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Mao B, Zhu S, Li D, Xiao J, Wang B, Yan Y. Comparison of safety and effectiveness between robotic and laparoscopic major hepatectomy: a systematic review and meta-analysis. Int J Surg 2023; 109:4333-4346. [PMID: 37720925 PMCID: PMC10720848 DOI: 10.1097/js9.0000000000000750] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/25/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Robotic platform has been increasingly applied in major hepatectomy. However, the role or advantage of robotic approach comparing with laparoscopic approach in major hepatectomy remains controversial. This meta-analysis compares perioperative outcomes of robotic major hepatectomy (RMH) to laparoscopic major hepatectomy (LMH) for hepatic neoplasms. METHODS PubMed, Web of Science, EMBASE, and Cochrane Library were searched to identify comparative studies compared RMH versus LMH for hepatic neoplasms. The search timeframe was set before May 2023. Main outcomes were mortality, overall morbidities, serious complications, and conversion to open surgery. Secondary outcomes were operative time, intraoperative blood loss, blood transfusion, postoperative length of hospital stay, R0 resection, reoperation, and readmission. Studies were evaluated for quality by Cochrane risk of bias tool or Newcastle-Ottawa scale. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42023410951). RESULTS Twelve retrospective cohort studies concerning total 1657 patients (796 RMH, 861 LMH) were included. Meta-analyses showed no significant differences in mortality (OR=1.23, 95% CI=0.50-2.98, P =0.65), overall postoperative complications (OR=0.83, 95% CI=0.65-1.06, P =0.14), operative time (MD=6.47, 95% CI=-14.72 to 27.65, P =0.55), blood transfusion (OR=0.77, 95% CI=0.55-1.08, P =0.13), R0 resection (OR=1.45, 95% CI=0.91-2.31, P =0.12), reoperation (OR=0.76, 95% CI=0.31-1.88, P =0.56), and readmission (OR=0.63, 95% CI=0.28-1.44, P =0.27) between RMH and LMH. Incidence of serious complications (OR=0.60, 95% CI=0.40-0.90, P =0.01), conversion to open surgery (OR=0.41, 95% CI=0.27-0.63, P <0.0001), blood loss (MD=-91.42, 95% CI=-142.18 to -40.66, P =0.0004), and postoperative hospital stay (MD=-0.64, 95% CI=-0.78 to -0.49, P <0.00001) were reduced for RMH versus LMH. CONCLUSIONS RMH is associated with comparable short-term surgical outcomes and oncologic adequacy compared to LMH when performed by experienced surgeons at large centres. RMH may result in reduced major morbidities, conversion rate, blood loss, and hospital stay, but these results were volatile. Further randomized studies should address the potential advantages of RMH over LMH.
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Affiliation(s)
- Benliang Mao
- Departments of General Surgery
- College of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | | | - Dan Li
- Thoracic Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou
| | - Junhao Xiao
- Departments of General Surgery
- College of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Bailin Wang
- Departments of General Surgery
- College of Clinical Medicine, Guizhou Medical University, Guiyang, China
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Lin HJ, Lin FCF, Yang TL, Chang CH, Kao CH, Tsai SCS. Cervical lymphatic malformations amenable to transhairline robotic surgical excision in children: A case series. Medicine (Baltimore) 2021; 100:e27200. [PMID: 34664849 PMCID: PMC8448076 DOI: 10.1097/md.0000000000027200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022] Open
Abstract
Lymphatic malformations are rare benign malformations that predominantly occur in the head and neck region. The advent of surgical robots in head and neck surgery may provide beneficial outcomes for pediatric patients. Here, we describe our experiences with transhairline incisions for robot-assisted surgical resection of cervical lymphatic malformations in pediatric patients.In this prospective longitudinal cohort study, we recruited consecutive patients under 18 years of age who were diagnosed with congenital cervical lymphatic malformations and scheduled for transhairline approach robotic surgery at a single medical center. We documented the docking times, console times, surgical results, complications, and postoperative follow-up outcomes.The studied patients included 2 with mixed-type lymphatic malformations and 2 with macrocystic-type lymphatic malformations. In all 4 patients, the incision was hidden in the hairline; the incision length was <5 cm in 3 patients but was extended to 6 cm in 1 patient. Elevating the skin flap and securely positioning it with Yang retractor took <1 hour in all cases. The mean docking time was 5.5 minutes, and the mean console time was 1 hour and 46 minutes. All 4 surgeries were completed endoscopically with the robot. The average total drainage volume in the postoperative period was 21.75 mL. No patients required tracheotomy or nasogastric feeding tubes. Neither were adverse surgery-associated neurovascular sequelae observed. All 4 patients were successfully treated for their lymphatic malformations, primarily with robotic surgical excisions.Cervical lymphatic malformations in pediatric patients could be accessed, properly visualized, and safely resected with transhairline-approach robotic surgery. Transhairline-approach robotic surgery is an innovative method for meeting clinical needs and addressing esthetic concerns.
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Affiliation(s)
- Han-Jie Lin
- Department of Otolaryngology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan, Republic of China
| | - Frank Cheau-Feng Lin
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan, Republic of China
| | - Tsung-Lin Yang
- Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan, Republic of China
- College of Medicine, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Chun-Hsiang Chang
- Department of Otolaryngology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan, Republic of China
| | - Chia-Hui Kao
- Department of Pediatrics, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan, Republic of China
| | - Stella Chin-Shaw Tsai
- Department of Otolaryngology, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan, Republic of China
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung, Taiwan, Republic of China
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Zhu QL, Xu X, Pan ZJ. Comparison of clinical efficacy of robotic right colectomy and laparoscopic right colectomy for right colon tumor: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27002. [PMID: 34414989 PMCID: PMC8376393 DOI: 10.1097/md.0000000000027002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/31/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The purpose of this study was to compare the clinical efficacy of robotic right colectomy (RRC) and laparoscopic right colectomy (LRC) in the treatment of right colon tumor. METHODS We systematically searched PubMed, Web of science, EMBASE ClinicalTrials.gov and Cochrane Central Register for studies (studies published between January 2011 and June 2020). The included studies compared the clinical efficacy of RRC and LRC in the treatment of right colon tumor, and analyzed the perioperative data. RESULTS Our meta-analysis included 10 studies involving 1180 patients who underwent 2 surgical procedures, RRC and LRC. This study showed that compared with LRC, there was no significant difference in first flatus passage (weighted mean difference [WMD]: -0.37, 95% CI: -1.09-0.36, P = .32), hospital length of stay (WMD: -0.23, 95% CI: -0.73-0.28, P = .32), reoperation (OR: 1.66, 95% CI: 0.67-4.10, P = .27), complication (OR: 0.83, 95% CI: 0.60-1.14, P = .25), mortality (OR: 0.45, 95% CI: 0.02-11.22, P = .63), wound infection (OR: 0.65, 95% CI: 0.34-1.25, P = .20), and anastomotic leak (OR: 0.73, 95% CI: 0.33-1.63, P = .44). This study showed that compared with LRC, the lymph nodes retrieved (WMD: 1.47, 95% CI: -0.00-2.94, P = .05) of RRC were similar, with slight advantages, and resulted in longer operative time (WMD: 65.20, 95% CI: 53.40-77.01, P < .00001), less estimated blood loss (WMD: -13.43, 95% CI: -20.65-6.21, P = .0003), and less conversion to open surgery (OR: 0.30, 95% CI: 0.17-0.54, P < .0001). CONCLUSIONS RRC is equivalent to LRC with respect to first flatus passage, hospital length of stay, reoperation, complication, and results in less conversion to LRC.
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Chen IHA, Ghazi A, Sridhar A, Stoyanov D, Slack M, Kelly JD, Collins JW. Evolving robotic surgery training and improving patient safety, with the integration of novel technologies. World J Urol 2021; 39:2883-2893. [PMID: 33156361 PMCID: PMC8405494 DOI: 10.1007/s00345-020-03467-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 09/21/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula. METHODS A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training. RESULTS Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots. CONCLUSIONS Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.
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Affiliation(s)
- I-Hsuan Alan Chen
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.
- Department of Surgery, Division of Urology, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying District, Kaohsiung, 81362, Taiwan.
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK.
| | - Ahmed Ghazi
- Department of Urology, Simulation Innovation Laboratory, University of Rochester, New York, USA
| | - Ashwin Sridhar
- Division of Uro-Oncology, University College London Hospital, London, UK
| | - Danail Stoyanov
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
| | | | - John D Kelly
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK
- Division of Uro-Oncology, University College London Hospital, London, UK
| | - Justin W Collins
- Division of Surgery and Interventional Science, Research Department of Targeted Intervention, University College London, London, UK.
- Wellcome/ESPRC Centre for Interventional and Surgical Sciences (WEISS), University College London, London, UK.
