Amanjot S. Sethi

Validation of a Novel Virtual Reality Robotic Simulator

PURPOSE We evaluated the face, content, and construct validity of what is, to our knowledge, the only available virtual reality simulator based on a complete kinematic representation of the da Vinci surgical system. MATERIALS AND METHODS A total of 5 experts (EPs) and 15 novices (NVs) completed exercises on the Mimic dV-Trainer (MdVT). All participants completed three repetitions of the following tasks: (1) Ring and Cone, (2) String Walk, and (3) Letterboard. Participants rated parameters of face and content validity on a five-point Likert-scale questionnaire. Workload imposed by the simulator was assessed using a NASA Task Load Index questionnaire (TLX). RESULTS Face validity of the MdVT was established as all 20 participants rated the simulator between average to easy-to-use and above-average to high in all parameters of realism. Participants in both EP and NV groups rated the MdVTs overall relevance to robotic surgery as very high. All five EPs assessed the simulator to be a very good practice format and very useful for training residents, thereby affirming content validity. A preliminary assessment of construct validity suggested that the MdVT could differentiate EPs from NVs. The overall TLX workload scores were lower in the EP group for all parameters except for temporal demand. CONCLUSIONS The MdVT demonstrated excellent face and content validity as well as reasonable workload parameters. The use of this simulator in resident training may help bridge the gap between the safe acquisition of surgical skills and effective performance during live robot-assisted surgery.

Robot Assisted Laparoscopic Partial Nephrectomy: A Viable and Safe Option in Children

PURPOSE The safety, benefits and usefulness of laparoscopic partial nephrectomy have been demonstrated in the pediatric population. We describe our technique, and determine the safety and feasibility of robot assisted laparoscopic partial nephrectomy based on our initial experience. MATERIALS AND METHODS We retrospectively reviewed robot assisted laparoscopic partial nephrectomy performed at our institution between 2002 and 2005. The technique was conducted via a transperitoneal approach with the da Vinci Surgical System using standard laparoscopic procedural steps. Clinical indicators of outcomes included estimated blood loss, complications, in hospital narcotic use and length of stay. RESULTS Robot assisted laparoscopic partial nephrectomy was completed successfully in 9 cases. Mean patient age was 7.2 years and mean followup was 6 months. Mean operative time was 275 minutes and mean estimated blood loss was 49 ml. Operative times improved significantly with experience. Overall patients had a mean hospitalization of 2.9 days and required 1.3 mg morphine per kg. All patients had a normal remaining renal moiety confirmed on Doppler ultrasound. The only complication was an asymptomatic urinoma discovered on ultrasound, which was treated with percutaneous drainage and ultimately resolved. CONCLUSIONS Our initial experience shows the safety and feasibility of robot assisted laparoscopic partial nephrectomy in children. Operative time decreases with experience. The enhanced visualization and dexterity of a robotic system potentially offer improved efficiency and safety over standard laparoscopy. Robot assisted laparoscopy is an option for partial nephrectomy and may become the minimally invasive treatment of choice.

Comparison of laparoscopy training using the box trainer versus the virtual trainer.

The virtual reality trainer was found to be a reasonable alternative to the box trainer for laparoscopic skills training.

Robot-Assisted Laparoscopic Nephrectomy and Contralateral Ureteral Reimplantation in Children

BACKGROUND Robot-assisted laparoscopic surgery (RALS) has expanded the role for minimally invasive surgery within pediatrics. RALS may be particularly beneficial for the treatment of children with a refluxing nonfunctioning renal moiety and contralateral vesicoureteral reflux. In this report, we describe a single RALS procedure, which includes both nephrectomy or partial nephrectomy, and contralateral extravesical ureteral reimplantation (EVUR). METHODS A retrospective review was performed of four patients who underwent RALS nephrectomy/partial nephrectomy and concurrent EVUR in one setting. Procedures were performed by a single surgeon using a robot-assisted laparoscopic approach. Four ports were used in a transperitoneal approach with patient positioning changed without moving the robotic system between the nephrectomy and reimplant. We described the technique and assessed its safety and efficacy. RESULTS All cases were treated with the single RALS approach. Mean patient age was 2.3 years. Three patients underwent a nephrectomy and one a lower pole partial nephrectomy. The mean estimated blood loss was 16 mL, mean operative time was 291 minutes, and mean length of stay was 2.3 days. There was one case of postoperative ureteral obstruction that was treated with 3 weeks of ureteral stenting without further sequela. Overall, the mean follow-up time was 21 months and follow-up renal ultrasonographs and radionuclide cystograms were normal in all patients. CONCLUSIONS A single RALS procedure that combines nephrectomy/partial nephrectomy and EVUR offers a novel approach to a clinical dilemma that often requires two operations. In this small series, RALS was safe and efficacious. We recommend routine Double-J stenting for the solitary reimplanted ureter.

Laparoscopic adrenalectomy: Surgical techniques

Since its first description in 1992, laparoscopic adrenalectomy has become the gold standard for the surgical treatment of most adrenal conditions. The benefits of a minimally invasive approach to adrenal resection such as decreased hospital stay, shorter recovery time and improved patient satisfaction are widely accepted. However, as this procedure becomes more widespread, critical steps of the operation must be maintained to ensure expected outcomes and success. This article reviews the surgical techniques for the laparoscopic adrenalectomy.

Pathologic upstaging after laparoscopic radical nephrectomy

OBJECTIVE Accurate tumor staging in renal cancer is critical for prognostic projections, follow-up schedules, clinical trials and potential systemic therapies. We studied patients undergoing laparoscopic radical nephrectomy (LRN) to determine the extent of upstaging on histopathology evaluation and correlated the clinical and pathology staging to determine the factors responsible for upstaging. PATIENTS AND METHODS A retrospective review of patients undergoing LRN for renal cell cancer was performed. Clinical staging was determined by CT/MRI scan and/or related preoperative work up (using AJCC TNM staging criteria). Histopathology reports were studied in to determine the p-stage. Lymph node (LN) status was evaluated with attention to number and positivity of LNs in the specimen. Pathologic features that dictated upstaging were analyzed. The factors responsible for pathologic upstaging were analyzed. Statistical analysis was performed using JMP 5.0.12 software; comparisons were done using chi square or Fisher exact test. RESULTS One hundred twenty three patients qualified for the study; mean age was 62.14+/-13.6 years, M:F ratio was 60:63 and mean tumor size of 5.3+/-2.0 cm. Clinical versus pathologic T stage distribution was T1a=41:37, T1b=43:31, T2=25:12, T3a=11:31, T3b=3:10 and T4=0:2. A total 38/123 (31%) patients were upstaged following histopathology examination. Upstaging was due to change in tumor size in 12, renal sinus fat involvement in 8, renal or adrenal vein involvement in 14, focal perirenal fat involvement in 6, and focal renal capsule penetration in 4 patients. Fifty two patients had LNs in the specimen with 19 (16%) patients had 2 or more lymph nodes and 5 had positive LNs. Mean tumor size was 5.3+/-2 cms at clinical, and 5.0+/-2.6 cms at pathology staging (P=NS). 5 patients had LN metastasis detected with tumor size of 5.5, 5.6, 6.8, and 7.2 cms in diameter, and one patient with LN metastasis was T1a stage (3.2 cm). Renal vein/inferior venal cava/adrenal vein was involved in 14 patients, adrenal was involved in 21 patients and renal sinus was involved in 19/123 patients. CONCLUSIONS Pathologic upstaging of malignant renal neoplasms occurred in about 31% of patients following LRN. Down staging was less common and mean tumor size does not significantly change.

RANDOMIZED PROSPECTIVE EVALUATION OF THE EFFECT OF PATIENT POSITIONING ON SURGICAL OUTCOMES DURING LAPAROSCOPIC RENAL AND ADRENAL SURGERY

INTRODUCTION AND OBJECTIVES: We report a prospective comparison of operative table positioning (i.e. flexion or no flexion) and its effect on outcomes in laparoscopic renal and adrenal surgery. METHODS: 30 consecutive patients undergoing laparoscopic nephrectomy or adrenalectomy by a single surgeon (CPS) were randomized to surgery with (FL) or without (NF) a 45 degree flexion of the operative table. A single surgeon performed all operations with a transperitoneal pure laparoscopic or hand assisted approach. Operative parameters such as ease of bowel mobilization (BM), ease of renal hilar dissection (HD), and overall difficulty of dissection (DD) were recorded on a 10 point Likert scale. Operative (OT), estimated blood loss (EBL), post-operative pain and peri-operative complications were also recorded prospectively. RESULTS: There were 15 and 15 patients in the FL and NF groups respectively. There were no statistically significant differences in BM, HD, DD, OT, EBL, or post-operative pain. The two complications in the FL group which included testicular pain and a minor serosal injury during mobilization of the colon. This serosal injury was repaired laparoscopically without further sequelae. There was one trocar site infection in the NF group. CONCLUSIONS: Although flexion of the operative table during laparoscopic nephrectomy and adrenalectomy has become standard practice, the effects of such positioning on operative time, ease of exposure, post-operative pain and complications has not been previously defined. Our prospective comparison suggests that there is no benefit to table flexion during laparoscopic renal and adrenal surgery. Surgical exposure, dissection and outcomes do not appear to be affected by patient positioning in this series