Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1-year follow-up

Robotics in laparoscopic surgery - A review

Because of the increasing use of laparoscopic surgeries, robotic technologies have been developed to overcome the challenges these surgeries impose on surgeons. This paper presents an overview of the current state of surgical robots used in laparoscopic surgeries. Four main categories were discussed: handheld laparoscopic devices, laparoscope positioning robots, master–slave teleoperated systems with dedicated consoles, and robotic training systems. A generalized control block diagram is developed to demonstrate the general control scheme for each category of surgical robots. In order to review these robotic technologies, related published works were investigated and discussed. Detailed discussions and comparison tables are presented to compare their effectiveness in laparoscopic surgeries. Each of these technologies has proved to be beneficial in laparoscopic surgeries.

Coupling Effect Suppressed Compact Surgical Robot with 7-Axis Multi-Joint Using Wire-Driven Method

Currently, the most prevalent surgical treatment method is laparoscopic surgery. Robotic surgery has many advantages over laparoscopic surgery. Therefore, robotic surgery technology is currently constantly evolving. The advantages of robotic surgery are that it can minimize incision, bleeding, and sequelae. Other advantages of robotic surgery are that it can reduce hospitalization, recovery period, and side effects. The appeal of robotic surgery is that it requires fewer surgical personnel compared to laparoscopic surgery. This paper proposes an ultra-compact 7-axis vertical multi-joint robot that employs the wire-driven method for minimally invasive surgery. The proposed robot analyzes the degree of freedom and motion coupling for control. The robot joint is composed of a total of seven joints, and among them, the 7-axis joint operates the forceps. At this time, the forceps joint (#7 axis) can only operate open and close functions, while the link is bent and rotatable, regardless of position change. This phenomenon can be analyzed by Forward Kinematics. Also, when the DOF rotates, the passing wires become twisted, and the wire is generated through length change and coupling phenomenon. The maximum rotation angle of DOF is 90° and the rotating passing wire is wound by the rotation of the wire pulley. If the DOF is rotated to the full range of 120°, the second DOF will be rotated to 90°, and at this time, the coupling phenomenon caused by the first DOF rotation can be eliminated. The length change and the robot joint angle change related to the motor drive, based on the surgical robot control using the wire-driven method, are correlated, and the values for the position and direction of the end effector of the robot can be obtained through a forward kinematic analysis. The coupling problem occurring in the wire connecting the robot driving part can be solved through a kinematic analysis. Therefore, it was possible to test the position of the slave robot and the performance of the surgical forceps movement using the master system.

A comparison of immediate postoperative complications in using left internal mammary artery + vein versus only vein as conduit in patients undergoing off-pump coronary artery bypass grafting

Objective:

The objective of the study is to compare the immediate postoperative cardiac complications in patients undergoing off-pump coronary artery bypass grafting (OPCABG) using mixed (arterial and venous grafts) versus only venous grafts and to compare the requirement of packed red cell units and intra-aortic balloon pump (IABP) in both the groups.

Materials and Methods:

This was an observational, analytical, prospective study.

Sample Size:

Fifty new patients were included in the study.

Inclusion/Exclusion Criteria:

Patients diagnosed with triple-vessel coronary artery disease (CAD) undergoing OPCABG with an ejection fraction (EF) of more than 30%. Patients who have undergone prior CABG, EF <30%, preexisting valvular heart disease, any evidence pulmonary hypertension, preoperative IABP, any history of neurological dysfunction, left atrium size more than 5.5 cm, and history of coagulation disorder was excluded from the study.

Results:

The most common immediate postoperative cardiac complication observed was atrial fibrillation followed by ventricular arrhythmias in both the groups. There was no statistically significant difference in complication rate between the two groups. Postoperative requirement of IABP and requirements of blood products were also similar in both the groups.

Conclusion:

Patients undergoing off-pump CABG have similar immediate postoperative complications irrespective of the type of conduit used.

Comparison Between Robotic and Laparoscopic or Open Anastomoses: A Systematic Review and Meta-Analysis

INTRODUCTION

Robotic surgery has been increasingly used in fashioning various surgical anastomoses. Our aim was to collect and analyze outcomes related to anastomoses performed using a robotic approach and compare them with those done using laparoscopic or open approaches through meta-analysis.

