First experience in colorectal surgery with a new robotic platform with haptic feedback

How robotic platforms are revolutionizing colorectal surgery techniques: a comparative review

INTRODUCTION

In the last two decades, robotic technology has fundamentally transformed the field of colorectal surgery by providing surgeons with unprecedented levels of precision and control. Nevertheless, robotic surgery presents certain challenges such as prolonged operating times, high costs, limited accessibility, and the necessity for specialized training.

AREAS COVERED

This comparative review analyzes the impact of robotic platforms on colorectal surgery and its outcomes, with the expanding market of this technology. The major databases including PubMed, Scopus, and Google Scholars were searched using the key term 'robotic assisted surgery,' 'robotic platforms,' and 'colorectal surgery' to identify relevant articles as of August 2024. The most utilized robotic platforms currently available on the market - Da Vinci, Versius, Senhance, and Revo-I - are compared through their peri- and post-operative outcomes, including operative duration, blood loss, hospitalization period, oncological outcomes, and cost, providing a comprehensive insight into the future of robotic-assisted colorectal surgery.

EXPERT OPINION

Robotic surgery significantly improves patient outcomes, including shorter postoperative recovery times and effective cancer resection margins. However, challenges faced with these platforms include longer intraoperative times, arm clashing, the need for bedside assistance, and cost. Nevertheless, with the evolution toward managing more complex rectal cancer cases and more challenging dissection planes, the need for robotic platforms will only grow.

Comparison of short- and mid-term outcomes between the Senhance digital laparoscopic system and laparoscopic colectomy: a propensity score matching study

BACKGROUND

The Senhance digital laparoscopic system (Senhance) is a surgical robot approved for use in Japan after the da Vinci system. Our institution was the first to introduce this system, which has been used primarily for gastrointestinal surgery. Featuring tactile feedback, eye-movement-controlled camera operation, stereoscopic vision, and magnification, the short-term postoperative outcomes of the Senhance in abdominal surgery have been documented. This study aimed to evaluate the safety and feasibility of Senhance by examining mid-term postoperative outcomes.

METHODS

Between January 2018 and December 2020, 743 patients underwent colorectal cancer colectomy at our institution. We compared 50 cases of Senhance-assisted colectomy with 430 laparoscopic colectomy cases using 1:1 propensity score matching, adjusting for covariates such as sex, age, tumor location, BMI, ASA-PS, cT, and cN. Short- and mid-term surgical outcomes were compared between the Senhance (S) and laparoscopic (L) groups.

RESULTS

After matching, 47 patients were included in each group. There were no significant differences in the patient backgrounds. The operative time was significantly longer in the S group compared to the L group (median: 240 [101-378] minutes vs. 191 [100-370] minutes, p < 0.01). No significant differences were observed in postoperative complications of Clavien-Dindo grade 2 or higher within 30 days post-surgery, and no robot-related adverse events were reported. The 3-year disease-free survival rates were 88.7% in the S group and 77.1% in the L group (p = 0.178; HR, 1.423; 95% CI 0.916-2.211). The overall survival rate was 97.7% in both groups (p = 0.897; HR, 1.202; 95% CI 0.075-19.26).

CONCLUSION

Senhance-assisted colectomy is safe with mid-term outcomes comparable to laparoscopic surgery. However, the extended operation time remains challenging, necessitating further studies, including randomized controlled trials and multicenter studies, to validate these findings.

Total Mesorectal Excision with New Robotic Platforms: A Scoping Review

Colorectal surgery is one of the specialties that have significantly benefited from the adoption of robotic technology. Over 20 years since the first robotic rectal resection, the Intuitive Surgical Da Vinci system remains the predominant platform. The introduction of new robotic systems into the market has enabled the first documented total mesorectal excision (TME) using alternative platforms. This scoping review aimed to assess the role and adoption of these emerging robotic systems in performing TME for rectal cancer surgery. Methods: A comprehensive search of the Medline, Embase, and Cochrane databases was conducted up to August 2024, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Results: Thirty-six studies were included in the review. The majority of rectal surgical procedures were performed using eight different robotic platforms. Intraoperative, short-term, and functional outcomes were generally favorable. However, pathological results were frequently incomplete. Several studies identified the lack of advanced robotic instruments as a significant limitation. Conclusions: The quality of the resected specimen is critical in rectal cancer surgery. Although TME performed with new robotic platforms appears to be feasible and safe, the current body of literature is limited, particularly in the assessment of pathological and long-term survival outcomes.

Experiences in robotic colorectal surgery: comprehensive insights from a multi-center analysis using the Senhance Robotic System

Robotic-assisted surgery has revolutionised minimally invasive approaches, particularly in colorectal surgery. While many single-center studies on colorectal surgeries exist in present literature, including experiences with Senhance® Robotic Systems, comprehensive multi-center studies are lacking. This study, conducted through the TransEnterix European Patient Registry ("TRUST"), aims to assess the safety and feasibility in this context. The present study explored procedural times, complications, robotic malfunction and limitations, adverse events and pain management outcomes for colorectal procedures, including sigmoid resection, right hemicolectomy and rectal surgery collected in two European centers. Data from 355 colorectal surgeries showed that the median duration of surgery was 147.2 min (IQR: 124.3-183.0), the docking time was reported with a median of 3.4 min (IQR: 2.0-5.4) and the console time was found at a mean of 84.4 min (SD: 33.6). Despite minimal blood loss, pain scores, and robotic malfunction, 2.9% of the cases (10 instances) required conversions to either an open or laparoscopic approach. Further, most robotic limitations were attributed to limited motion (18.9%, 67 cases) and collisions (11.5%, 41 cases). Adverse events (24 cases, 6.8%) were effectively managed, with 23 instances judged completely unrelated to the robotic system. This study underscores the positive outcomes and safety profile of Senhance® Robotic Systems in colorectal surgery, contributing valuable insights for future research and clinical practice.

