Robotic surgery: a current perspective

Identification of surgical human-robot interactions and measures during robotic-assisted surgery: A scoping review

This study aims to identify the dynamics of robotic-assisted surgery (RAS) teams and their metrics. A scoping review across seven science, engineering, and clinical databases was conducted. It was found that literature focuses on skills and interactions centralized around the surgeon and technical components of the robotic system; however, limited literature exists on skill proceduralization specific for other surgical team members performing robotic-assisted surgery procedures. A framework that identifies the individuals (i.e., surgeon, surgical team members, and robotic platform), with their respective skill requirements (technical and nontechnical), and the required interactions among the team and RAS systems was developed. Future research in RAS human-robot interaction can address the need to understand changing dynamics and skills required by the surgical team with the continuing evolution and adoption of surgical robot technology.

Industrial Robotics and the Future of Work

Starting in the 1970s with robots that were physically isolated from contact with their human co-workers, robots now collaborate with human workers towards a common task goal in a shared workspace. This type of robotic device represents a new era of workplace automation. Industrial robotics is rapidly evolving due to advances in sensor technology, artificial intelligence (AI), wireless communications, mechanical engineering, and materials science. While these new robotic devices are used mainly in manufacturing and warehousing, human-robot collaboration is now seen across multiple goods-producing and service-delivery industry sectors. Assessing and controlling the risks of human-robot collaboration is a critical challenge for occupational safety and health research and practice as industrial robotics becomes a pervasive feature of the future of work. Understanding the physical, psychosocial, work organization, and cybersecurity risks associated with the increasing use of robotic technologies is critical to ensuring the safe development and implementation of industrial robotics. This commentary provides a brief review of the uses of robotic technologies across selected industry sectors; the risks of current and future industrial robotic applications for worker and employer alike; strategies for integrating human-robot collaboration into a health and safety management system; and the role of robotic safety standards in the future of work.

Short-term outcomes and the learning curve for laparoscopic right hemicolectomy using the ArtiSential: a multicenter pooled analysis

BACKGROUND

Minimally invasive surgery for colorectal cancer has demonstrated significant advantages over traditional methods, but laparoscopic procedures remain technically challenging. ArtiSential is an articulated handheld laparoscopic system designed to offer greater maneuverability similar to robotic surgery, while addressing cost constraints. However, its clinical efficacy in right hemicolectomy (RHC) for right-sided colon cancer remains underexplored.

METHODS

A multicenter, retrospective study was conducted from January 2021 to October 2022, enrolling 511 patients who underwent laparoscopic RHC for right-sided colon cancer. Of these, 167 patients underwent ArtiSential-assisted RHC, while 344 underwent conventional RHC. Propensity-score matching (PSM) was used to balance baseline variables. Additionally, we employed cumulative sum analysis to evaluate the learning curve associated with ArtiSential use.

RESULTS

After PSM, each group consisted of 165 patients, with no significant differences in baseline clinical characteristics. The median operation time was 148 min for both procedures (p = 0.423). No significant differences were observed in complication rates, including intraoperative blood loss, open conversion, postoperative ileus, anastomotic leakage, or wound complications between ArtiSential-assisted RHC and conventional RHC. Moreover, the total expenses were not different between the groups. Cumulative sum analysis indicated that surgeons reached proficiency with ArtiSential after an average of 19 cases.

CONCLUSION

ArtiSential-assisted RHC proves to be a safe and feasible option, yielding comparable outcomes to conventional RHC with no significant differences in intraoperative or postoperative metrics. Surgeons can achieve proficiency with ArtiSential after performing an average of 19 cases. These findings suggest that ArtiSential could be a valuable addition to the minimally invasive surgical toolkit for right-sided colon cancer treatment.

Development of anatomically accurate digital organ models for surgical simulation and training

Advancements in robotics and other technological innovations have accelerated the development of surgical procedures, increasing the demand for training environments that accurately replicate human anatomy. This study developed a system that utilizes the AutoSegmentator extension of 3D Slicer, based on nnU-Net, a state-of-the-art deep learning framework for automatic organ extraction, to import automatically extracted organ surface data into CAD software along with original DICOM-derived images. This system allows medical experts to manually refine the automatically extracted data, making it more accurate and closer to the ideal dataset. First, Python programming is used to automatically generate and save JPEG-format image data from DICOM data for display in Blender. Next, DICOM data imported into 3D Slicer is processed by AutoSegmentator to extract surface data of 104 organs in bulk, which is then exported in STL format. In Blender, a custom-developed Python script aligns the image data and organ surface data within the same 3D space, ensuring accurate spatial coordinates. By using Blender's CAD functionality within this space, the automatically extracted organ boundaries can be manually adjusted based on the image data, resulting in more precise organ surface data. Additionally, organs and blood vessels that cannot be automatically extracted can be newly created and added by referencing the image data. Through this process, a comprehensive anatomical dataset encompassing all required organs and blood vessels can be constructed. The dataset created with this system is easily customizable and can be applied to various surgical simulations, including 3D-printed simulators, hybrid simulators that incorporate animal organs, and surgical simulators utilizing augmented reality (AR). Furthermore, this system is built entirely using open-source, free software, providing high reproducibility, flexibility, and accessibility. By using this system, medical professionals can actively participate in the design and data processing of surgical simulation systems, leading to shorter development times and reduced costs.

Development of a classification system for potential sources of error in robotic-assisted spine surgery

PURPOSE

Robotic-assisted spine surgery (RASS) has increased in prevalence over recent years, and while much work has been done to analyze differences in outcomes when compared to the freehand technique, little has been done to characterize the potential pitfalls associated with using robotics. This study's goal was to leverage expert opinion to develop a classification system of potential sources of error that may be encountered when using robotics in spine surgery. This not only provides practitioners, particularly those in the early stages of robotic adoption, with insight into possible sources of error but also provides the community at large with a more standardized language through which to communicate.

METHODS

The Delphi method, which is a validated system of developing consensus, was utilized. The method employed an iterative presentation of classification categories that were then edited, removed, or elaborated upon during several rounds of discussion. Voting took place to accept or reject the individual classification categories with consensus defined as ≥ 80% agreement.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Safety in Spine Surgery Summit, consensus was achieved on a classification system that includes four key types of potential sources of error in RASS as well as a list of the most commonly identified sources within each category. Initial sources of error that were considered included: cannula skidding/skive, penetration, screw misplacement, registration failure, and frame shift. After completion of the Delphi process, the final classification included four major types of pitfalls including: Reference/Navigation, Patient Factors, Technique, and Equipment Factors (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into potential sources of error in the setting of robotic spine surgery. The working group established four discrete categories while providing a standardized language to unify communication.

A real-time approach for surgical activity recognition and prediction based on transformer models in robot-assisted surgery

PURPOSE

This paper presents a deep learning approach to recognize and predict surgical activity in robot-assisted minimally invasive surgery (RAMIS). Our primary objective is to deploy the developed model for implementing a real-time surgical risk monitoring system within the realm of RAMIS.

METHODS

We propose a modified Transformer model with the architecture comprising no positional encoding, 5 fully connected layers, 1 encoder, and 3 decoders. This model is specifically designed to address 3 primary tasks in surgical robotics: gesture recognition, prediction, and end-effector trajectory prediction. Notably, it operates solely on kinematic data obtained from the joints of robotic arm.

RESULTS

The model's performance was evaluated on JHU-ISI Gesture and Skill Assessment Working Set dataset, achieving highest accuracy of 94.4% for gesture recognition, 84.82% for gesture prediction, and significantly low distance error of 1.34 mm with a prediction of 1 s in advance. Notably, the computational time per iteration was minimal recorded at only 4.2 ms.

CONCLUSION

The results demonstrated the excellence of our proposed model compared to previous studies highlighting its potential for integration in real-time systems. We firmly believe that our model could significantly elevate realms of surgical activity recognition and prediction within RAS and make a substantial and meaningful contribution to the healthcare sector.

In vivo evaluation of tissue damage from varying grasping forces using the Saroa surgical system

Robot-assisted surgery can help to reduce patient burden and operator stress by enabling precise manipulations with multiple joint motions, but may also cause complications due to the lack of tactile sensation. The Saroa surgical system was developed with a haptic feedback function, and allows operators to adjust grasping forces as desired. In this study, we investigated tissue damage from varying grasping forces using the Saroa surgical system, and assessed the utility of this system. The grasping forceps of the Saroa system were used to grasp the lungs, esophagus, aorta, liver, spleen, small intestine, and large intestine of six beagle dogs with forces of 1, 2, and 3 N for durations of 1, 2, and 4 min. The effects of different grasping forces and durations on tissue damage were histologically evaluated. Histological evaluations showed that grasping force caused tissue damage in the lung and liver, but not the other organs. These results showed the lung and liver were more vulnerable to grasping forces, and exhibited more severe tissue damage at higher forces. These findings suggest that the haptic feedback function of the Saroa system could help to reduce intraoperative organ damage, especially in the fields of lung and liver surgery.