METHODS

A systematic review was conducted for articles comparing robotic with laparoscopic and/or open operations (colectomy, low anterior resection, gastrectomy, Roux-en-Y gastric bypass (RYGB), pancreaticoduodenectomy, radical cystectomy, pyeloplasty, radical prostatectomy, renal transplant) published up to June 2019 searching Medline, Scopus, Google Scholar, Clinical Trials and the Cochrane Central Register of Controlled Trials. Studies containing information about outcomes related to hand-sewn anastomoses were included for meta-analysis. Studies with stapled anastomoses or without relevant information about the anastomotic technique were excluded. We also excluded studies in which the anastomoses were performed extracorporeally in laparoscopic or robotic operations.

RESULTS

We included 83 studies referring to the aforementioned operations (4 randomized controlled and 79 non-randomized, 10 prospective and 69 retrospective) apart from colectomy and low anterior resection. Anastomoses done using robotic instruments provided similar results to those done using laparoscopic or open approach in regards to anastomotic leak or stricture. However, there were lower rates of stenosis in robotic than in laparoscopic RYGB (p=0.01) and in robotic than in open radical prostatectomy (p<0.00001). Moreover, all anastomoses needed more time to be performed using the robotic rather than the open approach in renal transplant (p≤0.001).

CONCLUSION

Robotic anastomoses provide equal outcomes with laparoscopic and open ones in most operations, with a few notable exceptions.

Robotically Assisted Thoracic Surgery: Proposed Guidelines for Privileging and Credentialing

Objective

Increased use of robotically assisted thoracic surgery (RATS) necessitates effective credentialing guidelines to ensure safe outcomes. We provide a stepwise algorithm for granting privileges and credentials in RATS. This algorithm reflects graduated responsibility and complexity of the surgical procedures performed. Furthermore, it takes into account volume, outcomes, surgeon's competency, and appropriateness of robot usage.

Methods

We performed a literature review for available strategies to grant privileges and credentials for implementing robotic surgery. The following terms were queried: robot, robotic, surgery, and credentialing. We provide this algorithm on the basis of review of the literature, our institutional experience, and the experience of other medical centers around the United States.

Results

Currently, two pathways for robotic training exist: residency and nonresidency-trained. In the United Sates, Joint Commission: Accreditation, Health Care, Certification requires hospitals to credential and privilege physicians on their medical staff. In the proposed algorithm, a credentialing designee oversees and reviews all requests. Residency-trained surgeons must fulfill 20 cases with program directors’ attestation to obtain full privileges. Nonresidency-trained surgeons are required to fulfill simulation, didactics including online modules, wet laboratories (cadaver or animal), and observation of at least two cases before provisional privileges can be granted. A minimum number of cases (10 per year) are required to maintain privileges. All procedures are monitored via departmental QA/QI committee review. Investigational uses of the robot require institutional review board approval, and complex operations may require additional proctoring and QA/QI review.

Conclusions

Safety concerns with the introduction of novel and complex technologies such as RATS must be paramount. Our algorithm takes into consideration appropriate use and serves as a basic guideline for institutions that wish to implement a RATS program.

A systematic review on robotic coronary artery bypass graft surgery

BACKGROUND

Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival.

METHODS

Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB).

RESULTS

The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques.

CONCLUSIONS

A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.

Trends in Robotic-Assisted Coronary Artery Bypass Grafts: A Study of The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 2006 to 2012

BACKGROUND

Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and outcomes of robotic-assisted CABG (RA-CABG).

METHODS

A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups.

RESULTS

The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p < 0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p < 0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p < 0.0001), including postoperative renal failure (2.2% vs 2.9%, p < 0.0001), and shorter length of stay (4 vs 5 days, p < 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29).

CONCLUSIONS

RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.

Coronary artery bypass graft surgery: the past, present, and future of myocardial revascularisation

The development of the heart-lung machine ushered in the era of modern cardiac surgery. Coronary artery bypass graft surgery (CABG) remains the most common operation performed by cardiac surgeons today. From its infancy in the 1950s till today, CABG has undergone many developments both technically and clinically. Improvements in intraoperative technique and perioperative care have led to CABG being offered to a more broad patient profile with less complications and adverse events. Our review outlines the rich history and promising future of myocardial revascularization.