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.

Robotic versus laparoscopic right hemicolectomy: a systematic review of the evidence

Robotics may facilitate the realization of fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis and off-midline extraction, when compared to laparoscopy. Our aim was to compare laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. MEDLINE was searched for original studies comparing laparoscopic right hemicolectomy with robotic right hemicolectomy in terms of peri-operative outcomes. The systematic review complied with the PRISMA 2020 recommendations. Variables related to patients' demographics, surgical procedures, post-operative recovery and pathological outcomes were collected and qualitatively assessed. Two-hundred and ninety-three publications were screened, 277 were excluded and 16 were retained for qualitative analysis. The majority of included studies were observational and of limited sample size. When the type of anastomosis was left at surgeon's discretion, intra-corporeal anastomosis was favoured in robotic right hemicolectomy (4/4 studies). When compared to laparoscopy, robotics allowed harvesting more lymph nodes (4/15 studies), a lower conversion rate to open surgery (5/14 studies), a shorter time to faeces (2/3 studies) and a shorter length of stay (5/14 studies), at the cost of a longer operative time (13/14 studies). Systematic review of existing studies, which are mostly non-randomized, suggests that robotic surgery may facilitate fully minimally invasive right hemicolectomy, including intra-corporeal anastomosis, and offer improved post-operative recovery.

Robotic Surgery in Urology: History from PROBOT® to HUGOTM

The advent of robotic surgical systems had a significant impact on every surgical area, especially urology, gynecology, and general and cardiac surgery. The aim of this article is to delineate robotic surgery, particularly focusing on its historical background, its evolution, its present status, and its future perspectives. A comprehensive literature review was conducted upon PubMed/MEDLINE, using the keywords "robotic surgical system", "robotic surgical device", "robotics AND urology". Additionally, the retrieved articles' reference lists were investigated. Analysis concentrated on urological surgical systems for laparoscopic surgery that have been given regulatory approval for use on humans. From the late 1980s, before daVinci® Era in 2000s, ancestor platform as Probot® and PUMA 560 were described to outline historical perspective. Thus, new robotic competitors of Intuitive Surgical such as Senhance®, Revo-I®, Versius®, Avatera®, Hinotori®, and HugoTM RAS were illustrated. Although daVinci® had high level competitiveness, and for many years represented the most plausible option for robotic procedures, several modern platforms are emerging in the surgical market. Growing competition through unique features of the new robotic technologies might extend applications fields, improve diffusion, and increase cost-effectiveness procedures. More experiences are needed to identify the role of these new advancements in surgical branches and in healthcare systems.

New Robotic Platforms in General Surgery: What's the Current Clinical Scenario?

Background and Objectives: Robotic surgery has been widely adopted in general surgery worldwide but access to this technology is still limited to a few hospitals. With the recent introduction of new robotic platforms, several studies reported the feasibility of different surgical procedures. The aim of this systematic review is to highlight the current clinical practice with the new robotic platforms in general surgery. Materials and Methods: A grey literature search was performed on the Internet to identify the available robotic systems. A PRISMA compliant systematic review was conducted for all English articles up to 10 February 2023 searching the following databases: MEDLINE, EMBASE, and Cochrane Library. Clinical outcomes, training process, operating surgeon background, cost-analysis, and specific registries were evaluated. Results: A total of 103 studies were included for qualitative synthesis after the full-text screening. Of the fifteen robotic platforms identified, only seven were adopted in a clinical environment. Out of 4053 patients, 2819 were operated on with a new robotic device. Hepatopancreatobiliary surgery specialty performed the majority of procedures, and the most performed procedure was cholecystectomy. Globally, 109 emergency surgeries were reported. Concerning the training process, only 45 papers reported the background of the operating surgeon, and only 28 papers described the training process on the surgical platform. Only one cost-analysis compared a new robot to the existing reference. Two manufacturers promoted a specific registry to collect clinical outcomes. Conclusions: This systematic review highlights the feasibility of most surgical procedures in general surgery using the new robotic platforms. Adoption of these new devices in general surgery is constantly growing with the extension of regulatory approvals. Standardization of the training process and the assessment of skills' transferability is still lacking. Further studies are required to better understand the real clinical and economical benefit.

[The first experience of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity]

OBJECTIVE

To study the results of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity.

MATERIAL AND METHODS

A prospective cohort study included 74 patients who underwent bariatric surgery (Senhance digital laparoscopy system) between January 2022 and May 2023. Of these, 12 patients underwent robot-assisted longitudinal gastrectomy, 20 patients - robot-assisted Roux-en-Y gastric bypass, 36 patients - robot-assisted gastric bypass with one anastomosis/mini-gastric bypass, 6 patients - surgical exploration. We assessed duration of surgery, docking, placement of trocars and robotic manipulators, the need for their intraoperative displacement, incidence of intraoperative complications and conversions to laparoscopic surgery, intraoperative blood loss and early postoperative complications, severity of pain syndrome on the 1st day after surgery.

RESULTS

Mean surgery time was 87 [67, 120], 116 [78, 139], 96 [79, 125] and 141 [112, 184] min, respectively. Intraoperative blood loss was less than 50 ml. There were no complications requiring surgical treatment, cardiovascular, respiratory and other complications within 1 month.