Robotic sacrocolpopexy: a game worth playing? A critical literature analysis

Robotic sacrocolpopexy is an advanced minimally invasive technique for the surgical management of urogenital prolapse. It offers superior precision, reduced blood loss, and lower conversion rates compared to traditional approaches. However, longer operative times, higher costs, and the need for specialized training remain the most significant challenges of robotic surgery. The advantages of robotic sacrocolpopexy are reduced intraoperative complications, lower blood loss, and decreased conversion rates compared to traditional approaches. However, it was described to involve longer operative times, increased costs, and the need for a specialized training. Additionally, the technique shows significant potential for reducing complications in obese patients and improving cosmetic outcomes. Comparative studies highlight that robotic and laparoscopic sacrocolpopexy yield similar long-term outcomes, with differences primarily in operative time and cost-efficiency robotics. The lack of standardized protocols remains a limitation, and long-term data on durability and cost-benefit analyses are needed. Future research should prioritize optimizing outcomes, reducing costs, and improving accessibility to robotic urogynecologic surgery.

Building consensus: development of a best practice guideline (BPG) for avoiding errors in robotic-assisted spine surgery (RASS)

INTRODUCTION

With the rapid increase in the use of robotic-assisted spine surgery (RASS), reports describing complications have inevitably emerged. This study builds on previous work done to identify, characterize, and classify potential sources of error in spine surgery performed with enabling technology in the operating room. The goal of this study is to leverage expert opinion to develop a set of best practice guidelines that can be employed to minimize complications and optimize patient safety, specifically as it relates to RASS.

METHODS

After assembling a group of attending spine surgeons experienced in the use of RASS across the country, formal consensus regarding the best practices was developed using the Delphi method and nominal group technique. After a review of the relevant literature and evidence, an initial survey of study group members (n=12) helped frame potential areas for investigation. Statements were subsequently edited, removed, or elaborated upon during four iterative rounds of live discussion with the opportunity for panelists to propose new guidelines at any point in the process. Respondents were able to suggest modifications and refine the statements until consensus, defined as ≥ 80% agreement, was achieved.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Summit for Safety in Spine Surgery, consensus was achieved on 27 best practice guideline statements. This BPG had the key focus areas of 1) general protocols, 2) screw planning/execution, 3) optimization of surgical technique, and 4) areas for robotic improvement. (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into the best practices for minimizing errors in RASS with the presentation of 27 recommendations that can serve to reduce practice variability, optimize safety, and guide future research.

An integrated fuzzy neural network model for surgical approach selection using double hierarchy linguistic information

The selection of the most effective surgical approach is a critical decision in major surgery. With several approaches available, it is important to select the one that will have the most beneficial effect on the patient's health. Multi criteria decision making techniques are essential for identifying the most effective surgical approach to optimize patient health. Therefore, we develop a two novel decision making models under the double hierarchy linguistic information to select the best surgical approach for patient health. A more flexible way to express uncertainty and fuzziness in the surgical approach information is possible using the double hierarchy linguistic term set, which is made up of the first and second hierarchy linguistic term sets. Initially, we discuss the double hierarchy linguistic term set and its aggregation operator based on the Aczel-Alsina norms, as well as some basic properties of the Aczel-Alsina aggregation operator under the double hierarchy linguistic term sets. Next, we develop two novel decision making models under double hierarchy linguistic information, known as the WASPAS method and the double hierarchy linguistic neural network with the Aczel-Alsina aggregation operator. After that, we apply the proposed decision making models to select the most effective surgical approach to optimize patient health. For this, we collect the information about the surgical approach from the three highly qualified experts of the surgical approach. Further, we follow the procedure of the proposed models to compute the final output and select the most effective surgical approach to optimize patient health. After that, we evaluate the sensitivity of the proposed models in the context of surgical decision making. Moreover, we evaluate the validity and efficiency of the proposed decision making models by comparing them with existing decision making models.

Feasibility of Robotic Surgical Approach in Peritoneal Carcinomatosis

INTRODUCTION

Advances in robotic instrumentation have facilitated minimally invasive completion of complex cancer operations. The objective of this study is to determine the feasibility of robotic approach for cytoreduction (R-CRS) for peritoneal carcinomatosis in a series of 16 consecutive cases.

METHODS

Single institution retrospective study of consecutive patients with peritoneal carcinomatosis deemed appropriate for R-CRS after multidisciplinary review between 2017 and 2022. Feasibility was defined as the proportion of patients in whom complete cytoreduction was achieved without conversion to open.

RESULTS

A total of 16 patients (median interquartile range [IQR]: age 60 ys [45.8-70.5], body mass index 29 [24.5-33.6], peritoneal carcinomatosis index 5 [2.8-6.3]) underwent R-CRS of which six also received hyperthermic intraperitoneal chemtotherapy. Seven patients had gastrointestinal primary cancers (3 colorectal, 3 appendiceal, 1 small bowel neuroendocrine); and nine had gynecologic cancers (7 ovarian, 2 endometrial). Median operative time was 6.0 h (IQR: 5.0-9.0), and median estimated blood loss was 87.5 mL (IQR: 30.0-262.5). Robotic procedures included: pelvic tumor debulking 12 (75%), omentectomy 8 (50%), peritonectomy 6 (38%), large bowel resection 6 (37%), retroperitoneal mass resection 4 (25%), and hepatectomy 3 (19%). Median length of stay was 3.5 ds (IQR: 1.8-5.3) for the whole cohort and only 2 ds (IQR: 1.0-5.5) for patients who did not undergo hyperthermic intraperitoneal chemotherapy. Feasibility rate was 87.5%, whereas conversion, 30-d complication, and 30-d mortality rates were 12.5%, 18.8%, and 0%, respectively.

CONCLUSIONS

Our experience with R-CRS demonstrates feasibility of the approach with a potential for benefit in short-term outcomes in a carefully selected cohort of patients when performed at a high-volume robotic surgery center.

A comprehensive analysis of robotic assisted vs. laparoscopic distal pancreatectomy using propensity score matching

Using the propensity-matched methodology, this meta-analysis and comprehensive review aimed to compare robotic distal pancreatectomy with laparoscopic distal pancreatectomy in terms of perioperative and short-term oncologic outcomes. Within the scope of this investigation, complete and total adherence to the PRISMA guidelines for Systematic Reviews and Meta-Analyses was established. The search we conducted in PubMed, Google Scholar, and EMBASE was automated to find relevant papers that matched the tendency up to July 1, 2024. The length of time spent while operating, the rate of conversion, and the collection of lymph nodes were the primary factors that were considered. Other metrics that were taken into consideration were the approximate amount of blood loss, the length of time spent in the hospital, the need for transfusions, and the occurrence of major adverse events. In the end, there were 8 studies that involved 1649 patients. Of those patients, 758 had robotic assisted distal pancreatectomy, whereas 891 underwent laparoscopic distal pancreatectomy. In comparison to laparoscopic distal pancreatectomy, the robotic assisted technique did result in higher anticipated blood loss and conversion rates; however, it also required longer durations of operation due to its lengthier duration. In terms of lymph node retrieval, the duration of hospital stay, the need for blood transfusions, and the incidence of postoperative pancreatic fistula, there were no distinctions that could be considered statistically significant between the two techniques. A realistic and risk-free surgical alternative is a distal pancreatectomy that is performed with the aid of robotic technology. When compared to laparoscopic surgery, the outcomes of robot-assisted surgery were superior in terms of conversion rates to laparotomy and less anticipated intraoperative blood loss. However, the operation took longer to complete than laparoscopic surgery.

Evaluation of current and emerging endoluminal robotic platforms using the IDEAL framework

BACKGROUND

Robotic-assisted endoluminal systems are rapidly evolving within the field of minimally invasive surgery. The IDEAL framework (Idea, Development, Exploration, Assessment, and Surveillance) can be used to evaluate novel technologies. This review provides a summary of current and emerging endoluminal systems using the IDEAL framework.

METHODS

A scoping review was conducted to include all existing and developing robotic-assisted endoluminal systems. Data was collected via virtual interviews, questionnaires, biomedical databases, company websites, and peer-reviewed articles. Key metrics were reported, enabling the assignment of each system to an IDEAL stage.

