Robotic surgery in gynecology

Safe Implementation of Robotic Surgery for Gynecologic Diseases at a Tertiary Center: Retrospective Analysis of 149 Cases and Review of the Literature

Objectives

The initial learning curve is a barrier to introducing robotic surgery. Evidence regarding appropriate simulation programs that allow for a smooth introduction of gynecological robotic surgery remains limited.

Materials and Methods

We retrospectively analyzed 149 patients who underwent robotic surgery for gynecologic diseases. Before their first procedure, the surgeons completed a robotic surgery training program. Assistant surgeons also completed simulation programs, including setup procedures and manipulation of the robotic arm.

Results

The mean (± standard deviation) operative, setup, and console times were 170 ± 54 min, 22 ± 8 min, and 126 ± 51 min, respectively. No patient required blood transfusion or conversion to laparoscopy or laparotomy. Patients undergoing surgery by the same surgeon were divided into three groups (first-third, middle-third, and last-third of patients undergoing surgery) to assess chronological changes. No statistically significant differences were found between the operative and console times among these groups. The setup times for the middle and last third of patients were 20 ± 7 min and 18 ± 7 min, respectively, which were statistically significantly shorter than those for the first third of patients. No significant differences in the operative and console times done by five physicians who completed programs were observed between the first 75 and the latter 74 procedures; however, the setup times of the latter 74 procedures were significantly shorter than those of the first 74 procedures (25 ± 9 min vs. 19 ± 6 min; P < 0.001).

Conclusion

The setup time was influenced by clinical experience. An appropriate simulation program allowed a safe implementation of robotic surgery.

Laparoscopic Robotic Assisted Surgery in Reproductive Medicine

Laparoscopic Robot-assisted surgery is one of the most promising and rapidly developing surgical advancements of the twenty-first century with a potential to make significant contributions to reproductive medicine and preservation of fertility. Presently, laparoscopic robotic assisted surgery is used for various benign and malignant gynecological procedures, including fertility enhancing procedures. Laparoscopic Robot-assisted surgery is superior to traditional open procedures with regards to post-surgical hospital stay and blood loss; however, the difference is comparable to laparoscopic surgery. Regarding operative times, the results have been inconsistent due to variations in surgeons' experience. The primary drawbacks of robotic systems are their high installation and maintenance costs and historical lack of tactile feedback; however, this has been overcome by the most recent evolution of robotic systems. Along with the major advances in cancer therapy, the number of female cancer survivors of reproductive age has dramatically increased. Consequently, fertility preservation and fertility enhancement have gained more emphasis in reproductive surgery in the last decade. A broad range of surgical procedures such as tubal reanastomosis, myomectomy, treatment of deep infiltrating endometriosis, ovarian transposition, radical trachelectomy, and ovarian transplantation has been introduced to restore or preserve fertility using Laparoscopic Robot-assisted surgery. In this article, we aim to present the current applications, advantages, and disadvantages of Laparoscopic Robot-assisted surgical technology in the field of reproductive surgery, including the more recent advances of Artificial Intelligence (AI) in the field.

[Brief history and application prospect of robotic spine surgery]

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

Assessment of the evolution of psychomotor skills in the robotic surgery simulation process

Robotic surgery is a rapidly expanding field, given the wide variety of new robotic platforms emerging. Looking at the training of surgeons in robotic surgery is of extreme necessity and urgency, considering the ongoing technological advancements. In this research, the performance during the virtual reality simulation phase of training for robotic surgery was analyzed. It was observed that, in addition to the lack of consensus among societies regarding the required simulation hours, there is no guidance on the best curriculum to be adopted. From the data in this study, it can be inferred that the more advanced skills have fewer proficient individuals, meaning that fewer surgeons in training have reached proficiency in all skill exercises. Even with differences in the number of exercises performed proficiently between groups that underwent varying amounts of simulation time, there is no statistically significant difference in the proportion between them.

The first robotic-assisted hysterectomy below the bikini line with the Dexter robotic system™

Background

Robotic-assisted hysterectomy (RAH) is a widely accepted minimally invasive approach for uterus removal. However, as RAH is typically performed in the umbilical region, it usually results in scars in cosmetically suboptimal locations. This is the first case of RAH with cervicosacropexy performed below the bikini line, using the new Dexter robotic system™.

Objectives

The aim of this article is to show the surgical steps of the first RAH with cervicosacropexy performed below the bikini line with the new Dexter robotic system™ (Distalmotion), and furthermore assess the feasibility of this approach using this robotic platform.

Materials and Methods

A 43-year-old woman with uterine adenomyosis and recurrent uterine prolapse underwent a robotic-assisted subtotal hysterectomy with cervicosacropexy, performed below the bikini line, using the Dexter robotic system™, at the Clinic of Gynecology and Obstetrics at Universitätsklinikum Schleswig-Holstein (UKHS) in Kiel, Germany.

Main outcome measures

Perioperative data, surgical approach specifics, objective, and subjective outcomes of this new approach.

Results

The procedure was performed without intra-operative complications; estimated blood loss was 10 ml. Operative time was 150 minutes, console time 120 minutes, total docking time 6 minutes. Dexter performed as expected; no device-related issues or robotic arm collisions occurred. The patient did not require pain medication and was released on the second postoperative day.

Conclusion

RAH performed below the bikini line using the Dexter robotic system™ is a feasible, safe, and adequate procedure. These initial results should be confirmed and further extensively refurbished with larger patient cohorts, and functional and psychological outcomes need further investigation.

