Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis

Minimally invasive laparoscopic and robotic anterior lumbar interbody fusion: a systematic review and future directions

INTRODUCTION

Anterior Lumbar Interbody Fusion (ALIF) is a commonly performed spine surgery procedure used to treat lumbar conditions such as degenerative disc disease, spondylolisthesis, and spinal deformities. Traditionally, it has been performed using open and mini-open surgical techniques. Recently, however, laparoscopic and robotic-assisted ALIF have gained attention for their potential benefits, including shorter recovery times, fewer complications, and improved patient outcomes. However, the safety, effectiveness, and long-term outcomes of these newer techniques remain to be fully compared to conventional methods.

METHODS

The systematic review was conducted in accordance with the PRISMA 2020 guidelines. MEDLINE and Cochrane databases were searched for studies on laparoscopic and robotic approaches to the anterior spine, with a focus on ALIF. Article selection and data extraction were independently conducted by two reviewers. Studies involving animal models, non-ALIF robotic techniques, or non-English publications were excluded.

RESULTS

A total of 650 articles were initially identified. After screening, a full-text review was conducted on 80 articles, of which 48 studies met the inclusion criteria: 42 focused on laparoscopic ALIF (L-ALIF) and 6 on robotic-assisted ALIF (R-ALIF). Laparoscopic ALIF achieved similar outcomes to mini-open methods, offering limited consistent benefits while presenting challenges such as a steep learning curve and a higher risk of retrograde ejaculation. Data on robotic-assisted ALIF, though limited, indicated improved precision and a reduced rate of intraoperative complications. However, high costs, logistical challenges, and the lack of substantial long-term outcome data remain significant barriers to the broader adoption of this technique in spine surgery.

CONCLUSION

L-ALIF and R-ALIF present promising minimally invasive alternatives to mini-open ALIF approaches. L-ALIF yields outcomes similar to mini-open techniques, though its technical demands warrant careful consideration. R-ALIF shows potential for improved precision and reduced complications, but logistical and financial constraints limit its wider adoption. Future studies should focus on multicenter prospective trials, alongside efforts to reduce costs and enhance training, to refine the role of these techniques in optimizing patient outcomes.

Robotic versus laparoscopic heller myotomy for esophageal achalasia: an updated systematic review and meta-analysis

BACKGROUND

The surgical treatment for esophageal achalasia has evolved over the years, with laparoscopic Heller myotomy (LHM) and partial fundoplication becoming widely used worldwide. More recently, an increased interest in the robotic Heller myotomy (RHM) has arisen.

PURPOSE

Compare short-term and functional outcomes of RHM vs. LHM.

METHODS

Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcome was esophageal perforation (EP). Risk ratio (RR), standardized mean difference (SMD), and 95% confidence intervals (95% CI) were effect size and relative inference measures. PROSPERO Registration Number: CRD42024512644.

RESULTS

Fourteen observational studies (12962 patients) were included. Of those, 2503 (19.3%) underwent RHM. The patient age ranged from 34 to 66 years and 51.7% were males. EP occurred in 259 patients (1.99%). The cumulative incidence of EP was 1.67% for RHM and 2.07% for LHM. Compared to LHM, RHM was associated with a reduced risk of EP (RR: 0.31; 95% CI 0.16-0.59). No differences were found in term of dysphagia requiring reoperation or additional endoscopic procedures (RR: 0.47; 95% CI 0.20-1.09) and postoperative Eckardt score (SMD: -0.42; 95% CI -0.94, 0.11). Blood loss, conversion to open, operative time, and hospital length of stay were comparable.

CONCLUSIONS

RHM may be associated with a reduced risk of EP compared to LHM. However, because of selection bias, diverse surgeon expertise, variations in surgical technique, and prior endoscopic procedures these findings should not be viewed as conclusive while the superiority of one approach over the other remains to be established.

Comparison of short-term outcomes of robotic versus laparoscopic right colectomy for patients ≥ 65 years of age: a systematic review and meta-analysis of prospective studies

Robotic right colectomy (RRC) has been researched and compared in the past to the laparoscopic approach (LRC). However, it remains unclear whether RRC outperforms LRC in patients aged 65 or older with colon cancer or adenoma. Thus, this systematic review and meta-analysis aims to compare the short-term outcomes of RRC to LRC in this particular age group. PubMed, Scopus, and Cochrane Library were searched for related literature. Studies and data were extracted by two independent reviewers. Inverse variances weighted mean differences (WMD) with random effects model were used for continuous values, and odds ratios (OR) with random effects model using the Mantel-Haenszel's formula were used for dichotomous values. Heterogeneity using Higgins I2 and p values were calculated. A sensitivity analysis was performed for operative duration and number of harvested lymph nodes. In total 382 patients, 157 in RRC and 225 in LRC, were included in this study. A statistically significant increase of 43.91 min [95%CI: 19.61, 68.22], P = 0.001, was observed regarding operative duration in the RRC group, compared to LRC, but with high heterogeneity, I2 = 89%. However, a statistically significant decrease of 42% [OR = 0.58 (0.34, 0.98), P = 0.04, I2=2%] was observed with regard to overall complications in RRC compared to LRC. Non-significant differences between the two approaches were observed in the number of harvested lymph nodes [WMD = 0.44 (95%CI: -3.94, 4.82), P = 0.85, I2 = 52%], wound infections [OR = 0.63 (95%CI: 0.11, 3.52), P = 0.60, I2 = 13%], rate of ileus [OR = 0.29 (95%CI: 0.08, 1.00), P = 0.05, I2 = 0%], length of hospitalization [WMD = 0.18 (95%CI: - 0.74, 1.11), P = 0.70, I2 = 0%], and anastomotic leakage [OR = 0.52 (95%CI: 0.09, 3.11), P = 0.47, I2 = 0%]. The results of the operative duration and number of harvested lymph nodes remained statistically significant and non-significant, respectively, after sensitivity analysis. Robotic right colectomy appears to require a longer operative duration, but possibly offers lower rates of overall complications, compared to laparoscopic right colectomy in patients ≥ 65 years of age. Due to the lack of studies identified in the literature, and the ones included being non-randomized, no solid conclusions can be drawn and cautious interpretation of the results is advised. Future studies are necessary to further examine both short- and long-term outcomes. Prospero registration: CRD42024603354.

Augmenting Robot-Assisted Pattern-Cutting With Periodic Perturbations: Can We Make Dry Lab Training More Realistic?

OBJECTIVE

Teleoperated robot-assisted minimally-invasive surgery (RAMIS) offers many advan tages over open surgery, but RAMIS training still requires optimization. Existing motor learning theories could improve RAMIS training. However, there is a gap between current knowledge based on simple movements and training approaches required for the more complicated work of RAMIS surgeons. Here, we studied how surgeons cope with time-dependent perturbations.

METHODS

We used the da Vinci Research Kit and investigated the effect of time-dependent force and motion perturbations on learning a circular pattern-cutting surgical task. Fifty-four participants were assigned to two experiments, with two groups for each: a control group trained without perturbations and an experimental group trained with 1 Hz perturbations. In the first experiment, force perturbations alternatingly pushed participants' hands inwards and outwards in the radial direction. In the second experiment, the perturbation constituted a periodic up-and-down motion of the task platform.

RESULTS

Participants trained with perturbations learned how to overcome them and improve their performances during training without impairing them after the perturbations were removed. Moreover, training with motion perturbations provided participants with an advantage when encountering the same or other perturbations after training, compared to training without perturbations.

CONCLUSION

Periodic perturbations can enhance RAMIS training without impeding the learning of the perturbed task.

SIGNIFICANCE

Our results demonstrate that using challenging training tasks that include perturbations can better prepare surgical trainees for the dynamic environment they will face with patients in the operating room.