RESULTS

The review identified 17 distinct systems from 16 companies. Nine systems received regulatory approval in their respective countries. Our evaluation showed that two systems were at the pre-IDEAL Stage 0. Seven systems were in the Idea stage (Stage 1), six systems were in the Development stage (Stage 2) and two systems completed Stage 3. No system underwent long-term study evaluation (Stage 4).

CONCLUSIONS

There is a gap in long-term clinical data of robotic-assisted endoluminal systems, indicated by the absence of systems at Stage 4. Collaborative efforts amongst the medical community, regulatory bodies, and industry specialists are vital to ensure the delivery of evidence-based medicine in the discipline of robotics.

An initial exploratory clinical study and outcome assessment of gastrointestinal surgeries using advanced robotic-assisted techniques

BACKGROUND

In addition to the Da Vinci surgical robot, domestic surgical robots are being developed rapidly. Chinese Toumai® laparoscopic surgical robot was approved for urological surgery in 2022.This study aims to systematically evaluate the safety and efficacy of the Toumai® robotic surgical system in performing complex gastrointestinal surgeries.

METHODS

This prospective, single-center, single-arm exploratory study was conducted at Gansu Provincial Hospital between June 2022 and October 2023, enrolling 12 patients undergoing gastrectomy and 9 patients undergoing colorectal resection. The primary endpoints are oncological outcomes and surgical success rates, while secondary endpoints encompassed intraoperative blood loss, operative duration, complication rates, system performance metrics, length of hospital stay, and postoperative pain levels.

RESULTS

All patients successfully underwent robotic-assisted surgery with adequate oncological resection and favorable postoperative outcomes. There were no conversions to open or laparoscopic surgery, resulting in a 100% procedural success rate. The median docking time for radical gastrectomy was 17.50 (14.25, 21.50) minutes, with a median master-slave control time of 121.50 (105.50, 172.00) minutes, median intraoperative blood loss of 100.00 (50.00, 275.00) mL, and a median postoperative hospital stay of 9.00 (7.25, 10.75) days. For radical colorectal surgery, the median docking time was 22 (17.50, 30.50) minutes, the median master-slave control time was 68 (56.50, 119.00) minutes, with a median blood loss of 50 (50.00, 150.00) mL, and a median postoperative hospital stay of 7 (7.00, 10.00) days. No intraoperative organ injury, mortality, system failure, or severe postoperative complications were reported.

CONCLUSIONS

These preliminary findings provide compelling evidence supporting the safety and efficacy of the Toumai® laparoscopic surgical robotic system in performing gastric and colorectal surgeries.

An early evaluation of robot-assisted and conventional techniques for posterior approach atlantoaxial displacement instrumentation - a systematic review and meta-analysis

Atlantoaxial dislocation (AAD) is a serious condition in which the first two cervical vertebrae lose their anatomical position and stability. This may lead to neurological complications, including death. The treatment of AAD remains controversial, and posterior instrumentation with pedicle screw placement is one of the commonly used methods. The goal of this study is to evaluate the effectiveness of robot-assisted (RA) surgery compared to conventional techniques for posterior AAD instrumentation. Following Cochrane and PRISMA guidelines, five major databases were searched from inception to December 2024. Studies evaluating RA surgery compared to freehand (FH) or computer navigation methods were included. Outcomes included screw accuracy, surgery time, radiation exposure, and complications. A random-effects mean difference (MD) and odds ratio (OR) were used. After a comprehensive search, three studies were included. Two studies compared RA to FH, and one compared RA to navigation. Blood loss (MD -103.11 [-148.73, -57.49], p < 0.01) and radiation dose (MD -8.19 [-10.18, -6.19], p < 0.01) were lower in the RA group compared to FH. Operating time was significantly longer in the RA group compared to conventional methods (MD 36.55 [30.07, 43.04], p < 0.01). The number of correct screws (OR 2.15 [1.11, 4.15], p = 0.02) and satisfactory screws (OR 3.18 [1.13, 8.90], p = 0.03) was higher in the RA group. RA surgery provides significantly higher pedicle screw accuracy compared to FH and navigation methods, although at the cost of increased surgery time. Blood loss and radiation exposure were lower in the RA group compared to FH. While the results are promising, this meta-analysis included only three small trials. Future randomized controlled trials are needed to fully evaluate the effectiveness of RA surgery for AAD instrumentation.

Transperitoneal vs retroperitoneal robotic partial nephrectomy: a meta-analysis and systematic review of propensity-matched studies

The main aim of this meta-analysis is to assess and compare the impact of two different surgical approaches, transperitoneal and retroperitoneal, on perioperative outcomes in robotic partial nephrectomy. A systematic search of MEDLINE, PubMed, Google Scholar, and the Cochrane Database was conducted to identify relevant studies published between January 2000 and January 2025. Included were nine non-randomized controlled trials with a total of 2420 patients with matching propensity scores. Among these patients, 1321 had robotic TPPN and 1099 had robotic RPPN, the abbreviation for robotic partial nephrectomy. Shorter operating times, shorter hospital stays, less estimated intraoperative blood loss, and fewer total postoperative problems were related to RPPN compared to TPPN. There were no notable disparities between the two groups when comparing the duration of renal ischemia, the fall in postoperative glomerular filtration rate (GFR), the occurrence of serious postoperative sequelae, or the necessity for blood transfusions. Compared to TPPN, RPPN demonstrates certain advantages in perioperative metrics such as surgical time, hospital stay, and overall complication rates. However, further high-quality studies are needed to confirm these findings.

From Pioneering Discoveries to Innovative Therapies: A Journey Through the History and Advancements of Nanoparticles in Breast Cancer Treatment

Nanoparticle technology has revolutionized breast cancer treatment by offering innovative solutions addressing the gaps in traditional treatment methods. This paper aimed to comprehensively explore the historical journey and advancements of nanoparticles in breast cancer treatment, highlighting their transformative impact on modern medicine. The discussion traces the evolution of nanoparticle-based therapies from their early conceptualization to their current applications and future potential. We initially explored the historical context of breast cancer treatment, highlighting the limitations of conventional therapies, such as surgery, radiation, and chemotherapy. The advent of nanotechnology has introduced a new era characterized by the development of various nanoparticles, including liposomes, dendrimers, and gold nanoparticles, designed to target cancer cells with remarkable precision. We further described the mechanisms of action for nanoparticles, including passive and active targeting, and reviewed significant breakthroughs and clinical trials that have validated their efficacy. Current applications of nanoparticles in breast cancer treatment have been examined, showcasing clinically approved therapies and comparing their effectiveness with traditional methods. This article also discusses the latest advancements in nanoparticle research, including drug delivery systems and combination therapy innovations, while addressing the current technical, biological, and regulatory challenges. The technical challenges include efficient and targeted delivery to tumor sites without affecting healthy tissue; biological, such as potential toxicity, immune system activation, or resistance mechanisms; economic, involving high production and scaling costs; and regulatory, requiring rigorous testing for safety, efficacy, and long-term effects to meet stringent approval standards. Finally, we have explored emerging trends, the potential for personalized medicine, and the ethical and social implications of this transformative technology. In conclusion, through comprehensive analysis and case studies, this paper underscores the profound impact of nanoparticles on breast cancer treatment and their future potential.

A review of wrist mechanism design and the application in gastrointestinal minimally invasive surgery of multi-degree-of-freedom surgical laparoscopic instruments

BACKGROUND

This paper aims to comprehensively review current designs of Multi-degree-of-freedom (Multi-DOF) wrist mechanisms and the applications of Multi-DOF surgical instruments in gastrointestinal minimally invasive surgery (MIS).

METHODS

By reviewing the advantages and limitations of traditional laparoscopic and robotic surgical instruments, we present the development of Multi-DOF surgical instruments. Then, we summarize the Multi-DOF wrist mechanisms, delineating their pros and cons. Finally, the surgical outcomes and efficiency of Multi-DOF surgical instruments are reviewed.

RESULTS

The utilization of Multi-DOF surgical instruments for both benign and malignant gastrointestinal diseases demonstrates perioperative outcomes comparable to traditional laparoscopic and robotic surgeries. In certain aspects, it exhibits advantages such as shorter operative times and faster gastrointestinal function recovery.

CONCLUSION

Further research is needed to effectively combine these driving mechanisms to achieve a new type of transmission mechanism with high rigidity and precision, ample working space, and decoupled degrees of freedom. Multi-DOF surgical instruments offer the advantages of high flexibility and lower costs, displaying good feasibility and safety in practical clinical applications within gastrointestinal surgery. Their promotion in primary care hospitals could benefit a larger patient population. However, more extensive sample-sized multicenter studies are still warranted to elucidate such surgical instruments' advantages further.