CONCLUSION

Robot-assisted bariatric surgery using the Senhance system is feasible and safe for patients. Immediate results of robotic surgery are comparable to those after laparoscopy. However, large experience and cost-effectiveness analysis are required to assess the feasibility of robotic systems in bariatric surgery.

Robotic colon surgery in obese patients: a systematic review and meta-analysis

BACKGROUND

Colon cancer resection can be technically difficult in the obese (OB) population. Robotic surgery is a promising technique but its benefits remain uncertain in OB patients. The aim of this study is to compare OB versus non-obese (NOB) patients undergoing robotic colon surgery, as well as OB patients undergoing robotic versus open or laparoscopic colonic surgery.

METHODS

A systematic review and meta-analysis was performed. Primary outcome measures included length of stay (LOS), surgical site infection (SSI) rate, complications, anastomotic leak and oncological outcomes.

RESULTS

A total of eight studies were included, with five comparing OB and NOB patients undergoing robotic colon surgery included in meta-analysis. A total of 263 OB patients and 400 NOB patients formed the sample for meta-analysis. There was no significant difference between the two groups in operative time, conversion to open, LOS, lymph node yield, anastomotic leak and postoperative ileus. There was a trend towards a significant increase in overall complications and SSI in the OB group (32.3% OB versus 26.8% NOB for complications, 14.2% OB versus 9.9% NOB for SSI). The three included studies comparing surgical techniques were too heterogeneous to undergo meta-analysis.

CONCLUSION

Robotic colon surgery is safe in obese patients, but high-quality prospective evidence is lacking. Future studies should report on oncological safety and the cost-effectiveness of adopting the robotic technique in these challenging patients.

The Senhance Surgical System in Colorectal Surgery: A Systematic Review

The Senhance Surgical System allows for infrared eye tracking, haptic feedback, and an adjustable upright seat allowing for improved ergonomics. This systematic review was designed with the aim of reviewing the current literature pertaining to the use of the Senhance Surgical System in colorectal surgery. Medline, EMBASE, and CENTRAL were searched. Articles were eligible for inclusion if they evaluated adults undergoing colorectal surgery with the Senhance Surgical System. The primary outcome was intraoperative efficacy; as defined by operative time, estimated blood loss (EBL), and conversion. A DerSimonian and Laird inverse variance random-effects meta-analysis was used to generate overall effect size estimates and narrative review was provided for each outcome. Six observational studies with 223 patients (mean age: 63.7, 41.2% female, mean BMI: 24.4 kg/m²) were included. The most common indication for surgery was colorectal cancer (n = 180, 80.7%) and the most common operation was anterior resection (n = 72, 32.3%). Meta-analyses demonstrated a pooled total operative time of 229.8 min (95% CI 189.3-270.4, I² = 0%), console time of 141.3 min (95% CI 106.5-176.1, I² = 0%), and docking time of 10.8 min (95% CI 6.4-15.2, I² = 0%). The pooled EBL was 37.0 mL (95% CI 24.7-49.2, I² = 20%). Overall, there were nine (4.0%) conversions to laparoscopy/laparotomy. The Senhance Surgical System has an acceptable safety profile, reasonable docking and console times, low conversion rates, and an affordable case cost across a variety of colorectal surgeries. Further prospective, comparative trials with other robotic surgical platforms are warranted.

Robotics in laparoscopic surgery - A review

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

Short-term results of robot-assisted colorectal cancer surgery using Senhance Digital Laparoscopy System

BACKGROUND

The Senhance Digital Laparoscopy System (Asensus Surgical Inc, Morrisville, NC, United States), which was introduced for the first time in Japan by our hospital, is a new surgical assistive robot following the da Vinci Surgical System. We herein report the short-term outcomes of 55 colorectal cancer surgery cases using this system at our hospital to assess the feasibility and safety of our procedures.

MATERIALS AND METHODS

We retrospectively reviewed the patient backgrounds and surgical outcomes of 55 patients who underwent Senhance-assisted laparoscopic colorectal cancer surgery.

RESULTS

The median age was 71 years. There were 31 males and 24 females, and the median body mass index was 23.1 kg/m² . Fifteen patients had a history of abdominal surgery. The most common surgical technique was ileocecal resection (18 cases, 32.7%), followed by high anterior resection (11 cases, 20.0%). D2 or D3 dissection was performed in each operation, and D3 dissection was performed in 41 cases (74.5%). The median operative time was 240 minutes, the median blood loss was 5 mL, there were no intraoperative complications, and there were no cases of intraoperative blood transfusion. The median postoperative hospital stay was 7 days, which was comparable to conventional laparoscopic surgery. Postoperative complications of grade 2 or higher in the Clavien-Dindo classification were observed in two cases.

CONCLUSION

The short-term results of 55 colorectal cancer surgery cases using the Senhance Digital Laparoscopy System were excellent and the system was introduced and surgery was safely performed.

Robotic colorectal surgery using the Senhance® robotic system: a single center experience

BACKGROUND

The aim of this study was to evaluate the initial experience of a single robotic center with the Senhance^® robotic systems (TransEnterix Surgical Inc, Morrisville, NC, USA) in colorectal surgery.

METHODS

We performed a retrospective analysis of prospectively collected data of patients who underwent colorectal surgery using the Senhance^® robotic systems, from November 2018 to November 2020. Perioperative, intraoperative, and short-term postoperative data were assessed.