Meta-analysis of the efficacy and safety of robot-assisted comparative laparoscopic surgery in lateral lymph node dissection for rectal cancer

INTRODUCTION

A meta-analysis was conducted on the perioperative and oncological outcomes of robot-assisted and laparoscopic lateral lymph node dissection in rectal cancer. There are few articles and reports on this topic, and a lack of high-quality research results in unreliable research conclusions. This study includes prospective and retrospective studies to obtain more reliable findings.

MATERIALS AND METHODS

Databases were searched, including PubMed, EMBASE, Cochrane, and Web of Science. The search was conducted from the time of database construction to March 2024. The quality of the literature was evaluated using the NOS scoring system. Meta-analysis was performed using R language software. Statistical heterogeneity was assessed using the I2 statistic, and sensitivity analysis was performed.

RESULTS

Six relevant literatures that met the criteria were finally included, and 652 patients were included, including 316 (48.5%) in the robot-assisted lateral lymph node dissection for rectal cancer group (RLLND) and 336 (51.5%) in the laparoscopic lateral lymph node dissection for rectal cancer group (LLLND). Analysis of the results showed that compared with the laparoscopic group, the robotic group had less mean intraoperative blood loss (MD = - 22, 95% CI - 40.03 to - 3.97, P < 0.05), longer operative time (MD = 51.57, 95%CI 7.69 to 95.45, P < 0.05), and a shorter mean hospital stay (MD = - 1.25, 95%CI - 2.46 to - 0.05, P < 0.05), a low rate of urinary complications (OR 0.39, 95%CI 0.23 to 0.64, P < 0.01), a low overall rate of postoperative complications (OR 0.6, 95%CI 0.42 to 0.87, P < 0.01), and a high number of lateral lymph node dissection (MD = 1.18, 95% CI 0.14 to 2.23, P < 0.05), and there was no statistically significant difference between the two groups in terms of postoperative anastomotic leakage, postoperative intestinal obstruction, and total number of lymph nodes obtained (P > 0.05).

CONCLUSION

Compared with laparoscopy, robotic lateral lymph node dissection for rectal cancer reduces intraoperative blood loss, shortens the average length of hospital stay, reduces urologic complications, decreases overall postoperative complications, and collects more lateral lymph nodes. However, the surgical time is prolonged.

Advances of surgical robotics: image-guided classification and application

Surgical robotics application in the field of minimally invasive surgery has developed rapidly and has been attracting increasingly more research attention in recent years. A common consensus has been reached that surgical procedures are to become less traumatic and with the implementation of more intelligence and higher autonomy, which is a serious challenge faced by the environmental sensing capabilities of robotic systems. One of the main sources of environmental information for robots are images, which are the basis of robot vision. In this review article, we divide clinical image into direct and indirect based on the object of information acquisition, and into continuous, intermittent continuous, and discontinuous according to the target-tracking frequency. The characteristics and applications of the existing surgical robots in each category are introduced based on these two dimensions. Our purpose in conducting this review was to analyze, summarize, and discuss the current evidence on the general rules on the application of image technologies for medical purposes. Our analysis gives insight and provides guidance conducive to the development of more advanced surgical robotics systems in the future.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

Tremor Estimation and Removal in Robot-Assisted Surgery Using Improved Enhanced Band-Limited Multiple Fourier Linear Combiner

BACKGROUND

During a robot-assisted minimally invasive surgery, hand tremors in a surgeon's manipulation of the master manipulator can cause vibrations of the slave surgical instruments.

METHODS

This letter addresses this problem by proposing an improved Enhanced Band-Limited Multiple Linear Fourier Combiner (E-BMFLC) algorithm for filtering the physiological tremor signals of a surgeon's hand. The proposed method uses the amplitude of the input signal to adapt the learning rate and a dense division of the combiner bands for the higher amplitude bands of the tremor signals.

RESULTS

By using the proposed improved E-BMFLC algorithm, the compensation accuracy can be improved by 4.5%-8.9%, as well as a spatial position error of less than 1 mm.

CONCLUSION

The results show that among all filtering methods, the improved E-BMFLC filtering method has the highest number of successful experiments and the lowest experimental time.

Robotic-assisted vs. Laparoscopic Heller's Myotomy for Achalasia in Children

INTRODUCTION

Robotic-assisted Heller-Dor procedure has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia in children. Our aim is to compare the effectiveness, safety and associated costs between both procedures.

METHODS

A retrospective single center study was conducted among consecutive children operated for achalasia (Heller-Dor operation) between 2005 and 2021, who were divided into two groups according to the surgical approach: laparoscopic (LAP-group) or robotic (ROB-group). Demographics, clinical features, surgery time, length of hospital stay (LOS), postoperative complications, long-term outcomes and economic data were compared between both groups.

RESULTS

A total of 24 patients were included (12 in LAP-group; 12 in ROB-group), with no demographic or clinical differences between them. ROB-group patients presented lower intraoperative blood loss (23 ± 15 vs. 95 ± 15 ml; p < 0.001), shorter surgery time (178 ± 25 vs. 239 ± 55 min; p = 0.009) and shorter LOS, with a median of 2 days (Q1-Q3: 2-3) when compared to LAP-group (4 days [Q1-Q3:3-5]; p = 0.008). Three post-operative complications were reported, all in LAP-group (2 esophageal perforations and 1 esophageal tightness). After a median follow-up of 11 years, ROB-group patients presented fewer recurrences (0 vs 5; p = 0.039), less reintervention rate (0 % vs 41.7 %; p < 0.039) and lower associated economic costs (28,660$ vs. 60,360$; p < 0.001).

CONCLUSION

This is the first comparative study of robotic and laparoscopic treatment of achalasia in children. Initial outcomes of robotic-assisted Heller-Dor procedure suggests some intraoperative (less blood loss and surgical time) and postoperative advantages (fewer complications and reinterventions). However, long-term studies with larger numbers of patients are needed.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

The evolution of robotics: research and application progress of dental implant robotic systems

The use of robots to augment human capabilities and assist in work has long been an aspiration. Robotics has been developing since the 1960s when the first industrial robot was introduced. As technology has advanced, robotic-assisted surgery has shown numerous advantages, including more precision, efficiency, minimal invasiveness, and safety than is possible with conventional techniques, which are research hotspots and cutting-edge trends. This article reviewed the history of medical robot development and seminal research papers about current research progress. Taking the autonomous dental implant robotic system as an example, the advantages and prospects of medical robotic systems would be discussed which would provide a reference for future research.

Proposal of set-up standardization for general surgery procedures with the CMR Versius system, a new robotic platform: our initial experience

BACKGROUND

The article describes our initial experience using CMR Versius platform for several procedures in general surgery.

METHODS

Between September 2022 and April 2023, seventy patients underwent robotic surgery in a multi-robotic referral center (San Paolo University Hospital, Milan, Italy). Three surgeons with only laparoscopic experience performed 24 cholecystectomies, 13 inguinal hernia repairs, 9 ventral hernia repairs, 7 right hemicolectomies, 11 left hemicolectomies, 1 sigmoidectomy, 1 ileocecal resection, 1 ventral rectopexy, 1 Nissen fundoplication, 1 total splenectomy, and 1 exploration with multiple biopsies.

RESULTS

All surgeries were full-robotic, with only one conversion to laparoscopy. The short length of stay and low rate of severe morbidity are promising findings. Although operative time was lengthened, clinical outcomes were not affected.

CONCLUSIONS

Our experience demonstrates that the adoption of Versius system is safe and feasible in general surgery. The standardization of port placement and BSU set-up can certainly reduce the operative time.