Current Status and Future of Artificial Intelligence in Medicine

Artificial intelligence (AI) has rapidly emerged as a transformative force in medicine, revolutionizing various aspects of healthcare from diagnostics and treatment to public health and patient care. This narrative review synthesizes evidence from diverse study designs, exploring the current and future applications of AI in medicine. We highlight AI's role in improving diagnostic accuracy, optimizing treatment strategies, and enhancing patient care through personalized interventions and remote monitoring, drawing upon recent advancements and landmark studies. Emerging trends such as explainable AI and federated learning are also examined. While acknowledging the tremendous potential of AI in medicine, the review also addresses the barriers and ethical challenges that need to be overcome, including concerns about algorithmic bias, transparency, over-reliance, and the potential impact on the healthcare workforce. We emphasize the importance of establishing regulatory guidelines, fostering collaboration between clinicians and AI developers, and ensuring ongoing education for healthcare professionals. Despite these challenges, the future of AI in medicine holds immense promise, with the potential to significantly improve patient outcomes, transform healthcare delivery, and address healthcare disparities.

Technological Advancements in Augmented, Mixed, and Virtual Reality Technologies for Surgery: A Systematic Review

Recent advancements in artificial intelligence (AI) have shown significant potential in the medical field, although many applications are still in the research phase. This paper provides a comprehensive review of advancements in augmented reality (AR), mixed reality (MR), and virtual reality (VR) for surgical applications from 2019 to 2024 to accelerate the transition of AI from the research to the clinical phase. This paper also provides an overview of proposed databases for further use in extended reality (XR), which includes AR, MR, and VR, as well as a summary of typical research applications involving XR in surgical practices. Additionally, this paper concludes by discussing challenges and proposed solutions for the application of XR in the medical field. Although the areas of focus and specific implementations vary among AR, MR, and VR, current trends in XR focus mainly on reducing workload and minimizing surgical errors through navigation, training, and machine learning-based visualization. Through analyzing these trends, AR and MR have greater advantages for intraoperative surgical functions, whereas VR is limited to preoperative training and surgical preparation. VR faces additional limitations, and its use has been reduced in research since the first applications of XR, which likely suggests the same will happen with further development. Nonetheless, with increased access to technology and the ability to overcome the black box problem, XR's applications in medical fields and surgery will increase to guarantee further accuracy and precision while reducing risk and workload.

Beyond the Band-Aid: Robot-Assisted Laparoscopy for Splenic Aneurysms-A Systematic Review

BACKGROUND

Splenic artery aneurysm (SAA) is characterized by a weakening and bulging of splenic artery. Robot-assisted (RA) laparoscopic surgery is a minimally invasive surgical technique. This systematic review aimed to assess the use of RA laparoscopic surgery to manage SAA.

METHODS

Five medical databases were used to identify studies that investigated the use of robotic devices in laparoscopic SAA management in humans. Original peer-reviewed articles were included. Two authors independently screened articles and extracted data on factors including patient demographics, surgical procedures, and outcomes.

RESULTS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses search identified 7 studies with a total of 28 patients who underwent RA laparoscopic surgery for SAA. The studies reported successful surgeries using various techniques, including end-to-end anastomosis, ligation, and graft placement. 3-dimensional printed models were used in 1 study as an aid for preoperative surgery planning. Mean operation time was 210 minutes, and 3 complications were reported (robotic arm failure during surgery and 2 conversions to open surgery).

CONCLUSIONS

RA laparoscopic surgery offers several advantages more than traditional open surgery for SAA management. However, more research is needed to confirm these potential benefits and establish RA laparoscopic surgery as a standard treatment option for SAA. Future studies should involve larger patient groups, compare this method to traditional techniques, and evaluate its cost-effectiveness. Additionally, incorporating advancements like mixed reality for preoperative planning and 3D printing to improve surgical planning and patient communication.

Engineering with Biomedical Sciences Changing the Horizon of Healthcare-A Review

In the dynamic realm of healthcare, the convergence of engineering and biomedical sciences has emerged as a pivotal frontier. In this review we go into specific areas of innovation, including medical imaging and diagnosis, developments in biomedical sensors, and drug delivery systems. Wearable biosensors, non-wearable biosensors, and biochips, which include gene chips, protein chips, and cell chips, are all included in the scope of the topic that pertains to biomedical sensors. Extensive research is conducted on drug delivery systems, spanning topics such as the integration of computer modeling, the optimization of drug formulations, and the design of delivery devices. Furthermore, the paper investigates intelligent drug delivery methods, which encompass stimuli-responsive systems such as temperature, redox, pH, light, enzyme, and magnetic responsive systems. In addition to that, the review goes into topics such as tissue engineering, regenerative medicine, biomedical robotics, automation, biomechanics, and the utilization of green biomaterials. The purpose of this analysis is to provide insights that will enhance continuing research and development efforts in engineering-driven biomedical breakthroughs, ultimately contributing to the improvement of healthcare. These insights will be provided by addressing difficulties and highlighting future prospects.

Comparison of surgical performance using articulated (ArtiSential®) and conventional instruments for colorectal laparoscopic surgery: A single-centre, open, before-and-after, prospective study

AIM

Rigid surgical instruments limit movement whereas articulated instruments offer better control in small spaces and allow for intuitive and ergonomic movements. However, the effectiveness of the use of articulated instruments in improving colorectal laparoscopic outcomes remains unclear. The aim of this work was to determine whether colorectal laparoscopic surgical proficiency improved when multijoint instruments were used instead of conventional ones.

METHOD

We enrolled 70 consecutive patients (n = 20 for conventional instruments) aged 19-80 years who underwent elective laparoscopic surgery for colorectal diseases. Unedited surgery videos were validated using the modified Global Operative Assessment of Laparoscopic Skills (mGOALS) scale. Learning curves were analysed using a cumulative sum control chart for mGOALS grades.

RESULTS

The surgery type, length of hospital stay and 30-day postoperative complication rates were comparable between the groups, and the surgeon's mGOALS grades were similar (p = 0.190). However, in the articulated group, the scores were significantly higher for depth perception (p = 0.012) and tissue-handling domains (p = 0.046), while surgical duration was significantly shorter and intraoperative blood loss was significantly lower (p = 0.022), compared with those in the conventional (p = 0.002) group. Learning curve findings indicated that the first 10 and subsequent 40 surgeries in the articulated group were within the inexperienced and experienced phases, respectively. The mGOALS score in the experienced phase improved in the articulated group compared with that in the conventional group (p = 0.036).

CONCLUSIONS

The use of articulated instruments in laparoscopic colorectal surgery showed potential benefits. Further studies are needed to confirm these findings.

Comparison of robotic vs. laparoscopic treatment in pediatric ovarian benign tumors

OBJECTIVE

To compare the differences in surgical outcomes of robot-assisted treatment and laparoscopy for benign ovarian tumors among pediatric patients.

METHODS

A total of 39 patients underwent robot-assisted surgery, and their outcomes were compared with 55 patients treated with laparoscopy during the same period by the same surgeons.

RESULTS

There were no significant differences between the two groups in terms of age (7.5 ± 4.5 vs. 8.8 ± 3.8 years, p = 0.2496), weight (29.3 ± 17.7 vs. 31.7 ± 14.6 kg, p = 0.4383), or tumor size (5.0 ± 3.3 vs. 5.1 ± 3.8 cm, p = 0.8541). However, the operative time was significantly longer in the robotic surgery group (102.7 ± 33.5 vs. 89.3 ± 50.9 min, p = 0.0112). There was no significant difference in intraoperative blood loss. Fewer patients in the robotic surgery group opted for day surgery compared to the laparoscopy group (15.4% vs. 54.5%, p < 0.001). There was no significant difference in the length of hospital stay between the two groups of patients who chose inpatient surgery (5.6 ± 3.4 vs. 4.4 ± 2.9 d, p = 0.1213). There was no conversion to open surgery and no early postoperative complications in both groups.

CONCLUSION

Robot-assisted surgery and laparoscopy yield comparable outcomes for the treatment of benign ovarian tumors in children, although robotic surgery has a longer operative time.