Expanding Robotic-Assisted Surgery in Gynecology Using the Potential of an Advanced Robotic System

Minimally invasive surgery (MIS) in gynecology was introduced to achieve the same surgical objectives as traditional open surgery while minimizing trauma to surrounding tissues, reducing pain, accelerating recovery, and improving overall patient outcomes. Minimally invasive approaches, such as laparoscopic and robotic-assisted surgeries, have become the standard for many gynecological procedures. In this review, we aim to summarize the advantages and main limitations to a broader adoption of robotic-assisted surgery compared to laparoscopic surgeries in gynecology. We present a new surgical system, the Dexter Robotic System™ (Distalmotion, Switzerland), that facilitates the transition from laparoscopy expertise to robotic-assisted surgery.

Investigation of the Effect of Puncture Order and Position on the Difficulty of Lower and Middle Abdominal Port Placement

Objectives

Port placements at the mid-abdomen (mainstay of robotic surgery [Rob]) appear to be difficult compared to that at lower abdomen (mainstay of conventional laparoscopy [Con-Lap]). We hypothesized that the reason for this may be the difference in port puncture places.

Materials and Methods

We examined how the differences between the place and puncture order of ports affected Con-Lap cases with ports mainly placed in the lower abdomen and Rob cases with ports mainly placed in the middle abdomen. The trocar time was measured from the time when the puncture position and skin incision were determined and initiated, respectively, to the time when the port was punctured and fixed and used as the indicator of difficulty.

Results

In the Con-Lap group analysis, the trocar time of the left lower port was longer (right lower: 77 s, middle lower: 117.5 s, and left lower: 138 s, P < 0.0001). In the Rob group analysis, the trocar time of the left most port was significantly longer (right-most: 89.0 s, right-middle: 92.5 s, left-middle: 121.0 s, and left-most: 197.0 s; P < 0.0001). In addition, the total trocar time was significantly longer in the first puncture at the right-middle port in the Rob group (right-most first: 8.4 min, right-middle first: 12.4 min, and left-middle first: 8.5 min, P = 0.0063).

Conclusion

In the mid-abdomen port placement, mainstay of Rob cases, the puncture order, and port site have a significant impact on the difficulty of the procedure. It is preferable to avoid initially puncturing the right-middle port in case of the Rob.

Robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with gel implant and latissimus dorsi muscle flap: Our initial experience

BACKGROUND

This study reports the preliminary results of da Vinci robot XI robot-assisted nipple-sparing mastectomy immediate breast reconstruction (R-NSMIBR) with gel implant and latissimus dorsi muscle flap.

METHODS

A total of 15 patients who underwent R-NSMIBR with gel implant and latissimus dorsi muscle flap surgery for breast cancer between September 2022 and November 2022 were evaluated.

RESULTS

Mean total operative time for R-NSMIBR was 361.9 ± 77.0 min. As the learning curve increased, the robot arm docking time decreased rapidly from the initial 25-10 min. Average total blood loss was 27.8 ± 10.7 mL and posterior surgical margin positivity rate was 0%. Perioperative complications and local recurrences or deaths were not observed at a mean follow-up of 3 ± 1 month 15 patients were satisfied with postoperative aesthetic results.

CONCLUSIONS

R-NSMIBR with a gel implant and latissimus dorsi muscle flap could be a new therapeutic option for breast reconstruction.

[The Importance of Feedback in Proctoring in Robotic Surgery - a Cornerstone of the Concept of Success?]

Robot-assisted surgical methods are a development and supplement to conventional laparoscopy. Thus, appropriate training of surgeons in this specialty is indispensable. Especially for the initial phase, simulation programs - similar to those used in aviation - are ideally suited to introduce surgeons to the technically challenging surgical procedure. Later on, but still at the beginning of the learning curve, proctoring has proven its worth in order to allow the surgeon to be trained on site, to train him individually and to introduce him to more complex cases. An essential component of successful training concepts is the feedback: after some time and in written form, the surgeon to be trained receives a summary or a guideline, which describes the existing situation as well as suggestions for improvement and future potential. The implementation of such feedback allows the surgeon, in addition to the number of cases completed, to put his self-assessment into perspective and adjust development goals. Thus, feedback is the crucial interface between the beginning of a learning curve and advanced surgical skills, including the possibility of realistic self-assessment.

Preclinical evaluation of the Versius surgical system: A next-generation surgical robot for use in minimal access prostate surgery

Objectives

To evaluate the Versius surgical system for robot-assisted prostatectomy in a preclinical cadaveric model using varying system setups and collect surgeon feedback on the performance of the system and instruments, in line with IDEAL-D recommendations.

Materials and methods

Procedures were performed in cadaveric specimens by consultant urological surgeons to evaluate system performance in completing the surgical steps required for a prostatectomy. Procedures were conducted using either a 3-arm or 4-arm bedside unit (BSU) setup. Optimal port placements and BSU layouts were determined and surgeon feedback collected. Procedure success was defined as the satisfactory completion of all steps of the procedure, according to the operating surgeon.

Results

All four prostatectomies were successfully completed; two were completed with a 3-arm BSU setup and two using a 4-arm BSU setup. Small adjustments were made to the port and BSU positioning, according to surgeon preference, in order to complete the surgical steps. The surgeons noted some instrument difficulties with the Monopolar Curved Scissor tip and the Needle Holders, which were subsequently refined between the first and second sessions of the study, in line with surgeon feedback. Three cystectomies were also successfully completed, demonstrating the capability of the system to perform additional urological procedures.

Conclusions

This study provides a preclinical assessment of a next-generation surgical robot for prostatectomies. All procedures were completed successfully, and port and BSU positions were validated, thus supporting the progression of the system to further clinical development according to the IDEAL-D framework.

Robot-Assisted Tubal Reanastomosis after Sterilization: A Choice for Family Planning

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning.

Learning curve analysis of multiport robot-assisted hysterectomy

PURPOSE

The purpose of this study was to evaluate the surgical outcomes and learning curve of multiport robot-assisted hysterectomy.