Robotic colorectal surgery and future directions

As the adoption of robotic-assisted procedures expands across various surgical specialties, colorectal surgery stands out as a prominent beneficiary. This rise in usage can be traced back to the increased accessibility of robotic platforms and a growing institutional shift towards cutting-edge surgical methods. When compared with traditional laparoscopic methods, robotic techniques offer distinct advantages. Their true potential shines in surgeries involving complex anatomical regions, where the robot's enhanced dexterity and range of motion prove invaluable. The three-dimensional, magnified view provided by robotic systems further boosts surgical precision and clarity. These advantages render robotic assistance especially suitable for colorectal surgeries, notably in intricate areas such as the rectum and endoluminal spaces. As the medical world emphasizes minimally invasive surgical methods, there's a pressing need to evolve and optimize robotic techniques in colorectal surgery. This article traces the evolution of robotic interventions in colorectal surgeries, highlighting both its historical milestones and anticipated future trends. We'll also explore emerging robotic tools and systems set to reshape the colorectal surgical arena.

Feasibility of robotic cholecystectomy at an academic center with a young robotic surgery program: a retrospective cohort study with umbrella review

Laparoscopic cholecystectomy (LC) has been standard of care for surgical treatment of benign gallbladder pathology for decades. With the advent of robotic surgical technology, robotic cholecystectomy (RC) has gained attention as an alternative to conventional laparoscopy. This study introduces a single-surgeon experience with laparoscopic versus robotic cholecystectomy and an umbrella systematic review of the outcomes of both approaches. A retrospective chart review was performed at a single institution on a prospectively maintained database of patients undergoing laparoscopic or robotic cholecystectomy for benign gallbladder pathology. An umbrella systematic review was conducted using PRISMA methodology. A total of 103 patients were identified; 61 patients underwent LC and 42 underwent RC. In the RC cohort, 17 cases were completed using a four-port technique while 25 were completed using a three-port technique. Patients undergoing RC were older compared to the LC group (44.78 vs 57.02 years old; p < 0.001) and exhibited lower body mass index (29.37 vs 32.37 kg/m2, p = 0.040). No statistically significant difference in operative time or need for postoperative ERCP was noted. Neither this series nor the umbrella systematic review revealed significant differences in conversion to open surgery or readmissions between the LC and RC cohorts. Three-port RC was associated with reduced operative time compared to four-port RC (101.28 vs 150.76 min; p < 0.001). Robotic cholecystectomy is feasible and safe at a young robotic surgery program in an academic center setting and comparable to laparoscopic cholecystectomy clinical outcomes.

The Utilization of e-Health in Lymphedema Care: A Narrative Review

Background: Electronic health (e-Health), refers to technologies that can be utilized to enhance patient care as well as collect and share health information. e-Health comprises several umbrella terms, including telehealth, mobile health, e-Health, wearables, and artificial intelligence. The types of e-Health technologies being utilized in lymphedema (LE) care are unknown. Method: In this narrative review, a search of published research on the utilization of e-Health technologies in LE-related care was conducted. Results: Five different types of e-Health modalities were found (robotics, artificial intelligence, electronic medical records, smart wearable devices, and instructive online information) spanning 14 use cases and 4 phases of care (preventative, diagnostic, assessment, and treatment phases). Broad e-Health utilization examples were found including robotic-assisted surgery to reduce the likelihood of LE after lymphadenectomy, machine learning to predict patients at risk of filarial-related LE, and a novel wearable device prototype designed to provide lymphatic drainage. Conclusions: e-Health has reported merit in the prevention, diagnoses, assessment, and treatment of LE with utilization demonstrating cutting edge applicability of e-Health for achieving optimal patient care and outcomes. As technology continues to advance, additional research into the utilization of e-Health in LE care is warranted.

Novel miniature transendoscopic telerobotic system for endoscopic submucosal dissection (with videos)

BACKGROUND AND AIMS

The lack of tissue traction and instrument dexterity to allow for adequate visualization and effective dissection were the main issues in performing endoscopic submucosal dissection (ESD). Robot-assisted systems may provide advantages. In this study we developed a novel transendoscopic telerobotic system and evaluated its performance in ESD.

METHODS

A miniature dual-arm robotic endoscopic assistant for minimally invasive surgery (DREAMS) was developed. The DREAMS system contained the current smallest robotic ESD instruments and was compatible with the commercially available dual-channel endoscope. After the system was established, a prospective randomized controlled study was conducted to validate the performance of the DREAMS-assisted ESD in terms of efficacy, safety, and workload by comparing it with the conventional technique.

RESULTS

Two robotic instruments can achieve safe collaboration and provide sufficient visualization and efficient dissection during ESD. Forty ESDs in the stomach and esophagus of 8 pigs were completed by DREAMS-assisted ESD or conventional ESD. Submucosal dissection time was comparable between the 2 techniques, but DREAMS-assisted ESD demonstrated a significantly lower muscular injury rate (15% vs 50%, P = .018) and workload scores (22.30 vs 32.45, P < .001). In the subgroup analysis of esophageal ESD, DREAMS-assisted ESD showed significantly improved submucosal dissection time (6.45 vs 16.37 minutes, P = .002), muscular injury rate (25% vs 87.5%, P = .041), and workload (21.13 vs 40.63, P = .001).

CONCLUSIONS

We developed a novel transendoscopic telerobotic system, named DREAMS. The safety profile and technical feasibility of ESD were significantly improved with the assistance of the DREAMS system, especially in the narrower esophageal lumen.

Prospective cohort study investigating quality of life outcomes following multi-speciality robotic-assisted surgery

INTRODUCTION

Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities.

PATIENTS AND METHODS

A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes.

STATISTICAL ANALYSIS USED

Mixed-effects linear regressions were used to determine changes in QoL trajectories.

RESULTS

Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS.

CONCLUSIONS

RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.

Delving into New Frontiers: assessing ChatGPT's proficiency in revealing uncharted dimensions of general surgery and pinpointing innovations for future advancements

PURPOSE

The advent of artificial intelligence (AI) has significantly influenced various medical domains, including general surgery. This research aims to assess ChatGPT, an AI language model, in its ability to shed light on the historical facets of general surgery and pinpoint opportunities for innovation.

METHODS

A series of 7 pertinent questions on field of general surgery was posed to ChatGPT. The AI-generated responses were meticulously examined for their relevance, accuracy, and novelty. Additionally, the study explored the AI's ability to recognize knowledge gaps and propose inventive solutions. Expert general surgeons and general surgical residents possessing comprehensive research experience assessed ChatGPT's answers by comparing them to established guidelines and existing literature.

RESULTS

ChatGPT presented information that was relevant and accurate, albeit superficial. However, it exhibited convergent thinking and was unable to produce truly groundbreaking ideas to transform general surgery. Instead, it pointed to current popular trends with significant potential for further development. It failed to provide references when prompted and even created references that could not be verified in exhibiting databases.

CONCLUSION

While ChatGPT demonstrated a comprehensive understanding of existing general surgical knowledge and the capacity to generate relevant, evidence-based material, it displayed limitations in producing truly groundbreaking concepts or discoveries beyond current knowledge. These results highlight the necessity of enhancing AI-driven models to facilitate the emergence of new insights and promote synergistic, human-AI partnerships for expediting advancements within the general surgery domain.

Comparison of robotic right colectomy and laparoscopic right colectomy: a systematic review and meta-analysis

BACKGROUND

For right colon surgery, there is an increasing body of literature comparing the safety of robotic right colectomy (RRC) with laparoscopic right colectomy (LRC). The aim of the present systematic review and meta-analysis is to assess the safety and efficacy of RRC versus LRC, including homogeneous subgroup analyses for extracorporeal anastomosis (EA) and intracorporeal anastomosis (IA).

METHODS

PubMed, Web of Science, Embase, and Cochrane Library databases were searched for studies published between January 2000 and January 2022. Length of hospital stay, operation time, rate of conversion to laparotomy, time to first flatus, number of harvested lymph nodes, estimated blood loss, rate of overall complication, ileus, anastomotic leakage, wound infection, and total costs were measured.

