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Dive into the research topics where Azad S. Najmaldin is active.

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Featured researches published by Azad S. Najmaldin.


Journal of Pediatric Surgery | 2013

The first decade of robotic surgery in children

Thomas P. Cundy; Kunal Shetty; James Clark; Tou Pin Chang; Kumuthan Sriskandarajah; Nicholas E. Gattas; Azad S. Najmaldin; Guang-Zhong Yang; Ara Darzi

BACKGROUND Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children. METHODS A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012. RESULTS Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%. CONCLUSIONS Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.


Journal of Pediatric Surgery | 2013

Work-related upper limb musculoskeletal disorders in paediatric laparoscopic surgery. A multicenter survey

Ciro Esposito; Alaa El Ghoneimi; Atsuyuki Yamataka; Steve Rothenberg; Marcela Bailez; Marcelo Martínez Ferro; Piergiorgio Gamba; Marco Castagnetti; Girolamo Mattioli; Pascale Delagausie; Dimitris Antoniou; Philippe Montupet; Antonio Marte; Amulya K. Saxena; Mirko Bertozzi; Paul Philippe; François Varlet; Hubert Lardy; Antony Caldamone; Alessandro Settimi; Gloria Pelizzo; François Becmeur; Maria Escolino; Teresa De Pascale; Azad S. Najmaldin; Felix Schier

BACKGROUND Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons. METHODS A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG. RESULTS The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10 years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ(2)=0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ(2)=0.05). CONCLUSIONS These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms.


BJUI | 2014

Meta-analysis of robot-assisted vs conventional laparoscopic and open pyeloplasty in children

Thomas P. Cundy; Leanne Harling; Archie Hughes-Hallett; Erik Mayer; Azad S. Najmaldin; Thanos Athanasiou; Guang-Zhong Yang; Ara Darzi

To critically analyse outcomes for robot‐assisted pyeloplasty (RAP) vs conventional laparoscopic pyeloplasty (LP) or open pyeloplasty (OP) by systematic review and meta‐analysis of published data.


Journal of Pediatric Surgery | 2014

International attitudes of early adopters to current and future robotic technologies in pediatric surgery

Thomas P. Cundy; Hani J. Marcus; Archie Hughes-Hallett; Azad S. Najmaldin; Guang-Zhong Yang; Ara Darzi

BACKGROUND Perceptions toward surgical innovations are critical to the social processes that drive technology adoption. This study aims to capture attitudes of early adopter pediatric surgeons toward robotic technologies in order to clarify 1) specific features that are driving appeal, 2) limiting factors that are acting as diffusion barriers, and 3) future needs. METHODS Electronic surveys were distributed to pediatric surgeons with personal experience or exposure in robotic surgery. Participants were classified as experts or nonexperts for subgroup analysis. Coded Likert scale responses were analyzed using the Friedman or Mann-Whitney test. RESULTS A total of 48 responses were received (22 experts, 26 nonexperts), with 14 countries represented. The most highly rated benefits of robot assistance were wristed instruments, stereoscopic vision, and magnified view. The most highly rated limitations were capital outlay expense, instrument size, and consumables/maintenance expenses. Future technologies of greatest interest were microbots, image guidance, and flexible snake robots. CONCLUSIONS Putative benefits and limitations of robotic surgery are perceived with widely varied weightings. Insight provided by these responses will inform relevant clinical, engineering, and industry groups such that unambiguous goals and priorities may be assigned for the future. Pediatric surgeons seem most receptive toward technology that is smaller, less expensive, more intelligent and flexible.


Journal of Pediatric Surgery | 2015

Learning curve evaluation using cumulative summation analysis-a clinical example of pediatric robot-assisted laparoscopic pyeloplasty.

Thomas P. Cundy; Nicholas E. Gattas; Alan D. White; Azad S. Najmaldin

BACKGROUND The cumulative summation (CUSUM) method for learning curve analysis remains under-utilized in the surgical literature in general, and is described in only a small number of publications within the field of pediatric surgery. This study introduces the CUSUM analysis technique and applies it to evaluate the learning curve for pediatric robot-assisted laparoscopic pyeloplasty (RP). METHODS Clinical data were prospectively recorded for consecutive pediatric RP cases performed by a single-surgeon. CUSUM charts and tests were generated for set-up time, docking time, console time, operating time, total operating room time, and postoperative complications. Conversions and avoidable operating room delay were separately evaluated with respect to case experience. Comparisons between case experience and time-based outcomes were assessed using the Students t-test and ANOVA for bi-phasic and multi-phasic learning curves respectively. Comparison between case experience and complication frequency was assessed using the Kruskal-Wallis test. RESULTS A total of 90 RP cases were evaluated. The learning curve transitioned beyond the learning phase at cases 10, 15, 42, 57, and 58 for set-up time, docking time, console time, operating time, and total operating room time respectively. All comparisons of mean operating times between the learning phase and subsequent phases were statistically significant (P=<0.001-0.01). No significant difference was observed between case experience and frequency of post-operative complications (P=0.125), although the CUSUM chart demonstrated a directional change in slope for the last 12 cases in which there were high proportions of re-do cases and patients <6 months of age. CONCLUSIONS The CUSUM method has a valuable role for learning curve evaluation and outcome quality monitoring. In applying this statistical technique to the largest reported single surgeon series of pediatric RP, we demonstrate numerous distinctly shaped learning curves and well-defined learning phase transition points.