METHODS

Eighty-eight patients were identified who underwent multiport robot-assisted surgery for hysterectomy. A retrospective analysis was performed. The cumulative summation technique (CUSUM) was used to investigate the learning curve in surgical proficiency by analyzing total operative, docking, and console times.

RESULTS

The patients' median age was 51 years. In addition, the median operative time was 120.5 min (range 56-344 min). The most common indication for surgery was myoma (33.0%). The median estimated blood loss was 30 mL (range 5-200 mL). There was no conversion to laparoscopic or open surgery. No transfusion was required, and only one complication including umbilical incisional hernia was reported. A tendency of decline in total operative time following the first 23 cases was found. The CUSUM graph for total operative time indicated the generation of three distinct performance phases: learning (n = 23), competence (n = 36), and mastery (n = 29). The median docking time was 3 min (range 1-10 min) and median console time was 70 min (range 24-298 min).

CONCLUSION

The multiport robot-assisted surgery is an easy and safe procedure with minimal postoperative complications and can be quickly learned. The learning curve was 23 cases to significantly decrease the operative time.

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

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

Robotic-assisted abdominal aortic surgery: evidence and techniques

In various disciplines, robotic-assisted surgery is a well-proven routine procedure, but have never been established in vascular surgery so far. This review summarizes the results to date of robotic-assisted abdominal aortic surgery (RAAS) in the treatment of aorto-iliac occlusive disease (AIOD) and abdominal aortic aneurysm (AAA). Web-based literature search of robotic-assisted surgical procedures on the abdominal aorta and iliac arteries between 1990 and 2020 including the Cochrane Library, OVID Medline, Embase, and PubMed medical databases. All studies conducting Robotic-assisted surgery were included in the quantitative analysis regarding operative and cross-clamping times, conversion rates, mortality and morbidity within the first 30 days, and in-hospital stay. Case reports and case studies (< 5 patients) were not included. Twenty-four studies were deemed thematically eligible for inclusion; after exclusion of duplicate publications, nine met the inclusion criteria for further analysis. A total of 850 patients who had either abdominal aortic aneurysm or aorto-iliac occlusive disease underwent RAAS. One study of abdominal aortic aneurysm, three of aorto-iliac occlusive disease, and five studies of both disease entities were analyzed quantitatively. For AAA, conversion rates ranged from 13.1 to 20% and perioperative mortality ranged from 0 to 1.6% with in-hospital stay of 7 days. For aorto-iliac occlusive disease, conversion rates ranged from 0 to 20%, and perioperative mortality ranged from 0 to 3.6% with in-hospital stay of 5–8 days. RAAS has been shown to be technically feasible with acceptable short-term outcomes and questionable benefits in terms of in-hospital stay and complication rates. RAAS is currently considered only an outsider procedure. Randomized-controlled trials are indispensable for regular use in vascular surgery as well as a clear approval situation for the vascular sector.

A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications

BACKGROUND

Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period.

METHODS

Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days.

RESULTS

A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R²=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R²=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R²=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R²=0.779). 90-day reoperation rates did not change significantly.

CONCLUSIONS

At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.

Long-term satisfaction of patients after laparoscopic and robotic-assisted hysterectomy

Introduction

Da-Vinci-Xi is the most recent device used in gynecologic robotic surgery. The aim of the present study was to compare the long-term satisfaction of patients who had undergone conventional laparoscopic hysterectomy or robotic assisted laparoscopic hysterectomy using the Da-Vinci-Xi surgical system.

Methods

All hysterectomies performed at the University Hospital of Luebeck from 2018 to 2019 were reviewed. Postoperative outcomes were compared between women who had undergone total hysterectomy with da Vinci Xi (n = 42) or conventional laparoscopy (n = 97). Postoperative outcomes included pain, elimination of complaints after surgery, bladder function, sexual function, satisfaction with the cosmetic outcome, positive experiences after robotic surgery, and satisfaction with the surgeon’s preoperative explanation. Obese patients were evaluated separately in a subgroup analysis.

Results

Both groups had similar baseline characteristics and complication rates. Preoperative complaints subsided after surgery in a little more than 90% of patients. No significant differences were noted between groups in this regard (p = 0.262), or with reference to postoperative pain after one week (p = 0.866) and one month (p = 0.580), stress incontinence (p = 0.343), sexual function (p = 0.766) and the cosmetic outcome of the abdominal incisions (p = 0.273). The majority of patients who had undergone robotic surgery (96.8%) would be willing to undergo the procedure again if necessary. The subgroup analysis of obese patients revealed no significant differences.

Conclusion

The Da-Vinci-Xi device did not improve the long-term surgical satisfaction of normal-weight or obese patients who underwent hysterectomy compared with patients who underwent conventional laparoscopy performed by experienced laparoscopic surgeons.

Complications in laparoscopic and robotic-assisted surgery: definitions, classifications, incidence and risk factors - an up-to-date review

Almost all gynecological and general-surgical operations are - or can be - performed laparoscopically. In comparison to an abdominal approach, the minimally invasive access offers several advantages; however, laparoscopy (both conventional and robotic-assisted) can be associated with a number of approach-specific complications. Although the majority of them are related to the laparoscopic entry, adverse events may also occur due to the presence of pneumoperitoneum or the use of laparoscopic instruments. Unfortunately, a high proportion of complications (especially affecting the bowel and ureter) remain unrecognized during surgery. This narrative review provides comprehensive up-to-date information about definitions, classifications, risk factors and incidence of surgical complications in conventional and robotic-assisted laparoscopy, with a special focus on gynecology. The topic is discussed from various perspectives, e.g. in the context of stage of surgery, injured organs, involved instruments, and in relation to malpractice claims.