RESULTS

There were 57 patients (28 women and 29 men, mean age 61.7 ± 6.2 years [range 23-84 years]). Forty-eight (84.2%) patients underwent surgery for colorectal cancer (22 colon cancer and 26 rectal cancer) and 9 (15.8%) for benign conditions. Mean operating time was 194 min ± 57.8 min (range 90-380 min). In total, 27(47.4%) operations were performed on the colon and 30 (52.6%) on the rectum; mean length of postoperative hospital stay was 8 ± 6.2 days (range 3-48 days). There were 2 (3.4%) conversions to open surgery. No intraoperative complications occurred. Seven patients (12.3%) had postoperative complications 3 (5.3%) of whom had to be treated under general anesthesia. There was no mortality. In 48 patients operated on for colorectal cancer, the mean lymph-node harvest was 18 ± 7.9 (range 7-38 lymph nodes). In the rectal cancer group of 26 patients, the distal resection margin was 3.3 ± 1.8 cm.

CONCLUSIONS

In our experience, surgery using the new Senhance^® robotic system was safe and feasible in surgery of the colon and rectum. Randomized controlled trials comparing this type of colorectal surgery with laparoscopic and/or other types of robotic surgery are needed.

[The first clinical experience of using the new Senhance remote-controlled robotic system in general surgery in Russia]

Until recently, clinical studies in the field of robotic-assisted surgery have been conducted in Russia only on the basis of the DaVinci system. The advent of a new robotic system separated the concept of «robotic surgery» from DaVinci. An increase in the number of alternative surgical robots will expand the possibilities of studying the functionality of these systems, differences in their operation, safety and efficiency for patients, and convenience for surgeons.

OBJECTIVE

Evaluation of own initial experience of using Senhance robotic surgical system in the work of the general surgery department.

MATERIAL AND METHODS

A prospective collection of data on the surgical treatment of patients with various pathologies using the Senhance robotic system was carried out, followed by its analysis in relation to the duration of the operation, the incidence of intraoperative complications and the need for conversion, as well as the volume of blood loss and early postoperative complications.

RESULTS AND DISCUSSION

Now, only perioperative, and early postoperative data are available for analysis. While accumulating our own experience with the Senhance system, we concluded that, since the transition from robotic to manual laparoscopic surgery and vice versa does not require changing of access points and is performed quickly, it is practically expedient to perform some stages of the operation manually, and others using surgical robot. For example, with the help of manual laparoscopy, it is more ergonomic to perform wide tractions and movements of organs and tissues. At the same time, robotic surgery has undeniable advantages when performing lymph node dissection, performing manual sutures, including anastomoses, which does not lead to an increase in the duration of the intervention.

CONCLUSION

Presented experience of using the Senhance system has shown that it meets the declared indicators of convenience, efficiency and safety of operations in general surgery.

Potential Contenders for the Leadership in Robotic Surgery

Purpose: To summarize the scientific published literature on new robotic surgical platforms with potential use in the urological field, reviewing their evolution from presentation until the present day. Our goal is to describe the current characteristics and possible prospects for these platforms. Materials and Methods: A nonsystematic search of the PubMed, Cochrane library's Central, EMBASE, MEDLINE, and Scopus databases was conducted to identify scientific literature about new robotic platforms other than the Da Vinci^® system, reviewing their evolution from inception until December 2020. Only English language publications were included. The following keywords were used: "new robotic platforms," "Revo-I robot," "Versius robot," and "Senhance robot." All relevant English-language original studies were analyzed by one author (R.F.) and summarized after discussion with an independent third party (E.M., S.Y., S.P., and M.A.). Results: Since 1995, Intuitive Surgical, Inc., with the Da Vinci surgical system, is the leading company in the robotic surgical market. However, Revo-I^®, Versius^®, and Senhance^® are the other three platforms that recently appeared on the market with available articles published in peer-reviewed journals. Among these three new surgical systems, the Senhance robot has the most substantial scientific proof of its capacity to perform minimally invasive urological surgery and as such, it might become a contender of the Da Vinci robot. Conclusions: The Da Vinci surgical platform has allowed the diffusion of robotic surgery worldwide and showed the different advantages of this type of technique. However, its use has some drawbacks, especially its price. New robotic platforms characterized by unique features are under development. Of note, they might be less expensive compared with the Da Vinci robotic system. We found that these new platforms are still at the beginning of their technical and scientific validation. However, the Senhance robot is in a more advanced stage, with clinical studies supporting its full implementation.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

First experience using the Senhance surgical system in laparoscopic local gastrectomy for gastrointestinal stromal tumor

Various innovative robotic systems have been developed to improve surgery precision. The Senhance Surgical System (SSS) is a digital laparoscopic system offering eye tracking and haptic feedback. Several reports have described application of the SSS to general surgeries, including cholecystectomy and colectomy. However, use of the SSS for gastric tumor has not been reported. We experienced a case of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) with the SSS. A 74-year-old man diagnosed with GIST underwent LLG with the SSS. Operation, docking, and console times were 117, 11, and 59 minutes, respectively. No perioperative complications were encountered. This study is the first to report LLG for GIST with the SSS. LLG with the SSS was safe and feasible. The SSS can use reusable forceps and contribute to reducing medical costs. The development of instruments is also progressing, and various kinds of surgery are likely to be indicated.

The first single-incision plus one-port transverse colon resection using Senhance Digital Laparoscopy System: a case report

BACKGROUND

We have introduced the Senhance Digital Laparoscopy System and actively use for colorectal cancer surgery. Recently, we also try to perform surgery by reduce port as less invasive method. For the first time, we report a case of single-incision plus one-port transverse colectomy using Senhance system.