Integrating AI into Breast Reconstruction Surgery: Exploring Opportunities, Applications, and Challenges

Background: Artificial intelligence (AI) has significantly influenced various sectors, including healthcare, by enhancing machine capabilities in assisting with human tasks. In surgical fields, where precision and timely decision-making are crucial, AI's integration could revolutionize clinical quality and health resource optimization. This study explores the current and future applications of AI technologies in reconstructive breast surgery, aiming for broader implementation. Methods: We conducted systematic reviews through PubMed, Web of Science, and Google Scholar using relevant keywords and MeSH terms. The focus was on the main AI subdisciplines: machine learning, computer vision, natural language processing, and robotics. This review includes studies discussing AI applications across preoperative, intraoperative, postoperative, and academic settings in breast plastic surgery. Results: AI is currently utilized preoperatively to predict surgical risks and outcomes, enhancing patient counseling and informed consent processes. During surgery, AI supports the identification of anatomical landmarks and dissection strategies and provides 3-dimensional visualizations. Robotic applications are promising for procedures like microsurgical anastomoses, flap harvesting, and dermal matrix anchoring. Postoperatively, AI predicts discharge times and customizes follow-up schedules, which improves resource allocation and patient management at home. Academically, AI offers personalized training feedback to surgical trainees and aids research in breast reconstruction. Despite these advancements, concerns regarding privacy, costs, and operational efficacy persist and are critically examined in this review. Conclusions: The application of AI in breast plastic and reconstructive surgery presents substantial benefits and diverse potentials. However, much remains to be explored and developed. This study aims to consolidate knowledge and encourage ongoing research and development within the field, thereby empowering the plastic surgery community to leverage AI technologies effectively and responsibly for advancing breast reconstruction surgery.

The Role of Robotics in Cardiac Surgery: Innovations, Outcomes, and Future Prospects

In recent years, there has been a notable increase in the use of robotic technology in medical surgery, especially in heart surgery. Many advancements in surgery have been made possible by the development of these robotic devices, such as the da Vinci surgical system (Intuitive Surgical, Sunnyvale, California, United States). These advancements include improved ergonomics, three-dimensional (3D) imaging, and increased dexterity. This research evaluates the advancements, results, and potential applications of robots in heart surgery. A systematic review that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles was carried out. The PubMed and Cochrane databases underwent a thorough search that turned up articles from 2015 to 2023. Nine articles that satisfied the requirements for inclusion were evaluated for quality using the Critical Appraisal Skills Programme (CASP) checklists. Standardized templates and conventional content analysis techniques were used for data extraction and analysis, respectively. Nine studies with a range of approaches, including randomized, prospective, observational, and retrospective investigations, were included in the review. This research included a variety of robotic heart treatments, including mitral valve repair, atrial septal defect (ASD) closure, and coronary artery bypass grafting (CABG). Notable results include identical or shorter operating durations, fatality rates that are comparable to those of conventional techniques, fewer postoperative complications, and shorter hospital stays. Surgeons did, however, face an initial learning curve. Variants of the da Vinci surgical system were the most frequently used robotic systems. Robotic heart surgery has shown encouraging outcomes in terms of effectiveness, safety, and patient recovery. The dependability of robotic procedures is demonstrated by shorter operating times, reduced blood loss, a low incidence of conversion to conventional methods, and a reduction in postoperative complications. Shorter hospital stays suggest better patient outcomes and potential financial advantages. Nonetheless, the need for specific training and knowledge among surgeons is emphasized. Sustained investigation and advancement are essential for the refinement and broader use of robotic heart surgery. Robotic-assisted cardiac surgery has a promising future with a focus on improved patient outcomes, training, and procedural development.

The existence of manual mode increases human blame for AI mistakes

People are offloading many tasks to artificial intelligence (AI)-including driving, investing decisions, and medical choices-but it is human nature to want to maintain ultimate control. So even when using autonomous machines, people want a "manual mode", an option that shifts control back to themselves. Unfortunately, the mere existence of manual mode leads to more human blame when AI makes mistakes. When observers know that a human agent theoretically had the option to take control, the humans are assigned more responsibility, even when agents lack the time or ability to actually exert control, as with self-driving car crashes. Four experiments reveal that though people prefer having a manual mode, even if the AI mode is more efficient and adding the manual mode is more expensive (Study 1), the existence of a manual mode increases human blame (Studies 2a-3c). We examine two mediators for this effect: increased perceptions of causation and counterfactual cognition (Study 4). The results suggest that the human thirst for illusory control comes with real costs. Implications of AI decision-making are discussed.

Robotic versus laparoscopic surgery for colorectal disease: a systematic review, meta-analysis and meta-regression of randomised controlled trials

INTRODUCTION

Robotic surgery (RS) is gaining prominence in colorectal procedures owing to advantages like three-dimensional vision and enhanced dexterity, particularly in rectal surgery. Although recent reviews report similar outcomes between laparoscopic surgery (LS) and RS, this study investigates the evolving trends in outcomes over time, paralleling the increasing experience in RS.

METHODS

A systematic review, meta-analysis and meta-regression were conducted of randomised controlled trials exploring postoperative outcomes in patients undergoing RS or LS for colorectal pathology. The primary outcome measure was postoperative complications. Risk of bias was evaluated using the Cochrane Collaboration's assessment tool. Randomised controlled trials were identified from the PubMed®, Embase® and CINAHL® (Cumulative Index to Nursing and Allied Health Literature) databases via the Cochrane Central Register of Controlled Trials.

RESULTS

Of 491 articles screened, 13 fulfilled the inclusion criteria. Meta-analysis of postoperative complications revealed no significant difference between RS and LS (relative risk [RR]: 0.96, 95% confidence interval [CI]: 0.79 to 1.18, p=0.72). Meta-regression analysis of postoperative complications demonstrated a significant trend favouring RS over time (yearly change in Ln(RR): -0.0620, 95% CI: -0.1057 to -0.0183, p=0.005). Secondary outcome measures included operative time, length of stay, blood loss, conversion to open surgery, positive circumferential resection margins and lymph nodes retrieved. The only significant findings were shorter operative time favouring LS (mean difference: 41.48 minutes, 95% CI: 22.15 to 60.81 minutes, p<0.001) and fewer conversions favouring RS (RR: 0.57, 95% CI: 0.37 to 0.85, p=0.007).

CONCLUSIONS

As experience in RS grows, evidence suggests an increasing safety profile for patients. Meta-regression revealed a significant temporal trend with complication rates favouring RS over LS. Heterogeneous reporting of complications hindered subgroup analysis of minor and major complications. LS remains quicker. Rising adoption of RS coupled with emerging evidence is expected to further elucidate its clinical efficacy.

Robotic-assisted versus laparoscopic-assisted extended mesorectal excision: a comprehensive meta-analysis and systematic review of perioperative and long-term outcomes

BACKGROUND

Concurrent neoadjuvant chemo-radiation (nCRT) with total mesorectal excision (TME) alone sometimes fails to cure lateral lymph node metastasis (LLNM). Therefore, additional lateral lymph node dissection (LLND) can help in the treatment of these patients. This is what we refer to as extended total mesorectal excision (eTME). Such operations (TME alone or eTME) can be performed using conventional laparoscopic techniques and robotic-assisted techniques as well. Our meta-analysis aims to compare the results of robot-assisted (R-eTME) versus laparoscopic-assisted extended mesorectal excision (L-eTME) in terms of short- and long-term outcomes.

METHODOLOGY

Databases searched using title and abstract included Medline (via PubMed), Web of Science, Scopus, and Embase, up to February 20, 2024. All studies that documented robotic versus laparoscopic procedures for extended total mesorectal excision (R-eTME versus L-eTME) and reported more than two relevant outcomes, were included in the study.

RESULTS

Our meta-analysis demonstrates four significant outcomes (operative time, urinary complications, overall recurrence, and admission days) between the laparoscopic and robotic groups. The robotic approach shows advantages over the laparoscopic approach in these outcomes except for the operative time (minute), which was longer in the robotic group compared to the laparoscopic group. The laparoscopic group is associated with a higher overall recurrence than the robotic group with an Odds Ratio of 2(95% CI, 1-4, p = 0.05).

CONCLUSION

This meta-analysis study showed that the R-eTME group had a lower recurrence rate compared to the L-eTME group. Additionally, hospital admission days increased significantly in the laparoscopic group. Other long-term outcomes did not differ significantly between the two groups. Short-term outcomes were similar, except for more urinary complications in the laparoscopic group. In conclusion, the study suggests that robotic surgery may offer advantages over laparoscopic surgery for eTME. Further research and analysis could provide further insight into the potential benefits of robotic surgery in this procedure, particularly when surgeon experience, center volume, and learning curve are taken into consideration.