Robotic surgery in otolaryngology and head and neck surgery: a review

Recent advancements in robotics technology have allowed more complex surgical procedures to be performed using minimally invasive approaches. In this article, we reviewed the role of robotic assistance in Otolaryngology and Head and Neck Surgery. We highlight the advantages of robot-assisted surgery and its clinical application in this field.

Meta-analysis of robot-assisted versus conventional laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease

BACKGROUND

Conventional laparoscopic Nissen fundoplication (CLF) is generally considered the surgical approach of choice for gastro-oesophageal reflux disease. Robotic-assisted laparoscopic fundoplication (RALF) has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance by eliminating tremors and fatigue. A meta-analysis of randomized clinical trials (RCTs) was performed to compare RALF and CLF.

METHODS

Medline, Embase, ISI Web of Knowledge CPCI-S and The Cochrane Library were searched and the methodological quality of included trials was evaluated. Outcomes evaluated were intraoperative, dysphagia, flatulence, antisecretory medication, satisfaction with intervention, operation time, hospital stay and total cost. Results were pooled in meta-analyses as risk ratios and weighted mean differences (WMD).

RESULTS

Of 221 patients in six RCTs, 111 were allocated to CLF and 110 to RALF. RALF prolonged total time necessary to carry out fundoplication (WMD 3.17 (95% confidence interval. 2.33-4.00) min; P < 0.00001, χ(2) P = 0.25, I(2) = 24%). Operation complication, antisecretory medication, satisfaction with intervention, the time needed for hiatal dissection, the time from incision to completion of sutures, the total operation time and total cost were similar in both groups.

CONCLUSION

Clinical outcomes from RALF were comparable to CLF approach, but RALF prolonged the operation time. Currently, CLF should be routinely used as costs are lower.

Robotics and surgery: a long-term relationship?

This article introduces robotic surgical systems by explaining the shortcomings of traditional laparoscopic surgery, and how these new systems have been developed to address them. This is followed by a descriptive section of robotic systems past and present and their use in different surgical specialities. Finally, we discuss advances that are planned for the development of current systems and the future role of robotics in surgery.

Robotic technology in urology

Urology has increasingly become a technology-driven specialty. The advent of robotic surgical systems in the past 10 years has led to urologists becoming the world leaders in the use of such technology. In this paper, we review the history and current status of robotic technology in urology. From the earliest uses of robots for transurethral resection of the prostate, to robotic devices for manipulating laparoscopes and to the current crop of master-slave devices for robotic-assisted laparoscopic surgery, the evolution of robotics in the urology operating theatre is presented. Future possibilities, including the prospects for nanotechnology in urology, are awaited.

[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.

Does Robotic Technology Make Minimally Invasive Cardiac Surgery Too Expensive? A Hospital Cost Analysis of Robotic and Conventional Techniques

BACKGROUND

While potential benefits of robotic technology include decreased morbidity and improved recovery, some have suggested a prohibitively high cost. This study was undertaken to compare actual hospital costs of robotically assisted cardiac procedures with conventional techniques.

METHODS

We conducted a retrospective review of clinical and financial data of 20 patients who underwent atrial septal defect (ASD) closure and 20 patients who underwent mitral valve repair (MVr) using either robotic techniques or a conventional approach with a sternotomy. Total hospital cost (actual resource consumption) was subdivided into operative and postoperative costs.

RESULTS

Robotic technology did not significantly increase total hospital cost for ASD closure or MVr (p = 0.518 and p = 0.539). However, when including the initial capital investment for the robot through amortization of institutional costs, total hospital cost was increased by $3,773 for robotic ASD closure and $3,444 for robotic MVr (p = 0.021 and p = 0.004). The major driver of cost for robotic cases (operating room time) decreased over time.