Journal of Endourology | 2014

Experience Related Factors Compensate for Haptic Loss in Robot-Assisted Laparoscopic Surgery

Thomas P. Cundy; Nicholas E. Gattas; Guang-Zhong Yang; Ara Darzi; Azad S. Najmaldin

BACKGROUND AND PURPOSE Surgeons anecdotally report awareness of nontactile sensory cues that compensate for absent haptic feedback in robot-assisted surgery. This study investigates this poorly understood adaptive process by evaluating frequency of in vivo suture damage. PATIENTS AND METHODS Consecutive cases of children undergoing robot-assisted dismembered pyeloplasty were examined. Suture damage was defined as incomplete (i.e., fraying) or complete (i.e., broken) loss of thread integrity and prospectively recorded with clinical data. Suture technique, size, and robotic instruments used for suturing were subjected to post hoc analysis. Statistical analysis was undertaken using appropriate nonparametric tests. RESULTS Overall frequency of suture damage was 2.6% among 1135 sutures used in 52 patients. The mean number of sutures used for cases in this series was 22 (standard deviation±6). There was a significant inverse trend between surgeon experience and suture damage frequency (P=0.014), implying that greater surgeon experience was associated with less suture damage. The impact of experience on suture damage was most apparent when comparing the earliest quartile subgroup (Q1) with the later three quartile subgroups (Q2-Q4) (P<0.001). Plateau of suture damage frequency was seen after approximately 28 cases. Continuous sutures had significantly higher damage frequency compared with interrupted sutures (P=0.022). Significantly higher frequency of suture damage was seen with cases in which forceps instruments were used for suturing compared with paired needle drivers (1.4% vs 7.1%, P<0.001). All events of inadvertent tissue injury involved damage to exposed edges of the renal pelvis (n=5). CONCLUSIONS Suture damage is likely to be encountered during the learning curve of robot-assisted surgery but decreases with surgeon experience. Preferential use of larger suture size, interrupted sutures, and paired needle driver instruments may help to minimize suture damage. Experience-related perceptual skills that compensate for haptic loss are likely to be acquirable in a preclinical simulation environment.


International Journal of Medical Robotics and Computer Assisted Surgery | 2015

The learning curve of robot-assisted laparoscopic fundoplication in children: a prospective evaluation and CUSUM analysis

Thomas P. Cundy; Simon P. Rowland; Nicholas E. Gattas; Alan D. White; Azad S. Najmaldin

Fundoplication is a leading application of robotic surgery in children, yet the learning curve for this procedure (RF) remains ill‐defined. This study aims to identify various learning curve transition points, using cumulative summation (CUSUM) analysis.


European Journal of Pediatric Surgery | 2013

Robot-Assisted Minimally Invasive Surgery for Pediatric Solid Tumors: A Systematic Review of Feasibility and Current Status

Thomas P. Cundy; Hani J. Marcus; James Clark; Archie Hughes-Hallett; Erik Mayer; Azad S. Najmaldin; Guang-Zhong Yang; Ara Darzi

INTRODUCTION Open surgery remains the primary technique for resection of pediatric solid tumors despite the popularity of minimally invasive surgery (MIS) for oncological indications in adults and nononcological indications in children. Robot-assisted surgery offers technical and ergonomic advantages that might make MIS more achievable in this setting, permitting benefits for both the patient and surgeon. The aim of this study is to critically appraise the current status of robot-assisted MIS for pediatric solid tumors. MATERIALS AND METHODS A systematic search of multiple electronic literature databases was undertaken, supplemented by several relevant secondary sources. RESULTS A total of 23 publications met eligibility criteria, reporting 40 cases overall. Indications for surgery were widely varied, with over 20 different pathologies described. One-third of tumors were classified as malignant. Most procedures involved abdominal or retroperitoneal located tumors in adolescent patients (age range, 1-18 years). The collective complication and conversion rates were 10% and 12.5%, respectively. Oncological adverse events involved two isolated events of tumor spillage and residual disease. The evidence is limited to case reports and small case series only. CONCLUSIONS For the diverse and highly selective cases in this review, robot-assisted MIS seems safe and feasible. Current status is low volume, in a relatively static state of adoption, and without any apparent index pathology or procedure. The benefits of robot assistance seem well suited but remain unsubstantiated by evidence. Higher quality studies are needed to determine true safety and efficacy.


BJUI | 2015

Robotic versus non-robotic instruments in spatially constrained operating workspaces: a pre-clinical randomized crossover study

Thomas P. Cundy; Hani J. Marcus; Archie Hughes-Hallett; Thomas MacKinnon; Azad S. Najmaldin; Guang-Zhong Yang; Ara Darzi

To compare the effectiveness of robotic and non‐robotic laparoscopic instruments in spatially constrained workspaces.


Archive | 2017

Robot Assisted Surgery for Choledochal Cyst

Naved K. Alizai; Michael J. Dawrant; Azad S. Najmaldin

For the child with a choledochal cyst the treatment of choice is cyst excision with hepaticoenterostomy [1]. Traditionally this has been performed as an open procedure with hepaticojejunostomy. In 1995, the first report of this condition being treated by minimally invasive laparoscopic surgery was published [2]. Initially the uptake of this procedure was slow, because it is a technically demanding procedure. However the last 7 years have seen a marked upsurge in the application of laparoscopic treatment of choledochal cyst with the publication of some large [3–5] and some staggeringly large series [6–8] from centres in South-East Asia, where the condition is more prevalent. The minimally invasive approach has clearly become their standard approach. We adopted this technique in 2007. However, as a department with an interest in robotic surgery and providing supra-regional paediatric liver care, in 2009, we made the transition from conventional laparoscopic to robot assisted excision of choledochal cyst and Roux-en-Y hepaticojejunostomy. This new technique has become our standard approach for treating patients with choledochal cysts [9, 10].

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Ara Darzi

Imperial College London

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Erik Mayer

Imperial College London

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Alessandro Settimi

University of Naples Federico II

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Ciro Esposito

University of Naples Federico II

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Maria Escolino

University of Naples Federico II

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