Hybrid robotic systems

Standard laparoscopic instruments have limited dexterity because of their few degrees of freedom, making some surgical tasks extremely challenging. Robotic surgery was developed to overcome these issues, but the da Vinci system is associated with high costs. During recent years, many companies developed new robotic systems to improve dexterity and ergonomics with less impact on cost-effectiveness. This work describes the main commercially available modular robotic platforms, focusing on the technology, architecture and features, and advantages and disadvantages of each system. One of the main advantages of modular systems is the possibility of performing the whole procedure robotically or performing part of the procedure laparoscopically and part robotically as a hybrid approach. Next-generation robotic systems mainly include a modular design, open or semiopen consoles, smaller instruments, decreased cost, and augmented reality. To date, there are still few data in the literature comparing the systems, as many of them are awaiting regulatory approval. Thus, future studies are necessary to answer these questions. Many other robotic platforms are currently under development and will be available on the market, with a potential to alter surgical practice.

Comparison of da Vinci Robotic Cholecystectomy and Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis of Postoperative Outcomes and Cost-Effectiveness

Robotic cholecystectomy (RC) using the da Vinci surgical system has been introduced as a potential alternative to the gold standard laparoscopic cholecystectomy (LC) for gallbladder removal. This systematic review aims to evaluate and compare the postoperative outcomes (operative time, bile leak, and postoperative complications) and cost-effectiveness between da Vinci RC and LC. A comprehensive search of electronic databases, including EMBASE, MEDLINE, Cochrane Library, and PubMed, used Medical Subject Headings terms and Boolean operators to identify relevant studies. Comparative trials assessing postoperative outcomes and costs between RC and LC were included. Data were extracted independently by researchers and analyzed using the RevMan 5.4 software (The Cochrane Collaboration, London, UK). The analysis included six studies with a total of 1,013 patients, comprising three randomized controlled trials (RCTs) and three cohorts conducted across Switzerland, Taiwan, the USA, and Italy. Results showed that LC had a significantly shorter operation duration than RC (standardized mean difference: 0.27; 95% CI, 0.05-0.49; p = 0.01). No significant differences were observed between RC and LC in terms of bile leak rates (odds ratio, 0.37; 95% CI, 0.06-2.21; p = 0.27) or postoperative complications (odds ratio, 0.50; 95% CI, 0.18-1.37; p = 0.18). Cost analysis revealed that RC was more cost-effective than LC (standardized mean difference, 3.16; 95% CI, 0.39-5.93; p = 0.03), with substantial heterogeneity noted among the studies. The findings suggest that RC does not provide significant clinical advantages over LC in postoperative outcomes and incurs higher costs. Due to the heterogeneity and the limited number of RCTs included, a major multicenter RCT is recommended to validate these results further. In conclusion, LC remains the preferred approach due to its shorter operative time and cost-effectiveness, with no significant differences in clinical outcomes compared to da Vinci RC. Further research with larger, multicenter trials is warranted to confirm these findings and guide clinical decision-making.

Robot-assisted congenital diaphragmatic hernia repair in adults: A case series

RATIONALE

Congenital diaphragmatic hernia (CDH) is a rare condition predominantly affecting neonates, with only a few cases remaining undetected until adulthood. Surgical repair is the primary treatment approach for adults with confirmed CDH. Traditionally, these procedures include laparotomy, thoracotomy, and minimally invasive techniques such as thoracoscopy and laparoscopy. However, only a few cases of robotic diaphragmatic hernia repair have been reported in recent decades.

PATIENT CONCERNS

The patients, aged 31 and 71 years, presented with atypical symptoms of chest tightness and fever. Imaging studies revealed a left-sided Bochdalek CDH in 1 patient and a right-sided Morgagni CDH in the other.

DIAGNOSES

The patients were diagnosed as CDH in adult with different symptoms.

INTERVENTIONS

Both patients received robot-assisted diaphragmatic hernia repair at our institution.

OUTCOMES

The patients received robotic-assisted diaphragmatic hernia repair with acceptable surgery outcome and safety. There was no complication or recurrence.

LESSONS

This case series indicates that the robotic transabdominal approach for CDH repair in adults can be an optimal minimally invasive approach for selected patients, demonstrating adequate surgical safety and favorable outcomes.

Evaluating the benefit of contact-force feedback in robotic surgery using the Saroa surgical system: A preclinical study

INTRODUCTION

Robotic surgery without contact-force feedback could be less safe, as forces exerted by the robot system may exceed tissue tolerance. This study aimed to evaluate the benefit of contact-force feedback.

METHODS

Nine junior and 11 senior surgeons performed two tasks using Saroa, a robotic surgical system with a force feedback function. In Task A, the participants estimated the order of stiffness of substances when feedback was on and off. In Task B, the effect of feedback on compression with a designated force (3 N) was assessed.

RESULTS

In Task A, the proportion of participants who correctly estimated the order of stiffness of the substances was similar when feedback was on and off. However, the median maximum force applied to the substances was significantly smaller when feedback was on than when it was off (5.0 vs. 6.9 N, p = .011), which was more obvious among the junior surgeons (5.0 vs. 7.7 N, p = .015) than among the senior surgeons (4.7 vs. 5.9 N, p = .288). In Task B, deviations from the designated force (3 N) for three substances were smaller when feedback was on (0, -0.1, and 0.7, respectively) than when it was off (-0.3, -0.5, and 1.3, respectively). Regarding the dispersion of the force to the substances, the interquartile range tended to be smaller with feedback; this trend was more obvious in the junior surgeons.

CONCLUSION

With contact-force feedback, tissue stiffness could be estimated with a small force, particularly by the junior surgeons; specified force could be accurately applied to the tissue.

Collaborative Implementation of Robotic Surgery Into an Academic Pediatric Surgery Practice

INTRODUCTION

Robotic surgery continues to drive evolution in minimally invasive surgery. Due to the confined operative fields encountered, pediatric surgeons may uniquely benefit from the precise control offered by robotic technologies compared to open and laparoscopic techniques. We describe a unique collaborative implementation of robotic surgery into an academic pediatric surgery practice through adult robotic surgeon partnership. We compare robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC) outcomes, hypothesizing that RC will be equivalent to LC in key quality outcomes.

METHODS

We evaluate 14 mo of systems development and training, and 24 mo of collaborative operative experience evoking a purposeful tiered case progression, establishing core robotic competencies, prior to advancing operative complexity. Univariate analyses compared LC versus RC.

RESULTS

36 robotic operations were performed in children aged 8-18 y, in a tiered progression from 24 cholecystectomies to 2 ileocecectomies, 2 paraesophageal hernia repairs, 1 anterior rectopexy, 1 spleen-preserving distal pancreatectomy, 1 Heller myotomy, 1 choledochal cyst resection with roux-en-y hepaticojejunostomy, 1 median arcuate ligament release, and 1 thoracic esophageal duplication cyst resection. For LC and RC, there were no significant differences in procedure duration, discharge opioids, hospital readmission, or rates of surgical site infection or bile duct injury.

CONCLUSIONS

Robotic surgery has potential to significantly enhance pediatric surgery. RC appears equivalent to LC but presents multiple additional theoretical benefits in pediatric patients. Our pilot program experience supports the feasibility and safety of pediatric robotic surgery. We emphasize the importance of a stepwise progression in operative difficulty and collaboration with adult robotic surgery experts.

Robotic Versus Laparoscopic Pancreaticoduodenectomy for Pancreatic Cancer: Evaluation and Analysis of Surgical Efficacy

BACKGROUND

Evidence is limited for the treatment of pancreatic cancer among minimally invasive pancreatoduodenectomy.

METHODS

This retrospective analysis evaluated patients who underwent robotic pancreaticoduodenectomy (RPD) or laparoscopic pancreaticoduodenectomy (LPD) from April 2016 to April 2023. Their baseline and perioperative data, including operative time, R0 resection rates, and severe complications rates, were analyzed, and the follow-up data, such as disease-free survival (DFS) and overall survival (OS), were collected.

RESULTS

A total of 253 cases of LPD and RPD were performed, and 101 cases with pancreatic cancer were included, of which 54 were LPD and 47 were RPD. The conversion rate (4.3% vs. 29.6%, p = 0.001) and blood loss (400 vs. 575 mL, p < 0.05) were lower in the RPD group. No significant difference was observed between the two groups in terms of operative time, vessel resection rates, and TNM-stage diagnosis; however, R0 resection rates (80.9% vs. 70.4%) and lymph node harvest (24.2 vs. 21.9) had a higher tendency in the RPD group, and postoperative length of stay was shorter in the RPD cohort (11 vs. 13 days). Moreover, improved 1- to 3-years DFS (75.7%, 61.7%, and 36.0% vs. 59.0%, 35.6%, and 21.9%) and OS (94.7%, 84.7%, and 50.8% vs. 84.1%, 63.6%, and 45.5%) was found in the RPD group in comparison with the LPD group.

