Robotic Surgery in Gynecology

Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy

BACKGROUND

To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications.

METHODS

A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2).

RESULTS

Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications.

CONCLUSION

Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

Robotic surgery in endometrial cancer: first Polish experience

In Poland, robotic surgery is nowadays perceived as a new method of surgical treatment in endometrial cancer patients. We aim to present the first Polish group of endometrial cancer patients treated using robotic surgery. The analysis was based on 79 patients with mean age of 59.72 ± 11.709 (range 27-83) years and endometrial cancer scheduled for surgical treatment. Mean BMI was 31.38 ± 8.78 (range 19.03-65.97) kg/m2. The data were collected based on a questionnaire consisting of 19 questions concerning the patient's perception of robotic surgery before the procedure. Patients with a family history of neoplastic diseases indicate precision of movements as the most important reason for choosing robotic surgery (p = 0.0035). Patients after surgery procedures in the past named shorter hospitalization as a major benefit (p = 0.0037). Patients who chose robotic surgery for financial reasons stressed the cosmetic effect as a priority (p = 0.0319). Shorter length of hospital stay, less blood loss, enlarged view, and good visualization were statistically significant reasons for choosing robotic surgery (p < 0.05). Women who consider work, good material status, and well-being as the most important aspects of their lives cited the cosmetic effect as a benefit of robotic surgery (p = 0.0029 vs. p = 0.0074 vs. p = 0.01745, respectively). In the follow-up after operations, no patients regretted choosing robotic surgery. Good visualization, precise movements, less blood loss, and cosmetic effects are the most frequent reasons for choosing robotic surgery. Even patients after other types of surgery in the past decided on robot-assisted radical hysterectomy because of the clear benefits of this approach.

Coaxial-Robotic Single-Site Myomectomy: Surgical Outcomes Compared with Robotic Single-Site Myomectomy by Propensity Score Matching Analysis

BACKGROUND

The aim of this study was to introduce a coaxial-robotic single-site myomectomy (C-RSSM) technique to compensate for the shortcomings of robotic single-site myomectomy (RSSM) using semi-rigid instruments and to compare the surgical outcomes of C-RSSM and RSSM.

METHODS

The medical records of 13 consecutive women who had undergone C-RSSM and 131 consecutive women who had undergone RSSM were retrospectively reviewed. Patient characteristics and surgical outcomes after propensity score matching were evaluated and compared between the two groups.

RESULTS

According to the propensity score matching results, the C-RSSM group had a lower estimated blood loss (75.0 vs. 210.5 mL, p = 0.001) and a shorter operating time (101.0 vs. 146.1 min, p = 0.008) relative to the RSSM group. In RSSM, there was one case of conversion to conventional laparoscopy and four cases of conversion to the multi-site robotic approach. There was no case of conversion from C-RSSM to conventional laparoscopy or the multi-site robotic approach.

CONCLUSIONS

C-RSSM was found to be associated with shorter operative time and lower estimated blood loss. However, further prospective studies are needed to confirm these advantages.

The value of surgical admissions for malignant uterine cancer. A comparative analysis of robotic, laparoscopic, and laparotomy surgery in a university hospital

Background

Robotic surgery for malignant uterine cancer raises issue of economic sustainability for providers. The objective of this study was to assess the value of surgical admissions for malignant uterine cancer in a University Hospital through an analysis of their costs and outcomes by comparing three different surgical approaches (laparotomy, laparoscopic, and robotic surgery).

Methods

Hospitalizations between 1 January 2019 and 31 October 2021 for malignant uterine cancer surgery were selected and stratified. For each surgical approach, mean values (with 95% confidence intervals, CI) were calculated for cost items. Moreover, 30-day readmission frequency was calculated for the three approaches compared to each other. ANOVA and Student's t-test and relative risk (RR) were used for statistical analysis. A break-even analysis was carried out by evaluating the volume of robotic and non-robotic surgical admissions.

Results

A total of 1,336 hospitalizations were included in the study, 366 with robotic, 591 with laparoscopic, and 379 with laparotomy surgery. Robotic surgery, compared to laparoscopic and laparotomy ones, showed a statistically significant difference (p < 0.001) in the economic margin, which was largely negative (-1069.18 €; 95%CI:-1240.44--897.92 €) mainly due to devices cost, and a lower percentage of 30-day readmissions (1.4%; 95%CI: 0.2-2.6%), with a statistically significant difference only vs. laparotomy (p = 0.029). Laparoscopic compared to laparotomy surgery showed a significantly (p < 0,001) more profitable economic margin (1692.21 €; 95%CI: 1531.75 €-1852.66 €) without a significant difference for 30-day readmissions. Break-even analysis showed that, on average, for each malignant uterine cancer elective surgery performed laparoscopically, 1.58 elective robotic surgeries are sustainable for the hospital (95% CI: 1.23-2.06).

Conclusion

Break-even analysis could be a useful tool to support hospital management in planning and governance of malignant uterine cancer surgery. Systematic application of this tool will allow defining over time right distribution of robotic, laparoscopic, and laparotomy surgeries' volumes to perform to ensure both quality and economic-financial balance and therefore value of uterine oncological surgery. Concerning research, this study paves the way for a multicentric study, the extension of outcomes of malignant uterine surgery to be considered and assessed, and the future inclusion of other therapeutic interventions in the analysis.

Improving disease prevention, diagnosis, and treatment using novel bionic technologies

Increased human life expectancy, due in part to improvements in infant and childhood survival, more active lifestyles, in combination with higher patient expectations for better health outcomes, is leading to an extensive change in the number, type and manner in which health conditions are treated. Over the next decades as the global population rapidly progresses toward a super-aging society, meeting the long-term quality of care needs is forecast to present a major healthcare challenge. The goal is to ensure longer periods of good health, a sustained sense of well-being, with extended periods of activity, social engagement, and productivity. To accomplish these goals, multifunctionalized interfaces are an indispensable component of next generation medical technologies. The development of more sophisticated materials and devices as well as an improved understanding of human disease is forecast to revolutionize the diagnosis and treatment of conditions ranging from osteoarthritis to Alzheimer's disease and will impact disease prevention. This review examines emerging cutting-edge bionic materials, devices and technologies developed to advance disease prevention, and medical care and treatment in our elderly population including developments in smart bandages, cochlear implants, and the increasing role of artificial intelligence and nanorobotics in medicine.

Perioperative and Survival Outcomes of Robotic-Assisted Surgery, Comparison with Laparoscopy and Laparotomy, for Ovarian Cancer: A Network Meta-Analysis

Objective

We aimed to compare the perioperative and survival outcomes of robotic-assisted surgery, traditional laparoscopy, and laparotomy approaches in ovarian cancer.