CONCLUSIONS

Robotic technology did not significantly increase hospital cost. While the absolute cost for robotic surgery was higher than conventional techniques after taking into account the institutional cost of the robot, the major driver of cost for robotic procedures will likely continue to decrease, as the surgical team becomes increasingly familiar with robotic technology. Furthermore, other benefits, such as improvement in postoperative quality of life and more expeditious return to work may make a robotic approach cost-effective. Thus, it is possible that the benefits of robotic surgery may justify investment in this technology.

Computer-assisted surgery using telemanipulators: an evidence-based analysis

OBJECTIVE

The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of computer-assisted surgery with telemanipulators.

THE TECHNOLOGY

The technology for computer-assisted surgery with telemanipulators is a robotic arm that carries an endoscope while two other manipulator arms carry interchangeable tools, such as scissors and grippers. In a master-slave telemanipulator system, the master may consist of a joystick input system, or for surgery, may mimic the motion of the slave robot, such as the da Vinci and ZEUS surgical systems. These systems are capable of telerobotic surgery, or surgery from remote locations.

REVIEW STRATEGY

The Cochrane and INAHTA databases yielded 4 health technology assessments or systematic reviews on computer-assisted surgery using telemanipulators. A search of MEDLINE and EMBASE January 1, 2001 to November 24, 2003 was conducted. This search produced 448 studies, of which 19 met the inclusion criteria.

SUMMARY OF FINDINGS

Published health technology assessments indicate that there are limited data from studies, although there is initial evidence of the safety and efficacy of telemanipulators in some procedures when they are used at large academic centres for surgery on selected patients. Most studies are Level 3 and 4 observational studies and assess a wide variety of surgical procedures. Limited studies indicate the promise of telemanipulators, but their efficacy is not fully established. In some procedures, the advantages that telemanipulators may offer may also be achieved by non-robotic minimally invasive/laparoscopic techniques. To date, cost-effectiveness has not been demonstrated. Patients who have undergone robotic surgery must be followed to further define outcomes (e.g., long-term quality of the graft after coronary arterial bypass graft [CABG] surgery). The exact role of computer-assisted surgery with telemanipulators has not been fully defined. Telemanipulators should be used in procedures for which their performance offers the greatest advantage over non-computer-enhanced surgical procedures.

Robotic surgery: a current perspective

OBJECTIVE

To review the history, development, and current applications of robotics in surgery.

BACKGROUND

Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving.

METHODS

A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications.

RESULTS

Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques.

CONCLUSIONS

Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.

Robotic cardiac surgery: overview

Most endoscopic procedures are excisional, not reconstructive or microsurgical, mostly because conventional endoscopic instrumentation lacks dexterity due to long, nonarticulated instruments, a fixed pivot point and counterintuitive movement of the instrument tip, and lack of depth perception. Endoscopic approaches to cardiac surgery have not been successful; however, the development of robotic surgical systems has overcome many limitations of endoscopy. Computer-assisted surgery has created a computerized digital interface between the surgeon's hands and surgical instrument tips and enhances surgical ability, thereby enabling endoscopic microsurgery. Recently, robotic systems have allowed cardiac surgeons to perform minimally invasive endoscopic coronary artery bypass grafting (CABG) and valve procedures. This article summarizes the use of robotics in cardiac surgery and discusses its potential in our specialty.

The ZEUS robotic system: experimental and clinical applications

Laparoscopic procedures provide shorter hospitalization, less pain, better cosmetic results, and faster returns to normal than traditional surgery. Surgeons performing them, however, are hampered by lack of tridimensional view and haptic sense, and by remoteness; but this physical gap also allows robotic and computer interfaces. The computer digitizes surgical movements and images and modifies this information to filter out nonfinalized movements such as tremor, increasing dexterity and precision. Digitized information can also be transmitted to remote locations, allowing surgical care in remote or underserved areas, and enhancing surgical education. There are several robotic surgical systems available; this article reviews the experimental and clinical use of the ZEUS robotic system and discusses its possible role in the future operating room.