Surgical and Patient Outcomes of Robotic Versus Conventional Laparoscopic Hysterectomy: A Systematic Review

Hysterectomy is a commonly performed gynecologic surgery that can be associated with significant morbidity and mortality. However, the evolution of the surgical approach, from open to minimally invasive gynecologic surgery (MIGS), has substantially improved patient outcomes by reducing perioperative complications, pain, and length of hospitalization. The evident advantages and the approval of the da Vinci Surgical System by the Food and Drug Administration led to the exponential rise in the use of MIGS. In particular, robotic hysterectomy (RH) witnessed unparalleled popularity compared to other MIGS despite the lack of strong evidence demonstrating its superiority. Therefore, we conducted a systematic review of the literature to evaluate and compare various patient and surgical outcomes of RH with conventional laparoscopic hysterectomy (CLH), including operating time, estimated blood loss, length of hospitalization, overall complications, survival, and cost. Overall, the outcomes were comparable between RH and CLH except concerning cost. RH is significantly more expensive than CLH due to the higher costs of robotic equipment, including disposable instruments, equipment maintenance, and sterilization. Although RH demonstrated comparable outcomes and higher costs, its technical advantages such as improved ergonomics, three-dimensional view, a wider range of wristed mobility, mechanical lifting of robot's hand, and greater stability might benefit patient subsets (e.g., obesity, large uterine weights >750 g). Therefore, large and multicentered randomized control trials are imperative to determine the most effective surgical approach between RH and other MIGS for different patient subsets.

Optimizing first trocar access for robot-assisted radical prostatectomy: Optical trocar access through the upper abdominal quadrant using the Kii Fios First Entry trocar

OBJECTIVES

A pre-equipped metal trocar is required to use as a camera trocar due to a specification change in the da Vinci X/Xi system (Intuitive Surgical). We observed slight slippage of a trocar placed by the open method. With optical trocar access (OTA), the initial trocar is viewed directly with a laparoscope during placement. Reports regarding OTA for robotic surgery are limited, particularly for robot-assisted radical prostatectomy (RARP). We modified the OTA procedure such that it was appropriate for RARP.

PATIENTS AND METHODS

A total of 158 patients were enrolled in this study. The first trocar placement time (FTPT) was compared between the open and OTA groups. In the OTA group, the trocar was mainly placed through the upper abdominal quadrant. We also analyzed the differences between the conventional and modified OTA procedures using the Kii Fios First Entry trocar (Applied Medical). We examined the factors affecting the FTPT using linear regression models. A P value <.05 was considered significant.

RESULTS

The FTPT was significantly shorter in the OTA group than the open group (P < .0001). The modified method was associated with a shorter FTPT (P = .0001). None of the patient characteristics affected the FTPT in either group. No major complications were observed.

CONCLUSIONS

OTA was applied successfully during RARP. Use of the Kii Fios First Entry trocar with upper abdominal quadrant placement was suitable for RARP.

Robotic Natural Orifice Transluminal Endoscopic Surgery Hysterectomy and Salpingo-Oophorectomy in a Porcine Model

Purpose. The emergence of robotic-assisted surgical techniques has gained significant indications in terms of reduced trauma, shortened recovery, and higher patients' satisfaction. However, limitations by present surgical robotic systems used in natural orifice transluminal endoscopic surgery (NOTES) gynecology still exists, such as arm collisions, countertraction, instrument dexterity, and, in particular, space confinement due to the narrow pelvic anatomy. The current study evaluated the use of a miniaturized single-site surgical robotic system and its feasibility in performing robotic NOTES gynecological procedures using a live porcine animal model. Methods. Using a transrectal approach, the fully internalized robotic arms were deployed in a reverse configuration to access the lower pelvic cavity of the animals to perform NOTES gynecological procedures. Results. Robotic-assisted transrectal gynecological procedures were successfully performed using the new robotic system. A hemi-hysterectomy with unilateral salpingo-oophorectomy was completed in the first animal and a total hysterectomy with bilateral salpingo-oophorectomy in the second animal with an average docking time of 22.5 minutes and console time of 63 minutes and 58 minutes, respectively. The overall blood loss for each procedure was estimated to be <20 mL per animal with no intraoperative complications. Conclusions. The reverse configuration of the miniaturized surgical robotic system has demonstrated its capability to provide a potential solution to maintain clear visualization of the surgical field, optimal triangulation, and dexterity robotic NOTES gynecological procedures within the deep confined space of the pelvic cavity.

Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy

INTRODUCTION

The aim of the present study was to compare surgical outcomes of total laparoscopic hysterectomy with those of the robotic approach using the da Vinci Xi system.

METHODS

Patients who underwent hysterectomy with da Vinci Xi for early endometrial cancer or benign indications from 2018 to 2019 were selected. The control group consisted of patients who underwent conventional laparoscopy.

RESULTS

A total of 300 patients were included in the study. The mean duration of surgery differed significantly (p = 0.025) between those who underwent laparoscopy (125.01 ± 76.168) and robotic-assisted surgery (142.96 ± 82.657 min). Blood loss, median hospital stay, intraoperative and postoperative complications were similar in both groups. No statistical difference was observed in the subgroups with a body mass index of more than 30 kg/m² or more than 40 kg/m² concerning the duration of surgery or the surgical outcome.

CONCLUSION

The da Vinci Xi did not improve surgical outcomes in patients who underwent hysterectomy by trained laparoscopists and takes more time than conventional laparoscopy when performed in patients of normal weight.

Lymphadenectomy in endometrial cancer - achieving more with less?

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.

Survey of current practices and opinions of German Society of Gynecologic Endoscopy members regarding the treatment of ovarian neoplasia by robotic surgery

PURPOSE

As data on this topic are sparse and contradictory, we aimed to ascertain the opinions of the members of the German Society of Gynecologic Endoscopy (AGE) regarding the use of robotic surgery in the treatment of ovarian malignancies.

METHODS

In 2015, an anonymous questionnaire was sent to AGE members to assess their views on the treatment of ovarian malignancies by robotic surgery according to T stage and the current treatment practices in their facilities.