Methods

PubMed, Cochrane Library, Embase, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) were searched using multiple terms for ovarian cancer surgeries, including comparative studies in Chinese and English. Literatures are published before August 31, 2021. The outcomes include operating time, estimated blood loss, length of hospital stay, postoperative/intraoperative/total complications, pelvic/para-aortic/total lymph nodes, transfusion, and five-year overall survival rate. The dichotomous data, continuous data, and OS data were pooled and reported as relative risk, standardized mean differences, and hazard ratio HRs with 95% confidence intervals, respectively. The Newcastle–Ottawa Scale was used to evaluate the risk of bias of included studies.

Results

Thirty-eight studies, including 8,367 patients and three different surgical approaches (robotic-assisted laparoscopy surgery, traditional laparoscopy, or laparotomy approaches), were included in this network meta-analysis. Our analysis shows that the operating time of laparotomy was shorter than laparoscopy. The robotic-assisted laparoscopy has the least estimated blood loss during the surgery, followed by laparoscopy, and finally laparotomy. Compared with laparotomy, the incidence of blood transfusion was lower in the robotic-assisted laparoscopy and laparoscopy groups, and the length of hospital stay is shorter. Laparotomy had a significantly higher incidence of total complications than robotic-assisted laparoscopy and laparoscopy and higher postoperative complications than laparoscopy. For the number of pelvic/para-aortic/total lymph nodes removed by different surgical approaches, our analysis revealed no statistical difference. Our analysis also revealed no significant differences in intraoperative complications and 5-year OS among the three surgical approaches.

Conclusion

Compared with laparotomy, robotic-assisted laparoscopy and laparoscopy had a shorter hospital stay, decreased blood loss, fewer complications, and transfusion happened. The 5-year OS of ovarian cancer patients has no difference between robotic-assisted laparoscopy, laparoscopy, and laparotomy groups.

Perioperative morbidity of different operative approaches in early cervical carcinoma: a systematic review and meta-analysis comparing minimally invasive versus open radical hysterectomy

Purpose

Radical hysterectomy and pelvic lymphadenectomy is the standard treatment for early cervical cancer. Studies have shown superior oncological outcome for open versus minimal invasive surgery, but peri- and postoperative complication rates were shown vice versa. This meta-analysis evaluates the peri- and postoperative morbidities and complications of robotic and laparoscopic radical hysterectomy compared to open surgery.

Methods

Embase and Ovid-Medline databases were systematically searched in June 2020 for studies comparing robotic, laparoscopic and open radical hysterectomy. There was no limitation in publication year. Inclusion criteria were set analogue to the LACC trial. Subgroup analyses were performed regarding the operative technique, the study design and the date of publication for the endpoints intra- and postoperative morbidity, estimated blood loss, hospital stay and operation time.

Results

27 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Meta-analysis showed no significant difference between robotic radical hysterectomy (RH) and laparoscopic hysterectomy (LH) concerning intra- and perioperative complications. Operation time was longer in both RH (mean difference 44.79 min [95% CI 38.16; 51.42]), and LH (mean difference 20.96 min; [95% CI − 1.30; 43.22]) than in open hysterectomy (AH) but did not lead to a rise of intra- and postoperative complications. Intraoperative morbidity was lower in LH than in AH (RR 0.90 [0.80; 1.02]) as well as in RH compared to AH (0.54 [0.33; 0.88]). Intraoperative morbidity showed no difference between LH and RH (RR 1.29 [0.23; 7.29]). Postoperative morbidity was not different in any approach. Estimated blood loss was lower in both LH (mean difference − 114.34 [− 122.97; − 105.71]) and RH (mean difference − 287.14 [− 392.99; − 181.28]) compared to AH, respectively. Duration of hospital stay was shorter for LH (mean difference − 3.06 [− 3.28; − 2.83]) and RH (mean difference − 3.77 [− 5.10; − 2.44]) compared to AH.

Conclusion

Minimally invasive radical hysterectomy appears to be associated with reduced intraoperative morbidity and blood loss and improved reconvalescence after surgery. Besides oncological and surgical factors these results should be considered when counseling patients for radical hysterectomy and underscore the need for new randomized trials.

Single-Incision versus Multiport Robotic Myomectomy: A Propensity Score Matched Analysis of Surgical Outcomes and Surgical Tips

We aimed to compare the perioperative outcomes of single-incision robotic myomectomy (SIRM) and multiport robotic myomectomy (MPRM) and provide surgical tips. We retrospectively analyzed the medical records of 462 patients with symptomatic leiomyoma who underwent MPRM or SIRM between March 2019 and April 2021. Demographic characteristics and surgical outcomes, including the total operative time (OT), estimated blood loss (EBL), and surgical complication rate, were compared between the two groups. Patients in the SIRM group had lower a body mass index and rate of previous pelvic surgery and were younger than those in the MPRM group. The myoma type was not different between groups; however, the MPRM group had larger, and more myomas than the SIRM group. After propensity score matching, these variables were not significantly different between the groups. The total OT, EBL, difference in hemoglobin levels, transfusion rate, and postoperative fever were not different between the groups. No postoperative complications occurred in the SIRM group. In the MPRM group, one patient needed conversion to laparotomy, and two patients had postoperative complications (umbilical incisional hernia and acute kidney injury). In conclusion, both MPRM and SIRM are feasible and effective surgical options for symptomatic myomas with cosmetic benefits and minimal risk of laparotomy conversion.

First report comparing the two types of single-incision robotic sacrocolpopexy: Single site using the da Vinci Xi or Si system and single port using the da Vinci SP system

OBJECTIVE

The gold standard procedure for treating patients with apical pelvic organ prolapse (POP) is sacrocolpopexy. However, no report comparing the two types of single-incision robotic sacrocolpopexy, namely, single-site robotic sacrocolpopexy (SS-RSC) and single-port robotic sacrocolpopexy (SP-RSC) exists. Therefore, we compared the safety and effectiveness of SS-RSC and SP-RSC.

MATERIALS AND METHODS

In this study, 48 patients who underwent single-incision RSC, 40 non-consecutive patients who underwent SS-RSC, and 8 consecutive patients who underwent SP-RSC for symptomatic POP quantification stage III-IV and were eligible for the 1-year follow-up (FU) were included. We compared the surgical time and operative outcomes of SS-RSC and SP-RSC. We also compared the data of the initial 8 cases in each group.

RESULTS

The mean patient age was 59.2 ± 11.0 years and 66.1 ± 8.0 years in the SS-RSC (n = 40) and SP-RSC (n = 8) groups, respectively. The mean operative time (OT) and console time were comparable between the SS-RSC and SP-RSC groups (135.3 ± 31.6 min vs 141.8 ± 23.5 min; 94.6 ± 32.2 min vs 89 ± 9.5 min, respectively). The docking time and cervix suturing time were short in the SP-RSC group (P < 0.05). However, in the analysis of the initial 8 cases in each group, all surgical times except the cervix suturing time were shorter in the SP-RSC group (P < 0.05). Three cases had intraoperative bladder injury (two [5.0%] in the SS-RSC and one [12.5%] in the SP-RSC group). Two cases (5.0%) had umbilical incisional hernia in the SS-RSC group. Two cases had vaginal mesh erosion on the posterior vaginal wall, with 1 case in each group. One case (2.5%) experienced a recurrence of POP; an anterior compartment POP-Q stage 2 following SS-RSC at the 4-week FU.