- Division of Uro-Oncology, University College London Hospital, London, UK.
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Yu DY, Chang YW, Lee HY, Kim WY, Kim HY, Lee JB, Son GS. Detailed comparison of the da Vinci Xi and S surgical systems for transaxillary thyroidectomy. Medicine (Baltimore) 2021; 100:e24370. [PMID: 33546074 PMCID: PMC7837914 DOI: 10.1097/md.0000000000024370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022] Open
Abstract
Robotic surgical systems have evolved over time. The da Vinci Xi system was developed in 2014 and was expected to solve the shortcomings of the previous S system. Therefore, we conducted this study to compare these 2 systems and identify if the Xi system truly improves surgical outcomes.In this retrospective study, a total of 86 patients with unilateral papillary thyroid carcinoma without central lymph node involvement underwent gasless transaxillary hemithyroidectomy using 2 robotic systems, the da Vinci S and Xi. Forty patients were in the da Vinci S group and 46 patients were in the da Vinci Xi group. All surgeries were performed by 1 surgeon (YWC). All surgery video files were analyzed to compare the duration of each surgical step.The total operation time was significantly shorter in the Xi group than in the S group (153.0 minutes vs 105.7 minutes, P < .01). Time for robot docking was shorter in the Xi group (19.8 minutes vs 10.6 minutes, P < .01), and all procedures performed in the console also required a shorter time in this group. The overall complication rate did not differ significantly (P = .464).The da Vinci Xi system made robotic thyroidectomy easier and faster without increasing the complication rate. It is a safe and valuable system for robotic thyroidectomy.
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Dias AR, Ramos MFKP, Szor DJ, Abdalla R, Barchi L, Yagi OK, Ribeiro-Junior U, Zilberstein B, Cecconello I. ROBOTIC GASTRECTOMY: TECHNIQUE STANDARDIZATION. Arq Bras Cir Dig 2021; 33:e1542. [PMID: 33470372 PMCID: PMC7812686 DOI: 10.1590/0102-672020200003e1542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Trocars position for the Si model (position is similar for the Xi, although trocars stay more in line). Robotic gastrectomy is gaining popularity worldwide. It allows reduced blood loss and lesser pain. However, it widespread use is limited by the extensive learning curve and costs. AIM To describe our standard technique with reduced use of robotic instruments. METHODS We detail the steps involved in the procedure, including trocar placement, necessary robotic instruments, and meticulous surgical description. RESULTS After standardizing the procedure, 28 patients were operated with this budget technique. For each procedure material used was: 1 (Xi model) or 2 disposable trocars (Si) and 4 robotic instruments. Stapling and clipping were performed by the assistant through an auxiliary port, limiting the use of robotic instruments and reducing the cost. CONCLUSION This standardization helps implementing a robotic program for gastrectomy in the daily practice or in one`s institution.
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Affiliation(s)
- Andre Roncon Dias
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | | | - Daniel Jose Szor
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | - Ricardo Abdalla
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | - Leandro Barchi
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | - Osmar Kenji Yagi
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | | | - Bruno Zilberstein
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
| | - Ivan Cecconello
- Cancer Institute, Hospital das Clínicas, University of São Paulo, São Paulo, SP, Brazil
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Abstract
PURPOSE OF REVIEW The increasing use of robotics in urologic surgery facilitates collection of 'big data'. Machine learning enables computers to infer patterns from large datasets. This review aims to highlight recent findings and applications of machine learning in robotic-assisted urologic surgery. RECENT FINDINGS Machine learning has been used in surgical performance assessment and skill training, surgical candidate selection, and autonomous surgery. Autonomous segmentation and classification of surgical data have been explored, which serves as the stepping-stone for providing real-time surgical assessment and ultimately, improve surgical safety and quality. Predictive machine learning models have been created to guide appropriate surgical candidate selection, whereas intraoperative machine learning algorithms have been designed to provide 3-D augmented reality and real-time surgical margin checks. Reinforcement-learning strategies have been utilized in autonomous robotic surgery, and the combination of expert demonstrations and trial-and-error learning by the robot itself is a promising approach towards autonomy. SUMMARY Robot-assisted urologic surgery coupled with machine learning is a burgeoning area of study that demonstrates exciting potential. However, further validation and clinical trials are required to ensure the safety and efficacy of incorporating machine learning into surgical practice.
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Affiliation(s)
- Runzhuo Ma
- Center for Robotic Simulation & Education, Catherine & Joseph Aresty Department of Urology, USC Institute of Urology, University of Southern California, Los Angeles, California, USA
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Arca MJ, Adams RB, Angelos P, Fanelli RD, Mammen JMV, Nelson MT, Neumeister MW, Robinson AJ, Buyske J. American Board of Surgery Statement on Assessment and Robotic Surgery. Am J Surg 2020; 221:424-426. [PMID: 33097190 DOI: 10.1016/j.amjsurg.2020.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 11/18/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Jo Buyske
- The American Board of Surgery, United States.
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Onofrio R, Trucco P. A methodology for Dynamic Human Reliability Analysis in Robotic Surgery. Appl Ergon 2020; 88:103150. [PMID: 32678771 DOI: 10.1016/j.apergo.2020.103150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 03/29/2020] [Accepted: 05/08/2020] [Indexed: 06/11/2023]
Abstract
Surgery has changed significantly in recent years due to the introduction of advanced technologies, resulting in increased system complexity at the technical, human and organisational levels, which may lead to higher variability of patient outcome due to new error pathways. Current approaches towards a safer surgery are largely based on ex-post analysis of events and process monitoring (e.g. root cause analysis, safety checklists, safety audits). However, adopting a proactive approach enables the prior identification of critical factors and the design of safer sociotechnical systems, thanks to a multi-level (or mesoergnomics) perspective. In this paper, a methodology for performing mesoergonomics analysis of surgical procedures is proposed. It is a methodology for Dynamic Human Reliability Analysis in Robotic Surgery based on a modified version of human error assessment and reduction technique (HEART) integrated with a method for incorporating uncertainties related to the influence of personal and organisational factors on the execution of a surgical procedure. The pilot application involves a robot-assisted radical prostatectomy procedure, and the results reveal that team-related factors have the greatest impact on patient outcome variability.
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Affiliation(s)
- Rossella Onofrio
- Department of Management, Economics and Industrial Engineering - Politecnico di Milano, Via Lambruschini, 4/b - 20156, Milan, Italy.
| | - Paolo Trucco
- Department of Management, Economics and Industrial Engineering - Politecnico di Milano, Via Lambruschini, 4/b - 20156, Milan, Italy
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Abstract
BACKGROUND Although robot-assisted distal pancreatectomy (RADP) has been successfully performed since 2003, its advantages over open distal pancreatectomy (ODP) are still uncertain. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of RADP vs ODP. METHODS Multiple databases (PubMed, Medline, EMBASE, Web of Science, and Cochrane Library) were searched to identify studies that compare the outcomes of RADP and ODP (up to February, 2020). Fixed and random effects models were applied according to different conditions. RESULTS A total of 7 studies from high-volume robotic surgery centers comprising 2264 patients were included finally. Compared with ODP, RADP was associated with lower estimated blood loss, lower blood transfusion rate, lower postoperative mortality rate, and shorter length of hospital stay. No significant difference was observed in operating time, the number of lymph nodes harvested, positive margin rate, spleen preservation rate, rate of severe morbidity, incidence of postoperative pancreatic fistula, and severe postoperative pancreatic fistula (grade B and C) between the 2 groups. CONCLUSIONS With regard to perioperative outcomes, RADP is a safe and feasible alternative to ODP in centers with expertise in robotic surgery. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.
