What have we learnt after two years working with the da Vinci robot system in digestive surgery?

Tissue histology on the correlation between fracture energy and elasticity

PURPOSE

Preemptively estimating tissue damage is crucial for a safe surgical procedure. We previously investigated the possibility of estimating the fracture energies of biological tissues based on their elasticities. However, the reason behind the presence of these correlations is poorly understood. In this study, we investigate the effect of a tissue's histology on the correlation between the fracture energy and elasticity. We hypothesize that two tissues with similar fibrous structure will show a similar correlation between the fracture energy and elasticity.

METHODS

Porcine duodenum were used for this study. Two tensile tests were performed for each porcine duodenum specimen to determine its elasticity and tearing energy. The correlation between fracture energy and elasticity was then investigated using the results from the mechanical tests. Furthermore, duodenum specimens were fixed in 10% formalin while under tension. Microscopic images were then taken to visualize the fibrous structure within the duodenum tissues under tension.

RESULTS

The results from the tensile test showed that the fracture energy had an isotropic positive and linear correlation with the elasticity to the negative 0.5th power (R2 = 0.89), which was also previously reported in small intestinal (jejunum) specimens. Furthermore, the tearing patterns of the duodenum were identical to the ones reported in the jejunum. Hematoxylin and eosin staining on tissues fixed under tension showed that the endomysium fibers are involved in providing resistance toward traction.

CONCLUSION

Through mechanical tests, we showed that porcine duodenum tissues also have a correlation between its fracture energy and elasticity. We also discussed that the histological structure of a tissue is an important factor that dictates how the tearing energy of a tissue will correlate to the elasticity. We understood that since the tearing mechanism between the duodenum and jejunum was similar, the correlations between their fracture energies and elasticities were also similar.

Transhiatal robot-assisted minimally invasive esophagectomy: unclear benefits compared to traditional transhiatal esophagectomy

Esophagectomy is a high-risk operation, regardless of technique. Minimally invasive transthoracic esophagectomy could reduce length of stay and pulmonary complications compared to traditional open approaches, but the benefits of minimally invasive transhiatal esophagectomy are unclear. We performed a retrospective review of prospectively gathered data for open transhiatal esophagectomies (THEs) and transhiatal robot-assisted minimally invasive esophagectomies (TH-RAMIEs) performed at a high-volume academic center between 2013 and 2017. Multivariate logistic regression was used to calculate adjusted odds ratios (aORs) for outcomes. 465 patients met inclusion criteria (378 THE and 87 TH-RAMIE). THE patients more likely had an ASA score of 3 + (89.1% vs 77.0%, p = 0.012), whereas TH-RAMIE patients more likely had a pathologic staging of 3+ (43.7% vs. 31.2%, p = 0.026). TH-RAMIE patients were less likely to receive epidurals (aOR 0.06, 95% confidence interval [CI] 0.03-0.14, p < 0.001), but epidural use itself was not associated with differences in outcomes. TH-RAMIE patients experienced higher rates of pulmonary complications (adjusted odds ratio [OR] 1.82, 95% CI 1.03-3.22, p = 0.040), particularly pulmonary embolus (aOR 5.20, 95% CI 1.30-20.82, p = 0.020). There were no statistically significant differences in lymph node harvest, unexpected ICU admission, length of stay, in-hospital mortality, or 30-day readmission or mortality rates. The TH-RAMIE approach had higher rates of pulmonary complications. There were no statistically significant advantages to the TH-RAMIE approach. Further investigation is needed to understand the benefits of a minimally invasive approach to the open transhiatal esophagectomy.

Eye-Tracking Metrics Predict Perceived Workload in Robotic Surgical Skills Training

OBJECTIVE

The aim of this study is to assess the relationship between eye-tracking measures and perceived workload in robotic surgical tasks.

BACKGROUND

Robotic techniques provide improved dexterity, stereoscopic vision, and ergonomic control system over laparoscopic surgery, but the complexity of the interfaces and operations may pose new challenges to surgeons and compromise patient safety. Limited studies have objectively quantified workload and its impact on performance in robotic surgery. Although not yet implemented in robotic surgery, minimally intrusive and continuous eye-tracking metrics have been shown to be sensitive to changes in workload in other domains.

METHODS

Eight surgical trainees participated in 15 robotic skills simulation sessions. In each session, participants performed up to 12 simulated exercises. Correlation and mixed-effects analyses were conducted to explore the relationships between eye-tracking metrics and perceived workload. Machine learning classifiers were used to determine the sensitivity of differentiating between low and high workload with eye-tracking features.