CONCLUSION

Single-incision RSC, both SS-RSC and SP-RSC, is a feasible and effective surgical option for treating symptomatic apical POP with an aesthetic finish.

Single assistant versus dual assistant robotic surgery for robot-assisted laparoscopic hysterectomy using da Vinci Xi or X

BACKGROUND

To verify the usefulness of single assistant robotic surgery (SA-RS) using da Vinci Xi or X performed for total hysterectomy.

METHODS

The SA-RS group (S-group) includes surgeries in which the surgeon performed all surgical operations other than that of the uterine manipulator, while the dual assistant robotic surgery group (D-group) includes surgeries performed by the surgeon with two assistants. In S-group, the forceps and camera were replaced during surgery in cases of a large uterus with limited range of motion of the instrument. A comparative study of patient background, intraoperative and postoperative results and surgery-related cost was performed between the two groups.

RESULTS

No significant differences were observed between the two groups. On the contrary, S-group showed a significant reduction in preparation time and wound closure time, and a savings of $768.

CONCLUSION

SA-RS for total hysterectomy was possible, which is excellent in terms of cost, esthetics, and manpower.

Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications?

OBJECTIVES

To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database.

METHODS

We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors.

RESULTS

We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62 years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01).

CONCLUSION

In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.

Robot-Assisted Laparoscopic Surgery for Pelvic Organ Prolapse among Peri- and Post-Menopausal Women

For patients with apical compartment pelvic organ prolapse (POP), abdominal sacrocolpopexy has been considered superior to the vaginal approach in terms of less dyspareunia and decreased risk of recurrence. Robot-assisted sacrocolpopexy (RSC) can help overcome difficulties in laparoscopic sacrocolpopexy (LSC) by facilitating deep dissection and suturing. Moreover, RSC is a safe and efficacious option for patients with POP. It has several benefits, such as its high anatomical cure rate, improvement of sexual function, reduction of perioperative complications, and low recurrence rate. In addition, it can be a safe option for elderly patients. RSC has a steep learning curve and numerous other reported advantages compared with LSC; however, insufficient data conclude that the former is universally superior, especially in cost effectiveness. Thus, further studies are needed to support the widespread adoption of robot-assisted surgery for pelvic floor reconstruction.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via Ovid, and EMBASE via Ovid, on 8 January 2018. We searched www.ClinicalTrials.gov. on 16 January 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing RAS versus CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We examined different procedures in separate comparisons and for hysterectomy subgrouped data according to type of disease (non-malignant versus malignant). When more than one study contributed data, we pooled data using random-effects methods in RevMan 5.3.

MAIN RESULTS

We included 12 RCTs involving 1016 women. Studies were at moderate to high overall risk of bias, and we downgraded evidence mainly due to concerns about risk of bias in the studies contributing data and imprecision of effect estimates. Procedures performed were hysterectomy (eight studies) and sacrocolpopexy (three studies). In addition, one trial examined surgical treatment for endometriosis, which included resection or hysterectomy. Among studies of women undergoing hysterectomy procedures, two studies involved malignant disease (endometrial cancer); the rest involved non-malignant disease.• RAS versus CLS (hysterectomy)Low-certainty evidence suggests there might be little or no difference in any complication rates between RAS and CLS (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.54 to 1.59; participants = 585; studies = 6; I² = 51%), intraoperative complication rates (RR 0.77, 95% CI 0.24 to 2.50; participants = 583; studies = 6; I² = 37%), postoperative complications (RR 0.81, 95% CI 0.48 to 1.34; participants = 629; studies = 6; I² = 44%), and blood transfusions (RR 1.94, 95% CI 0.63 to 5.94; participants = 442; studies = 5; I² = 0%). There was no statistical difference between malignant and non-malignant disease subgroups with regard to complication rates. Only one study reported death within 30 days and no deaths occurred (very low-certainty evidence). Researchers reported no survival outcomes.Mean total operating time was longer on average in the RAS arm than in the CLS arm (mean difference (MD) 41.18 minutes, 95% CI -6.17 to 88.53; participants = 148; studies = 2; I² = 80%; very low-certainty evidence), and the mean length of hospital stay was slightly shorter with RAS than with CLS (MD -0.30 days, 95% CI -0.53 to -0.07; participants = 192; studies = 2; I² = 0%; very low-certainty evidence).• RAS versus CLS (sacrocolpopexy)Very low-certainty evidence suggests little or no difference in rates of any complications between women undergoing sacrocolpopexy by RAS or CLS (RR 0.95, 95% CI 0.21 to 4.24; participants = 186; studies = 3; I² = 78%), nor in intraoperative complications (RR 0.82, 95% CI 0.09 to 7.59; participants = 108; studies = 2; I² = 47%). Low-certainty evidence on postoperative complications suggests these might be higher with RAS (RR 3.54, 95% CI 1.31 to 9.56; studies = 1; participants = 68). Researchers did not report blood transfusions and deaths up to 30 days.Low-certainty evidence suggests that RAS might be associated with increased operating time (MD 40.53 min, 95% CI 12.06 to 68.99; participants = 186; studies = 3; I² = 73%). Very low-certainty evidence suggests little or no difference between the two techniques in terms of duration of stay (MD 0.26 days, 95% CI -0.15 to 0.67; participants = 108; studies = 2; I² = 0%).• RAS versus open abdominal surgery (hysterectomy)A single study with a total sample size of 20 women was included in this comparison. For most outcomes, the sample size was insufficient to show any possible differences between groups.• RAS versus CLS for endometriosisA single study with data for 73 women was included in this comparison; women with endometriosis underwent procedures ranging from relatively minor endometrial resection through hysterectomy; many of the women included in this study had undergone previous surgery for their condition. For most outcomes, event rates were low, and the sample size was insufficient to detect potential differences between groups.

AUTHORS' CONCLUSIONS

Evidence on the effectiveness and safety of RAS compared with CLS for non-malignant disease (hysterectomy and sacrocolpopexy) is of low certainty but suggests that surgical complication rates might be comparable. Evidence on the effectiveness and safety of RAS compared with CLS or open surgery for malignant disease is more uncertain because survival data are lacking. RAS is an operator-dependent expensive technology; therefore evaluating the safety of this technology independently will present challenges.

Automatic Vessel Detection Technique in Laparoscopic Surgical Imaging Including Surgical Instruments

In this paper, we propose a new technique to recognize vessels in robot-assisted laparoscopic surgery images by using surgical instruments. The proposed method does not require additional hardware or parameter adjustment because it detects blood vessels by using only the color information of the image. The concept of a hessian matrix is used in the HSV color space of the image to detect the edges of the blood vessels. In addition, the histogram equalization technique, clustering technique, and region growing are used to remove the surgical tools. Images of actual robot-assisted laparoscopic surgery videos were used. The processing speed was approximately 0.3 s per frame at 640p and approximately 0.8 s per frame at 1280p. The average recall was 92.67%.