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Affiliation(s)
- Jiangjiao Zhou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
| | - Zhuo Lv
- Department of General Surgery, Chengbu County People's Hospital, Shaoyang, Hunan Province, China
| | - Heng Zou
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
| | - Li Xiong
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
| | - Zhongtao Liu
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
| | - Wenhao Chen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
| | - Yu Wen
- Department of General Surgery, The Second Xiangya Hospital, Central South University, No. 139 Middle Renmin Road, Changsha
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Graham M, Assis F, Allman D, Wiacek A, Gonzalez E, Gubbi M, Dong J, Hou H, Beck S, Chrispin J, Bell MAL. In Vivo Demonstration of Photoacoustic Image Guidance and Robotic Visual Servoing for Cardiac Catheter-Based Interventions. IEEE Trans Med Imaging 2020; 39:1015-1029. [PMID: 31502964 DOI: 10.1109/tmi.2019.2939568] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Cardiac interventional procedures are often performed under fluoroscopic guidance, exposing both the patient and operators to ionizing radiation. To reduce this risk of radiation exposure, we are exploring the use of photoacoustic imaging paired with robotic visual servoing for cardiac catheter visualization and surgical guidance. A cardiac catheterization procedure was performed on two in vivo swine after inserting an optical fiber into the cardiac catheter to produce photoacoustic signals from the tip of the fiber-catheter pair. A combination of photoacoustic imaging and robotic visual servoing was employed to visualize and maintain constant sight of the catheter tip in order to guide the catheter through the femoral or jugular vein, toward the heart. Fluoroscopy provided initial ground truth estimates for 1D validation of the catheter tip positions, and these estimates were refined using a 3D electromagnetic-based cardiac mapping system as the ground truth. The 1D and 3D root mean square errors ranged 0.25-2.28 mm and 1.24-1.54 mm, respectively. The catheter tip was additionally visualized at three locations within the heart: (1) inside the right atrium, (2) in contact with the right ventricular outflow tract, and (3) inside the right ventricle. Lasered regions of cardiac tissue were resected for histopathological analysis, which revealed no laser-related tissue damage, despite the use of 2.98 mJ per pulse at the fiber tip (379.2 mJ/cm2 fluence). In addition, there was a 19 dB difference in photoacoustic signal contrast when visualizing the catheter tip pre- and post-endocardial tissue contact, which is promising for contact confirmation during cardiac interventional procedures (e.g., cardiac radiofrequency ablation). These results are additionally promising for the use of photoacoustic imaging to guide cardiac interventions by providing depth information and enhanced visualization of catheter tip locations within blood vessels and within the beating heart.
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Graham M, Assis F, Allman D, Wiacek A, Gonzalez E, Gubbi M, Dong J, Hou H, Beck S, Chrispin J, Bell MAL. In Vivo Demonstration of Photoacoustic Image Guidance and Robotic Visual Servoing for Cardiac Catheter-Based Interventions. IEEE Trans Med Imaging 2020; 39:1015-1029. [PMID: 31502964 DOI: 10.1117/12.2546910] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Cardiac interventional procedures are often performed under fluoroscopic guidance, exposing both the patient and operators to ionizing radiation. To reduce this risk of radiation exposure, we are exploring the use of photoacoustic imaging paired with robotic visual servoing for cardiac catheter visualization and surgical guidance. A cardiac catheterization procedure was performed on two in vivo swine after inserting an optical fiber into the cardiac catheter to produce photoacoustic signals from the tip of the fiber-catheter pair. A combination of photoacoustic imaging and robotic visual servoing was employed to visualize and maintain constant sight of the catheter tip in order to guide the catheter through the femoral or jugular vein, toward the heart. Fluoroscopy provided initial ground truth estimates for 1D validation of the catheter tip positions, and these estimates were refined using a 3D electromagnetic-based cardiac mapping system as the ground truth. The 1D and 3D root mean square errors ranged 0.25-2.28 mm and 1.24-1.54 mm, respectively. The catheter tip was additionally visualized at three locations within the heart: (1) inside the right atrium, (2) in contact with the right ventricular outflow tract, and (3) inside the right ventricle. Lasered regions of cardiac tissue were resected for histopathological analysis, which revealed no laser-related tissue damage, despite the use of 2.98 mJ per pulse at the fiber tip (379.2 mJ/cm2 fluence). In addition, there was a 19 dB difference in photoacoustic signal contrast when visualizing the catheter tip pre- and post-endocardial tissue contact, which is promising for contact confirmation during cardiac interventional procedures (e.g., cardiac radiofrequency ablation). These results are additionally promising for the use of photoacoustic imaging to guide cardiac interventions by providing depth information and enhanced visualization of catheter tip locations within blood vessels and within the beating heart.
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Wang A, Polotti CF, Wang S, Elsamra S, Siddiqui MM. Characterization of a learning curve for robotic cystectomy with intracorporeal urinary diversion at two institutions using the cumulative sum (CUSUM) method. Can J Urol 2019; 26:10033-10038. [PMID: 31860420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Robotic cystectomy with intracorporeal urinary diversion (RCID) is a technically challenging procedure. It is understood that this approach has a learning curve; however, limited studies have characterized this learning curve. The cumulative sum (CUSUM) method plots the learning curve. The aim of this study was to use the CUSUM approach to investigate the number of cases required to reach a consistent, desired performance level for RCID. MATERIALS AND METHODS Retrospective study of the first 27 and 28 RCID cases performed by two new fellowship trained faculty at two separate institutions from November 2014 to January 2018. Total operating time was calculated and the CUSUM method was used to describe the learning curve, the number of cases needed for a consistent performance level. RESULTS Twenty-seven and 28 patients were reviewed from two institutions (A and B), with 8 and 7 females, 19 and 21 males and an average age of 66.7 and 67.6 years, respectively. Twelve and ten cases, respectively, had final pathology of stage T3 bladder cancer or higher. The CUSUM curve demonstrated a learning curve of 10 and 11 cases, respectively, when the curve transitioned from steady improvement in OR times (upward slope of curve) to a relative steady state of OR times (plateau of curve). The average lymph node yield, rate of ureteral stricture, and positive margins were also examined with no learning curve noted. CONCLUSION In RCID, approximately 10 cases were required by robotically trained new faculty to reach a steady-state level of performance.
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Affiliation(s)
- Alexis Wang
- Division of Urology, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
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Chen A, Ghodoussipour S, Titus MB, Nguyen JH, Chen J, Ma R, Hung AJ. Comparison of clinical outcomes and automated performance metrics in robot-assisted radical prostatectomy with and without trainee involvement. World J Urol 2019; 38:1615-1621. [PMID: 31728671 DOI: 10.1007/s00345-019-03010-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/05/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE In this study, we investigate the effect of trainee involvement on surgical performance, as measured by automated performance metrics (APMs), and outcomes after robot-assisted radical prostatectomy (RARP). METHODS We compared APMs (instrument tracking, EndoWrist® articulation, and system events data) and clinical outcomes for cases with varying resident involvement. Four of 12 standardized RARP steps were designated critical ("cardinal") steps. Comparison 1: cases where the attending surgeon performed all four cardinal steps (Group A) and cases where a trainee was involved in at least one cardinal step (Group B). Comparison 2, where Group A is split into Groups C and D: cases where attending performs the whole case (Group C) vs. cases where a trainee performed at least one non-cardinal step (Group D). Mann-Whitney U and Chi-squared tests were used for comparisons. RESULTS Comparison 1 showed significant differences in APM profiles including camera movement time, third instrument usage, dominant instrument moving time, velocity, articulation, as well as non-dominant instrument moving time and articulation (all favoring Group A p < 0.05). There was a significant difference in re-admission rates (10.9% in Group A vs 0% in Group B, p < 0.02), but not for post-operative outcomes. Comparison 2 demonstrated a significant difference in dominant instrument articulation (p < 0.05) but not in post-operative outcomes. CONCLUSIONS Trainee involvement in RARP is safe. The degree of trainee involvement does not significantly affect major clinical outcomes. APM profiles are less efficient when trainees perform at least one cardinal step but not during non-cardinal steps.
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Affiliation(s)
- Andrew Chen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Saum Ghodoussipour
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Micha B Titus
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Jessica H Nguyen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Jian Chen
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Runzhuo Ma
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA
| | - Andrew J Hung
- Center for Robotic Simulation and Education, Catherine and Joseph Aresty Department of Urology, University of Southern California Institute of Urology, 1441 Eastlake Avenue, Suite 7416, Los Angeles, CA, 90033, USA.
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Gharios J, Hain E, Dohan A, Prat F, Terris B, Bertherat J, Coriat R, Dousset B, Gaujoux S. Pre- and intraoperative diagnostic requirements, benefits and risks of minimally invasive and robotic surgery for neuroendocrine tumors of the pancreas. Best Pract Res Clin Endocrinol Metab 2019; 33:101294. [PMID: 31351817 DOI: 10.1016/j.beem.2019.101294] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pancreatic neuroendocrine tumours (PanNET) are rare tumours, accounting for 1%-2% of all pancreatic neoplasms. These tumors are classified as functioning neuroendocrine tumours (F-PanNETs) or non-functioning (NF-PanNETs) depends on whether the tumour is associated with clinical hormonal hypersecretion syndrome or not. In the last decades, diagnosis of PanNETs has increased significantly due to the widespread of cross-sectional imaging. Whenever possible, surgery is the cornerstone of PanNETs management and the only curative option for these patients. Indeed, after R0 resection, the 5-year overall survival rate is around 90-100% for low grade lesions but significantly drops after incomplete resections. Compared to standard resections, pancreatic sparing surgery, i.e. enucleation and central pancreatectomy, significantly decreased the risk of pancreatic insufficiency. It should be performed in patients with good general condition and normal pancreatic function to limit the operative risk and enhance the benefit of surgery. Nowadays, due to many known advantages of minimally invasive surgery, there is an ongoing trend towards laparoscopic and robotic pancreatic surgery. The aim of this study is to describe the pre- and intraoperative diagnostic requirements for the management of PanNETs and the benefits and risks of minimally invasive surgery including laparoscopic and robotic approach in view of the recent literature.