RESULTS

Gaze entropy increased as perceived workload increased, with a correlation of .51. Pupil diameter and gaze entropy distinguished differences in workload between task difficulty levels, and both metrics increased as task level difficulty increased. The classification model using eye-tracking features achieved an accuracy of 84.7% in predicting workload levels.

CONCLUSION

Eye-tracking measures can detect perceived workload during robotic tasks. They can potentially be used to identify task contributors to high workload and provide measures for robotic surgery training.

APPLICATION

Workload assessment can be used for real-time monitoring of workload in robotic surgical training and provide assessments for performance and learning.

Design and Control of a 3 Degree-of-Freedom Parallel Passive Haptic Device

Teleoperated robotic surgery and surgical simulation provide surgeons with tools that can improve the health outcomes of their patients. The limiting factor in many of these systems, however, is the lack of a haptic system that can render high impedance without compromising transparency or stability. To address this issue, we constructed a 3-Degree-of-Freedom haptic device using brakes as actuators. A novel controller is also proposed to increase the range of forces the device can generate and eliminate stiction. The device uses a modified Delta kinematic structure making it light and rigid. Since brakes are intrinsically stable, the device safely generates a wide range of impedance making it well suited for many surgical applications. The novel controller attempts to minimize the sum of forces acting perpendicular to the virtual surface eliminating un-smooth force output and stiction characteristic to passive devices, while increasing the range of displayable forces. The controller was validated using six testing scenarios where it rendered contact with frictionless surfaces. When using the controller, the device rendered the desired surface without stiction. Since the controller successfully rendered complex geometry, it can also work in other applications, such as robotic surgery and surgical simulation.

Robotics Total Mesorectal Excision Up To the Minute

Surgical techniques have evolved over the past few decades, and minimally invasive surgery has been rapidly adapted to become a preferred operative approach for treating colorectal diseases. However, many of the procedures remain a technical challenge for surgeons to perform laparoscopically, which has prompted the development of robotic platforms. Robotic surgery has been introduced as the latest advance in minimally invasive surgery. The present article provides an overview of robotic rectal surgery and describes many advances that have been made in the field over the past two decades. More specifically, the introduction of the robotic platform and its benefits, and the limitations of current robotic technology, are discussed. Although the main advantages of robotic surgery over conventional laparoscopy appear to be lower conversion rates and better surgical specimen quality, oncological and functional outcomes appear to be similar to those of other alternatives. Other potential benefits include earlier recovery of voiding and sexual function after robotic total mesorectal excision. Nevertheless, the costs and lack of haptic feedback remain the primary limitations to the widespread use of robotic technology in the field.

Three-dimensional posture estimation of robot forceps using endoscope with convolutional neural network

BACKGROUND

In recent years, there has been significant developments in surgical robots. Image-based sensing of surgical instruments, without the use of electric sensors, are preferred for easily washable robots.

METHODS

We propose a method to estimate the three-dimensional posture of the tip of the forceps tip by using an endoscopic image. A convolutional neural network (CNN) receives the image of the tracked markers attached to the forceps as an input and outputs the posture of the forceps.

RESULTS

The posture estimation results showed that the posture estimated from the image followed the electrical sensor. The estimated results of the external force calculated based on the posture also followed the measured values.

CONCLUSION

The method which estimates the forceps posture from the image using CNN is effective. The mean absolute error of the estimated external force is smaller than the human detection limit.

[Initial experience in robot-assisted colorectal surgery in Mexico]

BACKGROUND

Colorectal surgery has advanced notably since the introduction of the mechanical suture and the minimally invasive approach. Robotic surgery began in order to satisfy the needs of the patient-doctor relationship, and migrated to the area of colorectal surgery. An initial report is presented on the experience of managing colorectal disease using robot-assisted surgery, as well as an analysis of the current role of this platform.

MATERIAL AND METHODS

A retrospective study was conducted in order to review five patients with colorectal disease operated using a robot-assisted technique over one year in the initial phase of the learning curve. Gender, age, diagnosis and surgical indication, surgery performed, surgical time, conversion, bleeding, post-operative complications, and hospital stay, were analysed and described. A literature review was performed on the role of robotic assisted surgery in colorectal disease and cancer.

RESULTS

The study included 5 patients, 3 men and 2 women, with a mean age of 62.2 years. Two of them were low anterior resections with colorectal primary anastomoses, one of them extended with a loop protection ileostomy, a Frykman-Goldberg procedure, and two left hemicolectomies with primary anastomoses. The mean operating time was 6hours and robot-assisted 4hours 20minutes. There were no conversions and the mean hospital stay was 5 days.