Cost effectiveness of preoperative screening for healthy patients undergoing robotic hysterectomy

The objective of this study was to determine whether routine preoperative type and screen blood testing is cost effective and medically warranted for benign diagnosis in healthy patients undergoing robotic hysterectomy. The study was designed as a cross sectional retrospective descriptive study. Four hundred and twenty two medical records of American Society of Anesthesiologists (ASA) Classifications I and II patients undergoing robotically-assisted laparoscopic hysterectomy between 1 June 2011 and 31 May 2014 at a 211 bed regional medical center were analysed. The results from this study paralleled the findings of other published research. Preoperative type and screen testing was performed on 249 (59%) of the patients in the study. Ten patients (2.4% of the group) converted to open laparotomy. Mean estimated blood loss was 59.59ml. No perioperative transfusions were required. The results indicate that preoperative type and screen testing is not warranted for patients meeting the inclusion criteria.

IT applications in healthcare management: a survey

Healthcare management is currently undergoing substantial changes, and reshaping our perception of the medical field. One spectrum is that of the considerable changes that we see in surgical machines and equipment, and the way the procedures are performed. Computing power, Internet and associated technologies are transforming surgical operations into model based procedures. The other spectrum is the management side of healthcare, which is equally critical to the medical profession. In particular, recent advances in the field of Information Technology (IT) is assisting in better management of health appointments and record management. With the proliferation of IT and management, data is now playing a vital role in diagnostics, drug administration and management of healthcare services. With the advancement in data processing, large amounts of medical data collected by medical centres and providers, can now be mined and analysed to assist in planning and making appropriate decisions. In this article, we shall provide an overview of the role of IT that have been reshaping the healthcare management, hospital, health profession and industry.

A Kalman-Filter-Based Common Algorithm Approach for Object Detection in Surgery Scene to Assist Surgeon's Situation Awareness in Robot-Assisted Laparoscopic Surgery

Although the use of the surgical robot is rapidly expanding for various medical treatments, there still exist safety issues and concerns about robot-assisted surgeries due to limited vision through a laparoscope, which may cause compromised situation awareness and surgical errors requiring rapid emergency conversion to open surgery. To assist surgeon's situation awareness and preventive emergency response, this study proposes situation information guidance through a vision-based common algorithm architecture for automatic detection and tracking of intraoperative hemorrhage and surgical instruments. The proposed common architecture comprises the location of the object of interest using feature texture, morphological information, and the tracking of the object based on Kalman filter for robustness with reduced error. The average recall and precision of the instrument detection in four prostate surgery videos were 96% and 86%, and the accuracy of the hemorrhage detection in two prostate surgery videos was 98%. Results demonstrate the robustness of the automatic intraoperative object detection and tracking which can be used to enhance the surgeon's preventive state recognition during robot-assisted surgery.

First experience of the Egyptian National Cancer Institute using the robot-assisted laparoscopic approach in radical hysterectomies for cervical cancer

AIM OF WORK

Robotics in surgery led to an improvement of visualization, a better handling of tissues and better suturing. This study aimed to document the first experience of the Egyptian National Cancer Institute (NCI) using the robot-assisted laparoscopic approach in radical hysterectomies for cervical cancer and to highlight observed advantages, disadvantages, morbidity and oncological outcomes.

PATIENTS AND METHODS

Data of cases that had either early cervical cancer (stage IB-IIA1 with a tumor ≥2 cm) or locally advanced cervical cancer (Stage IIA2-IIB after chemo-radiotherapy) were collected prospectively. Study patients underwent robotic radical hysterectomies for their cervical cancers at the NCI, Cairo University, between January 1, 2015 and December 31, 2016. For each patient, duration of surgery, amount of blood loss, and intra-operative complications were recorded. Similarly, the duration of postoperative hospital-stay, analgesia used and post-operative gastrointestinal recovery were documented. Pathological assessment of safety margins and the lymph nodes number yield were also assessed.

RESULTS

Twenty patients underwent robotic radical hysterectomy during the study period. Twelve cases had early cervical cancer while 8 suffered locally advanced disease. The mean procedure time was 319 (range 240-560) minutes; the mean blood loss was 309 (range 150-600) ml. Three cases had bladder injuries during their procedures. The median hospital stay was 6 (range 4-10) days. One case had a positive margin. The median of lymph nodes yield number was 15 (range 10-25). Follow-up ranged 9-31 months, with only one case developing local recurrence.

CONCLUSION

Robotic radical hysterectomy is a feasible approach with a tolerable rate of complications.

Robotic-Assisted Radical Hysterectomy Results in Better Surgical Outcomes Compared With the Traditional Laparoscopic Radical Hysterectomy for the Treatment of Cervical Cancer

Objective

The aim of this study was to compare the surgical outcomes of robotic-assisted radical hysterectomy (RRH) with traditional laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in a large retrospective cohort of a total of 933 patients.

Methods

We have enrolled 100 patients into the RRH and 833 patients into the TLRH group. The surgical outcomes include operating time, blood loss, transfusion rate, pelvic lymph node yield, hospitalization days, duration of bowel function recovery, catheter removal before and after 3 weeks, conversion to laparotomy, and intraoperative and postoperative complications. Follow-up results were also analyzed for all patients.

Results

Both groups have similar patient and tumor characteristics but patients with a larger lesion size were preferably enrolled in the TLRH treatment group. The treatment with RRH was generally superior to TLRH with respect to operating time, blood loss, length of hospitalization, duration of bowel function recovery, and postoperative complications. On follow-up of patients, there were no relapses reported in the RRH group compared with 4% of relapse cases and 2.9% of deaths because of metastasis in the TLRH group. No conversion of laparotomy occurred in the RRH group. No significant difference was found with respect to intraoperative complications and blood transfusion between both groups.

Conclusions

The results from this study suggest that RRH is superior to TLRH with regard to surgical outcome and may pose a safe and feasible alternative to TLRH. The operating time and lymph node yield is acceptable. Our study is one of the largest single-center studies of surgical outcomes comparing RRH with TLRH during cervical cancer treatment and will significantly contribute to the safety of alternative treatment options for patients. Furthermore, the difference detected between TLRH and RRH group is further strengthened by the great expertise of the surgeon performing laparoscopic surgeries.

Costs and mortality rates of surgical approaches to hysterectomy in Brazil

OBJECTIVE

To analyze the costs of hysterectomies performed in Brazil due to benign conditions, and to assess its hospital admittance and mortality rates.

METHODS

A retrospective cohort was carried out from January 2010 to December 2014, analyzing all hysterectomies (n = 428,346) registered on the DATASUS database between January 2010 and December 2014. Data were collected through a structured questionnaire and analyzed using the SPSS 20.0 for Windows.