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Affiliation(s)
- Joseph Gharios
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Elisabeth Hain
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Anthony Dohan
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Radiology, Cochin Hospital, APHP, Paris, France
| | - Fréderic Prat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Benoit Terris
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Pathology, Cochin Hospital, APHP, Paris, France
| | - Jérôme Bertherat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Endocrinology, Cochin Hospital, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France
| | - Romain Coriat
- Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France; Department of Gastroenterology, Cochin Hospital, APHP, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, Referral Center for Rare Adrenal Diseases, Cochin Hospital, APHP, Paris, France; Faculté de Médecine Paris Descartes, Université Paris Descartes, Sorbonne Paris Cité, France.
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Yoshikawa K, Koseki K, Endo Y, Yamamoto S, Kanae K, Takeuchi R, Yozu A, Mutsuzaki H. Adjusting Assistance Commensurates with Patient Effort During Robot-Assisted Upper Limb Training for a Patient with Spasticity After Cervical Spinal Cord Injury: A Case Report. ACTA ACUST UNITED AC 2019; 55:medicina55080404. [PMID: 31344963 PMCID: PMC6723405 DOI: 10.3390/medicina55080404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/18/2019] [Accepted: 07/22/2019] [Indexed: 11/20/2022]
Abstract
Limited evidence is available on optimal patient effort and degree of assistance to achieve preferable changes during robot-assisted training (RAT) for spinal cord injury (SCI) patients with spasticity. To investigate the relationship between patient effort and robotic assistance, we performed training using an electromyography-based robotic assistance device (HAL-SJ) in an SCI patient at multiple settings adjusted to patient effort. In this exploratory study, we report immediate change in muscle contraction patterns, patient effort, and spasticity in a 64-year-old man, diagnosed with cervical SCI and with American Spinal Injury Association Impairment Scale C level and C4 neurological level, who underwent RAT using HAL-SJ from post-injury day 403. Three patient effort conditions (comfortable, somewhat hard, and no-effort) by adjusting HAL-SJ’s assists were set for each training session. Degree of effort during flexion and extension exercise was assessed by visual analog scale, muscle contraction pattern by electromyography, modified Ashworth scale, and maximum elbow extension and flexion torques, immediately before and after each training session, without HAL-SJ. The amount of effort during training with the HAL-SJ at each session was evaluated. The degree of effort during training can be set to three effort conditions as we intended by adjusting HAL-SJ. In sessions other than the no-effort setting, spasticity improved, and the level of effort was reduced immediately after training. Spasticity did not decrease in the training session using HAL-SJ with the no-effort setting, but co-contraction further increased during extension after training. Extension torque was unchanged in all sessions, and flexion torque decreased in all sessions. When performing upper-limb training with HAL-SJ in this SCI patient, the level of assistance with some effort may reduce spasticity and too strong assistance may increase co-contraction. Sometimes, a patient’s effort may be seemingly unmeasurable; hence, the degree of patient effort should be further measured.
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Affiliation(s)
- Kenichi Yoshikawa
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan.
| | - Kazunori Koseki
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan
| | - Yusuke Endo
- Department of Physical Therapy, Faculty of Health Science, Health Science University, 7187 Kodachi, Fujikawaguchiko-machi, Minamitsuru-gun, Yamanashi 401-0380, Japan
| | - Satoshi Yamamoto
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami, Inashiki-gun, Ibaraki 300-0394, Japan
| | - Kyoko Kanae
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan
| | - Ryoko Takeuchi
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan
| | - Arito Yozu
- Department of Rehabilitation, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan
- Center for Medical Sciences, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami, Inashiki-gun, Ibaraki 300-0394, Japan
| | - Hirotaka Mutsuzaki
- Department of Orthopaedic Surgery, Ibaraki Prefectural University of Health Sciences Hospital, 4733 Ami, Inashiki-gun, Ibaraki 300-0331, Japan
- Center for Medical Sciences, Ibaraki Prefectural University of Health Sciences, 4669-2 Ami, Inashiki-gun, Ibaraki 300-0394, Japan
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Broeders IAMJ. [Learning in the high-tech era: are we getting a grip on the learning curve?]. Ned Tijdschr Geneeskd 2019; 163:D3988. [PMID: 31283122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
This comment reflects the author's opinion on the outcomes of the first 100 robot-assisted Whipple procedures. Results were comparable to outcomes of open surgery in high-volume centres. The researchers state that learning curve effects are, in fact, not acceptable. They intended to avoid these effects by high-volume experience, thorough preparation, support during surgery, and the ability of robotic systems to carry out precise work in laparoscopic settings. Their results are in contrast with the results of the Leopard-2 trial in the Netherlands. In this trial, laparoscopic Whipple procedures were associated with higher mortality. Robot surgery may be helpful in complex laparoscopic procedures, but it may also support further learning by providing virtual reality training and dual console setups which allow for step-by-step learning. Future developments in big data analysis may enable benchmarking for a variety of parameters on surgical performance. This may provide additional support in avoiding learning curve effects for patients.
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Affiliation(s)
- Ivo A M J Broeders
- Meander Medisch Centrum, afd. Heelkunde, Amersfoort
- Contact: I.A.M.J. Broeders
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Affiliation(s)
- Kyle H. Sheetz
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
| | - Justin B. Dimick
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, Ann Arbor, MI
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Valverde A, Akkari I, Sezeur A, Goasguen N, Cahais J, Oberlin O, Flejou JF, Lupinacci RM. Operative start time may impact the quality of mesorectal excision in minimally invasive rectal surgery: retrospective analysis of 137 patients. G Chir 2019; 40:163-169. [PMID: 31484003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Timing of major elective operations is a potentially important outcome variable. This study examined the impact of operative start time (OST) on pathologic and short-term outcomes of minimally invasive rectal surgery (MIRS). METHODS All rectal tumors patients who underwent MIRS from May 2012 to April 2016 were identified. Peroperative outcomes and the oncological quality of surgical excision were compared between patients with OST before 13.00h and after. RESULTS A total of 137 patients were included in the study (71 Romarobot-assisted and 66 conventional laparoscopic). Ninety-nine (72%) patients were operated before 13.00h and 38 after 13.00h. The majority of cases were low/middle rectal tumors (69%). Patient's baseline characteristics were quite similar in both groups. The rate of severe complication (p=0.460) or reoperation (p=0.614) was the same. Pathologic criteria (T or N stage, number of harvested lymph nodes, and presence of any positive margin) were the same between groups except for the quality of mesorectal excision (ME) that was significantly poorer for cases beginning after 13.00h (complete 91% vs 74%; p=0.016). The OST was found to be the only parameter associated with a poor quality of ME [OR 2.55 (1.08 - 6.36)]. CONCLUSION Perioperative outcome after MIRS does not appear to be influenced by OST. Poorer quality of ME was observed and may thus raise important questions about the timing and sequence of case scheduling.
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Liu R, Wakabayashi G, Kim HJ, Choi GH, Yiengpruksawan A, Fong Y, He J, Boggi U, Troisi RI, Efanov M, Azoulay D, Panaro F, Pessaux P, Wang XY, Zhu JY, Zhang SG, Sun CD, Wu Z, Tao KS, Yang KH, Fan J, Chen XP. International consensus statement on robotic hepatectomy surgery in 2018. World J Gastroenterol 2019; 25:1432-1444. [PMID: 30948907 PMCID: PMC6441912 DOI: 10.3748/wjg.v25.i12.1432] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
The robotic surgical system has been applied in liver surgery. However, controversies concerns exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. To promote the development of robotic hepatectomy, this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts’ consensus and recommendations to promote its development. Based on the World Health Organization Handbook for Guideline Development, a Consensus Steering Group and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings. Based on the published articles and expert panel opinion, 7 recommendations were generated by the GRADE method using an evidence-based method, which focused on the safety, feasibility, indication, techniques and cost-effectiveness of hepatectomy. Given that the current evidences were low to very low as evaluated by the GRADE method, further randomized-controlled trials are needed in the future to validate these recommendations.