RESULTS

Forty-two studies (RRC: 2772 patients; LRC: 12,469 patients) were evaluated. Regardless of the type of anastomosis, RRC showed shorter length of hospital stay, lower rate of conversion to laparotomy, shorter time to first flatus, lower rate of overall complications, and a higher number of harvested lymph nodes compared with LRC, but longer operative time and higher total costs. In the IA subgroup, RRC had a shorter length of hospital stay, longer operative time, and lower rate of conversion to laparotomy compared with LRC, with no difference for the remaining outcomes. In the EA subgroup, RRC had a longer operative time, lower estimated blood loss, lower rate of overall complications, and higher total costs compared with LRC, with the other outcomes being similar.

CONCLUSION

The safety and efficacy of RRC is superior to LRC, especially when an intracorporeal anastomosis is performed. Most included articles were retrospective, offering low-quality evidence and limited conclusions.

Fragility of statistically significant findings from randomized trials in comparing laparoscopic versus robotic abdominopelvic surgeries

BACKGROUND

Utility of robotic over laparoscopic approach has been an area of debate across all surgical specialties over the past decade. The fragility index (FI) is a metric that evaluates the frailty of randomized controlled trials (RCTs) findings by altering the status of patients from an event to non-event until significance is lost. This study aims to evaluate the robustness of RCTs comparing laparoscopic and robotic abdominopelvic surgeries through the FI.

METHODS

A search was conducted in MEDLINE and EMBASE for RCTs with dichotomous outcomes comparing laparoscopic and robot-assisted surgery in general surgery, gynecology, and urology. The FI and reverse fragility Index (RFI) metrics were used to assess the strength of findings reported by RCTs, and bivariate correlation was conducted to analyze relationships between FI and trial characteristics.

RESULTS

A total of 21 RCTs were included, with a median sample size of 89 participants (Interquartile range [IQR] 62-126). The median FI was 2 (IQR 0-15) and median RFI 5.5 (IQR 4-8.5). The median FI was 3 (IQR 1-15) for general surgery (n = 7), 2 (0.5-3.5) for gynecology (n = 4), and 0 (IQR 0-8.5) for urology RCTs (n = 4). Correlation was found between increasing FI and decreasing p-value, but not sample size, number of outcome events, journal impact factor, loss to follow-up, or risk of bias.

CONCLUSION

RCTs comparing laparoscopic and robotic abdominal surgery did not prove to be very robust. While possible advantages of robotic surgery may be emphasized, it remains novel and requires further concrete RCT data.

Modeling of and Experimenting with Concentric Tube Robots: Considering Clearance, Friction and Torsion

Concentric tube robots (CTRs) are a promising prospect for minimally invasive surgery due to their inherent compliance and ability to navigate in constrained environments. Existing mechanics-based kinematic models typically neglect friction, clearance, and torsion between each pair of contacting tubes, leading to large positioning errors in medical applications. In this paper, an improved kinematic modeling method is developed. The effect of clearance on tip position during concentric tube assembly is compensated by the database method. The new kinematic model is mechanic-based, and the impact of friction moment and torsion on tubes is considered. Integrating the infinitesimal torsion of the concentric tube robots eliminates the errors caused by the interaction force between the tubes. A prototype is built, and several experiments with kinematic models are designed. The results indicate that the error of tube rotations is less than 2 mm. The maximum error of the feeding experiment does not exceed 0.4 mm. The error of the new modeling method is lower than that of the previous kinematic model. This paper has substantial implications for the high-precision and real-time control of concentric tube robots.

Neurocognitive and motor-control challenges for the realization of bionic augmentation

Robotic fingers and arms that augment the motor abilities of non-disabled individuals are increasingly feasible yet face neurocognitive barriers and hurdles in efferent motor control.

Ultra-soft and highly stretchable tissue-adhesive hydrogel based multifunctional implantable sensor for monitoring of overactive bladder

A highly stretchable and tissue-adhesive multifunctional sensor based on structurally engineered islets embedded in ultra-soft hydrogel is reported for monitoring of bladder activity in overactive bladder (OAB) induced rat and anesthetized pig. The use of hydrogel yielded a much lower sensor modulus (1 kPa) compared to that of the bladder (300 kPa), while the strong adhesiveness of the hydrogel (adhesive strength: 260.86 N/m) allowed firm attachment onto the bladder. The change in resistance of printed liquid metal particle thin-film lines under strain were used to detect bladder inflation and deflation; due to the high stretchability and reliability of the lines, surface strains of 200% could be measured repeatedly. Au electrodes coated with Platinum black were used to detect electromyography (EMG). These electrodes were placed on structurally engineered rigid islets so that no interfacial fracture occurs under high strains associated with bladder expansion. On the OAB induced rat, stronger signals (change in resistance and EMG root-mean-square) were detected near intra-bladder pressure maxima, thus showing correlation to bladder activity. Moreover, using robot-assisted laparoscopic surgery, the sensor was placed onto the bladder of an anesthetized pig. Under voiding and filling, bladder strain and EMG were once again monitored. These results confirm that our proposed sensor is a highly feasible, clinically relevant implantable device for continuous monitoring OAB for diagnosis and treatment.

Surgical Strategy and Application of Robotic-Assisted Benign Sacral Neurogenic Tumor Resection

BACKGROUND

Robotic surgery may be advantageous in neurogenic sacral tumor resection but only a few studies reported robotic-assisted neurogenic sacral tumor resection.

OBJECTIVE

To propose a new surgical strategy for robotic-assisted benign sacral neurogenic tumor resection and introduce the ultrasonic osteotomy surgical system in robotic surgery.

METHODS

Twelve patients who had robotic-assisted primary benign sacral neurogenic tumor resection between May 2015 and March 2021 were included. Our surgical strategy divides tumors into 4 types. Type I: Presacral tumors with diameter <10 cm. Type II: Narrow-base tumors involving the sacrum with diameter <10 cm. Type III: Broad-base tumors involving the sacrum with diameter <10 cm. Type IV: Tumors involving sacral nerve roots ≥2 levels and/or with diameter ≥10 cm.

RESULTS

Five type I, 5 type II, and 1 type III patients underwent tumor resection via an anterior approach, and 1 type IV patient via a combined approach. The median operation time, blood loss, and postoperative hospital stay of type I and II were much less than those of type IV. The ultrasonic osteotomy surgical system facilitated osteotomy in 2 type II and 1 type III patients. Eleven patients had total resections, and 1 type III patient had a partial resection. During the follow-up period of 7.9 to 70.9 months (median: 28.5 months), no local recurrences or deaths were noted.

CONCLUSION

With the largest single-center series to our knowledge, this surgical strategy helped to guide robotic-assisted benign sacral neurogenic tumor resection. The ultrasonic osteotomy surgical system was effective for type II and III.

Risk factors for and longitudinal course of male sexual dysfunction after robotic rectal cancer surgery

AIM

The aim of this work was to investigate the risk factors associated with the incidence of sexual dysfunction in patients who underwent robot-assisted surgery with several treatment options, such as neoadjuvant chemoradiotherapy and lateral lymph node dissection, and clarify the longitudinal course of erectile function in risk groups.

METHOD

A total of 203 male patients who underwent robot-assisted total mesorectal excision for rectal cancer between 2013 and 2019 were included. The risk factors for erectile and ejaculatory dysfunction as well as the longitudinal course of erectile function were retrospectively investigated in all cohorts and several risk groups, including those who underwent neoadjuvant chemoradiotherapy, lateral lymph node dissection and adjuvant chemotherapy. Erectile dysfunction was assessed using the International Index of Erectile Function and ejaculatory dysfunction was assessed using original questions. The survey was performed preoperatively and at 3, 6 and 12 months postoperatively.