CASE PRESENTATION

The case was a 57-year-old woman, diagnosed with transverse colon cancer referred to our department. The preoperative diagnosis was cT1bN0M0, Stage I. We performed single-incision plus one-port transverse colon resection using Senhance system without any problems. The operative time was 203 min and the blood loss was 35 ml.

CONCLUSION

We report the first case of single-incision plus one-port transverse colectomy using Senhance system. We trust this approach will find increasing use, enabling a safer means of minimally invasive robotic surgery.

Robot-assisted surgery with Senhance robotic system for colon cancer: our original single-incision plus 2-port procedure and a review of the literature

BACKGROUND

The Senhance robotic system provides such advantages as an eye-tracking camera control system, haptic feedback, operator comfort, and reusable endoscopic instruments. The aim of this small study was to assess the feasibility and safety of performing a reduced-port robot-assisted colectomy for colon cancer with the use of a novel robotic system.

METHODS

This was a single-center retrospective study of eight patients with colon cancer who underwent single-incision plus 2-port robot-assisted colectomy with the Senhance robotic system (SILS+2-S) between December 2019 and March 2020 at our hospital. Data on perioperative outcomes, which included operative time, operative blood loss, length of hospitalization, postoperative complications, and histopathological results, were collected prospectively.

RESULTS

The mean patient age was 70.9 years and the mean body mass index was 24.4 kg/m². One patient was converted to laparoscopy due to a damaged scope holder. The mean operative and console times were 229.1 and 139.1 min, respectively. The mean intraoperative blood loss was 49.4 ml. The mean length of the umbilical incision was 3.0 cm. The mean number of harvested lymph nodes was 18.3. The surgical margins were negative in all eight patients. There was neither morbidity nor mortality associated with the procedure, and no Clavien-Dindo classification Grade II-IV complications occurred.

CONCLUSIONS

SILS+2-S is a safe and feasible approach for patients with colon cancer. Further studies are needed to validate the advantages of SILS+2-S and to evaluate the long-term oncological outcomes.

Robotic surgical systems in urology: What is currently available?

Robotic assistance in laparoscopic surgery was introduced at the turn of this millennium, marking a milestone in the history of surgery. Urologists were early adopters of robotic technology and the indications of robot-assisted surgery in urology are expanding. Over the last 20 years, the da Vinci surgical system was the dominant system in the robotic surgical market. However, the recent expiration of Intuitive patents has allowed new systems to enter the market more freely. We performed a nonsystematic literature review using the PubMed/MEDLINE search engines. The aim of this review was to briefly summarize the currently available robotic surgical systems for laparoscopic urologic surgery. New surgical devices have already been launched in the robotic market and the da Vinci systems have some competition. The innovation of robotic technology is continuing, and new features such as an open-console design, haptic feedback, smaller instruments, and separately mounted robotic arms have been introduced. A new robotic era is rising, and new systems and technologies enhancing patient care are welcomed.

An early experience with the Senhance surgical robotic system in colorectal surgery: a single-institute study

BACKGROUND

We present our initial single-centre experience with Senhance surgical robot-assisted colorectal surgery and examine its safety and feasibility.

METHODS

From June 2019 to December 2019, patients who underwent Senhance surgical robot-assisted colorectal surgery in our hospital were retrospectively analysed. We focused on the short-term outcomes.

RESULTS

In total, 46 patients were enrolled in the study. Colorectal cancer was the most common indication for surgery (39 patients). The median total operation time was 283 min, and the median blood loss was 50 cc. Meanwhile, the median number of harvested lymph nodes was 20. Elderly age, advanced American Society of Anaesthesiologists stage, and right-sided colon surgery were associated with the occurrence of complications greater than grade III.

CONCLUSION

Our findings demonstrate the feasibility and safety of the Senhance surgical robotic system in colorectal surgery. Care should be taken regarding the indications and patient selection.

Robotic rectal resection: oncologic outcomes

Robotic surgery has progressively gained popularity in the treatment of rectal cancer. However, only a few studies on its oncologic effectiveness are currently present, with contrasting results. The purpose of this study is to report a single surgeon’s experience on robotic rectal resection (RRR) for cancer, focusing on the analysis of oncologic outcomes, both in terms of pathological features and long-term results. One-hundred and twenty-two consecutive patients who underwent RRR for rectal cancer from January 2013 to December 2019 were retrospectively enrolled. Patients’ characteristics and perioperative outcomes were collected. The analyzed oncologic outcomes were pathological features [distal (DM), circumferential margin (CRM) status and quality of mesorectal excision (TME)] and long-term outcomes [overall (OS) and disease-free survival (DFS)]. The mean operative time was 275 (± 60.5) minutes. Conversion rate was 6.6%. Complications occurred in 27 cases (22.1%) and reoperation was needed in 2 patients (1.5%). The median follow-up was 30.5 (5.9–86.1) months. None presented DM positivity. CRM positivity was 2.5% (2 cases) while a complete TME was reached in 94.3% of cases (115 patients). Recurrence rate was 5.7% (2 local, 4 distant and 1 local plus distant tumor relapse). OS and DFS were 90.7% and 83%, respectively. At the multivariate analysis, both CRM positivity and near complete/incomplete TME were recognized as negative prognostic factors for OS and DFS. Under appropriate logistic and operative conditions, robotic surgery for rectal cancer proves to be oncologically effective, with adequate pathological results and long-term outcomes. It also offers acceptable peri-operative outcomes, further confirming the safety and feasibility of the technique.