CONCLUSIONS

RPD had advantages in surgical safety and oncological outcomes compared with LPD, but was similar to the latter in perioperative outcomes. Long-term outcomes require further study.

Evaluation of forces applied to tissues during robotic-assisted surgical tasks using a novel force feedback technology

BACKGROUND

The absence of force feedback (FFB) is considered a technical limitation in robotic-assisted surgery (RAS). This pre-clinical study aims to evaluate the forces applied to tissues using a novel integrated FFB technology, which allows surgeons to sense forces exerted at the instrument tips.

METHODS

Twenty-eight surgeons with varying experience levels employed FFB instruments to perform three robotic-assisted surgical tasks, including retraction, dissection, and suturing, on inanimate or ex-vivo models, while the instrument sensors recorded and conveyed the applied forces to the surgeon hand controllers of the robotic system. Generalized Estimating Equations (GEE) models were used to analyze the mean and maximal forces applied during each task with the FFB sensor at the "Off" setting compared to the "High" sensitivity setting for retraction and to the "Low", "Medium", and "High" sensitivity settings for dissection and suturing. Sub-analysis was also performed on surgeon experience levels.

RESULTS

The use of FFB at any of the sensitivity settings resulted in a significant reduction in both the mean and maximal forces exerted on tissue during all three robotic-assisted surgical tasks (p < 0.0001). The maximal force exerted, potentially associated with tissue damage, was decreased by 36%, 41%, and 55% with the use of FFB at the "High" sensitivity setting while performing retraction, dissection, and interrupted suturing tasks, respectively. Further, the use of FFB resulted in substantial reductions in force variance during the performance of all three types of tasks. In general, reductions in mean and maximal forces were observed among surgeons at all experience levels. The degree of force reduction depends on the sensitivity setting selected and the types of surgical tasks evaluated.

CONCLUSIONS

Our findings demonstrate that the utilization of FFB technology integrated in the robotic surgical system significantly reduced the forces exerted on tissue during the performance of surgical tasks at all surgeon experience levels. The reduction in the force applied and a consistency of force application achieved with FFB use, could result in decreases in tissue trauma and blood loss, potentially leading to better clinical outcomes in patients undergoing RAS. Future studies will be important to determine the impact of FFB instruments in a live clinical environment.

The pioneering past and cutting-edge future of interventional neuroradiology

This review provides a thorough understanding of the developments in the field of interventional neuroradiology (INR). A concise overview of the pioneering past and current state of this field is presented first, followed by a greater emphasis on its future. Five main aspects predicted to undergo significant developments are identified and discussed. These include changes in 'education and training', 'clinical practice and logistics', 'devices and equipment', 'techniques and procedures', and 'relevant diagnostic imaging'. INR is at the crossroads of neuroradiology, neurosurgery, neurology, and the neurosciences. To progress we must value the uniqueness and vitality of this multidisciplinary aspect. While minimal access techniques offer very good anatomical accessibility to treat multiple pathologies of the central nervous system, it is also important to recognise its limitations. Medical, surgical, and radiosurgery modalities retain an important role in the management of some complex neuropathology. This review is certainly not exhaustive of all ongoing and predicted developments, but it is an important update for INR specialists and other interested professionals.

Internal validation of the Tampa Robotic Difficulty Scoring System: real-time assessment of the novel robotic scoring system in predicting clinical outcomes after hepatectomy

INTRODUCTION

As the robotic approach in hepatectomy gains prominence, the need to establish a robotic-specific difficulty scoring system (DSS) is evident. The Tampa Difficulty Score was conceived to bridge this gap, offering a novel and dedicated robotic DSS aimed at improving preoperative surgical planning and predicting potential clinical challenges in robotic hepatectomies. In this study, we internally validated the recently published Tampa DSS by applying the scoring system to our most recent cohort of patients.

METHODS

The Tampa Difficulty Score was applied to 170 recent patients who underwent robotic hepatectomy in our center. Patients were classified into: Group 1 (score 1-8, n = 23), Group 2 (score 9-24, n = 120), Group 3 (score 25-32, n = 20), and Group 4 (score 33-49, n = 7). Key variables for each of the groups were analyzed and compared. Statistical significance was accepted at p ≤ 0.05.

RESULTS

Notable correlations were found between the Tampa Difficulty Score and key clinical parameters such as operative duration (p < 0.0001), estimated blood loss (p < 0.0001), and percentage of major resection (p = 0.00007), affirming the score's predictive capacity for operative technical complexity. The Tampa Difficulty Score also correlated with major complications (Clavien-Dindo ≥ III) (p < 0.0001), length of stay (p = 0.011), and 30-day readmission (p = 0.046) after robotic hepatectomy.

CONCLUSIONS

The Tampa Difficulty Score, through the internal validation process, has confirmed its effectiveness in predicting intra- and postoperative outcomes in patients undergoing robotic hepatectomy. The predictive capacity of this system is useful in preoperative surgical planning and risk categorization. External validation is necessary to further explore the accuracy of this robotic DSS.

Deep pelvis and low visceral fat mass as risk factors for neurogenic bladder after rectal cancer surgery

BACKGROUND

Postoperative neurogenic bladder (PONB) frequently occurs as a complication after rectal cancer surgery. This study aimed to analyze risk factors for developing PONB after rectal cancer surgery, particularly the association between pelvic anatomy and visceral fat mass.

METHODS

We included 138 patients who underwent rectal resection for lower rectal cancer in our department between 2017 and 2021. PONB was defined as the need for urethral catheter reinsertion or oral medication administration for urinary retention after catheter removal with severe NB that required treatment for ≥ 60 days. We obtained visceral fat area (VFA) at the umbilical level based on a CT scan and measured five pelvic dimensions.

RESULTS

Of the 138 patients, 19 developed PONB, with 16 being severe cases. PONB more frequently occurs in patients with a height of < 158 cm, age ≥ 70 years, surgery lasting ≥ 8 h, intraoperative bleeding volume ≥ 150 mL, lateral lymph node dissection, and narrower pelvis. It was more prevalent in cases with low VFA. Conversely, gender, body mass index (BMI), and medical history showed no significant correlations. Multivariate analysis revealed older age, prolonged surgery, and low VFA as independent risk factors for PONB. Independent risk factors for severe PONB included low VFA, older age, prolonged surgery, and deep pelvis.

CONCLUSION

Lower VFA, older age, and prolonged surgery are independent risk factors for developing PONB. Additionally, a deep pelvis is an independent risk factor for severe PONB. Delicate surgical techniques should consider the risk of nerve injury in cases with low VFA and deep pelvis.

Robotic surgery: bibliometric analysis, continental distribution, and co-words analysis from 2001 to 2023

The project aimed to conduct an up-to-date and comprehensive bibliometric analysis of robotic surgery to provide a detailed and holistic understanding of the field. Three strategies were employed in the data analysis i.e. search terms were explored in (A) the title, abstract, and keywords and (B) only in the title of the documents. In 3rd part we analyzed the top 100 most cited papers. Vosviewer and R Studio were utilized for detailed bibliometric and network analyses. Strategy one identified 38,469 publications, and strategy two identified 6451 publications from 2001 to 2023. The top authors, universities, countries, sponsors, and sources based on the number of publications were identified for both strategies. The top 100 most cited papers were analyzed, providing the annual number of publications and various citation metrics. Top authors (by number of publications, total citations, h-index, g-index, and m-index), universities, and countries within these highly cited papers, along with their co-authorship networks and dynamics, were examined. Co-words analysis of the top 100 most cited papers revealed the primary focus of these documents across 25 categories. This comprehensive bibliometric analysis of robotic surgery highlighted significant contributions and collaborations in the field, emphasizing the importance of global and collaborative efforts in advancing robotic surgery research.

Robotics and AI into healthcare from the perspective of European regulation: who is responsible for medical malpractice?

The integration of robotics and artificial intelligence into medical practice is radically revolutionising patient care. This fusion of advanced technologies with healthcare offers a number of significant benefits, including more precise diagnoses, personalised treatments and improved health data management. However, it is critical to address very carefully the medico-legal challenges associated with this progress. The responsibilities between the different players concerned in medical liability cases are not yet clearly defined, especially when artificial intelligence is involved in the decision-making process. Complexity increases when technology intervenes between a person's action and the result, making it difficult for the patient to prove harm or negligence. In addition, there is the risk of an unfair distribution of blame between physicians and healthcare institutions. The analysis of European legislation highlights the critical issues related to the attribution of legal personality to autonomous robots and the recognition of strict liability for medical doctors and healthcare institutions. Although European legislation has helped to standardise the rules on this issue, some questions remain unresolved. We argue that specific laws are needed to address the issue of medical liability in cases where robotics and artificial intelligence are used in healthcare.