RESULTS

Erectile and ejaculatory dysfunction occurred in 46.8% and 15.7% of the patients, respectively. Multivariate analysis showed that neoadjuvant chemoradiotherapy was an independent risk factor for erectile dysfunction. Erectile function recovered longitudinally to the preoperative level overall, as well as in lateral lymph node dissection and postoperative adjuvant chemotherapy subgroups; however, recovery was poor in the neoadjuvant chemoradiotherapy group, even at 12 months postoperatively.

CONCLUSION

Neoadjuvant chemoradiotherapy was found to be a risk factor for erectile dysfunction after robot-assisted surgery for rectal cancer. Erectile function recovered postoperatively in patients undergoing lateral lymph node dissection; however, those receiving neoadjuvant chemoradiotherapy showed poor recovery, even at 12 months postoperatively.

Implementation of robotic rectal cancer surgery: a cross-sectional nationwide study

AIM

An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches.

METHODS

Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach.

RESULTS

Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13-16%) in 2018 to 22% (95% CI 20-24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3-5%) versus 7% (95% CI 6-8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38-46%) versus 29% (95% CI 26-31%)].

CONCLUSION

Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.

Fundoplication in laparoscopic Heller's cardiomyotomy for achalasia

BACKGROUND

Laparoscopic Heller's cardiomyotomy (LHC) is the preferred treatment of achalasia. It improves dysphagia by dividing muscles of the lower oesophageal sphincter, but this intervention can result in debilitating gastro-oesophageal reflux symptoms in some patients. To prevent these reflux symptoms, most surgeons add a fundoplication to Heller's cardiomyotomy, but there is no consensus regarding this or the type of fundoplication which is best suited for the purpose.

OBJECTIVES

To assess how the addition of a fundoplication affects postoperative reflux and dysphagia in people undergoing LHC and compare the different types of fundoplications used in combination with LHC to determine which is better at controlling reflux without worsening the dysphagia.

SEARCH METHODS

We searched three databases (CENTRAL, MEDLINE and Embase) on 31 October 2021 and trial registers to identify all published and unpublished randomised controlled trials (RCTs) in any language, comparing different fundoplications used in combination with LHC to treat achalasia. We also included RCTs where LHC with a fundoplication is compared with LHC without any fundoplication.

SELECTION CRITERIA

We only included RCTs which recruited adult participants with achalasia undergoing LHC with minimal hiatal dissection. We excluded non-randomised studies or studies involving paediatric participants. We also excluded studies where the procedure was done by open surgery and where circumferential hiatal dissection of the oesophagus was carried out, unless it was necessary to reduce a hiatus hernia or to facilitate a Toupet or Nissen fundoplication.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies to be included, assessed risk of bias using the Cochrane RoB 1 tool, and extracted the data. We calculated the risk ratio (RR) with 95% confidence interval (CI) using both fixed-effect and random-effect models with Review Manager (RevMan) software.

MAIN RESULTS

We included eight studies in this review, with a total of 571 participants with an average age of 45 years (range 33.5 to 50). LHC without any fundoplication was performed in 65 (11.3%) participants, 298 (52.1%) had Dor fundoplication, 81 (14.1%) had Toupet fundoplication, 72 (12.6%) had Nissen's fundoplication, and 55 (9.6%) participants had angle of His accentuation. Three studies with a total of 143 participants compared LHC + Dor to LHC without fundoplication. We found that the evidence is very uncertain as to whether the addition of a Dor fundoplication made any difference to the outcome of postoperative pathological acid reflux (RR 0.37, 95% CI 0.07 to 1.89; I2 = 56%; 2 studies, 97 participants; very low-certainty evidence) and uncertain for severe postoperative dysphagia (RR 3.00, 95% CI 0.34 to 26.33; I2 = 0%; 3 studies, 142 participants; low-certainty evidence). Three studies with 174 participants compared LHC + Dor to LHC + Toupet. The evidence suggests that there may be little to no difference in the outcomes of postoperative pathological acid reflux (RR 0.75, 95% CI 0.23 to 2.43; I2 = 60%; 3 studies, 105 participants; low-certainty evidence) and severe postoperative dysphagia (RR 0.78, 95% CI 0.19 to 3.15; I2 = 0%; 3 studies, 123 participants; low-certainty evidence) between the two interventions, but the certainty of the evidence is low. One study with 138 participants compared LHC + Dor to LHC + Nissen. Nissen fundoplication caused increased severe postoperative dysphagia (RR 0.19, 95% CI 0.04 to 0.83; 1 study, 138 participants; high-certainty evidence) when compared to Dor fundoplication. This study did not show a difference in postoperative pathological acid reflux (RR 4.72, 95% CI 0.23 to 96.59; 1 study, 138 participants; low-certainty evidence), but the certainty of evidence is low. One study with 110 participants compared LHC + Dor with LCH + angle of His accentuation, and reported that severe postoperative dysphagia was similar between the two interventions (RR 1.56, 95% CI 0.27 to 8.95; 1 study, 110 participants; moderate-certainty evidence), with moderate certainty of evidence. This study did not report on postoperative pathological acid reflux.

AUTHORS' CONCLUSIONS

When LHC was performed with minimal hiatal dissection, we were very uncertain whether the addition of a Dor fundoplication made a difference in controlling postoperative reflux, and we were uncertain if it increased the risk of severe postoperative dysphagia. There may be little to no difference in the outcomes of postoperative pathological acid reflux or severe dysphagia between Dor and Toupet fundoplications when used in combination with LHC, but the certainty of the evidence is low. Nissen (total) fundoplication used in combination with LHC for achalasia increased the risk of severe postoperative dysphagia. The angle of His accentuation and Dor fundoplication had a similar effect on severe postoperative dysphagia when combined with LHC, but their effect on postoperative pathological acid reflux was not reported.

Surgical and short-term outcomes in robotic and laparoscopic distal gastrectomy for gastric cancer with enhanced recovery after surgery protocol: A propensity score matching analysis

OBJECTIVE

This study aims to evaluate the short-term surgical outcomes of laparoscopy-assisted distal gastrectomy (LADG) and robot-assisted distal gastrectomy (RADG) for gastric cancer (GC) with enhanced recovery after surgery (ERAS) protocols.

METHODS

We reviewed the medical records of 202 patients undergoing radical distal gastrectomy; among them, 67 cases were assisted through RADG, while 135 cases were assisted through LADG along with ERAS. We retrospectively collected the medical records in succession from a database (January 2016-March 2019). We adopted propensity score matching to compare surgical and short-term outcomes of both groups.

RESULTS

After the successful examination of 134 cases, including 67 receiving RADG and 67 undergoing LADG, the operative times were noted as 5.78 ± 0.96 h for the RADG group and 4.47 ± 1.01 h for the LADG group (P < 0.001). The blood loss was noted as 125.52 ± 101.18 ml in the RADG group and 164.93 ± 109.32 ml in the LADG group (P < 0.05). The shorter time to first flatus was 38.82 ± 10.56 h in the RADG group and 42.88 ± 11.25 h in the LADG group (P < 0.05). In contrast, shorter days of postoperative hospital stay were 5.94 ± 1.89 days in the RADG group and 6.64 ± 1.92 days in the LADG group (P < 0.05). Also, the RADG group (84483.03 ± 9487.37) was much more costly than the LADG group (65258.13 ± 8928.33) (P < 0.001). The postoperative overall complication rates, numbers of dissected lymph nodes, visual analogue scale (VAS), and time to start a liquid diet for the RADG group and the LADG group were similar.

CONCLUSIONS

In this research, we concluded that RADG provides surgical benefits and short-term outcomes compared to LADG for GC with ERAS.