RESULTS

Hospital admissions were 300,231 for total abdominal hysterectomies, 46,056 for vaginal hysterectomies, 29,959 for subtotal abdominal hysterectomies and 1,522 for laparoscopic hysterectomies. Mortality rates were 0.26%, 0.09%, 0.07% and 0.05% for subtotal, total abdominal, laparoscopic, and vaginal hysterectomies, respectively. Among the procedures studied, total abdominal hysterectomies had the most costs (R$217,802,574.77), followed by vaginal hysterectomies (R$24,173,490.00), subtotal abdominal hysterectomies (R$19.253.300,00) and laparoscopic hysterectomies (R$794,680.40).

CONCLUSIONS

Total abdominal hysterectomies had the highest overall costs mainly because it was the most commonly performed technique. Mortality rates were greatest in subtotal abdominal hysterectomies; this, however, may be due to bias related to missing data in our database.

Perioperative outcomes of robotic hysterectomy with mini-laparotomy versus open hysterectomy for uterus weighing more than 250 g

To compare perioperative outcomes in patients undergoing robotic hysterectomy and extraction of specimen via mini-laparotomy (RHML) versus open hysterectomy (OH) when uterus weighs more than 250 g. To study the factors determining the length of hospital stay in 2 groups. A retrospective analysis of all hysterectomies performed for uterus weighing more than 250 g from the year 2012 to 2015 was conducted. A total of 140 patients were divided into 2 groups based on the type of surgery; RHML (n = 82) and OH (n = 58). Mini-laparotomy consisted of a customised incision connecting 2 left lateral port sites for specimen extraction after completing the hysterectomy robotically. Patient factors and perioperative outcomes were compared using Student's t tests and Chi-square analysis. Mean length of stay (RHML = 1.4 days; OH = 3.4 days), estimated blood loss (EBL) (RHML = 119.9 ml; OH = 547.5 ml) and operative time (RHML = 191.5 min; OH = 162.8 min) were significantly different. No significant differences were noted for patient BMI, age, comorbidities, intraoperative complications, pathology of uterus and uterus weight. Postoperative complications were significantly different between two groups (RHML = 6.0%; OH = 15.5%; p = .021). None of the patients stayed less than 24 h in OH group compared to 59.8% patients in RHML group. Type of procedure (p = .004) and EBL (p = .002) significantly predicted the length of stay. Patients undergoing RHML have significantly shorter length of stay, EBL and postoperative complications than OH. The operative time for RHML was longer than OH, but the overall decreased length of stay overcomes this disadvantage. RHML approach retains the benefits of da Vinci, while simultaneously preserving the specimen.

Role of robotic surgery in cervical malignancy

Surgical treatment is the mainstay of the management of early-stage cervical cancer. Abdominal radical hysterectomy and trachelectomy have long been the standard surgical approach to early-stage cervical cancer, achieving excellent survival outcomes. Recently, laparoscopic radical hysterectomy and trachelectomy have become the preferred alternative to abdominal surgery because laparoscopic approaches lead to better surgical outcomes without compromising survival outcomes. Since the robotic surgery platform was approved for the use of gynaecologic surgery in 2005, robotic radical hysterectomy and trachelectomy have been increasingly used in the surgical management of early-stage cervical cancer. However, the role of robotic surgery is poorly defined. This review examines the role of robotic surgery in the surgical management of cervical cancer by comparing the published data on its use with those of abdominal and laparoscopic surgeries.

Role of robotic surgery in ovarian malignancy

As part of minimally invasive surgery, robotic-assisted approach is becoming increasingly popular in gynecologic oncology. It has been shown to be effective and feasible for staging and treating endometrial and cervical cancer, but its role in the context of primary and recurrent ovarian cancers is presently debated. Scanty data are available in the literature, and the level of evidence supporting its use in ovarian cancer is quite low. However, from a retrospective case-control series, robotic surgery seems to be safe and feasible for early-stage ovarian cancer. Its use in treating patients with advanced-stage or relapsed ovarian cancer is still highly controversial, suggesting the choice of robotic approach in a highly selected population.

Automatic detection of hemorrhage and surgical instrument in laparoscopic surgery image

In this paper, we propose a new method for detecting hemorrhage areas and surgical instruments in robot-assisted laparoscopic surgery images. The proposed scheme utilizes CIELAB information to identify a region of interest (ROI) and segment it. Histogram equalization and Otsu's method are also adopted to compute the detection threshold. Detection is performed automatically and additional adjustment of parameters is not needed. Experiments to verify the proposed algorithm were conducted using actual robot-assisted laparoscopic surgery images. Using the proposed algorithm, the average time consumption was 0.37 s per frame for hemorrhage identification and 0.11 s for instrument detection. The sensitivities were also high enough for practical application.

Current concepts and practical techniques of nerve-sparing laparoscopic radical hysterectomy

Laparoscopic radical hysterectomy has been widely performed for patients with early-stage cervical cancer. The operative techniques for nerve-sparing to avoid bladder dysfunction have been established during the past three decades in abdominal radical hysterectomy, but how these techniques can be applied to laparoscopic surgery has not been fully discussed. Prolonged operation time or decreased radicality due to less accessibility via a limited number of trocars may be a disadvantage of the laparoscopic approach, but the magnified visual field in laparoscopy may enable fine manipulation, especially for preserving autonomic nerve tracts. The present review article introduces the practical techniques for sparing bladder branches of pelvic nerves in laparoscopic radical hysterectomy based on understanding of the pelvic anatomy, clearly focusing on the differences from the techniques in abdominal hysterectomy.

Surgical and clinical safety and effectiveness of robot-assisted laparoscopic hysterectomy compared to conventional laparoscopy and laparotomy for cervical cancer: A systematic review and meta-analysis

AIM

This study aimed to evaluate the surgical safety and clinical effectiveness of RH versus LH and laparotomy for cervical cancer.

METHODS

We searched Ovid-Medline, Ovid-EMBASE, and the Cochrane library through May 2015, and checked references of relevant studies. We selected the comparative studies reported the surgical safety (overall; peri-operative; and post-operative complications; death within 30 days; and specific morbidities), and clinical effectiveness (survival; recurrence; length of stay [LOS]; estimated blood loss [EBL]; operative time [OT]) and patient-reported outcomes.

RESULTS

Fifteen studies comparing RH with OH and 11 comparing RH with LH were identified. No significant differences were found in survival outcomes. The LOS was shorter and transfusion rate was lower with RH compared to OH or LH. EBL was significantly reduced with RH compared to OH. Compared to OH, overall complications, urinary infection, wound infection, and fever were significantly less frequent with RH. The overall, peri-operative, and post-operative complications were similar in other comparisons. Several patient-reported outcomes were improved with RH, though each outcome was reported in only one study.

CONCLUSIONS

RH appears to have a positive effect in reducing overall complications, individual adverse events including wound infection, fever, urinary tract infection, transfusion, LOS, EBL, and time to diet than OH for cervical cancer patients. Compared to LH, the current evidence is not enough to clearly determine its clinical safety and effectiveness. Further rigorous prospective studies with long-term follow-up that overcome the many limitations of the current evidence are needed.