Robotic kidney transplantation

Kidney transplantation is the best treatment option for patients with end-stage renal disease owing to improved survival and quality of life compared with dialysis. The surgical approach to kidney transplantation has been somewhat stagnant in the past 50 years, with the open approach being the only available option. In this scenario, evidence of reduced surgery-related morbidity after the introduction of robotics into several surgical fields has induced surgeons to consider robot-assisted kidney transplantation (RAKT) as an alternative approach to these fragile and immunocompromised patients. Since 2014, when the RAKT technique was standardized thanks to the pioneering collaboration between the Vattikuti Urology Institute and the Medanta hospital (Vattikuti Urology Institute-Medanta), several centres worldwide implemented RAKT programmes, providing interesting results regarding the safety and feasibility of this procedure. However, RAKT is still considered an alternative procedure to be offered mainly in the living donor setting, owing to various possible drawbacks such as prolonged rewarming time, demanding learning curve, and difficulties in carrying out this procedure in challenging scenarios (such as patients with obesity, severe atherosclerosis of the iliac vessels, deceased donor setting, or paediatric recipients). Nevertheless, the refinement of robotic platforms through the implementation of novel technologies as well as the encouraging results from multicentre collaborations under the umbrella of the European Association of Urology Robotic Urology Section are currently expanding the boundaries of RAKT, making this surgical procedure a real alternative to the open approach.

Current status and future perspectives of robotic liver surgery

Robotic liver resection has been reported in case series since the early 2000s. The surgical robot is capable of precise operation using articulated forceps with seven degrees of freedom. The robot also eliminates tremors and provides a good surgical field with highly detailed 3D high-definition images. The clinical results demonstrating their usefulness have been increasing year by year. Initially, a shorter hospital stay was observed in comparison with open hepatectomy. Recent reports have also shown lower conversion and complication rates in comparison with laparoscopic hepatectomy. The clamp and crush method with bipolar forceps, sealing devices, ultrasonic shears, and the combined procedure of Cavitron ultrasonic surgical aspirator and robotic forceps as hybrid procedures have been reported as effective methods of parenchymal transection in robotic surgery. Theoretically, the advantages of the robotic platform allow for more complex liver resection around hilar structures and major blood vessels, as well as for vascular reconstruction or biliary reconstruction. The application of robotic liver surgery for hilar cholangiocarcinoma, living donor hepatectomy, and living donor liver transplantation has been reported. Robotic liver surgery is becoming more popular for certain indications; however, it is important to further evaluate its long-term surgical and oncological outcomes and costs in comparison with conventional laparoscopic and open liver surgery, based on accumulated experience.

Evolution of Robotic Urology in Clinical Practice from the Beginning to Now: Results from the GRAND Study Register

BACKGROUND AND OBJECTIVE

Major urological guidelines do not currently recommend robot-assisted surgery compared with laparoscopic or open surgery due to the lack of high-quality evidence. We aimed to provide real-world data on the evolution of robotic urology and to compare its perioperative outcomes with those of laparoscopic and open surgeries.

METHODS

We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2005-2021), and performed multiple patient-level analyses. We included patients undergoing major urological surgeries and report the largest study in the field with 993 276 patients.

KEY FINDINGS AND LIMITATIONS

An open approach was performed in 733 416 cases, a laparoscopic approach in 109 428, and a robot-assisted approach in 150 432. Overall, 442 811 (45%) patients underwent radical prostatectomy, 129 943 (13%) radical cystectomy, 192 340 (19%) radical nephrectomy, 123 648 (12%) partial nephrectomy, 56 114 (5.6%) nephroureterectomy, and 48 420 (4.9%) pyeloplasty. The number of patients undergoing robot-assisted surgery increased exponentially, while the number of patients undergoing open surgery decreased substantially throughout the past few years. Patients undergoing minimally invasive surgery displayed slightly better, but clinically insignificant, baseline characteristics. After adjusting for the major risk factors in the multivariate regression analysis, robotic versus open surgery was associated with significantly lower odds of mortality for all five major oncological surgeries and with lower odds of intensive care unit admission, transfusion, and length of hospital stay for all six major urological surgeries.

CONCLUSIONS AND CLINICAL IMPLICATIONS

Robotic surgery is becoming the mainstay in major urological operations.

PATIENT SUMMARY

Patients selected for robotic surgery in Germany presented better perioperative outcomes compared to those operated with an open approach.

[Brief history and application prospect of robotic spine surgery]

Spinal robotics has rounded out twenty years in clinical, is mainly used for pedicle screw placement at present, can significantly increase the accuracy of screw placement and reduce radiation exposure to the patient and the surgeon. In the future, haptic feedback, automatic collision avoidance, and other technologies will further expand its application to complete precise operations such as decompression and correction, providing safety guarantee for the implementation of complex spinal surgery.

Robotics in Arthroplasty: Historical Progression, Contemporary Applications, and Future Horizons With Artificial Intelligence (AI) Integration

Robotic technology is increasingly utilized in surgical procedures to enhance precision, particularly in tasks demanding delicate maneuvers beyond human capabilities. Robotic orthopedic surgery emerges as a dynamic and compelling technology reshaping the landscape of surgical practice. This aids surgeons in achieving enhanced accuracy and reproducibility, ultimately aiming for improved patient outcomes. As of now, the majority of these systems are in a developed stage and are gradually gaining broader adoption. These systems have to show that they are user-friendly, are successful in clinical settings, and have a good cost-effectiveness ratio before they can be widely adopted in the field of surgery. In this review, we examine the evolution of robotics in orthopedic surgery, assess its current applications, and provide insights into the future trajectory of this technology, particularly in light of advances in artificial intelligence (AI) and machine learning (ML).

Mandibular bone segmentation from CT scans: Quantitative and qualitative comparison among software

OBJECTIVES

Nowadays, a wide variety of software for 3D reconstruction from CT scans is available; they differ for costs, capabilities, a priori knowledge, and, it is not trivial to identify the most suitable one for specific purposes. The article is aimed to provide some more information, having set up various metrics for the evaluation of different software's performance.

METHODS

Metrics include software usability, segmentation quality, geometric accuracy, mesh properties and Dice Similarity Coefficient (DSC). Five different software have been considered (Mimics, D2P, Blue Sky Plan, Relu, and 3D Slicer) and tested on four cases; the mandibular bone was used as a benchmark.

RESULTS

Relu software, being based on AI, was able to solve some very intricate geometry and proved to have a very good usability. On the other side, the time required for segmentation was significantly higher than other software (reaching over twice the time required by Mimics). Geometric distances between nodes position calculated by different software usually kept below 2.5 mm, reaching 3.1 mm in some very critical area; 75th percentile q75 is generally less than 0.5 mm, with a maximum of 1.11 mm. Dealing with consistency among software, the maximum DSC value was observed between Mimics and Slicer, D2P and Mimics, and D2P and Slicer, reaching 0.96.

SIGNIFICANCE

This work has demonstrated how mandible segmentation performance among software was generally very good. Nonetheless, differences in geometric accuracy, usability, costs and times required can be significant so that information here provided can be useful to perform an informed choice.

Perioperative and oncologic outcomes of robot-assisted versus open surgery for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to compare perioperative and oncologic outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) treated with robotic-assisted surgery versus open laparotomy. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Randomized controlled trials (RCTs) and cohort studies up to June 15, 2024, were identified using PubMed, EMBASE, and Google Scholar. Additionally, reference lists of included studies, relevant review articles, and clinical guidelines were manually searched. The primary outcomes evaluated were length of stay, 90-day mortality, postoperative pancreatic fistula (POPF), and Post-pancreatectomy haemorrhage (PPH). Secondary outcomes included estimated blood loss, reoperation rate, lymph node yield, and operative time. The final analysis included 10 retrospective cohort studies involving 23,272 patients (2,179 robotic-assisted and 21,093 open surgery). There were no significant differences between the two procedures in terms of postoperative pancreatic fistula, Post-pancreatectomy haemorrhage, lymph node yield, and operative time. However, patients undergoing robotic-assisted surgery had shorter lengths of stay, lower 90-day mortality, and less estimated blood loss compared to those undergoing open surgery. The reoperation rate was higher for the robotic-assisted group. Robotic-assisted surgery for pancreatic ductal adenocarcinoma is safe and feasible. Compared to open surgery, it offers better perioperative and short-term oncologic outcomes, but with a higher risk of reoperation.