CONCLUSION

This technology is currently being used worldwide in different surgical centres because of its advantages that have been clinically demonstrated by various studies. We report the first colorectal surgical cases in Mexico, with promising results. There is enough evidence to support and recommend the use of this technology as a viable and safe option.

Minimally invasive surgery in gastrointestinal cancer: benefits, challenges, and solutions for underutilization

Background and Objectives:

After the widespread application of minimally invasive surgery for benign diseases and given its proven safety and efficacy, minimally invasive surgery for gastrointestinal cancer has gained substantial attention in the past several years. Despite the large number of publications on the topic and level I evidence to support its use in colon cancer, minimally invasive surgery for most gastrointestinal malignancies is still underused.

Methods:

We explore some of the challenges that face the fusion of minimally invasive surgery technology in the management of gastrointestinal malignancies and propose solutions that may help increase the utilization in the future. These solutions are based on extensive literature review, observation of current trends and practices in this field, and discussion made with experts in the field.

Results:

We propose 4 different solutions to increase the use of minimally invasive surgery in the treatment of gastrointestinal malignancies: collaboration between surgical oncologists/hepatopancreatobiliary surgeons and minimally invasive surgeons at the same institution; a single surgeon performing 2 fellowships in surgical oncology/hepatopancreatobiliary surgery and minimally invasive surgery; establishing centers of excellence in minimally invasive gastrointestinal cancer management; and finally, using robotic technology to help with complex laparoscopic skills.

Conclusions:

Multiple studies have confirmed the utility of minimally invasive surgery techniques in dealing with patients with gastrointestinal malignancies. However, training continues to be the most important challenge that faces the use of minimally invasive surgery in the management of gastrointestinal malignancy; implementation of our proposed solutions may help increase the rate of adoption in the future.

Robot-assisted oesophageal and gastric surgery for benign disease: antireflux operations and Heller's myotomy

BACKGROUND

Robot-assisted general surgery operations are being performed more frequently. This review investigates whether robotic assistance results in significant advantages or disadvantages for the operative treatment of gastro-oesophageal reflux disease and achalasia.

METHODS

The electronic databases (Medline, Embase, PubMed) were searched for original English language publications for antireflux surgery and Heller's myotomy between January 1990 and December 2013.

RESULTS

Thirty-three publications included antireflux operations and 20 included Heller's myotomy. The publications indicate that the safety and effectiveness of robotic surgery is similar to that of conventional minimally invasive surgery for both operations. The six randomized trials of robot-assisted versus laparoscopic antireflux surgery showed no significant advantages but significantly higher costs for the robotic method. Gastric perforation during non-redo robotic fundoplication occurred in four trials.

CONCLUSIONS

No consistent advantage for robot-assisted antireflux surgery has been demonstrated, and there is an increased cost with current robotic technology. A reported advantage for robotic in reducing the perforation rate during Heller's myotomy for achalasia remains unproven. Gastric perforation during robotic fundoplication may be due to the lack of haptic feedback combined with the superhuman strength of the robot.

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 colorectal surgery: a systematic review

Aim. Robotic colorectal surgery may be a way to overcome the limitations of laparoscopic surgery. It is an emerging field; so, we aim in this paper to provide a comprehensive and data analysis of the available literature on the use of robotic technology in colorectal surgery. Method. A comprehensive systematic search of electronic databases was completed for the period from 2000 to 2011. Studies reporting outcomes of robotic colorectal surgery were identified and analyzed. Results. 41 studies (21 case series, 2 case controls, 13 comparative studies 1 prospective comparative, 1 randomized trial, 3 retrospective analyses) were reviewed. A total of 1681 patients are included in this paper; all of them use Da Vinci except 2 who use Zeus. Short-term outcome has been evaluated with 0 mortality and191 total major and minor complications. Pathological results were not analyzed in all studies and only 20 out of 41 provide data about the pathological results. Conclusion. Robotic surgery is safe and feasible option in colorectal surgery and a promising field; however, further prospective randomized studies are required to better define its role.

Robotic oncological surgery: our initial experience of 164 cases

Minimal access surgery is an accepted modality for benign surgery. Despite the advantages of laparoscopy, its acceptance in oncology is slow. Robotic surgery is an emerging field with rapid acceptance because of the 3-dimensional image, dexterity of instruments and autonomy of camera control. We report here our experience of using the Da Vinci robot for various oncological procedures. We performed 164 oncological surgeries from November 2009 to June 2011. The surgeries performed included thoracic, colorectal, hepatobiliary, gynaecological and urological system. We could complete 163 cases robotically. We share our initial experience of robotic surgery in oncology with comparison with other series.