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Affiliation(s)
- Rong Liu
- Second Department of Hepatopancreatobiliary Surgery, Chinese People’s Liberation Army (PLA) General Hospital, Beijing 100853, China
| | - Go Wakabayashi
- Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Ageo 362-8588, Japan
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu 705-703, South Korea
| | - Gi-Hong Choi
- Division of Hepatobiliary Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 03722, South Korea
| | - Anusak Yiengpruksawan
- Minimally Invasive Surgery Division, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Jin He
- Department of Surgery, the Johns Hopkins Hospital, Baltimore, MD 21287, United States
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa 56124, Italy
| | - Roberto I Troisi
- Department of Clinical Medicine and Surgery, Federico II University, Naples 80131, Italy
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow 11123, Russia
| | - Daniel Azoulay
- Hepato-Biliary Center, Paul Brousse University Hospital, Villejuif 94000, France
- Hepato-Biliary Center, Tel Hashomer University Hospital, Tel Aviv, Israel
| | - Fabrizio Panaro
- Department of Surgery/Division of HBP Surgery and Transplantation, Montpellier University Hospital—School of Medicine, Montpellier 34000, France
| | - Patrick Pessaux
- Head of the Hepato-biliary and pancreatic surgical unit, Nouvel Hôpital Civil, Strasbourg Cedex 67091, France
| | - Xiao-Ying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ji-Ye Zhu
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing 100044, China
| | - Shao-Geng Zhang
- Department of Hepatobiliary Surgery, 302 Hospital of Chinese PLA, Beijing 100039, China
| | - Chuan-Dong Sun
- Department of Hepatobiliary and Pancreatic Surgery, the Affiliated Hospital of Qingdao University, Qingdao 266071, Shandong Province, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Kai-Shan Tao
- Department of Hepatobiliary Surgery, Xijing Hospital, the Fourth Military Medical University, Xi’an 710032, Shaanxi Province, China
| | - Ke-Hu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jia Fan
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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Liao CH, Chen WH, Lee CH, Shen SC, Tsuei YS. Treating cerebrovascular diseases in hybrid operating room equipped with a robotic angiographic fluoroscopy system: level of necessity and 5-year experiences. Acta Neurochir (Wien) 2019; 161:611-619. [PMID: 30610374 DOI: 10.1007/s00701-018-3769-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 12/11/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND A hybrid operating room (OR) equipped with robotic angiographic fluoroscopy system has become prevalent in neurosurgery. The level of necessity of the hybrid OR in treating cerebrovascular diseases (CVD) is rarely discussed. OBJECTIVE The authors proposed a scoring and classification system to evaluate the cerebrovascular procedures according to the level of treatment necessity for CVD in a hybrid OR and shared our 5-year experiences. METHODS From December 2009 to January 2016, the registry of cerebrovascular procedures performed in the hybrid OR was retrieved. A scoring system was used to evaluate the importance of the surgical and interventional components of a cerebrovascular procedure performed in the hybrid OR. The score of either component ranged from 1, 1.5, to 2 (1 = no role, 1.5 = supplementary or informative, 2 = important or therapeutic). The total score of a procedure was by multiplying two individual scores. Levels of necessity were classified into level A (important), level B (beneficial), and level C (replaceable). RESULTS A total of 1027 cerebrovascular procedures were performed during this period: diagnostic angiography in 328, carotid artery stenting in 286, aneurysm coiling in 128, intra-operative DSA in 101, aspiration of ICH under image guidance in 79, intra-arterial thrombolysis/thrombectomy in 51, intracranial angioplasty/stenting in 30, hybrid surgery/serial procedures in 19, and rescue surgery during embolization in 5. According to the scoring system, hybrid surgery and serial procedures scored the highest points (2 × 2). The percentages distributed at each level: levels A (2.3%), B (17.5%), and C (80.2%). CONCLUSION This study conveys a concept of what a hybrid OR equipped with robotic angiographic fluoroscopy system is capable of and its potential. For cerebrovascular diseases, hybrid OR exerts its value via hybrid surgery or avoiding patient transportation in serial procedures (level A), via providing real-time high-quality angiography and image guidance (level B), which constituted about 20% of the cases. The subspecialty of the group using the hybrid OR directly reflects on the number of procedures categorized in each level. In a hybrid OR, innovative treatment strategies for difficult-to-treat CVD can be developed.
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Affiliation(s)
- Chih-Hsiang Liao
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
| | - Wen-Hsien Chen
- Department of Neuroradiology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Hsin Lee
- Department of Neurosurgery, Taichung Tzu Chi Hospital, Taichung, Taiwan
| | - Shih-Chieh Shen
- Department of Neurosurgery, Tri-service General Hospital Songshan Branch, Taipei, Taiwan
| | - Yuang-Seng Tsuei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.
- Department of Neurosurgery, Neurological Institute, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.
- Department of Neurosurgery, National Defense Medical Center, Tri-service General Hospital, Taipei, Taiwan.
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Truong A, Lopez N, Fleshner P, Zaghiyan K. Preservation of Pathologic Outcomes in Robotic versus Open Resection for Rectal Cancer: Can the Robot Fill the Minimally Invasive Gap? Am Surg 2018; 84:1876-1881. [PMID: 30606342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Open resection remains the standard of care in the surgical management of rectal cancer with recent studies unable to prove noninferiority of laparoscopic resection. Few studies directly compare robotic versus open techniques. This is a retrospective chart review of all consecutive patients undergoing robotic or open rectal cancer resection during a three-year period. The primary endpoint was a composite of complete mesorectal excision, circumferential resection margin <1 mm, and distal resection margin <1 mm. The study cohort included 64 patients undergoing robotic (n = 28) or open (n = 36) resection. Successful surgical resection was similar between the robotic (75%) and open (76%) approaches. Robotic resection was associated with significantly lower blood loss (P = 0.02) and significantly longer operative times (P = 0.009) compared with open resection. Length of hospital stay and complications were similar between groups. Both male gender (P = 0.03) and shorter tumor distance from the anal verge (P = 0.01) were predictors for unsuccessful surgical resection in open, but not robotic, surgery. Pathologic outcomes are similar between robotic and open rectal cancer resection, even early in the learning curve. Tumor distance from the anal verge complicates open total mesorectal excision; however, robotic surgery is less impacted. Robotic resection may be a promising minimally invasive approach for rectal cancer resection.
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Sigman M. An improvement in surgical technique or a sham? Value of robotic assistance for male reproductive surgery. Fertil Steril 2018; 110:815. [PMID: 30316416 DOI: 10.1016/j.fertnstert.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Mark Sigman
- Division of Urology, Alpert Medical School of Brown University, Providence, Rhode Island; Lifespan, Providence, Rhode Island
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Subramaniam R. Current Use of and Indications for Robot-assisted Surgery in Paediatric Urology. Eur Urol Focus 2018; 4:662-664. [PMID: 30194030 DOI: 10.1016/j.euf.2018.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/27/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022]
Abstract
The use of robot-assisted surgery (RAS) by paediatric urologists is increasing. This mini review looks at the current status of RAS in paediatric urology. The challenges involved in RAS use in children are reviewed, as well as the indications for and feasibility of procedures performed and, where possible, outcomes with RAS. PATIENT SUMMARY: The current status of robot-assisted surgery (RAS) in paediatric urology, together with the challenges in using RAS for children is outlined in this mini review. Innovative adaptation has pushed the boundaries as regards the feasibility of RAS procedures in children with good outcomes.
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Affiliation(s)
- Ramnath Subramaniam
- Leeds Teaching Hospitals NHS Trust, Leeds, UK; University of Leeds, Leeds, UK; University of Ghent, Ghent, Belgium.
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Abstract
Twenty years after it was introduced, robotic surgery has become more commonplace in urology – we examine its current uses and controversies
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Abstract
A postoperative complications rate of nearly 50% has compelled oesophago-gastric practice to adopt minimally invasive techniques such as robotic surgery
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Affiliation(s)
- Y A Qureshi
- Department of Oesophago-Gastric Surgery, University College London Hospital , London
| | - B Mohammadi
- Department of Oesophago-Gastric Surgery, University College London Hospital , London
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Abstract
Recent studies exploring the effects of surgical robots on teamwork are revealing challenges not reflected in clinical studies. This study is a sub analysis of observational data collected from 89 procedures utilising the da Vinci systems. Previous analyses had demonstrated interactions between flow disruptions and contextual factors. This study sought a more granular analysis to provide better insight for improvement. Raters sub-classified disruptions, based upon the original notes, grouped according to four operative phases (pre-robot; docking; surgeon on console; undocking; and finish). The need for repeated utterances; additional supplies retrieval; fogging or matter on the endoscope and procedure-specific training were particularly disruptive. Variations across phases reflect differing demands across the operative course. Combined qualitative and quantitative observational methodologies can identify otherwise undocumented sources of process variation and potential failure. Future observational frameworks should attempt to merge human reliability analysis, a priori modelling, and post hoc analyses of observational data. Practioner Summary: Robotic surgery introduces new challenges into the operating room. Direct observation was used to classify and identify flow disruptions in order to diagnose problems in need of improvement. This technique complements other error prediction and system diagnostic methods which may not account for the complexity and transparency of health care.
