then opened and the left anterior descending artery (LAD) identified. The endoscopic stabiliser was inserted and transformed into a coiled ring shape. After suction, sufficient immobilisation of the LAD was achieved. The proximal snare was placed using a 5-0 Prolene suture to give a bloodless field. After blunt dissection of the coronary artery, an arteriotomy was performed with a sharp blade and enlarged with endoscopic Potts scissors. Using an endoscopic needle holder and forceps via two thoracoports at the fourth intracostal space, a conventional end-to-side anastomosis was safely created with an 8-0 Prolene single running suture. Total endoscopic beating-heart bypass grafting, including ITA harvest, stabilisation, arteriotomy and performance of the anastomosis, was performed successfully in three patients. There were no intraoperative arrhythmias, and no postoperative haemorrhage. The patients required no intensive care management postoperatively. All patients were ready for discharge on the fourth postoperative day. Postoperative angiogram revealed that anastomoses are patent. We conclude that the endoscopic stabiliser can sufficiently immobilise the heart to enable endoscopic beating-heart coronary artery bypass grafting by means of an easily controllable instrumentation system.

Closed chest bilateral mammary artery grafting in double-vessel coronary artery disease

A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease.