François Louis Pugin

Randomized clinical trial of laparoendoscopic single-site versus conventional laparoscopic cholecystectomy

Conventional laparoscopy with three or more ports remains the ‘gold standard’ for cholecystectomy, but a laparoendoscopic single‐site (LESS) approach is emerging, designed to decrease parietal trauma and improve cosmesis. This study compared conventional laparoscopic (CL) with LESS cholecystectomy, with short‐term clinical results as the main outcomes.

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

Background  Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.

Reducing cost of surgery by avoiding complications: the model of robotic Roux-en-Y gastric bypass.

BackgroundRobotic surgery is a complex technology offering technical advantages over conventional methods. Still, clinical outcomes and financial issues have been subjects of debate. Several studies have demonstrated higher costs for robotic surgery when compared to laparoscopy or open surgery. However, other studies showed fewer costly anastomotic complications after robotic Roux-en-Y gastric bypass (RYGBP) when compared to laparoscopy.MethodsWe collected data for our gastric bypass patients who underwent open, laparoscopic, or robotic surgery from June 1997 to July 2010. Demographic data, BMI, complications, mortality, intensive care unit stay, hospitalization, and operating room (OR) costs were analyzed and a cost projection completed. Sensitivity analyses were performed for varied leak rates during laparoscopy, number of robotic cases per month, number of additional staplers during robotic surgery, and varied OR times for robotic cases.ResultsNine-hundred ninety patients underwent gastric bypass surgery at the University Hospital Geneva from June 1997 to July 2010. There were 524 open, 323 laparoscopic, and 143 robotic cases. Significantly fewer anastomotic complications occurred after open and robotic RYGBP when compared to laparoscopy. OR material costs were slightly less for robotic surgery (USD 5,427) than for laparoscopy (USD 5,494), but more than for the open procedure (USD 2,251). Overall, robotic gastric bypass (USD 19,363) was cheaper when compared to laparoscopy (USD 21,697) and open surgery (USD 23,000).ConclusionsRobotic RYGBP can be cost effective due to balancing greater robotic overhead costs with the savings associated with avoiding stapler use and costly anastomotic complications.

Augmented reality and image overlay navigation with OsiriX in laparoscopic and robotic surgery: not only a matter of fashion

BackgroundNew technologies can considerably improve preoperative planning, enhance the surgeon’s skill and simplify the approach to complex procedures. Augmented reality techniques, robot assisted operations and computer assisted navigation tools will become increasingly important in surgery and in residents’ education.MethodsWe obtained 3D reconstructions from simple spiral computed tomography (CT) slides using OsiriX, an open source processing software package dedicated to DICOM images. These images were then projected on the patients body with a beamer fixed to the operating table to enhance spatial perception during surgical intervention (augmented reality).ResultsChanging a windows deepness level allowed the surgeon to navigate through the patients anatomy, highlighting regions of interest and marked pathologies. We used image overlay navigation for laparoscopic operations such cholecystectomy, abdominal exploration, distal pancreas resection and robotic liver resection.ConclusionsAugmented reality techniques will transform the behaviour of surgeons, making surgical interventions easier, faster and probably safer. These new techniques will also renew methods of surgical teaching, facilitating transmission of knowledge and skill to young surgeons.

Minimally invasive necrosectomy for infected necrotizing pancreatitis.

Objectives: Infected necrotizing pancreatitis represents a serious and therapeutically challenging complication. Percutaneous drainage of infected pancreatic necrosis is often unsuccessful. Alternatively, open necrosectomies are associated with high morbidity. Recently, minimally invasive necrosectomy techniques have been tried with satisfying results; however, they frequently necessitate multiple sessions for definitive necrosectomy. To evaluate results of single large-port laparoscopic necrosectomy for proven infected necrotizing pancreatitis. Methods: Eight patients presenting proven infected pancreatic necrosis during course of acute pancreatitis and not responding to radiological drainage were prospectively offered minimally invasive necrosectomy. Laparoscopic necrosectomy were performed using a single large port placed along the drain tract directly into the infected necrosis. In all patients, drainage was placed during laparoscopic necrosectomy for continuous postoperative lavage. Results: No perioperative complications were recorded with a median operative time of 87 ± 42 minutes. No blood transfusions were needed. No surgical postoperative morbidity and mortality were recorded. In all cases, except for one patient with multiple abscesses, only one session of necrosectomy was sufficient to completely clear the necrotic abscess. Laparoscopic necrosectomy was successful in all patients, and none required complementary surgical or radiological treatment. Conclusions: Minimally invasive necrosectomy has been safe and highly efficient through single large-port laparoscopy for infected pancreatic necrosis in our series of patients. Minimally invasive necrosectomy is a promising technique for infected necrotizing pancreatitis and should be regarded as a valid therapeutic option for necrotizing pancreatitis.

Intra-operative fluorescent cholangiography using indocyanin green during robotic single site cholecystectomy.

Very recently, robotic single site cholecystectomy (RSSC) has been reported feasible and safe for selected cases. While an intra‐operative cholangiography can be performed, data is scarce with respect to its use. Indocyanin green (ICG) has been shown to be a viable option to visualize biliary anatomy. Since the introduction of a new near infrared camera integrated to the da Vinci Si System (Intuitive Surgical, Sunnyvale, CA), the surgeon is able to assess the biliary anatomy by a non‐invasive and non‐ionizing method. This paper presents the first report of ICG imaging during a RSSC.