Right hemicolectomy with D3 lymph node dissection for right-sided transverse colon cancer using the Senhance robotic system: a case report

Background

The evolution of remote systems and artificial intelligence technology has led to increase in robotic surgeries. One system used in this case report is the Senhance robotic system. The most important premise for using robotic surgery in cancer therapeutics is to ensure oncological safety. Similar to conventional laparoscopic surgery, robotic surgery needs to be a reliable and secure surgical procedure, such as complete mesocolic excisions with central vascular ligations in Western countries or D3 lymph node dissections (dissection of the lymph nodes that locates from the origin to the terminal branch of the main feeding artery of cancer) in Japan.

Case presentation

A 76-year-old man underwent clinical examination for severe anemia. He was diagnosed with transverse colon cancer of tumor (T)3, node (N)1a, metastasis (M)0 cancer stage IIIA. A right hemicolectomy with D3 lymph node dissection using the Senhance surgical system was performed. The operative time was 313 min and the estimated blood loss was 5 ml. He was discharged from our hospital 12 days after the surgery without any complications. What is the remarkable of this report, not only mobilization of right colon but also D3 lymph node dissection and vascular ligation were performed intraperitoneally by using Senhance robotic system as conventional laparoscopic surgery. We tried using fourth robotic arm to accomplish lymphadenectomies and middle colic artery dissection. A right hemicolectomy with D3 dissection using the Da Vinci surgical system was reported. Another report of a right hemicolectomy performed with the Senhance robotic system was identified; however, in that study, lymph node dissections were not performed intraperitoneally.

Conclusions

Therefore, to our knowledge, this is the first report using the Senhance robotic system for right hemicolectomy with D3 dissection. We hope that our case report will assist in the establishment of this robotic procedure in surgical practice.

Next-generation robotics in gastrointestinal surgery

The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.

Laparoscopic Robotic Surgery: Current Perspective and Future Directions

Just as laparoscopic surgery provided a giant leap in safety and recovery for patients over open surgery methods, robotic-assisted surgery (RAS) is doing the same to laparoscopic surgery. The first laparoscopic-RAS systems to be commercialized were the Intuitive Surgical, Inc. (Sunnyvale, CA, USA) da Vinci and the Computer Motion Zeus. These systems were similar in many aspects, which led to a patent dispute between the two companies. Before the dispute was settled in court, Intuitive Surgical bought Computer Motion, and thus owned critical patents for laparoscopic-RAS. Recently, the patents held by Intuitive Surgical have begun to expire, leading to many new laparoscopic-RAS systems being developed and entering the market. In this study, we review the newly commercialized and prototype laparoscopic-RAS systems. We compare the features of the imaging and display technology, surgeons console and patient cart of the reviewed RAS systems. We also briefly discuss the future directions of laparoscopic-RAS surgery. With new laparoscopic-RAS systems now commercially available we should see RAS being adopted more widely in surgical interventions and costs of procedures using RAS to decrease in the near future.

A first case of ileocecal resection using a Senhance Surgical System in Japan

BACKGROUND

Several manufacturers are in the process of developing various innovative systems and expect more options in the robot market. One of the latest systems, the Senhance® platform (TransEnterix Surgical Inc, Morrisville, NC, USA), has already been introduced in Europe and has also been approved for clinical use in Japan. We report the first case of colorectal resection using Senhance in Japan.

CASE PRESENTATION

The patient was a 79-year-old Japanese man who visited a previous physician for positive fecal occult blood. Upon close inspection, the preoperative diagnosis was cT2N0M0 stage I. We performed surgery using Senhance. The operation time was 198 min, and the estimated amount of bleeding was 10 g. He was discharged after surgery without any major complications. However, it is also true that the operability of the conventional port arrangement was poor during the surgical operation.

CONCLUSION

We report the first Senhance-assisted ileocecal resection for colorectal cancer in Japan. In the future, we would like to find more ways to use it by accumulating more cases.

A roadmap for robotic-assisted sigmoid resection in diverticular disease using a Senhance™ Surgical Robotic System: results and technical aspects

Since the turn of the century, robotic-assisted colorectal surgery has been synonymous with the da Vinci® robotic surgical system. We report in this study our first results in robotic-assisted sigmoid resection for diverticular disease using the Senhance™ Surgical Robotic System, while introducing a standardized roadmap for engaging the robotic arms. 12 patients underwent a sigmoid resection using the Senhance™ Surgical Robotic System. All four arms of the robotic system were engaged during all procedures according to a previously devised roadmap. A 4-trocar technique was used in all patients. Perioperative data, including those regarding technical difficulties, were collected and analyzed. Two procedures were converted into standard laparoscopy. There were no conversions to open surgery. The mean age of the patients was 62.5 years (47-79). One third of the patients were males. The mean BMI was 27 kg/m2 (19-38). The mean operative time, the mean console time and the mean docking time were 219 min (204-305), 149 min (124-205) and 10 min (6-15), respectively. The mean length of stay was 9 days (6-15). There was one major complication (8.3%, Clavien-Dindo IIIb). There were no mortalities. No other complications were observed. No patients were readmitted after discharge. The Senhance™ Surgical Robotic System can be used safely in sigmoid resection for diverticular disease after adequate training and systematic planning of the different steps of the procedure. Further experience is needed to judge the benefit for patient and surgeon, as well as the cost and time effectiveness.