The Remapping of Peripersonal Space in a Real but Not in a Virtual Environment

One of the most surprising features of our brain is the fact that it is extremely plastic. Among the various plastic processes supported by our brain, there is the neural representation of the space surrounding our body, the peripersonal space (PPS). The effects of real-world tool use on the PPS are well known in cognitive neuroscience, but little is still known whether similar mechanisms also govern virtual tool use. To this purpose, the present study investigated the plasticity of the PPS before and after a real (Experiment 1) or virtual motor training with a tool (Experiment 2). The results show the expansion of the PPS only following real-world tool use but not virtual use, highlighting how the two types of training potentially rely on different processes. This study enriches the current state of the art on the plasticity of PPS in real and virtual environments. We discuss our data with respect to the relevance for the development of effective immersive environment for trainings, learning and rehabilitation.

A Flexible Surgical Instrument for Robot-Assisted Minimally Invasive Surgery

In a narrow surgical space, flexible surgical instruments offer advantages over rigid counterparts in terms of operational dexterity. To this end, a flexible surgical instrument was designed in this study to realize dexterous motion using multiple segments in a series under wire-driven operation, satisfying the motion requirements of minimally invasive surgical operations. The forward and inverse kinematics of the instrument were solved using the geometrical method and the Newton–Raphson method, and the kinematics models were verified using a prototype. Experiments were conducted to verify the performance of the prototype device; the results showed that the time required for a kinematic solution was less than 0.1 ms. In addition, the device could flexibly reach the designated position in a narrow and long operating space and had excellent motion accuracy. Finally, it was verified that the prototype device had a certain load capacity.

Oncological outcomes of open, laparoscopic and robotic colectomy in patients with transverse colon cancer

BACKGROUND

Literature concerning surgical management of transverse colon cancer is scarce, since many key trials excluded transverse colon cancer. The aim of this study was to evaluate clinical and oncological outcomes comparing open, laparoscopic and robotic transverse colon cancer resection.

METHODS

Consecutive patients who underwent elective surgery for transverse colon cancer between December 2005 and July 2021 were included. Data were kept in a prospective database approved by the institutional ethics committee. Primary outcome was overall and disease-free survival. Secondary outcomes included complications, operative time, length of stay and lymph node harvest. Statistical analysis was corrected for age and tumour localisation.

RESULTS

Two hundred and forty-six (38 robotic, 71 open and 137 laparoscopic resections) were recruited in this study. There were five conversions during laparoscopic procedures. Operative time was significantly shorter in robotic vs laparoscopic procedures (195 vs 238 min, p = 0.005) and length of stay was shorter in robotic vs laparoscopic and open group (7 vs 9 vs 15 days, p < 0.001). There was no difference in overall complications. R0 resections were similar. Lymph node harvest was highest in the robotic group vs. laparoscopic or open (32 vs. 29 vs. 21, p < 0.001). Overall survival was 97%, 85% and 60% (p < 0.001) and disease-free survival was 91%, 78% and 56% (p < 0.001) for the robotic, laparoscopic and open groups, respectively.

CONCLUSIONS

Minimally invasive surgery for transverse colon cancer is safe and offers good clinical and oncological outcomes. Robotic resection is associated with significantly shorter operating times, higher lymph node harvest, lower conversion rate and does not increase morbidity. Differences in disease-free and overall survival should be further explored in randomised controlled trials.

The Learning Curve of Da Vinci Robot-Assisted Hemicolectomy for Colon Cancer: A Retrospective Study of 76 Cases at a Single Center

Background and Aims

Robotic-assisted right hemicolectomy (RARH) has many benefits in treating colon cancer, but it is a new technology that needs to be evaluated. This study aims to assess the learning curve (LC) of RARH procedures with the complete mesoscopic exception and D3 lymph node dissection for colon carcinoma.

Methods

A retrospective analysis was performed on a consecutive series of 76 patients who underwent RARH from July 2014 to March 2018. The operation time was evaluated using the cumulative sum (CUSUM) method to analyze the LC. The patients were categorized into two groups based on the LC: Phase I and Phase II. Statistical methods were used to compare clinicopathological data on intraoperative and perioperative outcomes at different stages of the study.

Results

The peak point of the LC was observed in the 27th case. Using the CUSUM method, we divide the LC into two stages. Stage 1 (initial learning stage): Cases 1–27 and Stage 2 (proficiency phase): Cases 28–76. There were no obvious distinctions between the two patients’ essential characteristics (age, sex, body mass index, clinical stage, and ASA score). The mean operation time of each group is 187.37 ± 45.56 min and 161.1 ± 37.74 min (P = 0.009), respectively. The intraoperative blood loss of each group is 170.4 ± 217.2 ml and 95.7 ± 72.8 ml (P = 0.031), respectively.

Conclusion

Based on the LC with CUSUM analysis, the data suggest that the learning phase of RARH was achieved after 27 cases. The operation time and the intraoperative blood loss decrease with more cases performed.

Assessment of the Versius Robotic Surgical System in Minimal Access Surgery: A Systematic Review

Background: Despite the superiority of minimal access surgery (MAS) over open surgery, MAS is difficult to perform and has a demanding learning curve. Robot-assisted surgery is an advanced form of MAS. The Versius® surgical robot system was developed with the aim of overcoming some of the challenges associated with existing surgical robots. The present study was designed to investigate the feasibility, clinical safety, and effectiveness of the Versius system in MAS. Materials and Methods: A comprehensive search was carried out in the Medline, Web of Science Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus databases for articles published until February 2022. The keywords used were Versius robot, visceral, colorectal, gynecology, and urologic surgeries. Articles on the use of the Versius robot in minimal access surgery (MAS) were included in the review. Results: Seventeen articles were reviewed for the study. The investigation comprised a total of 328 patients who had been operated on with this robot system, of which 48.3%, 14.2%, and 37.5% underwent colorectal, visceral, and gynecological procedures, respectively. Postoperative and major complications within 30 days varied from 7.4% to 39%. No major complications and no readmissions or reoperations were reported in visceral and gynecological surgeries. Readmission and reoperation rates in colorectal surgeries were 0–9%. Some procedures required conversion to conventional laparoscopic surgery (CLS) or open surgery, and all procedures were completed successfully. Based on the studies reviewed in the present report, we conclude that the Versius robot can be used safely and effectively in MAS. Conclusions: A review of the published literature revealed that the Versius system is safe and effective in minimal access surgery. However, the data should be viewed with caution until randomized controlled trials (RCTs) have been performed. Studies on the use of this robotic system in oncological surgery must include survival as one of the addressed outcomes.

New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study

BACKGROUND

Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis.

METHODS

Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment.

RESULTS

Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot.

CONCLUSIONS

This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

Overcoming the Force Limitations of Magnetic Robotic Surgery: Magnetic Pulse Actuated Collisions for Tissue-Penetrating-Needle for Tetherless Interventions

The field of magnetic robotics aims to obviate physical connections between the actuators and end-effectors. Such tetherless control may enable new ultra-minimally invasive surgical manipulations in clinical settings. While wireless actuation offers advantages in medical applications, the challenge of providing sufficient force to magnetic needles for tissue penetration remains a barrier to practical application. Applying sufficient force for tissue penetration is required for tasks such as biopsy, suturing, cutting, drug delivery, and accessing deep seated regions of complex structures in organs such as the eye. To expand the force landscape for such magnetic surgical tools, an impact-force based suture needle capable of penetrating in vitro and ex vivo samples with 3-DOF planar motion is proposed. Using custom-built 14G and 25G needles, we demonstrate generation of 410 mN penetration force, a 22.7-fold force increase with more than 20 times smaller volume compared to similar magnetically guided needles. With the MPACT-Needle, in vitro suturing of a gauze mesh onto an agar gel is demonstrated. In addition, we have reduced the tip size to 25G, which is a typical needle size for interventions in the eye, to demonstrate ex vivo penetration in a rabbit eye, mimicking procedures such as corneal injections and transscleral drug delivery.