RESULTS

Of the 228 respondents, 132 (58%) were fellows or attending physicians and 156 (68%) worked at university hospitals or tertiary referral centers. Most [n = 218 (96%)] respondents reported treating < 10% of their patients using robotic surgery. Respondents felt that T1 and borderline ovarian tumors, but not T2 (51%) or T3/4 (76%) tumors, should and could be treated by robot surgery. 162 (71%) respondents considered the currently available data on this subject to be insufficient, and 42% indicated their willingness to participate in clinical studies on the applicability of robotic surgery to the treatment of T1/2 ovarian tumors.

CONCLUSION

The majority of AGE members surveyed considered robotic surgery to be an option for the treatment of T1 ovarian malignancies and borderline ovarian tumors. However, prospective randomized studies are needed to determine the relevance of robotic surgery in this context.

Robotic surgery for colorectal cancer

Minimally invasive surgery has demonstrated many benefits in general surgery, particularly in colon and rectal procedures. On the other hand, it has some limitations that must be taken into account, especially technical drawback. Robotic surgery has incorporated many improvements to overcome this disadvantage, such as 3D visualization, articulating instruments assisting complex and precise movements. As a result, robotic colorectal surgery shows less intraoperative blood loss, shorter time to oral tolerance and initial flatus (particularly associated with "Enhanced Recovery After Surgery" protocol), less conversion rate to open surgery, shortened hospital stay, and longer distal margins compared to laparoscopic and open surgery. This approach also shows a shorter learning curve. Some studies suggest that it could decrease perioperatively or 30 days after the intervention's mortality, raise overall survival, reduce wound infection, and improve functional results, while others show no significant difference. However, it lengthens surgical time. Otherwise, the studies included do not show statistically significant changes in the number of resected lymph nodes and anastomotic leaks. Economic costs remain one of the major concerns, although to date there are no large-scale studies that have evaluated this aspect from a global point of view. Robotic surgery represents a qualitative leap in surgical instruments and, although there is no strong evidence in favor of the use of robotic surgery over laparoscopic or open surgery, there is enough evidence to support its use in colorectal surgery, with potential advantages for patients.

Updates and Controversies of Robotic-Assisted Surgery in Gynecologic Surgery

minimally invasive surgery (MIS) is the standard approach to performance of several gynecologic procedures, including hysterectomy, gynecologic cancer staging procedures, myomectomy, pelvic organ prolapse repair, and select adnexal procedures. Robotic-assisted surgery, a computer-based MIS approach, has been adopted widely in the United States and several other countries. Robotics may offer technological and ergonomic benefits that overcome limitations associated with conventional laparoscopy; however, it is not clear that reported claims of superiority translate into improved gynecologic patient outcomes compared with other MIS approaches. This review critically appraises the evolving role, benefits, limitations, and controversies of robotic-assisted surgery utilization in benign and oncologic gynecology settings.

Postoperative Telephone-Based Questionnaire on Quality of Life after Robotic-Assisted Laparoscopic Hysterectomy versus Conventional Total Laparoscopic Hysterectomy

Aim: The objective of the study was to evaluate the benefits of robotic-surgery for hysterectomy compared to conventional laparoscopy for benign indications. A specially prepared telephone-based questionnaire was used postoperatively. Method: All women (n = 155) undergoing total laparoscopic hysterectomy for benign indications either by the robotic-assisted procedure (RALH) or conventional laparoscopy (CL) between 1 January 2013 and 31 December 2017 at the Department of the Gynecology, University Hospitals, Campus Kiel, Germany, were eligible for analysis. Intra-operative and postoperative parameters affecting the patients’ quality of life were assessed by a telephone-based questionnaire. The latter addressed postoperative pain, limitations of basic hygiene, daily activity, active pursuit of hobbies, sexual intercourse, and days of sick leave. All patients received the questionnaire by post at least three weeks prior to being contacted on the phone. Results: 78% of the contacted patients responded to the questionnaire; 96% (n = 115) of the patients said they would recommend the operation to other patients. Both groups needed 42 days to resume their regular hobbies. In whole 90.8% (n = 108) were total satisfied with the cosmetic result of the abdominal incision; the numbers in the respective groups were 80% (80% n = 36) in RALH and 97.3% (n = 72) in CL. The difference was significant on the Chi-square test (p = 0.002). 5% (n = 7) were dissatisfied with the scar (13.3%; n = 6) in the RALH group, and 1.4% (n = 1) in CL. In all 1.7 % of patients were dissatisfied with the position of the incisions; the respective numbers were 4.4 % (n = 2) in the RALH group and no patient in the CL group. 33% of patients experienced no limitations in regard of sexual intercourse after the operation. The median number of days taken to resume sexual intercourse after the operation was 56 days in the CL group, and 49 days in the RALH group. Nearly 30% (n = 25) were hesitant to resume intercourse. The median operating time was 145 min in the RALH group, which was significantly longer than the 117 min taken in the CL group (p < 0.001). Conclusions: The RALH procedure was associated with some minor advantages for the patients according to the results, however it does not have major significant advantages, especially in regard of early restoration of sexual function, while the CL shows shorter operating times and similar limitation. Postoperative counseling of patients should be aligned to their fears and expectations in regard of sexual function.

Robotic versus laparoscopic hysterectomy; comparison of early surgical outcomes

Objective

To compare early surgical outcomes of robotic assisted laparoscopic hysterectomy with laparoscopic hysterectomy for benign diseases, in terms of operation time, estimated blood loss (EBL), perioperative complications, hospital stay and first gas discharge.

Material and Methods

Medical records of 146 patients who either underwent laparoscopic (n=84) or robotic assisted laparoscopic hysterectomy (n=62) for benign diseases were extracted from records. Demographic characteristics and operation time, EBL, length of hospital stay and first gas discharge were compared between the groups.