One hundred and two consecutive robotic-assisted minimally invasive colectomies--an outcome and technical update

BACKGROUND

The objective of this study was to review 102 consecutive robotic colectomies at our institution. We evaluated the 8-year experience of one surgeon (DLC) in Peoria, IL using the da Vinci system.

METHODS

An IRB-approved retrospective review was performed. Results were compared with the literature. Changes in technique over the years were evaluated.

RESULTS

One hundred and two robotic colectomies, right (59) and sigmoid (43), were performed. Mean age is 63.5 years and mean BMI 27.4 kg/m². Preoperative indications are polyps (53), diverticular disease (27), cancer (19), and carcinoid (3). Mean total case time (TCT) for all cases is 219.6 ± 45.1 (50-380) min, and mean robot operating time (ROT) is 126.6 ± 41.6 (12-306) min. Operative times for Right: Port setup time (PST) 32.4 ± 10.5 (20-64) min, ROT 145.2 ± 39.6 (53-306) min, TCT 212.3 ± 46.4 (50-380) min; times for sigmoid: PST 31.2 ± 9.6 (10-57) min, ROT 101.2 ± 29.2 (12-165) min, TCT 229.7 ± 41.6 (147-323) min. Median length of stay for all patients is 3 (2-27) days. The overall complication rate is 18.6%, the overall conversion rate 8.8%, and the anastomotic leak rate is 0.98%. Residents PGY 1-5 participated in 61 cases (59.8%).

CONCLUSION

We report our updated procedural sequence and technical alterations. Experience has allowed residents to evolve to be primary surgeons. We add our results to the current robotic literature.

Robotic-assisted bariatric surgery: a systematic review

BACKGROUND

Bariatric laparoscopic surgery has been shown to lead to sustainable weight-loss in obese individuals. Robotic-assisted laparoscopic surgery is proposed as the next major evolution in minimally invasive surgery. This study systematically reviews the literature regarding the feasibility and safety of robotic-assisted bariatric surgery in obese patients.

METHODS

A comprehensive search of electronic databases was completed for the period 2003 to 2010. Two independent reviewers assessed the studies for relevance, inclusion, and extracted data.

RESULTS

After an initial screen of 297 titles, 22 studies met the inclusion criteria. A total of 1253 patients with a mean preoperative body mass index of 46.6 kg/m(2) were obtained from 13 included studies. Major complications of malabsorptive procedures included eight anastomotic leaks (2.4%), bleeding (7/349 patients = 2%) and strictures/stenosis (13/430 patients = 3%). There were no reported deaths.

CONCLUSIONS

This systematic review demonstrates that robotic-assisted bariatric surgery is both a safe and feasible option for severely obese patients.

Robotic-assisted laparoscopic and thoracoscopic surgery with the da Vinci system: a 4-year experience in a single institution

PURPOSE

We set up a pilot study to evaluate the efficacy of telerobotic surgery using the da Vinci system for several procedures for which traditional laparoscopy (or thoracoscopy) is a standard approach in a single institution.

METHODS

We performed fundoplications (hiatal hernia repair and antireflux surgery, n=112), upside-down stomach (14), cholecystectomy (16), gastric banding (3), colectomy (5), esophagectomy (4), sub/total gastrectomy (2), gastrojejunostomy (2), along with thymectomy (100), thoracic symatectomy (11), lobectomy (5), mediastinal parathyroidectomy (5), and left pancreatic resection (1).

RESULTS

The median set up time for all procedures was reduced from 25.0 to 10.4 minutes. Conversion to traditional laparoscopy or thoracoscopy occurred in 12 cases and in open surgery in 11 cases. There was no morbidity related to the telerobotic system.

CONCLUSIONS

Robotically assisted laparoscopic and thoracoscopic surgery is feasible and safe for a variety of procedures in general, visceral, and thoracic surgery.

Surgical treatment of gastroesophageal reflux disease and upside-down stomach using the Da Vinci robotic system. A prospective study

So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease (GERD) is still obscure. In this prospective study, we analyzed the Da Vinci Intuitive Surgical robotic system for antireflux surgery. In April 2003, we set up a pilot study to evaluate the efficacy of laparoscopic telerobotic surgery using the three-arm Da Vinci system. Optimal trocar positions, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity, as well as mortality rate, were analyzed. The median age was 53 years (range 25-74) in 118 patients (52 female/66 male). In 17 patients, an upside-down stomach- and in 101 GERD was surgical indication. The median operating time has been reduced from 105 min to 91 min after 40 procedures and setup time from 24.5 min to 10.4 min after 10 procedures. The system is safe and it seems to be superior to traditional laparoscopy during dissection in the esophageal hiatus region. This compensates long setup- and operating times. Disadvantages are the high costs, the time to master the setup/system and the necessity of exact trocar positioning.