Complications of Robotic Gynecologic Surgery in the Severely Morbidly Obese

BACKGROUND

Surgeons are increasingly faced with the challenge of caring for obese patients. Advanced laparoscopic procedures have been shown to be safe in women with high BMI, but conversion rates remain high. Because robotics holds many potential advantages over traditional laparoscopic surgery, we sought to evaluate the outcome of robotic-assisted gynecologic surgery in obese patients.

METHODS

A retrospective chart review of obese female patients undergoing robotic gynecologic surgery between January 2008 and August 2010 was done. Patients were divided into three groups based on BMI (group I, BMI 30-34.9 kg/m²; group II, BMI 35-39.9 kg/m²; and group III, BMI >40 kg/m²). Patients were assessed for baseline characteristics, comorbid conditions, and surgical outcomes and complications.

RESULTS

A total of 128 obese patients were identified with 43 in group I, 30 in group II, and 55 in group III. There was an increased prevalence of diabetes and asthma in group III and younger age in group I. Of the 128, 117 (91 %) underwent hysterectomy and/or staging with the majority of patients having surgery for either endometrial cancer or fibroids. Conversion to laparotomy was more common in groups 2 and 3 with a positive correlation between increasing BMI and conversion. There was no difference in complications between the groups and only 1 major postoperative complication in the entire cohort.

CONCLUSIONS

Robotic-assisted gynecologic surgery can be safely performed in severely morbidly obese patients. Although conversion rates are higher with increasing obesity, a majority of procedures can still be completed minimally invasively.

Comparing the da Vinci si single console and dual console in teaching novice surgeons suturing techniques

BACKGROUND AND OBJECTIVES

Robot-assisted laparoscopic surgery is often taught with the surgical mentor at the surgeon console and the trainee at the patient's bedside. The da Vinci dual console (Intuitive Surgical, Sunnyvale, California) allows a surgical mentor to teach with both the mentor and the trainee working at a surgeon console simultaneously. The purpose of this study is to evaluate the effectiveness of the dual console versus the single console for teaching medical students robotic tasks.

METHODS

Forty novice medical students were randomized to either the da Vinci single-console or dual-console group and were taught 4 knot-tying techniques by a surgical mentor. The students were timed while performing the tasks.

RESULTS

No statistically significant differences in mean task times were observed between the single- and dual-console groups: interrupted stitch with a 2-handed knot (300 seconds for single vs 294 seconds for dual, P=.59), interrupted stitch with a 1-handed knot (198 seconds for single vs 212 seconds for dual, P=.88), figure-of-8 stitch with a 2-handed knot (261 seconds for single vs 219 seconds for dual, P=.20), and figure-of-8 stitch with a 1-handed knot (200 seconds for single vs 199 seconds for dual, P=.53).

CONCLUSION

No significant difference was observed in performance time when teaching knot-tying techniques to medical students using the da Vinci dual console compared with the single console. More research needs to be performed on the utility of the da Vinci dual console in surgical training.

The robotic metroplasty in a patient with hybrid septate variant anomaly

Complete uterovaginal septum is unusually associated with an obstructed left hemivagina and hemiuteri. Herein we present a case report of "hybrid septate variant" anomaly diagnosed in a 16-year-old girl. The uterine septum could not be completely removed hysteroscopically because of the obstructed vagina and thick uterine septum; therefore an abdominal approach, robotic metroplastic surgery was performed. We propose that the robotic technology has advantages over the classical laparoscopy related with the surgical correction of Müllerian anomaly.

Robotic Surgery for Rectal Cancer: An Update in 2015

During the last decade, robotic surgery for rectal cancer has rapidly gained acceptance among colorectal surgeons worldwide, with well-established safety and feasibility. The lower conversion rate and better surgical specimen quality of robotic compared with laparoscopic surgery potentially improves survival. Earlier recovery of voiding and sexual function after robotic total mesorectal excision is another favorable outcome. Long-term survival data are sparse with no evidence that robotic surgery offers major benefits in oncological outcomes. Although initial reports are promising, more rigorous scientific evaluation in multicenter, randomized clinical trials should be performed to definitely determine the advantages of robotic rectal cancer surgery.

Role of a Double Docking to Improve Lymph Node Dissection: When Robotically Assisted Laparoscopy for Para-aortic Lymphadenectomy Is Associated to a Pelvic Procedure

Objective

The objective of this study was to demonstrate that robotically assisted laparoscopy for aortic lymph node dissection was improved when double docking (DD) of the Da Vinci system is used for combined surgical procedures [defined by the combination of a pelvic procedure and a para-aortic lymphadenectomy (PAL)].

Methods

From February 2007 to February 2013, 41 patients underwent combined procedures including PAL up to the left renal vein in 2 cancer centers. We used 2 different approaches as follows: a single docking (SD) of the Da Vinci system (transperitoneal PAL and pelvic surgery) during the first period (22 patients) and a DD during the second period (19 patients). We recorded retrospectively the lymph node count (main criteria), operative time, estimated blood loss, hospital stay, and postoperative complications.

Results

We observed a statistical difference between SD and DD concerning aortic lymph node count (5.86 vs 10.89,P< 0.005). Operative time is longer in the DD group (326.1 vs 239.4 minutes,P< 0.05). No difference was observed concerning estimated blood loss. Hospital stay was longer in the DD group (4.9 vs 3.2 days,P< 0.05). Only 1 conversion to open was described in the SD group.

Conclusions

In our experience of robotically assisted laparoscopy, when PAL is combined to a pelvic procedure, the use of a DD seems to improve aortic lymph node count.

Despite a longer operative time compared to SD, DD seems to be a good solution to combine the advantages of robotic assistance to our quality criteria of aortic dissection.

Synopsis

We compare 2 techniques to realize robotic assisted para-aortic lymphadenectomy combined with pelvic procedure. Double docking seems to improve histological results compared to single docking.

WITHDRAWN: Robotic assisted surgery for gynaecological cancer

This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub2 (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full )

The editorial group responsible for this previously published document have withdrawn it from publication.

WITHDRAWN: Robotic surgery for benign gynaecological disease

This review is being withdrawn as now superceded by a new review covering both malignant an benign disease: Lawrie TA, Liu H, Lu D, Dowswell T, Song H, Wang L, Shi G. Robot‐assisted surgery in gynaecology. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD011422. DOI: 10.1002/14651858.CD011422.pub (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011422.pub2/full ).

The editorial group responsible for this previously published document have withdrawn it from publication.

Robot-assisted surgery in gynaecology

BACKGROUND

This is an updated merged review of two originally separate Cochrane reviews: one on robot-assisted surgery (RAS) for benign gynaecological disease, the other on RAS for gynaecological cancer. RAS is a relatively new innovation in laparoscopic surgery that enables the surgeon to conduct the operation from a computer console, situated away from the surgical table. RAS is already widely used in the United States for hysterectomy and has been shown to be feasible for other gynaecological procedures. However, the clinical effectiveness and safety of RAS compared with conventional laparoscopic surgery (CLS) have not been clearly established and require independent review.