Results

Mean age and mean body mass index of both groups were comparable. The difference in the mean EBL was not statistically significant between laparoscopic (91±65 mL) and robotic group (80±37 mL, p=0.43). The difference in the mean first gas discharge time was not statistically different between laparoscopic (15±5 hours) and robotic group (17±6 hours, p=0.33). The length of hospital stay was comparable between groups (1.4±0.5 vs 1.5±0.7 days, p=0.64). The mean operation time was longer for the robotic group (150±180 minimum) when compared with laparoscopic group (105±18 minimum, p<0.01). The mean uterine weight of the robotic group was significantly heavier compared with laparoscopic group (234±157 grams vs 153±119 grams, respectıvely, p<0.01).

Conclusion

Early surgical outcomes of robotic assisted laparoscopic and laparoscopic hysterectomy were comparable in terms of EBL, first gas discharge and hospital stay. Operation time was longer for robotic hysterectomy.

Establishment and evaluation of a training course in advanced laparoscopic surgery based on human body donors embalmed by ethanol-glycerol-lysoformin fixation

Background

Education of clinical anatomy and training of surgical skills are essential prerequisites for any surgical intervention in patients. Here, we evaluated a structured training program for advanced gynecologic laparoscopy based on human body donors and its impact on clinical practice.

Methods

The three-step training course included: (1) anatomical and surgical lectures, (2) demonstration and hands-on study of pre-dissected anatomical specimens, and (3) surgical training of a broad spectrum of gynecological laparoscopic procedures on human body donors embalmed by ethanol-glycerin-lysoformin. Two standardized questionnaires (after the course and 6 months later) evaluated the effectiveness of each of the training modules and the benefits to surgical practice.

Results

Eighty participants took part in 6 training courses using a total number of 24 body donors (3 trainees/body donor). Based on a 91.3% (73/80) response rate, participants rated high or very high the tissue and organ properties of the body donors (n = 72, 98.6%), the technical feasibility to perform laparoscopic surgery (n = 70, 95.9%), and the overall learning success (n = 72, 98.6%). Based on a 67.5% (54/80) response rate at 6 months, participants rated the benefit of the course to their daily routine as very high (mean 80.94 ± 24.61%, n = 53), and this correlated strongly with the use of body donors (r = 0.74) and the ability to train laparoscopic dissections (r = 0.77).

Conclusions

This study demonstrates the technical feasibility and didactic effectiveness of laparoscopic training courses in a professional and true-to-life setting by using ethanol-glycerol-lysoformin embalmed body donors. This cost-efficient fixation method offers the option to integrate advanced surgical training courses into structured postgraduate educational curricula to meet both the technical demands of minimal invasive surgery and the ethical concerns regarding patients´ safety.

[Ethical decision-making in the face of increasing economization of hospitals : A study on ethical mistrust in decisions taken on the length of hospital stay among students and doctors]

Are medical values receding in importance because of economization of the German health system? Within the frame of a vignette study, a case is presented based on prolongation of the hospitalization of an elderly and not entirely recovered patient. All respondents of the questionnaire predicted the relevance of decision criteria, such as medical accuracy, empathy towards the patient, and identification with the hospital. Participants (N = 1,239) believe that decision-makers view medical accuracy as the most important criterion, followed by empathy. The more the respondent had universalistic values, the more likely the person was to favor an extended hospitalization. The more security-oriented and less pro-social the respondent, the more likely the person was to support an early discharge. It can be concluded that in the course of their training doctors acquire their grounded deontological-ethical decision-making autonomy, which may in some cases contradict existing regulations.

Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost

BACKGROUND

New surgical innovations of nipple-sparing mastectomy (NSM), such as endoscopic NSM (E-NSM) or robotic NSM (R-NSM), were emerging. However, there was a lack of evidence comparing the effectiveness and safety in the management of breast cancer.

METHODS

A case-control comparison study was conducted for patients with breast cancer underwent E-NSM or R-NSM with immediate prosthesis breast reconstruction (IPBR) from July 2010 to February 2019 at a single institution to compare the clinical outcomes, learning curve, patient-reported cosmetic results, and medical cost.

RESULTS

A total of 91 E-NSM and 40 R-NSM procedures were retrieved and analyzed. The surgical margin involvement rate in both R-NSM (2.5%) and E-NSM (4.4%) procedures were relatively low (P = 0.52). The R-NSM group was associated with higher satisfaction rates in terms of scar appearance, scar length, and surgical wound position compared with the E-NSM group. Compared with E-NSM, the R-NSM operation time took longer (241 ± 61 vs. 215 ± 70 min, P = 0.01), less blood loss (32 ± 29 vs. 79 ± 62 ml, P < 0.01), and higher medical cost (10,587 ± 554 vs. 6855 ± 936 U.S. dollars, P < 0.01). There was no statistically significant difference in nipple ischemia/necrosis or overall complication between R-NSM and E-NSM. In the learning curve analysis, it took the 27th procedure in E-NSM and 10th procedure in R-NSM to decrease operation time significantly.

CONCLUSIONS

R-NSM was associated with higher wound-related satisfaction, lesser blood loss, and shorter learning curve compared with E-NSM, however, at the price of longer operation time and higher medical cost.

Pediatric and adolescent gynecology: Treatment perspectives in minimally invasive surgery

Minimally invasive surgery (MIS) is widely utilized across multiple surgical disciplines, including gynecology. To date, laparoscopy is considered a common surgical modality in children and adolescents to treat gynecological conditions. Robotic surgical devices were developed to circumvent the limitations of laparoscopy and have expanded the surgical armamentarium with better magnification, dexterity enhanced articulating instruments with 5-7 degrees of freedom, and ability to scale motion thus eliminating physiologic tremor. There are well-documented advantages of MIS over laparotomy, including decreased post-operative pain, shorter recovery times, and better cosmetic results. Indications for MIS in pediatric gynecology are reported in this review and technical considerations are described to highlight new treatment perspectives in children and adolescents, which have already been described in the literature regarding adult patients.