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.

Telerobotic gastrointestinal surgery: phase 2--safety and efficacy

BACKGROUND

The Federal Drug Administration (FDA) approved the da Vinci surgical system for all abdominal operations in July 2000. In the past 6 years, virtually all gastrointestinal operations have been accomplished using telerobotic techniques. The purpose of this review is to summarize the short-term outcomes achieved with telerobotic gastrointestinal operations.

METHODS

All case series of telerobotic gastrointestinal operations identified by PubMed searches are included in this review.

RESULTS

Case series document the safety and efficacy of telerobotic cholecystectomy, fundoplication, Heller myotomy, gastric bypass, colectomy, gastrectomy, and pancreatectomy. The procedures were accomplished with low rates of conversion to laparoscopic operations, mortality, and morbidity. When comparison groups were available, the analysis shows that telerobotic operations required more time than the laparoscopic operations, although for telerobotic cholecystectomy and telerobotic fundoplication, this difference disappeared in 10 to 20 operations. Specific patient advantages were not identified for telerobotic operations compared with laparoscopic operations, except for a decreased esophageal perforation rate during telerobotic Heller myotomy. Surgeons benefited from the three-dimensional imaging, the handlike motions of the robotic instruments, and an ergonomically comfortable position.

CONCLUSION

All telerobotic gastrointestinal operations are feasible and can be performed with safety and efficacy. It is difficult to demonstrate patient-specific advantages of telerobotic surgery over laparoscopic operations. Nonetheless, telerobotic surgical systems offer distinct advantages to surgeons and may facilitate an increase in the number of surgeons performing advanced laparoscopic gastrointestinal operations. In addition, telerobotics offer a digital information platform that enables surgical simulation and augmented-reality surgery.

First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer

BACKGROUND

Transthoracic esophagectomy with extended lymph node dissection is associated with higher morbidity rates than transhiatal esophagectomy. This morbidity rate could be reduced by the use of minimally invasive techniques. The feasibility of robot-assisted thoracoscopic esophagectomy (RTE) with mediastinal lymphadenectomy was assessed prospectively.

METHODS

This study investigated 21 consecutive patients with esophageal cancer who underwent RTE using the Da Vinci robotic system. Continuity was restored with a gastric conduit and a cervical anastomosis.

RESULTS

A total of 18 (86%) procedures were completed thoracoscopically. The operating time for the thoracoscopic phase was 180 min (range, 120-240 min), and the median blood loss was 400 ml (range, 150-700 ml). A median of 20 (range, 9-30) lymph nodes were retrieved. The median intensive care unit stay was 4 days (range, 1-129 days), and the hospital stay was 18 days (range, 11-182 days). Pulmonary complications occurred in 10 patients (48%), and one patient (5%) died of a tracheoneoesophageal fistula.

CONCLUSIONS

In this initial experience, robot-assisted thoracoscopic esophagectomy was found to be feasible, providing an effective lymphadenectomy with low blood loss. Standardization of the technique and increased experience should reduce the complication rate, which is in the range of the rate for open transthoracic dissection.

Computer-assisted laparoscopic repair of "upside-down" stomach with the Da Vinci system

Recently introduced telerobotic surgical systems attempt to elude the inherent limitations of traditional laparoscopic surgery. Four patients (3 male, 1 female) with mixed hiatal and paraesophageal hernias with fixed intrathoracic partial or complete displacement of the stomach were operatively treated using the Da Vinci robotic system. Tissue dissection, hiatoplasty, and anterior hemifundoplication (Dor) were performed with the telerobotic system. There were no surgical complications. The system broke down in the fourth patient due to a software defect. Advantages were seen in terms of the intrathoracic dissection of displaced stomach through a narrow hiatus, intracorporeal suturing due to 6 degrees of freedom plus grasping. At the moment, lack of the appropriate robotic instruments for abdominal surgery as well as the enormous functional cost of the robotic system are considered to be the most significant current impediment to the adoption of robotic abdominal surgery. The continuous evolution and upgrade of the system is quite promising so far. Telerobotic-assisted hiatal hernia operation is feasible with many advantages compared with the traditional laparoscopic approach, especially during the dissection in the mediastinum in patients with intrathoracic stomach. A prospective, randomized trial will be performed later to evaluate the advantages and limitations of robotic compared with traditional laparoscopy. Technological evolution will perhaps diminish the current problems and the cost associated with robotic surgery.