Augmented environments for the targeting of hepatic lesions during image-guided robotic liver surgery

BACKGROUND Stereotactic navigation technology can enhance guidance during surgery and enable the precise reproduction of planned surgical strategies. Currently, specific systems (such as the CAS-One system) are available for instrument guidance in open liver surgery. This study aims to evaluate the implementation of such a system for the targeting of hepatic tumors during robotic liver surgery. MATERIAL AND METHODS Optical tracking references were attached to one of the robotic instruments and to the robotic endoscopic camera. After instrument and video calibration and patient-to-image registration, a virtual model of the tracked instrument and the available three-dimensional images of the liver were displayed directly within the robotic console, superimposed onto the endoscopic video image. An additional superimposed targeting viewer allowed for the visualization of the target tumor, relative to the tip of the instrument, for an assessment of the distance between the tumor and the tool for the realization of safe resection margins. RESULTS Two cirrhotic patients underwent robotic navigated atypical hepatic resections for hepatocellular carcinoma. The augmented endoscopic view allowed for the definition of an accurate resection margin around the tumor. The overlay of reconstructed three-dimensional models was also used during parenchymal transection for the identification of vascular and biliary structures. Operative times were 240 min in the first case and 300 min in the second. There were no intraoperative complications. CONCLUSIONS The da Vinci Surgical System provided an excellent platform for image-guided liver surgery with a stable optic and instrumentation. Robotic image guidance might improve the surgeons orientation during the operation and increase accuracy in tumor resection. Further developments of this technological combination are needed to deal with organ deformation during surgery.

Hybrid natural orifice transluminal endoscopic surgery (NOTES) for Roux-en-Y gastric bypass: an experimental surgical study in human cadavers.

BACKGROUND AND STUDY AIMS The advantages of a hybrid natural orifice transluminal endoscopic surgery approach to Roux-en-Y gastric bypass (hNOTES-RYGBP) might include: easier access to the peritoneal cavity, reduced number of ports and related complications, improved cosmesis, and others. However, currently available conventional endoscopic and laparoscopic instruments might be unsuitable for complex surgical procedures using transluminal access. The aim of this study was to investigate the feasibility and limitations of a NOTES RYGBP. METHODS hNOTES-RYGBP was performed in human cadavers. Pouch creation was achieved by needle-knife dissection using a transvaginal, flexible scope. Articulating linear staplers were placed transumbilically to transect the stomach. Measurements of the small bowel were accomplished intraluminally or with flexible and rigid graspers. New methods were tested to create the gastro-jejunal anastomosis. A linear laparoscopic stapler was used to form the jejuno-jejunal anastomosis. RESULTS Stapler manipulation and anvil docking, bowel manipulation and measurement, and tissue dissection presented the main obstacles for hNOTES-RYGBP. Conventional instruments were too short for some transvaginal manipulations. The time to complete the procedure was 6 - 9 hours. It was feasible to perform a complete hNOTES-RYGBP in four out of seven cadavers. Two cadavers were unsuitable due to anatomical abnormalities or advanced decay. One procedure was terminated before completion because of time constraints. Combinations of flexible and rigid visualization and manipulation were helpful, especially for dissection and gastric pouch creation. CONCLUSIONS Several factors made hNOTES-RYGBP very challenging and time-consuming. A lack of proper instrumentation resulting in insufficient tissue traction, countertraction, and instrument manipulation complicated several steps during the procedure. A combination of flexible with rigid endoscopic techniques offers specific advantages for components of this type of surgery. Changes in instrument design are required to improve more complex endosurgical procedures.

History of robotic surgery: from AESOP® and ZEUS® to da Vinci®.

During the last century, robotics experienced significant growth fueled by the advent of electronics and computers. It has found applications in industry, in particular, the automotive industry, by making it possible to perform repetitive operations automatically. Minimally invasive surgery has become widespread since the late 1980s and now there is an ever-increasing range of procedures performed laparoscopically, with well demonstrated benefits over open surgery in terms of decreased hospitalization time, lower parietal complication rates, reduced postoperative pain, improved cosmetic results, and faster return to normal daily activities. However, this approach requires specific training in order to acquire the skills particular to this technique and its limitations. In minimally invasive surgery, the surgeon actually no longer controls the surgical field of vision, which he visualizes on a screen showing only a two-dimensional (2D) image, i.e., with no depth of field. Furthermore, the instruments used have only four degrees of freedom with a fixed entry point. This creates a lever arm effect that only amplifies the amplitude of the movements, decreasing the precision of the surgeon’s motions and accentuating any hand tremor. The laparoscopic approach thus has limitations that are inherent to it due to the introduction of a simple technical interface between the patient and the surgeon. It is that interface that was used in robotics, an interface that then became electromechanical and computerized, allowing the surgical procedure and imaging to be digitalized. These may then be processed and modified to improve their properties. The purpose of this review is to describe how robotic surgery has contributed solutions to the intrinsic limitations of laparoscopy over the years and affected its development.

Augmented reality to the rescue of the minimally invasive surgeon. The usefulness of the interposition of stereoscopic images in the Da Vinci ™ robotic console

Computerized management of medical information and 3D imaging has become the norm in everyday medical practice. Surgeons exploit these emerging technologies and bring information previously confined to the radiology rooms into the operating theatre. The paper reports the authors’ experience with integrated stereoscopic 3D‐rendered images in the da Vinci surgeon console.