Uterine anomalies and endometriosis

INTRODUCTION

Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data.

EVIDENCE ACQUISITION

The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis.

EVIDENCE SYNTHESIS

Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed.

CONCLUSIONS

The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.

Robotics in spinal surgery

Although the da Vinci robot system has garnered much attention in the realm of surgery over the past few decades, several new surgical robotic systems have been developed for spinal surgery with varying levels of robot autonomy and surgeon-specified input. These devices are currently being considered as potential avenues for increasing the precision of any surgical intervention. The following review will attempt to provide an overview of robotics in modern spine surgery and how these devices will continue to be employed in various sectors across the field.

Educational training in laparoscopic gynecological surgery based on ethanol-glycerol-lysoformin-preserved body donors

PURPOSE

Educational training of laparoscopic skills performed on body donors is considered the gold standard prior to surgery in living patients. Appropriate, safe, and feasible fixation of body donors, reflecting true-to-life conditions of tissues, is an essential prerequisite for training workshops.

MATERIALS AND METHODS

Here we describe and evaluate a modified ethanol-glycerol-lysoformin-based fixation technique. Body donors were fixed by perfusion (70% ethanol, 30% glycerol, 0.3% lysoformin; ca. 20l) via femoral artery and stored in a humid atmosphere (1% thymol) at 4°C. Technical equipment included a mobile operating table, endoscopy system with gas insufflation, suction/irrigation pump, standard and electrosurgical instruments. The tissue properties of ethanol-glycerol-lysoformin-fixed body donors and their suitability for laparoscopic surgery were tested and compared to the in vivo situation.

RESULTS

Modified ethanol-glycerol-lysoformin fixation was a simple, cost-efficient and hazard-free procedure, resulting in near-to-life tissue conditions regarding consistency and flexibility, with moderate discoloration and greater viscosity of organs. Key laparoscopic procedures (trocar handling, pneumoperitoneum, blunt/sharp dissection, partial/total removal of organs, bi- or monopolar electrosurgery, suturing techniques) could be performed without difficulty. Multiple reuse of body donors was feasible over one year. Compared to the in vivo situation, the investigation of body donors required a greater degree of gas insufflation and more energy for electrosurgery.

CONCLUSIONS

Modified ethanol-glycerol-lysoformin fixation applied to body donors permitted laparoscopic surgery in a realistic and practical manner. Due to its logistic advantages, this technique provides appropriate conditions to train laparoscopic skills and implement novel minimally invasive approaches.

Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant: Technique, Preliminary Results and Patient-Reported Cosmetic Outcome

BACKGROUND

Experience with application of a robotic surgery platform in the management of breast cancer is limited. The preliminary results of the robotic nipple-sparing mastectomy (R-NSM) and immediate breast reconstruction (IBR) with Gel implant procedure are reported.

METHODS

The medical records of patients from a single institution who underwent an R-NSM and IBR with Gel implant procedure for breast cancer during the period March 2017 to February 2018 were assessed. Data on clinicopathologic characteristics, type of surgery, complications, and recurrence were analyzed to determine the effectiveness and oncologic safety of R-NSM. Patient-reported cosmetic outcome results were obtained.

RESULTS

A total of 22 patients who received 23 R-NSM and IBR with Gel implant procedures were analyzed. The mean operation time for R-NSM was 118.8 ± 50.6 min, and 74.5 ± 26.6 min for Gel implant reconstruction. Docking time quickly dropped from 20 to 6-8 min, and the time needed to complete R-NSM was usually completed within 100 min after accumulation of case experience. Mean blood loss was 37 ± 38.2 mL, and the positive surgical margin rate was 0%. Three (13%) patients had transit nipple ischemia change, and no total nipple-areolar complex necrosis cases were observed. No local recurrence or mortality was found during a mean 6.9 ± 3.5 months of follow-up. All 22 patients were satisfied with the postoperative aesthetic outcome.

CONCLUSION

From our preliminary experience, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy.

Congress report of the 23rd AGE annual meeting from 26th - 28th April 2018 in Hamburg

The Study Group of Gynecological Endoscopy (AGE) has a growing number of members each year. This is an acknowledgment as well as a challenge for the study group. The challenges were faced in the form of exemplary cooperative work by the core members of AGE, the Velen Study Group for Ambulant Surgery (VAAO), the Foundation of Endometriosis Research (SEF), the Study Group of Urogynecology and Plastic Pelvic Floor Reconstruction (AGUB), the Study Group for Robotic-assisted Surgery in Gynecology (ARC^Gyn), and the Study Group of Gynecological Oncology (AGO). More than 1500 AGE members have been able to create significant effects preemptively by designing a Congress program that was prepared interactively. The program of live surgery was designed in the course of two days on the basis of an online inquiry. The first transmission of laparoscopy on a body donor and anatomic demonstrations on formalin-fixed specimens were especially significant in this context. Sessions of general gynecology, including myoma therapy, endometriosis and infertility treatment, and gynecologic oncology and urogynecology covered the entire spectrum of minimally invasive surgical techniques. Individual topics were addressed in specific courses. The Congress was preceded by an optional certified basic course (MIC I) of the AGE. Far more than 500 congress attendees from all German-speaking countries were spirited away to a paramedical steep face, which was ascended together with a renowned German extreme climber. The keynote lecture was especially impressive and held by the pioneer and founder of the neuropelveology. The world’s leading expert in this field described the responsibilities of our specialty in a visionary manner and motivated all of the listeners strongly in regard of their actions and efforts.