Robotic cholecystectomy using Senhance robotic platform versus laparoscopic conventional cholecystectomy: a propensity score analysis

INTRODUCTION

Our study objective was to evaluate differences in intraoperative and postoperative outcomes of robotic cholecystectomy (RC) using Senhance robotic platform vs laparoscopic cholecystectomy (LC).

MATERIAL AND METHODS

A retrospective case - matched analysis was performed for all patients who underwent cholecystectomy from November 2018 to November 2019. RC cases were matched to LC. RC was performed using Senhance robotic platform. Propensity score matching analysis with a ratio of 1:1 (RC: LC) was performed. The groups were matched according to age, sex, body mass index (BMI). All procedures were performed by two same experienced robotic surgeons at Klaipeda University Hospital (O.D. and V.E.). Age, BMI, operative time, blood loss and length of hospital stay were collected and analysed between those patient groups.

RESULTS

A total of 40 patients underwent RC or LC. There were no statistical differences between groups in concern of length of hospital stay, blood loss or complications. There were no bile duct injuries in either group, no intraoperative complications, no conversions either RC to LC or LC to open surgery. One patient in robotic group was reoperated on postoperative day 5 regarding sub-hepatic haematoma. The only statistical significance was in operative time (p < .05) which was longer in RC group. Median docking time was 12 min (range 5-23).

CONCLUSIONS

Robotic cholecystectomy using Senhance robotic platform appears to be safe in comparison with laparoscopic cholecystectomy. Laparoscopic cholecystectomy might be feasible in gaining robotic surgery skills.

Feasibility and Efficacy of Single-Port Robotic Cholecystectomy Using the da Vinci SP® Platform

Background

Single-incision laparoscopic cholecystectomy, first introduced in 1995, features acceptable cosmetic outcomes and postoperative pain control. The outcomes of single-port cholecystectomy by laparoscopy and robots were recently examined in many studies owing to surgeon and patient preference for minimally invasive surgery. A next-level da Vinci robotic platform was recently released. This study aimed to evaluate the feasibility and efficacy of robotic cholecystectomy (RC) using the da Vinci SP® system.

Methods

In this retrospective observational single-center study, we analyzed the medical records of 304 patients who underwent RC between March 1, 2017 and May 31, 2021.

Results

Of the 304 patients, the da Vinci Xi® (Xi) was used in 159 and the da Vinci SP® (SP) was used in 145. The mean operation time was 45.7 mins in the SP group versus 49.8 mins in the Xi group. The mean docking time of the SP group was shorter than that of the Xi group (5.7 min vs 8.8 min; p = 0.024). The mean immediate postoperative numerical rating scale (NRS) score was 4.0 in the SP group and 4.3 in the Xi group, showing a significant difference (p = 0.003). A separate analysis of only patients with acute cholecystitis treated with the da Vinci SP® showed that the immediate postoperative NRS score in the acute group was higher than that in the nonacute group.

Conclusions

This study demonstrated acceptable results of single-site cholecystectomy using da Vinci SP®. Thus, pure single-port RC using the da Vinci SP® for various benign gallbladder diseases may be an excellent treatment option.

Robotic Surgery for the Treatment of Achalasia Cardia: Surgical Technique, Initial Experiences and Literature Review

Background

The outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery and the introduction of robotic surgery. This article describes the technical details of robotic achalasia surgery, shares our initial experiences, and discusses why robotic surgery will become the first choice for the surgical treatment of achalasia.

Methods

The records of patients with a diagnosis of achalasia who underwent robotic surgery were evaluated retrospectively. The patients’ data were examined in terms of demographic parameters, duration of complaints, treatment options applied previously, robotic surgery technique, and postoperative outcomes.

Results

Of the six patients evaluated, four (66.7%) were males and two (33.3%) were females. Their mean age was 32 years (20-51 years), and the mean symptom duration was 4.6 years (2-9 years). All of the patients underwent robotic Heller cardiomyotomy surgery. After the myotomy procedure, five of the six patients (83.3%) underwent partial anterior fundoplication (Dor) as an antireflux procedure. The cruroraphy procedure was performed in one patient (16.7%) due to accompanying hiatal hernia, whereas the procedures were completed in five patients (83.3%) without performing posterior dissection of the oesophagus. In the postoperative follow-up period, no surgical problem was encountered, while reflux symptoms developed in one patient (16.7%) and were controlled by medical therapy.

Conclusions

The success of surgical treatment of achalasia is incontrovertible. Due to the various advantages of robotic surgery, it is now frequently used in narrow-area surgeries, such as achalasia surgery.

A prospective observational study assessing the feasibility and factors affecting same-day discharge in patients undergoing robotic-assisted surgery for gynecological cancers

Although robotic-assisted surgery is being increasingly used in the management of gynecologic cancers, most surgeons discharge patients on the next day of surgery citing concerns about immediate post-operative complications. Present study was conducted to evaluate the safety, factors influencing and quality of life for gynaecological cancer patients undergoing same-day discharge after robotic-assisted surgery. This is single institutional prospective observational study as pragmatic cohort including all well-selected gynecological cancer patients undergoing robotic-assisted surgery from September 2017 to June 2019. Patients were divided into two study groups [Same-day discharge (SDD) group vs. Next-day discharge (NDD) group] according to day of discharge. The entire cohort included 152 patients (38 in SDD group and 114 in NDD group). The difference between both SDD vs. NDD was significant for parameters including Age ≥ 70 years (0% vs. 18.4%, p: 0.010); Operative time > 60 min (39.5% vs. 60.5%, p: 0.024); patients with third-party insurance covering surgery (2.6% vs. 25.4%, p: 0.005) and place of residence ≥ 60 km from hospital (13.1% vs. 51.8%, p: < 0.0001). The quality of life was similar in both groups and none of the patients required readmission or emergency room visits. Same-day discharge after robot-assisted surgery in gynecologic cancer patients is a safe and feasible option. Younger patients, short surgical time, surgery early in the day, no claim for third-party insurance, residing nearby hospital within 60 km radius were influencing factors favouring same-day discharge.

Do People Trust in Robot-Assisted Surgery? Evidence from Europe

(1) Background: The goal of the paper was to establish the factors that influence how people feel about having a medical operation performed on them by a robot. (2) Methods: Data were obtained from a 2017 Flash Eurobarometer (number 460) of the European Commission with 27,901 citizens aged 15 years and over in the 28 countries of the European Union. Logistic regression (odds ratios, OR) to model the predictors of trust in robot-assisted surgery was calculated through motivational factors, using experience and sociodemographic independent variables. (3) Results: The results obtained indicate that, as the experience of using robots increases, the predictive coefficients related to information, attitude, and perception of robots become more negative. Furthermore, sociodemographic variables played an important predictive role. The effect of experience on trust in robots for surgical interventions was greater among men, people between 40 and 54 years old, and those with higher educational levels. (4) Conclusions: The results show that trust in robots goes beyond rational decision-making, since the final decision about whether it should be a robot that performs a complex procedure like a surgical intervention depends almost exclusively on the patient’s wishes.

Robotic esophagomyotomy for achalasia: technical note and review of the literature

INTRODUCTION

The treatment of achalasia has undergone continuous evolution with the advancement of technology. Since the beginning of the new millennium, the employment of robotics has led to technical facilitation with the execution of the myotomy and consequently to improvement of outcomes and decrease perioperative morbidity.

EVIDENCE ACQUISITION

We provide a detailed description of the surgical procedure and the perioperative management together with a literature search of Electronic PubMed/Medline database and Cochrane Library. English written studies on robotic assisted myotomy (case reports, reviews, single arm and comparative studies) were included.

