Bhavin C. Shah

Miniature In Vivo Robotics and Novel Robotic Surgical Platforms

Robotic surgical systems, such as the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California), have revolutionized laparoscopic surgery but are limited by large size, increased costs, and limitations in imaging. Miniature in vivo robots are being developed that are inserted entirely into the peritoneal cavity for laparoscopic and natural orifice transluminal endoscopic surgical (NOTES) procedures. In the future, miniature camera robots and microrobots should be able to provide a mobile viewing platform. This article discusses the current state of miniature robotics and novel robotic surgical platforms and the development of future robotic technology for general surgery and urology.

Multipurpose surgical robot as a laparoscope assistant.

BackgroundThis study demonstrates the effectiveness of a new, compact surgical robot at improving laparoscope guidance. Currently, the assistant guiding the laparoscope camera tends to be less experienced and requires physical and verbal direction from the surgeon. Human guidance has disadvantages of fatigue and shakiness leading to inconsistency in the field of view. This study investigates whether replacing the assistant with a compact robot can improve the stability of the surgeon’s field of view and also reduce crowding at the operating table.MethodsA compact robot based on a bevel-geared “spherical mechanism” with 4 degrees of freedom and capable of full dexterity through a 15-mm port was designed and built. The robot was mounted on the standard railing of the operating table and used to manipulate a laparoscope through a supraumbilical port in a porcine model via a joystick controlled externally by a surgeon. The process was videotaped externally via digital video recorder and internally via laparoscope. Robot position data were also recorded within the robot’s motion control software.ResultsThe robot effectively manipulated the laparoscope in all directions to provide a clear and consistent view of liver, small intestine, and spleen. Its range of motion was commensurate with typical motions executed by a human assistant and was well controlled with the joystick.ConclusionsQualitative analysis of the video suggested that this method of laparoscope guidance provides highly stable imaging during laparoscopic surgery, which was confirmed by robot position data. Because the robot was table-mounted and compact in design, it increased standing room around the operation table and did not interfere with the workspace of other surgical instruments. The study results also suggest that this robotic method may be combined with flexible endoscopes for highly dexterous visualization with more degrees of freedom.

Does type of mesh used have an impact on outcomes in laparoscopic inguinal hernia

BACKGROUND Theoretically, a lighter and softer mesh may decrease nerve entrapment and chronic pain by creating less fibrosis and mesh contracture in laparoscopic inguinal hernia repair. METHODS We performed a telephone survey of patients who underwent laparoscopic inguinal hernia surgery between 2001 and 2007. We recorded patient responses for chronic pain, foreign body sensation, recurrence, satisfaction, and return to work, and then studied the effect of type of mesh (polypropylene vs polyester) on these factors. RESULTS Of 109 consecutive patients surveyed (mean age, 54.5 y), 67 eligible patients underwent 84 transabdominal extraperitoneal procedures and 2 transabdominal preperitoneal procedures. Patients with polypropylene mesh had a 3 times higher rate of chronic pain (P = .05), feeling of lump (P = .02), and foreign body perception (P = .05) than the polyester mesh group. Our overall 1-year recurrence rate was 5.9%. The recurrence rate was 9.3% for the polypropylene group and 2.9% for the polyester group (P = .26). CONCLUSIONS A lightweight polyester mesh has better long-term outcomes for chronic pain and foreign body sensation compared with a heavy polypropylene mesh in laparoscopic inguinal hernia repair. We also saw a trend toward higher recurrence in the polypropylene group.

National trends in discharge disposition after hepatic resection for malignancy.

BACKGROUND There is a paucity of data on the trends in discharge disposition for patients undergoing hepatic resection for malignancy. AIM To analyse the national trends in discharge disposition after hepatic resection for malignancy. METHODS The National Inpatient Sample (NIS) database was queried (1993 to 2005) to identify patients that underwent hepatic resection for malignancy and analyse the discharge status (home, home health or rehabilitation/skilled facility). RESULTS A weighted total of 74,520 patients underwent hepatic resection of whom, 53,770 patients had a principal diagnosis of malignancy. The overall mortality improved from 6.3% to 3.4%. After excluding patients that died in the post-operative period and those with incomplete discharge status, 45,583 patients were included. The proportion of patients that had acute care needs preventing them from being discharged home without assistance increased from 10.9% in 1993 to 19.5% in 2005. While there was an increase in the number of patients discharged to home health care during this time (8.9% to 13.8%), there was a larger increase in the proportion of patients that were discharged to a rehabilitation or skilled nursing facility (2% to 5.7%). Despite a decrease in the mortality rates, there was no improvement in rate of patients discharged home without assistance over the period of the study. CONCLUSIONS The results of the present study demonstrate that after hepatic resection, a significant proportion of patients will need assistance upon discharge. This information needs to be included in patient counselling during pre-operative risk and benefit assessment.

The Subspecialization of Surgery: A Paradigm Shift

General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by “specialists”. The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Recent advances in the CoBRASurge robotic manipulator and dexterous miniature in vivo robotics for minimally invasive surgery

Abstract Minimally invasive surgery (MIS) reduces trauma and improves patient recovery. Traditional laparoscopic procedures are performed using multiple long, thin tools that are inserted through small incisions in the abdominal wall. The advantages of these procedures are often restricted to less complicated procedures owing to imaging and tissue manipulation limitations. These limitations can be overcome using advanced surgical systems, such as da Vinci®, that provide the surgeon with enhanced visualization and improved tool dexterity. However, the da Vinci system is expensive and occupies significant space in the operating room. The compact bevel-geared robot for advanced surgery, CoBRASurge, is a compact robotic system that addresses the space and expense limitations of large external robotic systems. This system provides a stable platform for laparoscopic tool manoeuvring, while also allowing the surgical team improved access to the patient. New methods for performing MIS, including single incision and natural orifice access, are also being developed to further minimize invasiveness through reducing or eliminating external incisions. However, the instruments for these procedures are further limited by accessing the peritoneal cavity through a single insertion point. Dexterous miniature robots that are completely inserted into the peritoneal cavity are being developed that mitigate these limitations to provide improved triangulation.

Discharge disposition after pancreatic resection for malignancy: analysis of national trends.

OBJECTIVES The aim of this study is to analyse national trends in discharge disposition following pancreatic resection for malignancy in the USA. METHODS The Nationwide Inpatient Sample database was queried for 1993-2005 to identify patients who underwent pancreatic resection for malignancy. The status of patients at discharge (to home, home with home health care or to another facility) was noted. RESULTS A weighted total of 51 866 patients who underwent pancreatectomy for malignant neoplasm of the pancreas were identified. Patients who died in the postoperative period and patients without a specified discharge disposition were excluded, leaving 43 603 patients for inclusion in the study. Overall mortality improved over the period of the study from 7.1% in 1993 to 5.2% in 2005. The number of patients discharged to another facility increased significantly from 5.5% in 1993 to 13.3% in 2005. Similarly, the number of patients discharged to home with home health assistance increased from 20.0% in 1993 to 33.0% in 2005. This corresponded with a statistically significant decrease in the number of patients discharged to home without assistance, from 74.5% in 1993 to 53.7% in 2005 (P= 0.002). CONCLUSIONS The results of our study demonstrate that following pancreatic resection for malignancy, nearly half the patients will require some assistance after discharge.

Impact of Advanced Laparoscopy Courses on Present Surgical Practice

Advanced laparoscopic workshops provide an efficacious instrument for educating surgeons in minimally invasive techniques.