Robotic Surgery: Urologic Implications

Current medical robots have nothing in common with the anthropomorphic robots in science fiction classics. They are in fact, manipulators, working on a master-slave principle. Robots can be defined as "automatically controlled multitask manipulators, which are freely programmable in three or more spaces." The success of robots in surgery is based on their precision, lack of fatigue, and speed of action. This review describes the theory, advantages, disadvantages, and clinical utilization of mechanical and robotic arm systems to replace the second assistant and provide camera direction and stability during laparoscopic surgery. The Robotrac system (Aesculap, Burlingame, CA), the First Assistant (Leonard Medical Inc, Huntingdon Valley, PA), AESOP (Computer Motion, Goleta, CA), ZEUS (Computer Motion), and the da Vinci (Intuitive Surgical, Mountain View, CA) system are reviewed, as are simple mechanical-assist systems such as Omnitract (Minnesota Scientific, St. Paul, MN), Iron Intern (Automated Medical Products Corp., New York, NY), the Bookwalter retraction system (Codman , Somerville, NJ), the Surgassistant trade mark (Solos Endoscopy, Irvine, CA), the Trocar Sleeve Stabilizer (Richard Wolf Medical Instruments Corp., Rosemont, IL), and the Endoholder (Codman, Somerville, NJ).

Robotics and the pediatric surgeon

Surgical robots are enabling devices for minimally invasive (laparoscopic) surgery (MIS). They use a computer to enhance a surgeon's skills as hand movements are transmitted to robotic arms. The computer filters tremor, which becomes important at high magnifications of 10 to 15 times available in MIS. It also provides motion scaling so that large hand movements are converted to very small movements of the robotic arm. The robotic arms also have wrists that make suturing and knot tying far more accurate and efficient. Surgical robots are currently used clinically for procedures such as MIS Nissen fundoplication, cholecystectomy, and splenectomy. Laboratory experience indicates that they may provide advantages for newborn procedures such as portoenterostomy for biliary atresia and repair of esophageal atresia and tracheoesophageal fistula. They have a potential for making possible MIS procedures, which can only be done open now, and for introducing entirely new procedures as well as for the performance of procedures by operators distant from the patient.

Robotic surgery using Zeus MicroWrist technology: the next generation

BACKGROUND

The use of computer-animated surgical instruments for various cardiac operations has been shown to be feasible, but to date, the available information regarding the operative and technical details of these procedures is still inadequate.

METHODS

We used the Zeus (Computer Motion Inc., Goleta, Calif, USA) telemanipulation system to perform the internal mammary artery (IMA) takedown in 56 patients, in 12 of whom we used the newest model with MicroWristTM (Computer Motion Inc., Goleta, Calif, USA) technology. Port orientation was based on thoracic anatomy, the decisive landmarks being the mammillary line and the axillary line. The distance between ports was at least 9 cm, and the patient's arm was positioned with the left shoulder raised and angulated by not more than 90 degrees.

RESULTS

Mean setup time was 44 +/- 18 minutes for the first five patients and 16 +/- 7 minutes for the last five patients, with an overall average of 24 +/- 12 minutes. IMA harvest time at the beginning reached a mean of 95 +/- 23 minutes and decreased to 44 +/- 18 minutes in the last five cases. Average IMA takedown time was 58 +/- 17 minutes. The IMA was patent with a good flow in all 56 patients.

CONCLUSIONS

The introduction of robotic technology into clinical routine has resulted in safe procedures with a short learning curve. However, basic training in the modality is a must in order to achieve technical excellence.

Coronary revascularization in the 21st century. Emphasis on contributions by Japanese surgeons

The first three decades of coronary artery surgery have provided the foundation for the next century of this evolution. It is apparent that a multitude of events including the development of cardioplegia, improving surgical instrumentation, technological advances including endoscopic approaches and computer assisted robotics and biologic discoveries such as the role of the endothelium have provided the underpinnings for improved surgical outcomes. However, the single most important determinant of late results is the type of bypass conduit used for grafting. Thus, use of the left internal thoracic artery (ITA) grafted to the left anterior descending coronary is a more important determinant of survival than is any other factor (progression of coronary artery disease, increased age, poor left ventricular function, diabetes, female gender and off-pump operations). Use of two ITAs provides further benefit and it is likely that three or more arterial conduits will be shown to be advantageous in this regard in due time. Japanese cardiothoracic surgeons have made significant contributions to the continuing evolution of coronary bypass surgery and particularly to the advance of arterial conduits. This report will address those contributions to this evolution.