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Affiliation(s)
- Ken R Catchpole
- a SmartState Endowed Chair in Clinical Practice and Human Factors, Department of Anesthesia and Perioperative Medicine , Medical University of South Carolina , Charleston , SC , USA
| | - Elyse Hallett
- b Department of Psychology , California State University , Long Beach , CA , USA
| | - Sam Curtis
- b Department of Psychology , California State University , Long Beach , CA , USA
| | - Tannaz Mirchi
- b Department of Psychology , California State University , Long Beach , CA , USA
| | - Colby P Souders
- c Department of Surgery , Cedars-Sinai Medical Center , West Hollywood , CA , USA
| | - Jennifer T Anger
- c Department of Surgery , Cedars-Sinai Medical Center , West Hollywood , CA , USA
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Huang YM, Huang YJ, Wei PL. Outcomes of robotic versus laparoscopic surgery for mid and low rectal cancer after neoadjuvant chemoradiation therapy and the effect of learning curve. Medicine (Baltimore) 2017; 96:e8171. [PMID: 28984767 PMCID: PMC5738003 DOI: 10.1097/md.0000000000008171] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Randomized controlled trials have demonstrated that laparoscopic surgery for rectal cancer is safe and can accelerate recovery without compromising oncological outcomes. However, such a surgery is technically demanding, limiting its application in nonspecialized centers. The operational features of a robotic system may facilitate overcoming this limitation. Studies have reported the potential advantages of robotic surgery. However, only a few of them have featured the application of this surgery in patients with advanced rectal cancer undergoing neoadjuvant chemoradiation therapy (nCRT).From January 2012 to April 2015, after undergoing nCRT, 40 patients with mid or low rectal cancer were operated using the robotic approach at our institution. Another 38 patients who were operated using the conventional laparoscopic approach were matched to patients in the robotic group by sex, age, the body mass index, and procedure. All operations were performed by a single surgical team. The clinicopathological characteristics and short-term outcomes of these patients were compared. To assess the effect of the learning curve on the outcomes, patients in the robotic group were further subdivided into 2 groups according to the sequential order of their procedures, with an equal number of patients in each group. Their outcome measures were compared.The robotic and laparoscopic groups were comparable with regard to pretreatment characteristics, rectal resection type, and pathological examination result. After undergoing nCRT, more patients in the robotic group exhibited clinically advanced diseases. The complication rate was similar between the 2 groups. The operation time and the time to the resumption of a soft diet were significantly prolonged in the robotic group. Further analysis revealed that the difference was mainly observed in the first robotic group. No significant difference was observed between the second robotic and laparoscopic groups.Although the robotic approach may offer potential advantages for rectal surgery, comparable short-term outcomes may be achieved when laparoscopic surgery is performed by experienced surgeons. However, our results suggested a shorter learning curve for robotic surgery for rectal cancer, even in patients who exhibited more advanced disease after undergoing nCRT.
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Affiliation(s)
- Yu-Min Huang
- Department of Surgery, College of Medicine
- Division of Gastrointestinal Surgery, Department of Surgery
- Cancer Research Center
| | - Yan Jiun Huang
- Department of Surgery, College of Medicine
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital
| | - Po-Li Wei
- Department of Surgery, College of Medicine
- Cancer Research Center
- Division of Colorectal Surgery, Department of Surgery, Taipei Medical University Hospital
- Division of Colorectal Surgery, Department of Surgery, Wan Fang Hospital
- Translational Laboratory, Department of Medical Research, Taipei Medical University Hospital
- Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei, Taiwan
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Zattoni F, Morlacco A, Cattaneo F, Soligo M, Meggiato L, Modonutti D, Valotto C, Dal Moro F, Zattoni F. Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies. Urology 2017; 109:38-43. [PMID: 28827196 DOI: 10.1016/j.urology.2017.06.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 05/21/2017] [Accepted: 06/19/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. RESULTS Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2, R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. CONCLUSION OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.
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Affiliation(s)
- Fabio Zattoni
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy; PhD Course in Clinical and Experimental Oncology and Immunology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy.
| | - Alessandro Morlacco
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Francesco Cattaneo
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Matteo Soligo
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Luca Meggiato
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Daniele Modonutti
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Claudio Valotto
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Fabrizio Dal Moro
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
| | - Filiberto Zattoni
- Department of Oncological and Surgical Sciences, Urology Clinic, University of Padua, Italy
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Buonpane C, Efiong E, Hunsinger M, Fluck M, Shabahang M, Wild J, Halm K, Long K, Buzas C, Blansfield J. Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database. Am Surg 2017; 83:918-924. [PMID: 28822402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.
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Abstract
PURPOSE OF REVIEW There has been a rapid and widespread adoption of the robotic surgical system with a lag in the development of a comprehensive training and credentialing framework. A literature search on robotic surgical training techniques and benchmarks was conducted to provide an evidence-based road map for the development of a robotic surgical skills for the novice robotic surgeon. RECENT FINDINGS A structured training curriculum is suggested incorporating evidence-based training techniques and benchmarks for progress. This usually involves sequential progression from observation, case assisting, acquisition of basic robotic skills in the dry and wet lab setting along with achievement of individual and team-based non-technical skills, modular console training under supervision, and finally independent practice. Robotic surgical training must be based on demonstration of proficiency and safety in executing basic robotic skills and procedural tasks prior to independent practice.
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Affiliation(s)
- Ashwin N. Sridhar
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Tim P. Briggs
- Department of Urology, University College London Hospital NHS Trust, London, UK
| | - John D. Kelly
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
| | - Senthil Nathan
- Department of Urology, University College London Hospital NHS Trust, London, UK
- Division of Surgery and Cancer, University College London, London, UK
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Kurosu K, Sumida I, Shiomi H, Mizuno H, Yamaguchi H, Okubo H, Tamari K, Seo Y, Suzuki O, Ota S, Inoue S, Ogawa K. A robust measurement point for dose verification in delivery quality assurance for a robotic radiosurgery system. J Radiat Res 2017; 58:378-385. [PMID: 27811201 PMCID: PMC5440860 DOI: 10.1093/jrr/rrw103] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 09/28/2016] [Indexed: 05/17/2023]
Abstract
In this CyberKnife® dose verification study, we investigated the effectiveness of the novel potential error (PE) concept when applied to the determination of a robust measurement point for targeting errors. PE was calculated by dividing the differences between the maximum increases and decreases in dose distributions by the original distribution after obtaining the former by shifting the source-to-axis and off-axis distances of each beam by ±1.0 mm. Thus, PE values and measurement point dose heterogeneity were analyzed in 48 patients who underwent CyberKnife radiotherapy. Sixteen patients who received isocentric dose delivery were set as the control group, whereas 32 who received non-isocentric dose delivery were divided into two groups of smaller PE (SPE) and larger PE (LPE) by using their median PE value. The mean dose differences (± standard deviations) were 1.0 ± 0.9%, 0.5 ± 1.4% and 4.1 ± 2.8% in the control, SPE and LPE groups, respectively. We observed significant correlations of the dose difference with the PE value (r = 0.582, P < 0.001) and dose heterogeneity (r = 0.471, P < 0.001). We concluded that when determining a robust measurement point for CyberKnife point dose verification, PE evaluation was more effective than the conventional dose heterogeneity-based method that introduced optimal measurement point dose heterogeneity of <10% across the detector.
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Affiliation(s)
- Keita Kurosu
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Department of Radiology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Iori Sumida
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
- Corresponding author. Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan. Tel: +81-6-6879-3482; Fax: +81-6-6879-3489;
| | - Hiroya Shiomi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hirokazu Mizuno
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hiroko Yamaguchi
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Okubo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Keisuke Tamari
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuji Seo
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Osamu Suzuki
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Seiichi Ota
- Department of Radiology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shinichi Inoue
- Department of Radiology, Osaka University Hospital, 2-15 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Kazuhiko Ogawa
- Department of Radiation Oncology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Robotically assisted minimally invasive mitral valve surgery. Clin Privil White Pap 2017;:1-17. [PMID: 28509527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Abstract
BACKGROUND Indicators of effectiveness and quality of care are of greatest importance in gauging the direct benefit of a new surgical technique, such as minimally-invasive pancreatic resections, when being compared with established approaches. METHODS Current expert opinion on minimally-invasive pancreatic resection (MIPR) was presented at the first MIPR state of the art conference during 12th world congress of the International Hepato-Pancreato-Biliary Association. RESULTS Studies exploring outcome of the minimally-invasive approach, alone or compared with open surgery, should consider all the necessary indicators of quality ensuring a high level of clinical care. Such studies should be implemented in a context that guarantees the correct indication for surgery, lower mortality rates, a low burden of post-operative morbidity through early recognition of adverse events and prevention of predictable complications, high standards of oncological "radicality", prompt recovery with access to adjuvant therapy as soon as possible, and reduction of health-care related costs. DISCUSSION Only by integrating MIPR with the outcome-improving effect of a dedicated pancreatic team will it be possible to assess more precisely the putative benefits of this minimally-invasive approach.