OBJECTIVES

To assess the effectiveness and safety of RAS in the treatment of women with benign and malignant gynaecological disease.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 5) and the Cochrane Gynaecological Cancer Review Group Trials Register. We also searched MEDLINE and EMBASE databases, to complement the searches of the original malignant and benign disease reviews (conducted up to July 2010 and November 2011, respectively), from July 2010 to June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of RAS compared with CLS or open surgery in women requiring surgery for gynaecological disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion and risk of bias, and extracted study data and entered them into an Excel spreadsheet. We subgrouped data according to type of procedure and pooled data using random-effects methods in RevMan 5.3. We performed sensitivity analyses by excluding studies at high risk of bias.

MAIN RESULTS

We included six RCTs involving 517 women. Most were at low to moderate overall risk of bias; one was at high risk of bias. Four studies evaluated RAS for hysterectomy (371 women), and two studies evaluated RAS for sacrocolpopexy (146 women). All studies compared RAS with CLS, except for one study, which compared RAS with CLS or a vaginal surgical approach for hysterectomy. Confidence intervals for the risk of intraoperative and postoperative complications included benefits with either approach when they were analysed together (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.46 to 1.99; participants = 513; studies = 6; I(2) = 74%) and separately (low-quality evidence). Moderate-quality evidence was found for the effects of RAS on intraoperative injury when compared with CLS (RR 1.23, 95% CI 0.44 to 3.46; participants = 415; studies = 5; I(2) = 0%), along with low-quality evidence for bleeding and infection complications.Mean total operating time was consistent across procedures and on average was about 42 minutes longer in the RAS arm compared with the CLS arm (95% CI 17 to 66 minutes; participants = 294; studies = 4; I(2) = 82%; moderate-quality evidence). Mean hospital stay for hysterectomy procedures was on average about seven hours shorter in the RAS arm than in the CLS arm (mean difference (MD) -0.30 days, 95% CI -0.54 to -0.06; participants = 217; studies = 2; I(2) = 0%; low-quality evidence). The estimated effect of conversion with RAS compared with CLS was imprecise (RR 1.28, 95% CI 0.40 to 4.12; participants = 337; studies = 4; I(2) = 0%; moderate-quality evidence). Limited data from two studies suggest that RAS for sacrocolpopexy may be associated with increased postoperative pain compared with CLS; this needs further investigation. We identified five ongoing trials-four of cancer surgery.

AUTHORS' CONCLUSIONS

We are uncertain as to whether RAS or CLS has lower intraoperative and postoperative complication rates because of the imprecision of the effect and inconsistency among studies when they are used for hysterectomy and sacrocolpopexy. Moderate-quality evidence suggests that these procedures take longer with RAS but may be associated with a shorter hospital stay following hysterectomy. We found limited evidence on the effectiveness and safety of RAS compared with CLS or open surgery for surgical procedures performed for gynaecological cancer; therefore its use should be limited to clinical trials. Ongoing trials are likely to have an important impact on evidence related to the use of RAS in gynaecology.

Cost assessment of robotics in gynecologic surgery: a systematic review

AIM

The application of robotics is an innovation in the field of gynecologic surgery. Our objective was to evaluate the currently available literature on the cost assessment of robotic surgery of various operations in the field of gynecologic surgery.

MATERIAL AND METHODS

PubMed and Scopus databases were systematically searched in order to retrieve the included studies in our review.

RESULTS

We retrieved 23 studies on a variety of gynecologic operations. The mean cost for robotic, open and laparoscopic surgery ranged from 1731 to 48,769, 894 to 20,277 and 411 to 41,836 Euros, respectively. Operative charges, in hysterectomy, for robotic, open and laparoscopic technique ranged from 936 to 33,920, 684 to 25,616 and 858 to 25,578 Euros, respectively. In sacrocolpopexy, these costs ranged from 2067 to 7275, 2904 to 69,792 and 1482 to 2000 Euros, respectively. Non-operative charges ranged from 467 to 39,121 Euros. The mean total costs for myomectomy ranged from 27,342 to 42,497 and 13,709 to 20,277 Euros, respectively, for the robotic and open methods, while the mean total cost of the laparoscopic technique was 26,181 Euros. Conversions to laparotomy were present in 79/36,185 (0.2%) cases of laparoscopic surgery and in 21/3345 (0.62%) cases of robotic technique. Duration of robotic, open and laparoscopic surgery ranged from 50 to 445, 83.7 to 701 and 74 to 330 min, respectively.

CONCLUSION

Robotic surgery has the potential to become cost-effective in centers with many patients while industry competition could reduce the cost of the robotic instrumentation, making robotic technology more affordable and cost-effective.

Prospective randomized study comparing robotic-assisted hysterectomy and regional lymphadenectomy with traditional laparotomy for staging of endometrial carcinoma -initial Indian experience

Robotic assisted hysterectomy with regional lymphadenectomy is increasingly used for the treatment of endometrial carcinoma. In the present study we evaluated the feasibility and technique of robotic assisted hysterectomy and lymphadenectomy in patients with endometrial carcinoma. A prospective randomized study was undertaken from July 2011 to June 2012, in 50 consecutive patients with carcinoma endometrium. Demographic (age, BMI) and perioperative data (operating time, estimated blood loss, total number of lymph nodes retrieved, hospital stay, conversion to open procedure, intraoperative and postoperative complications) of robotic assisted surgery were compared with open staging procedure. Mean age of the patient and BMI in both groups were comparable with no significant difference. Estimated blood loss (81.28 ml), hospital stay (1.94 days) and perioperative complications were significantly less in robotic assisted group in comparison to open method. Mean number of lymph nodes removed were 30.56 versus 27.6 which is suggestive of significant difference statistically. Operative time decreased as the experience of the surgeon increased but still significantly remained higher than the open procedure after 25 robotic assisted surgeries. All robotic surgeries were completed successfully without converting to open method. Robotic assisted staging procedure for endometrial carcinoma is feasible without converting to open method, with the advantages of decreased blood loss, short duration of hospital stay and less postoperative minor complications. Operative time will decrease further as the experience of surgeon increases. Para-aortic lymph node dissection is easily done and with a better ergonomics for surgeon.

Validation of a novel virtual reality simulator for robotic surgery

Objective. With the increase in robotic-assisted laparoscopic surgery there is a concomitant rising demand for training methods. The objective was to establish face and construct validity of a novel virtual reality simulator (dV-Trainer, Mimic Technologies, Seattle, WA) for the use in training of robot-assisted surgery. Methods. A comparative cohort study was performed. Participants (n = 42) were divided into three groups according to their robotic experience. To determine construct validity, participants performed three different exercises twice. Performance parameters were measured. To determine face validity, participants filled in a questionnaire after completion of the exercises. Results. Experts outperformed novices in most of the measured parameters. The most discriminative parameters were “time to complete” and “economy of motion” (P < 0.001). The training capacity of the simulator was rated 4.6 ± 0.5 SD on a 5-point Likert scale. The realism of the simulator in general, visual graphics, movements of instruments, interaction with objects, and the depth perception were all rated as being realistic. The simulator is considered to be a very useful training tool for residents and medical specialist starting with robotic surgery. Conclusions. Face and construct validity for the dV-Trainer could be established. The virtual reality simulator is a useful tool for training robotic surgery.

Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction

PURPOSE

Single-incision videoendoscopic surgery has recently become popular as a result of the ongoing search for less invasive procedures. The aim of this study was to evaluate the safety and efficacy of endoscopic single-port nipple-sparing mastectomy, axillary lymphadenectomy, and immediate reconstruction in patients with breast cancer.

PATIENTS AND METHODS

From May 14, 2012 through January 23, 2013, 10 patients underwent videoendoscopic single-port nipple-sparing mastectomy and axillary dissection via a single, limited incision and immediate prosthetic reconstruction. Patient charts were reviewed, and demographic data, operative time, complications and pathology results were analyzed.

RESULTS

In all patients, videoendoscopic surgery was performed successfully. Of 10 patients, 7 were diagnosed as having invasive ductal carcinoma, 2 had a ductal carcinoma in situ, and 1 underwent bilateral prophylactic mastectomy. The weight of the resected gland was 300-650 g, with a mean of 420 g. There were no operative complications, and the mean operative time was 250 minutes (range, 160-330 minutes). One-stage reconstruction with implants was performed on 4 patients, whereas expanders were placed in the remaining 6. Surgical margins of all cases were pathologically negative, and there were no recurrences observed during the early follow-up period.

CONCLUSIONS

Videoendoscopic single-port nipple-sparing mastectomy is technically feasible even in larger breasts, enabling immediate reconstruction with good cosmetic outcomes. However, further studies with larger clinical series and long-term follow-up are required to compare the safety and efficacy of the technique with those of the standard nipple-sparing mastectomy.

Deep infiltrating colorectal endometriosis treated with robotic-assisted rectosigmoidectomy

Robotic-assisted surgery for the treatment of deep infiltrating bowel endometriosis appears to be feasible, effective, and safe.

Background and Objective:

Deep infiltrating pelvic endometriosis with bowel involvement is one of the most aggressive forms of endometriosis. Nowadays, robotic technology and telemanipulation systems represent the latest developments in minimally invasive surgery. The aim of this study is to present our preliminary results and evaluate the feasibility of robotic-assisted laparoscopic colorectal resection for severe endometriosis.

Methods:

Between September 2009 and December 2011, 10 women with colorectal endometriosis underwent surgery with the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA, USA). We evaluated the following parameters: short-term complications, clinical outcomes and long-term follow-up, pain relief recurrence rate, and fertility outcomes.

Results:

Extensive ureterolysis was required in 8 women (80%). Ovarian cystectomy with removal of the cystic wall was performed in 7 women (70%). Torus resection was performed in all women, with unilateral and bilateral uterosacral ligament resection in 1 woman (10%) and 8 women (80%), respectively. In addition to segmental colorectal resection in all cases, partial vaginal resection was necessary in 2 women (20%). An appendectomy was performed in 2 patients (20%). The mean operative time with the robot was 157 minutes (range, 90–190 minutes). The mean hospital stay was 3 days. Six patients had infertility before surgery, with a mean infertility time of 2 years. After a 12-month follow-up period, 4 women (67%) conceived naturally and 2 (33%) underwent in vitro fertilization.

Conclusion:

We show that robotic-assisted laparoscopic surgery for the treatment of deep infiltrating bowel endometriosis is feasible, effective, and safe.

Analysis of disease recurrence and survival for women with uterine malignancies undergoing robotic surgery

OBJECTIVES

To evaluate recurrence-free survival (RFS) and overall survival (OS) for patients who underwent robotic-assisted laparoscopic hysterectomy (RALH) for uterine malignancies.

METHODS

Medical records from 372 patients with uterine malignancies who underwent RALH from 3/06 to 3/09 at two institutions were reviewed for clinico-pathologic data, adjuvant therapies, disease recurrence, and survival. Median follow-up for survival analysis was 31 ± 14 months. Thirty (8.1%) patients were lost to follow-up before 12 months and censored from the recurrence analysis.

RESULTS

Mean age and BMI of 372 patients was 61.8 ± 9.8 years and 32.2 ± 8.4 kg/m(2) (range 19-70). Robotic procedures included RALH 16 (4.3%), RALH with pelvic lymphadenectomy (PL) 96 (25.8%), and RALH with pelvic-and-aortic lymphadenectomy (PAL) 252 (67.7%) cases. Histology included 319 (85.8%) endometrioid and 53 (12.6%) high-risk histologies. Mean pelvic and aortic lymph node counts were 16.8 ± 8.7 and 8.4 ± 4.5, respectively. Lymph node metastases were identified in 26 (7.3%) cases. Adjuvant therapies were prescribed for 108 (29.1%) of patients: 7.8% brachytherapy, 1.9% pelvic radiation+brachytherapy, 7.8% chemotherapy, 11.6% chemotherapy+radiation. Risk of recurrence for all patients was 8.3% and 17 (4.6%) patients died of disease. The estimated 3-year recurrence-free survival (RFS) for the entire study group was 89.3% and the estimated 5-year overall survival (OS) was 89.1%, compared to 92.5% and 93.4% for the endometrioid sub-set.

CONCLUSIONS

Patients with endometrial cancer undergoing robotic hysterectomy with staging lymphadenectomies during our 3-years of robotic experience had low-risk for recurrence and excellent disease-specific survival at a median follow-up time of 31 months.

Effect of residents' previous laparoscopic surgery experience on initial robotic suturing experience

Objective. To assess the impact of gynecology residents' previous laparoscopic experience on the learning curve of robotic suturing techniques and the value of initial structured teaching in dry lab prior to surgery. Methods. Thirteen gynecology residents with no previous robotic surgery experience were divided into Group 1, consisting of residents with 2 or fewer laparoscopic experiences, and Group 2, consisting of residents with 3 or more laparoscopic experiences. Group 1 had a dry-laboratory training in suturing prior to their initial experience in the operating room. Results. For all residents, it took on average 382 ± 159 seconds for laparoscopic suturing and 326 ± 196 seconds for robotic suturing (P = 0.12). Residents in Group 1 had a lower mean suture time than residents in Group 2 for laparoscopic suturing (P = 0.009). The residents in Group 2, however, had a lower mean suture time on the robot compared to Group 1 (P = 0.5). Conclusion. Residents with previous laparoscopic suturing experience may gain more from a robotic surgery experience than those with limited laparoscopic surgery experience. In addition, dry lab training is more efficient than hands-on training in the initial phase of teaching for both laparoscopic and robotic suturing skills.