Initial Experience With a New Robotic Surgical System for Cholecystectomy

Background. Laparoscopic cholecystectomy has been the gold standard treatment for symptomatic cholelithiasis for more than 3 decades. Robotic techniques are gaining traction in surgery, and recently, the Senhance^™ robotic system was introduced. The system offers advantages over other robotic systems such as improved ergonomics, haptic feedback, eye tracking, and usability of standard laparoscopic trocars and reusable instruments. The Senhance was evaluated to understand the feasibility, benefits, and drawbacks of its use in cholecystectomy. Study Design. A prospectively maintained database of the first 20 patients undergoing cholecystectomy with the Senhance was reviewed at a single hospital. Data including operative time, console time, set up time, and adverse events were collected, with clinical outcome and operative time as primary outcome measures. A cohort of 20 patients having laparoscopic cholecystectomy performed by the same surgeon was used as a comparator group. Results. The 2 groups had comparable demographic data (age, sex, and body mass index). In the Senhance group, 19 of the 20 procedures (95%) were completed robotically. The median (interquartile range) total operating, docking, and console times were 86.5 (60.5-106.5), 11.5 (9-13), and 30.8 (23.5-35) minutes, respectively. In the laparoscopic group, the median (interquartile range) operating time was 31.5 (26-41) minutes. Postoperatively, only one patient had a surgical complication, namely a wound infection treated with antibiotics. Conclusion. Our results suggest that Senhance-assisted cholecystectomy is safe, feasible, and effective, but currently has longer operative times. Further prospective and randomized trials are required to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Robotic surgery using Senhance® robotic platform: single center experience with first 100 cases

Until recently, robotic surgery has been associated only with the da Vinci robotic system. A novel Senhance^® robotic system (TransEnterix Surgical Inc., Morrisville, NC, USA) was introduced almost 5 years ago. Published reports on experience using this robotic platform are very limited. We present a prospective analysis of the first 100 robotic surgeries in abdominal surgery, gynecology, and urology in Klaipeda University Hospital, Klaipeda, Lithuania. Out of 100 operated patients during the mentioned period, 49 were female and 51 men, age range 27-79 years, on an average 55 years. 39 underwent robotic abdominal surgical procedures, 31-urological, and 30 gynecological surgeries. Duration of surgery varied from 30 min to 6 h and 5 min, on an average 2 h 25 min. Almost half 49 (49%) were operated on for malignant diseases: prostate cancer-27, renal cell carcinoma-1, endometrial cancer-7, ovarian cancer-1, colorectal cancer-13 (7 colon and 6 rectum). In-hospital stay was on an average 4 days, range 1-15 days. There were 3 (3%) conversions: two to laparoscopy (both undergoing robotic radical prostatectomy) and one to open (undergoing total hysterectomy). 6 (6%) complications occurred during 30 postoperative days, 2 demanding surgery. According to the Clavien-Dido classification, they were grade II in 3, grade III a in 1 and grade III b in 2 cases. There was no mortality in this patient population. Our experience with different types of robotic surgeries allows us to state that the Senhance^® robotic system is feasible and safe in general surgery, gynecology, and urology, and wider implementation of this system worldwide is simply a question of time.

The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field

Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.

Haptic feedback in the da Vinci Research Kit (dVRK): A user study based on grasping, palpation, and incision tasks

BACKGROUND

It was suggested that the lack of haptic feedback, formerly considered a limitation for the da Vinci robotic system, does not affect robotic surgeons because of training and compensation based on visual feedback. However, conclusive studies are still missing, and the interest in force reflection is rising again.

METHODS

We integrated a seven-DoF master into the da Vinci Research Kit. We designed tissue grasping, palpation, and incision tasks with robotic surgeons, to be performed by three groups of users (expert surgeons, medical residents, and nonsurgeons, five users/group), either with or without haptic feedback. Task-specific quantitative metrics and a questionnaire were used for assessment.

RESULTS

Force reflection made a statistically significant difference for both palpation (improved inclusion detection rate) and incision (decreased tissue damage).

CONCLUSIONS

Haptic feedback can improve key surgical outcomes for tasks requiring a pronounced cognitive burden for the surgeon, to be possibly negotiated with longer completion times.

Feasibility and safety of robotic resection of complicated diverticular disease

This study aimed to assess intra- and postoperative outcomes of robotic resection of left-sided complicated diverticular disease. Retrospective analysis of a prospectively maintained institutional database on consecutive patients undergoing elective robotic resection for diverticular disease (2014-2018). All procedures were performed within an enhanced recovery pathway (ERP). Demographic, surgical and ERP-related items were compared between patients with simple and complicated diverticular disease according to intra-operative presentation. Postoperative complications and length of stay were compared between the two groups. Out of 150 patients, 78 (52%) presented with complicated and the remaining 72 (48%) with uncomplicated disease. Both groups were comparable regarding demographic baseline characteristics and overall ERP compliance. Surgery for complicated disease was longer (288 ± 96 vs. 258 ± 72 min, p = 0.04) and more contaminated (≥ class 3: 57.7 vs. 23.6%, p < 0.001) with a trend to higher conversion rates (10.3 vs. 2.8%, p = 0.1). While postoperative overall complications tended to occur more often after resections for complicated disease (28.2 vs. 15.3%, p = 0.075), major, surgical and medical complications did not differ between the two groups, and median length of stay was 3 days in both settings (p = 0.19). Robotic resection of diverticular disease was feasible and safe regardless of disease presentation by the time of surgery.