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Affiliation(s)
- Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Ahmidi N, Tao L, Sefati S, Gao Y, Lea C, Haro BB, Zappella L, Khudanpur S, Vidal R, Hager GD. A Dataset and Benchmarks for Segmentation and Recognition of Gestures in Robotic Surgery. IEEE Trans Biomed Eng 2017; 64:2025-2041. [PMID: 28060703 DOI: 10.1109/tbme.2016.2647680] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE State-of-the-art techniques for surgical data analysis report promising results for automated skill assessment and action recognition. The contributions of many of these techniques, however, are limited to study-specific data and validation metrics, making assessment of progress across the field extremely challenging. METHODS In this paper, we address two major problems for surgical data analysis: First, lack of uniform-shared datasets and benchmarks, and second, lack of consistent validation processes. We address the former by presenting the JHU-ISI Gesture and Skill Assessment Working Set (JIGSAWS), a public dataset that we have created to support comparative research benchmarking. JIGSAWS contains synchronized video and kinematic data from multiple performances of robotic surgical tasks by operators of varying skill. We address the latter by presenting a well-documented evaluation methodology and reporting results for six techniques for automated segmentation and classification of time-series data on JIGSAWS. These techniques comprise four temporal approaches for joint segmentation and classification: hidden Markov model, sparse hidden Markov model (HMM), Markov semi-Markov conditional random field, and skip-chain conditional random field; and two feature-based ones that aim to classify fixed segments: bag of spatiotemporal features and linear dynamical systems. RESULTS Most methods recognize gesture activities with approximately 80% overall accuracy under both leave-one-super-trial-out and leave-one-user-out cross-validation settings. CONCLUSION Current methods show promising results on this shared dataset, but room for significant progress remains, particularly for consistent prediction of gesture activities across different surgeons. SIGNIFICANCE The results reported in this paper provide the first systematic and uniform evaluation of surgical activity recognition techniques on the benchmark database.
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Sjövall H, Persson J. [Robot-assisted surgery on a broad front--without evidence for being cost-effective]. Lakartidningen 2016; 113:EAWT. [PMID: 27922703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Robot-assisted surgery on a broad front - without evidence for being cost-effective Robot-assisted surgery is currently heavily marketed. The HTA centre in Region Västra Götaland has produced five HTA reports regarding use of robot-assisted surgery in different clinical situations (prostatic cancer, benign gynaecological surgery, pediatric pyeloplasty and fundoplication, and rectal cancer), finding weak evidence for a patient value. The current report by Per Carlsson et al confirms that robot-assisted surgery indeed leads to increased costs that are not balanced by augmented patient value, i.e. robot-assisted surgery cannot be regarded as cost efficient. We comment critically on the capricious introduction of new techniques/devices, a procedure that stands in sharp contrast to the strictly formalized system for approval of new drugs.
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Affiliation(s)
- Henrik Sjövall
- Institute of Medicine - Göteborg, Sweden Institute of Medicine - Göteborg, Sweden
| | - Josefine Persson
- Hälsometri vid Sahlgrenska Akademin - Göteborg, Sweden Hälsometri vid Sahlgrenska Akademin - Göteborg, Sweden
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Harbin AC, Nadhan KS, Mooney JH, Yu D, Kaplan J, McGinley-Hence N, Kim A, Gu Y, Eun DD. Prior video game utilization is associated with improved performance on a robotic skills simulator. J Robot Surg 2016; 11:317-324. [PMID: 27853947 DOI: 10.1007/s11701-016-0657-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/30/2016] [Indexed: 10/20/2022]
Abstract
Laparoscopic surgery and robotic surgery, two forms of minimally invasive surgery (MIS), have recently experienced a large increase in utilization. Prior studies have shown that video game experience (VGE) may be associated with improved laparoscopic surgery skills; however, similar data supporting a link between VGE and proficiency on a robotic skills simulator (RSS) are lacking. The objective of our study is to determine whether volume or timing of VGE had any impact on RSS performance. Pre-clinical medical students completed a comprehensive questionnaire detailing previous VGE across several time periods. Seventy-five subjects were ultimately evaluated in 11 training exercises on the daVinci Si Skills Simulator. RSS skill was measured by overall score, time to completion, economy of motion, average instrument collision, and improvement in Ring Walk 3 score. Using the nonparametric tests and linear regression, these metrics were analyzed for systematic differences between non-users, light, and heavy video game users based on their volume of use in each of the following four time periods: past 3 months, past year, past 3 years, and high school. Univariate analyses revealed significant differences between heavy and non-users in all five performance metrics. These trends disappeared as the period of VGE went further back. Our study showed a positive association between video game experience and robotic skills simulator performance that is stronger for more recent periods of video game use. The findings may have important implications for the evolution of robotic surgery training.
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Affiliation(s)
- Andrew C Harbin
- Departments of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Kumar S Nadhan
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - James H Mooney
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daohai Yu
- Department of Clinical Sciences, Temple Clinical Research Institute, Lewis Katz School of Medicine at Temple University, 3440 N. Broad St-Kresge 216, Philadelphia, PA, 19140, USA.
| | - Joshua Kaplan
- Departments of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Andrew Kim
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Yiming Gu
- George Washington University, Washington, DC, USA
| | - Daniel D Eun
- Departments of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Lucas SR, Schabowsky CN. Clinical Engineering in Robotic Surgery Programs. Biomed Instrum Technol 2016; 50:415-420. [PMID: 27854493 DOI: 10.2345/0899-8205-50.6.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Affiliation(s)
- Rahila Essani
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA
| | - Roberto Bergamaschi
- Division of Colon & Rectal Surgery, State University of New York, Nichols Road, Stony Brook, NY 11794-819, USA.
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Suda K, Uyama I. [CURRENT STATUS AND FUTURE PERSPECTIVES OF ROBOTIC SURGERY]. Nihon Geka Gakkai Zasshi 2016; 117:381-386. [PMID: 30168999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The Da Vinci Surgical System was developed to overcome some of the disadvantages of conventional endoscopic surgery. We have been performing robotic gastrectomy or esophagectomy in patients with resectable gastric or esophageal cancer who agreed to uninsured use of the robot since 2009, resulting in reduced postoperative local complications including pancreatic fistula following gastrectomy and recurrent laryngeal nerve palsy after esophagectomy. Moreover, the greater the extent of resection and lymph node dissection, the greater this effect, suggesting that the robot may be more beneficial for advanced cancer than for early cancer. In the meantime, there have been a considerable number of reports, mostly focusing on early cancer, that the use of the robot may reduce cost-effectiveness in comparison with the conventional laparoscopic or thoracoscopic approach. Thus, since the beginning of October 2014, we have been conducting a multiinstitutional, single-arm prospective study designed to determine the impact of robotic assistance, which has been approved as advanced medical technology (senshiniryo) by the Japanese Ministry of Health, Labor and Welfare, on the outcomes after minimally invasive radical gastrectomy to treat resectable gastric cancer, with a focus on postoperative complications, long-term outcomes, and cost.
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Vedula SS, Malpani A, Ahmidi N, Khudanpur S, Hager G, Chen CCG. Task-Level vs. Segment-Level Quantitative Metrics for Surgical Skill Assessment. J Surg Educ 2016; 73:482-489. [PMID: 26896147 DOI: 10.1016/j.jsurg.2015.11.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 09/21/2015] [Accepted: 11/08/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Task-level metrics of time and motion efficiency are valid measures of surgical technical skill. Metrics may be computed for segments (maneuvers and gestures) within a task after hierarchical task decomposition. Our objective was to compare task-level and segment (maneuver and gesture)-level metrics for surgical technical skill assessment. DESIGN Our analyses include predictive modeling using data from a prospective cohort study. We used a hierarchical semantic vocabulary to segment a simple surgical task of passing a needle across an incision and tying a surgeon's knot into maneuvers and gestures. We computed time, path length, and movements for the task, maneuvers, and gestures using tool motion data. We fit logistic regression models to predict experience-based skill using the quantitative metrics. We compared the area under a receiver operating characteristic curve (AUC) for task-level, maneuver-level, and gesture-level models. SETTING Robotic surgical skills training laboratory. PARTICIPANTS In total, 4 faculty surgeons with experience in robotic surgery and 14 trainee surgeons with no or minimal experience in robotic surgery. RESULTS Experts performed the task in shorter time (49.74s; 95% CI = 43.27-56.21 vs. 81.97; 95% CI = 69.71-94.22), with shorter path length (1.63m; 95% CI = 1.49-1.76 vs. 2.23; 95% CI = 1.91-2.56), and with fewer movements (429.25; 95% CI = 383.80-474.70 vs. 728.69; 95% CI = 631.84-825.54) than novices. Experts differed from novices on metrics for individual maneuvers and gestures. The AUCs were 0.79; 95% CI = 0.62-0.97 for task-level models, 0.78; 95% CI = 0.6-0.96 for maneuver-level models, and 0.7; 95% CI = 0.44-0.97 for gesture-level models. There was no statistically significant difference in AUC between task-level and maneuver-level (p = 0.7) or gesture-level models (p = 0.17). CONCLUSIONS Maneuver-level and gesture-level metrics are discriminative of surgical skill and can be used to provide targeted feedback to surgical trainees.