Technique for single axillary incision robotic assisted quadrantectomy and immediate partial breast reconstruction with robotic latissimus dorsi flap harvest for breast cancer: A case report

RATIONALE

The clinical application of robotic surgery in breast conserving surgery or volume replacement with robotic latissimus dorsi flap harvest (RLDFH) has been rarely reported. In this study, we report the preliminary experience and clinical outcome of robotic assisted quadrantectomy (RAQ) and immediate partial breast reconstruction (IPBR) with RLDFH.

PATIENT CONCERN

Decreasing and avoid back scar length after latissimus dorsi flap harvest.

DIAGNOSES

One 28 years old female with left breast cancer underwent RAQ and IPBR with RLDFH. Initially, she was diagnosed with left breast infiltrating carcinoma that was clinical stage T3N1M0 and triple negative.

INTERVENTIONS

Neoadjuvant chemotherapy consisting of 4 cycles of epirubicin and cyclophosphamide followed by 4 cycles of docetaxel was performed. Breast magnetic resonance imaging showed residual breast cancer about 4.5 cm over the left upper outer quadrant of the breast. Sentinel lymph node biopsy showed no lymph node metastasis. RAQ, which took 82 minutes, was performed first, and the resected breast specimen's weight was 203 gm. She received IPBR with RLDFH, which took 97 minutes.

OUTCOMES

The overall blood loss was 40 mL. The final pathology result was ypT2 (4.2 cm)N0 (sn0/3)M0 and stage IIA. The resection margin was free of tumors. The post-operative recovery was smooth except for seroma formation over the back, which was relieved after repeated aspiration at an outpatient clinic. The patient was satisfied with the post-operative scar and aesthetic outcome. No local recurrence, distant metastasis or case mortality was found during 5 months of follow-up.

LESSONS

RAQ and IPBR with RLDFH is a safe alternative for small-to-medium-breast-size women with breast cancer who desire breast conservation and are indicated for volume replacement with autologous latissimus dorsi flap.

Endometriosis: A concise practical guide to current diagnosis and treatment

This book addresses the management of endometriosis from a holistic approach, including theoretical principles, conservative treatment of the condition, diagnostic and surgical procedures, as well as the outcome of research. Endometriosis and its treatment are complex issues. We believe that a combination of treatment modalities is needed in order to effectively address the pain, infertility, and other difficulties associated with endometriosis. In addition to theory and scientific principles, minimally invasive surgical procedures for the treatment of endometriosis are described in a stepwise manner. Separate sections of the books are devoted to specific conditions, urological procedures, and general surgical procedures because the condition is ideally treated on an interdisciplinary basis. Areas of overlap with other specialties are also addressed.

Inguinal hernia repair: is there a benefit to using the robot?

BACKGROUND

The number of robotic surgical procedures performed yearly is constantly rising, due to improved dexterity and visualization capabilities compared with conventional methods. We hypothesized that outcomes after robotic-assisted inguinal hernia repair would not be significantly different from outcomes after laparoscopic or open repair.

METHODS

All patients undergoing inguinal hernia repair between 2012 and 2016 were identified using institutional American College of Surgeons National Surgical Quality Improvement Program data. Demographics; preoperative, intraoperative, and postoperative characteristics; and outcomes were evaluated based on method of repair (Robot, Lap, or Open). Categorical variables were analyzed by Chi-square test and continuous variables using Mann-Whitney U.

RESULTS

A total of 510 patients were identified who underwent unilateral inguinal hernia repair (Robot: 13.8% [n = 69], Lap: 48.1% [n = 241], Open: 38.1% [n = 191]). There were no demographic differences between groups other than age (Robot: 52 [39-62], Lap: 57 [45-67], and Open: 56 [48-67] years, p = 0.03). Operative duration was also different (Robot: 105 [76-146] vs. Lap: 81 [61-103] vs. Open: 71 [56-88] min, p < 0.001). There were no operative mortalities and all patients except one were discharged home the same day. Postoperative occurrences (adverse events, readmissions, and death) were similar between groups (Robot: 2.9% [2], Lap: 3.3% [8], Open: 5.2% [10], p = 0.53). Although rare, there was a significant difference in rate of postoperative skin and soft tissue infection (Robot: 2.9% [2] vs. Lap: 0% [0] vs. Open: 0.5% [1], p = 0.02). Cost was significantly different between groups (Robot: $7162 [$5942-8375] vs. Lap: $4527 [$2310-6003] vs. Open: $4264 [$3277-5143], p < 0.001).

CONCLUSIONS

Outcomes after robotic-assisted inguinal hernia repair were similar to outcomes after laparoscopic or open repair. Longer operative duration during robotic repair may contribute to higher rates of skin and soft tissue infection. Higher cost should be considered, along with surgeon comfort level and patient preference when deciding whether inguinal hernia repair is approached robotically.

An atraumatic retractor for interdisciplinary use in conventional laparoscopy and robotic surgery

BACKGROUND

The removal of obstacles from the surgical field is a crucial aspect of any procedure in gynecological, urological or visceral laparoscopic surgery. Reliable instruments and skilled assistance are essential for the smooth execution of procedures. Blunt forceps are commonly used to keep tissue away from the operating field. The range of existing instruments has been enhanced by the introduction of laparoscopic retractors. However, no laparoscopic retractor can be used without causing tissue damage.

MATERIAL AND METHODS

We describe the ALKATOUT retractor, an innovative laparoscopic retractor designed for atraumatic assistance in any laparoscopic procedure including robotic surgery. The advantages of this laparoscopic instrument were evaluated in a single-center study.

RESULTS

The retractor has been used successfully in a variety of gynecological procedures and tested in laparoscopic procedures on human body donors.

CONCLUSIONS

The results of a single-center questionnaire completed by 25 operating room staff (surgical nurses, residents, and specialists) confirm the advantages of the ALKATOUT retractor.