Senhance robotic platform for gynecologic surgery: a review of literature

The advantages of endoscopic procedures are well demonstrated in various surgical procedures. In this field, the technological improvement has been significant. One of the most relevant was made by the introduction of robotic surgery that, thanks to the instruments articulation and the precision of movement, made possible to perform even the most complex procedures. The terms "Alf-X" OR "Senhance" OR "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. The principal findings considered in the present review were: the study design, the number of patients included in each study, operative time, estimated blood loss (EBL), conversion rate to standard laparoscopy (SLPS) or laparotomy (LPT), post-operative complications, post-operative hospital stay, and the possible advantages and disadvantages reported by the authors of the studies. A total of eight studies were considered eligible for the present review. The average operative time for TH reported was 110-140 min. In two case-control studies, the operative time was significantly prolonged (P < 0.05) for robotic procedures when compared with SLPS. The EBL was ≤ 100 ml in all studies. Whereas no statistically significant differences were shown in the two case-control studies in terms of conversion to LPT, all studies were in accordance with the post-operative hospital stay, reporting an average of 2 days for total hysterectomy and 1 day for adnexal surgery.

Updates in Urologic Robot Assisted Surgery

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.

Minimally Invasive Surgery in Pediatric Urology: Adaptations and New Frontiers

As the frontiers of minimally invasive surgery (MIS) continue to expand, the availability and implementation of new technology in pediatric urology are increasing. MIS is already an integral part of pediatric urology, but there is still much more potential change to come as both recent and upcoming advances in laparoscopic and robotic surgery are surveyed.

The future of robotic surgery

How robotics could help shape the future of surgical care.

Haptic feedback is useful in remote manipulation of flexible endoscopes

Background and study aims  We developed the Endoscopic Operation Robot (EOR) version 3, offering built-in haptic feedback and manipulation of the entire scope with one hand. Manipulation of the flexible endoscope is done entirely remotely. However, inclusion of haptic feedback places a huge burden on the system. Our purpose in this study was to determine whether haptic feedback is needed in remote manipulation of a flexible endoscope. Methods  Five endoscopists performed total colonoscopy using a colonoscopy training model. A trial was conducted in which the endoscope was inserted up to the cecum five times with haptic feedback and five times without haptic feedback. Insertion time, maximum and mean haptic force, and incidence of sigmoid colon overstretching were compared between groups. Results  Insertion time was significantly shorter with haptic feedback than without, and overstretching of the sigmoid colon was less frequent. Insertion could thus be performed without using excessive force. Conclusion  Haptic feedback is useful for remote control manipulation of flexible endoscopes.

First Experiences with the New Senhance® Telerobotic System in Visceral Surgery

Until recently, robotic-assisted surgery has exclusively been connected to the name DaVinci®. In 2016, a second robotic system, the Senhance®, became available. To introduce the new robotic system into clinical routine, detailed team training and an integration program were useful. Within the first 6 months, 116 cases were performed with this system. The integration program intended to start with simple and well-standardized clinical cases. We chose inguinal hernia repair using the TAPP (transabdominal preperitoneal) technique as the starting procedure. Subsequently, we added upper gastrointestinal surgery and cholecystectomies, and colorectal procedures have since also been included. Initial experience with the Senhance system as the first installation in Germany shows that it is suitable for surgery in general and for visceral surgery in particular. The application is safe due to the unproblematically quick changeover to normal laparoscopy and easy to integrate due to the very short system integration times (docking times). Since it is a laparoscopic-based system, following an integration program will enable experienced laparoscopic surgeons to very quickly manage more complex procedures. Due to lower costs, introducing robotic surgery starting with simple and standardized procedures is more feasible. After the establishment of this second robotic system, future studies will have to specifically look at differences in surgical results and basic conditions of different robotic-assisted systems. This paper documents the decision-making process of a hospital towards the integration of a robotic system and the selection criteria used while also demonstrating the planning and execution process during the introduction of the system into clinical routine.

Review of emerging surgical robotic technology

BACKGROUND

The use of laparoscopic and robotic procedures has increased in general surgery. Minimally invasive robotic surgery has made tremendous progress in a relatively short period of time, realizing improvements for both the patient and surgeon. This has led to an increase in the use and development of robotic devices and platforms for general surgery. The purpose of this review is to explore current and emerging surgical robotic technologies in a growing and dynamic environment of research and development.

METHODS

This review explores medical and surgical robotic endoscopic surgery and peripheral technologies currently available or in development. The devices discussed here are specific to general surgery, including laparoscopy, colonoscopy, esophagogastroduodenoscopy, and thoracoscopy. Benefits and limitations of each technology were identified and applicable future directions were described.

RESULTS

A number of FDA-approved devices and platforms for robotic surgery were reviewed, including the da Vinci Surgical System, Sensei X Robotic Catheter System, FreeHand 1.2, invendoscopy E200 system, Flex® Robotic System, Senhance, ARES, the Single-Port Instrument Delivery Extended Research (SPIDER), and the NeoGuide Colonoscope. Additionally, platforms were reviewed which have not yet obtained FDA approval including MiroSurge, ViaCath System, SPORT™ Surgical System, SurgiBot, Versius Robotic System, Master and Slave Transluminal Endoscopic Robot, Verb Surgical, Miniature In Vivo Robot, and the Einstein Surgical Robot.

CONCLUSIONS

The use and demand for robotic medical and surgical platforms is increasing and new technologies are continually being developed. New technologies are increasingly implemented to improve on the capabilities of previously established systems. Future studies are needed to further evaluate the strengths and weaknesses of each robotic surgical device and platform in the operating suite.