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Affiliation(s)
- S Swaroop Vedula
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland.
| | - Anand Malpani
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland
| | - Narges Ahmidi
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland
| | - Sanjeev Khudanpur
- Department of Electrical & Computer Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Gregory Hager
- Department of Computer Science, Johns Hopkins University, Baltimore, Maryland
| | - Chi Chiung Grace Chen
- Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Noureldin YA, Stoica A, Kassouf W, Tanguay S, Bladou F, Andonian S. Incorporation of the da Vinci Surgical Skills Simulator at urology Objective Structured Clinical Examinations (OSCEs): a pilot study. Can J Urol 2016; 23:8160-8166. [PMID: 26892058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION To incorporate the da Vinci Surgical Skills Simulator (dVSSS) into Objective Structured Clinical Examinations (OSCEs) and to assess basic robotic skills of urology Post-Graduate Trainees (PGTs). MATERIALS AND METHODS PGTs in post-graduate years (PGY-3 to PGY-5) from two Quebec urology training programs were recruited. During a 20 minute OSCE station, PGTs were asked to fill in a questionnaire and perform two tasks: pick and place, and energy dissection level 1. For each exercise, the norm-referenced method was used to establish a passing score to determine competency. The participant was considered competent in these two basic dVSSS exercises if he/she gained the passing score on both tasks. RESULTS All nine PGTs who attended the OSCE voluntarily participated in the study. They had performed a median of 10 (IQR: 2.5-16) laparoscopic procedures, 2 (0-8) robotic procedures, and assisted 10 (IQR: 0-15) robotic procedures at the bedside prior to this OSCE. Based on a passing score of 90 for task 1 and 72 for task 2, there were 3 (33%) competent PGTs, all of whom were from PGY-5 level. Therefore, there was significant difference among PGY levels in terms of competency for the basic robotic skills tested (p = 0.01). When compared with PGTs, experts had performed significantly higher numbers of robotic procedures (5.2 +/- 2.4 versus 25 +/- 8.7; p = 0.02). However, there was no significant difference in the performance parameters between PGTs and experts in both tasks. CONCLUSION This study confirms the feasibility of incorporating dVSSS into OSCEs to assess basic robotic skills of urology PGTs. Future studies need to include more complex exercises and larger sample size to expand on these results.
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Vetter MH, Green I, Martino M, Fowler J, Salani R. Incorporating resident/fellow training into a robotic surgery program. J Surg Oncol 2015; 112:684-9. [PMID: 26289120 DOI: 10.1002/jso.24006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 07/27/2015] [Indexed: 01/09/2023]
Abstract
With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described.
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Affiliation(s)
| | | | - Martin Martino
- University of South Florida, Allentown, Pennsylvania
- Lehigh Valley Health Network, Allentown, Pennsylvania
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Fergo C, Pommergaard HC, Burcharth J, Rosenberg J. [Three-dimensional laparoscopy has the potential to replace two-dimensional laparoscopy in abdominal surgery]. Ugeskr Laeger 2015; 177:V11140635. [PMID: 26099183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Studies comparing three-dimensional (3D) laparoscopy with 2D laparoscopy have shown shorter operation time, a short learning curve as well as better depth perception. Robotic surgery includes the EndoWrist function in addition to the 3D view; however robotic surgery lacks haptic feedback. No evidence from clinical trials for the potential benefits of robotic surgery exists. Thus, 3D laparoscopy is an eligible alternative to both 2D laparoscopy and robotic surgery.
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Affiliation(s)
- Charlotte Fergo
- Center for Perioperativ Optimering, Herlev Hospital, Herlev Ringvej 75, 2730 Herlev.
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Affiliation(s)
- Jason C Pradarelli
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor3University of Michigan Medical School, Ann Arbor
| | - Darrell A Campbell
- Michigan Surgical Quality Collaborative, University of Michigan, Ann Arbor4Department of Surgery, University of Michigan, Ann Arbor
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor4Department of Surgery, University of Michigan, Ann Arbor
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Laviana AA, Williams SB, King ED, Chuang RJ, Hu JC. Robot assisted radical prostatectomy: the new standard? MINERVA UROL NEFROL 2015; 67:47-53. [PMID: 25424387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Over the past decade, the robotic assisted radical prostatectomy (RARP) has grown increasingly popular and quickly equated itself as the most commonly used modality to treat locally-confined prostate cancer. Despite increased utilization, there is limited comparative research demonstrating superiority for RARP over the conventional radical retropubic prostatectomy (RRP). Furthermore, though perioperative and short-term oncologic outcomes are equivalent if not superior for the robotic approach, the optimal utilization of robotic technology remains to be determined with cost serving as a primary driver. In this review, we performed a literature search to identify comparative effectiveness research as it pertains to RARP versus RRP. We performed a PubMed literature search for a review of articles published between 2000 and 2014 using the following keywords to identify pertinent research: "robot or robotic prostatectomy", "open or retropubic prostatectomy", "cost", "resource utilization". Long-term data comparing RARP and RRP remains limited, though short-term positive surgical margins, biochemical recurrence-free survival, and need for adjuvant therapy appear at least equivocal, if not in favor of RARP versus RRP. Functional outcomes including return of continence and potency favor RARP while cost still favors RRP. Nonetheless, the generalization of results remains difficult with surgeon volume playing a large role in improving efficiency and quality. For the foreseeable future, an increasing number of prostatectomies will continue to be performed robotically. Though RARP appears to offer improved functional outcomes with good short-term oncologic outcomes, there is a need for longer-term studies to assess the true value of RARP. Outcomes aside, rigorous, prospective randomized-controlled trials must also be performed on the cost-effectiveness of RARP to determine its overall utility in an era of health care delivery reform.
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Affiliation(s)
- A A Laviana
- Institute of Urologic Oncology Department of Urology David Geffen School of Medicine at UCLA Los Angeles, CA, USA -
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Taylor AS, Lee B, Rawal B, Thiel DD. Impact of fellowship training on robotic-assisted laparoscopic partial nephrectomy: benchmarking perioperative safety and outcomes. J Robot Surg 2015; 9:125-30. [PMID: 26531112 DOI: 10.1007/s11701-015-0498-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/16/2015] [Indexed: 11/25/2022]
Abstract
To provide perioperative benchmark data for surgeons entering practice from formal robotic training and performing robotic-assisted laparoscopic partial nephrectomy (RAPN). Perioperative outcomes of the first 100 RAPN from a surgeon entering into practice directly from robotic fellowship training were analyzed. Postoperative complications were categorized by Clavien-Dindo grade. Surgical "trifecta scores" and Margin, Ischemia, and Complication (MIC) scoring were utilized to assess surgical outcomes. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, North Carolina). Median age of the cohort was 63 years (22-81 years), and 34 (34.3%) patients were over age 65. Forty-one (41.4%) patients had a BMI > 30. Thirteen (13.1%) had RENAL 10-12 tumors, 22 of which (22.2%) were >4 cm in size. Median warm ischemia time was 17 min, and 13 patients had resection without warm ischemia. Five patients were converted to open partial nephrectomy, and 1 patient was converted to laparoscopic nephrectomy. Twenty-one patients (21.2%) experienced a complication, 6 of whom had a major (Clavien grade 3 or higher) complication with one grade 5 complication. Operating room time decreased with experience, but surgical complications and hospital stay did not change with experience. MIC score of renal cell carcinoma (RCC) patients was 74.7%, while the surgical trifecta was reached in 71.3 % of RCC patients. Surgeons may enter practice directly from formal robotic training and perform RAPN with perioperative outcomes, surgical complications, surgical trifecta scores, and MIC scoring in line with those the most experienced robotic partial nephrectomists.
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Affiliation(s)
- Abby S Taylor
- Department of Urology, Section of Biostatistics at Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Bruce Lee
- Mayo School of Health Sciences, Mayo Clinic College of Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Bhupendra Rawal
- Department of Health Sciences Research, Section of Biostatistics at Mayo Clinic, Jacksonville, FL, USA
| | - David D Thiel
- Department of Urology, Section of Biostatistics at Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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