EVIDENCE SYNTHESIS

Between 2001 and 2020, 10 case reports, 13 single arm studies, 10 comparative studies, 2 meta-analysis, 11 reviews and 2 technical notes on robotic assisted esophagomyotomy for achalasia were published.

CONCLUSIONS

As reported by the studies available in the literature and evaluated in this manuscript, robotic assisted cardiomyotomy seems not only feasible but also a safer operation compared with traditional laparoscopic Heller myotomy, due to a significant lower incidence of intraoperative esophageal perforation. Also if large and randomized controlled studies are advocated, robotic assisted esophagocardiomyotomy might be considered superior to laparoscopic Heller myotomy that, until now, is mostly considered the gold standard in the surgical treatment of achalasia.

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk

Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

Robust Control of a New Asymmetric Teleoperation Robot Based on a State Observer

This study is mainly about the designation of a new type of haptic device and an asymmetric teleoperation robot system. Aiming at the problems of tracking and transparency of an asymmetric teleoperation system, a robust control algorithm based on a state observer was proposed. The Haptic Device was designed and was chosen as the master-robot of the system. The Baxter dual-arm robot was chosen as the slave-robot of the system. The simulation experiment of robust control based on a state observer of the asymmetric teleoperation robot was carried out. The experiment results showed that the maximum values of displacement tracking errors in three directions x, y, and z are 0.02 m, 0.01 m, and 0.015 m, respectively. Compared with single- joint PID control, the performance of the new control algorithm is improved. The force feedback experiment on the real asymmetric teleoperation robot system was carried out. The results showed that the force feedback wave is consistent with the actual situation and showed that the robust control algorithm proposed is superior to PID. Therefore, the algorithm perfectly satisfied the system. The experiment parameters also demonstrate that the haptic device satisfies the design requirements of the asymmetric teleoperation robots system and the industry standards.

Minimally Invasive Approach to Gastric GISTs: Analysis of a Multicenter Robotic and Laparoscopic Experience with Literature Review

Background: Gastrointestinal stromal tumors (GISTs) are most frequently located in the stomach. In the setting of a multidisciplinary approach, surgery represents the best therapeutic option, consisting mainly in a wedge gastric resection. (1) Materials and methods: Between January 2010 to September 2020, 105 patients with a primary gastrointestinal stromal tumor (GISTs) located in the stomach, underwent surgery at three surgical units. (2) Results: A multi-institutional analysis of minimally invasive series including 81 cases (36 laparoscopic and 45 robotic) from 3 referral centers was performed. Males were 35 (43.2%), the average age was 66.64 years old. ASA score ≥3 was 6 (13.3%) in the RS and 4 (11.1%) in the LS and the average tumor size was 4.4 cm. Most of the procedures were wedge resections (N = 76; 93.8%) and the main operative time was 151 min in the RS and 97 min in the LS. Conversion was necessary in five cases (6.2%). (3) Conclusions: Minimal invasive approaches for gastric GISTs performed in selected patients and experienced centers are safe. A robotic approach represents a useful option, especially for GISTs that are more than 5 cm, even located in unfavorable places.

Comparison of clinical efficacy of robotic right colectomy and laparoscopic right colectomy for right colon tumor: A systematic review and meta-analysis

BACKGROUND

The purpose of this study was to compare the clinical efficacy of robotic right colectomy (RRC) and laparoscopic right colectomy (LRC) in the treatment of right colon tumor.

METHODS

We systematically searched PubMed, Web of science, EMBASE ClinicalTrials.gov and Cochrane Central Register for studies (studies published between January 2011 and June 2020). The included studies compared the clinical efficacy of RRC and LRC in the treatment of right colon tumor, and analyzed the perioperative data.

RESULTS

Our meta-analysis included 10 studies involving 1180 patients who underwent 2 surgical procedures, RRC and LRC. This study showed that compared with LRC, there was no significant difference in first flatus passage (weighted mean difference [WMD]: -0.37, 95% CI: -1.09-0.36, P = .32), hospital length of stay (WMD: -0.23, 95% CI: -0.73-0.28, P = .32), reoperation (OR: 1.66, 95% CI: 0.67-4.10, P = .27), complication (OR: 0.83, 95% CI: 0.60-1.14, P = .25), mortality (OR: 0.45, 95% CI: 0.02-11.22, P = .63), wound infection (OR: 0.65, 95% CI: 0.34-1.25, P = .20), and anastomotic leak (OR: 0.73, 95% CI: 0.33-1.63, P = .44). This study showed that compared with LRC, the lymph nodes retrieved (WMD: 1.47, 95% CI: -0.00-2.94, P = .05) of RRC were similar, with slight advantages, and resulted in longer operative time (WMD: 65.20, 95% CI: 53.40-77.01, P < .00001), less estimated blood loss (WMD: -13.43, 95% CI: -20.65-6.21, P = .0003), and less conversion to open surgery (OR: 0.30, 95% CI: 0.17-0.54, P < .0001).

CONCLUSIONS

RRC is equivalent to LRC with respect to first flatus passage, hospital length of stay, reoperation, complication, and results in less conversion to LRC.

dV-Trainer vs. da Vinci Simulator: Comparison of Virtual Reality Platforms for Robotic Surgery

BACKGROUND

A virtual reality (VR) curriculum performed on the da Vinci Simulation System (DVSS) was previously shown to be effective in training fellows. The dV-Trainer is a separate platform with similar features to the da Vinci console, but its efficacy and utility versus the DVSS simulator are not well known.

MATERIALS AND METHODS

A mastery-based VR curriculum was completed by surgical fellows on the DVSS (2014-2016) and on the dV-Trainer (2016-2018) at a large academic center. Pre-test/post-test scores were used to evaluate performance between the two groups. Data was collected prospectively.

RESULTS

Forty-six fellows enrolled in the curriculum: surgical oncology (n=31), hepatobiliary (n=5), head/neck (n=4), endocrine (n=2), cardiothoracic (n=2), gynecology (n=1) and transplant surgery (n=1). Twenty-four used the DVSS and twenty-two used the dV-Trainer. Compared to the DVSS, the dV-Trainer was associated with lower scores on 2 of 3 VR modules in the pre-test (P=0.027, P<0.001, respectively) and post-test (P=0.021, P<0.001, respectively). Fellows in the dV-Trainer era scored lower on inanimate drills as well. Average VR curriculum score was lower on the dV-Trainer (71.3% vs 83.34%, P<0.001). dV-Trainer users spent more time completing the pre-test and post-test; however, overall simulator time to complete the curriculum was not significantly different (297 vs 231 minutes, P=0.142). Both groups showed improvement in scores after completion of the VR curriculum.

CONCLUSIONS

The dV-Trainer simulator allows for more usability outside the operating room to complete VR modules; however, the DVSS simulator group outperformed the dV-Trainer group on the post-test.

The Path to Surgical Robotics in Neurosurgery

Robotic systems may help efficiently execute complicated tasks that require a high degree of accuracy, and this, in large part, explains why robotics have garnered widespread use in a variety of neurosurgical applications, including intracranial biopsies, spinal instrumentation, and placement of intracranial leads. The use of robotics in neurosurgery confers many benefits, and inherent limitations, to both surgeons and their patients. In this narrative review, we provide a historical overview of robotics and its implementation across various surgical specialties, and discuss the various robotic systems that have been developed specifically for neurosurgical applications. We also discuss the relative advantages of robotic systems compared to traditional surgical techniques, particularly as it pertains to integration of image guidance with the ability of the robotic arm to reliably execute pre-planned tasks. As more neurosurgeons adopt the use of robotics in their practice, we postulate that further technological advancements will become available that will help achieve improved technical capabilities, user experience, and overall patient clinical outcomes.