Guy Cadiere

Evaluation of telesurgical (robotic) NISSEN fundoplication

BackgroundThe laparoscopic surgical approach has proven its benefit for the patient. There are however several short-comings, which have triggered considerable research for improvement. One improvement may be the introduction of telesurgery by the interposition of a computer interface between surgeon and patient. Material and Methods: A prospective randomized study was conducted in an advanced laparoscopic procedure. Nissen fundoplication. The control group underwent the conventional laparoscopic approach, while the investigational group underwent the telesurgical approach.ResultsFeasibility was 100%. The procedure was more time consuming in the Telesurgical group, at all stages of the operation. Mortality was nil and morbidity was comparable in both groups.ConclusionThe telesurgical approach is feasible in advanced laparoscopic procedures like Nissen fundoplication. At the present time there is however no obvious added benefit from this new technique.

Robotic Fundoplication: From Theoretic Advantages to Real Problems

ROBOTICS IN LAPAROSCOPIC SURGERY During the past decade, laparoscopy, through a dramatic worldwide diffusion, has become the gold standard in the surgical treatment of several conditions. Currently, it is still spreading and gaining popularity in new fields of surgery. Nevertheless, the laparoscopic technique has shown peculiar disadvantages and limitations intrinsic to this approach. Unlike traditional open surgery, in laparoscopy, the action of the surgeon’s hand is mediated by rigid, unarticulated instruments, and the visual access is not direct, but is mediated by a camera. Obviously, these limitations reduce the laparoscopic surgeon’s possibilities and increase technical difficulty, operative times, and risk of complications. In an effort to improve surgical technique by avoiding some of the disadvantages of laparoscopy while maintaining the advantages brought by the miniinvasive approach (less postoperative pain, shorter hospital stay, and early return to normal activities, robotics have been introduced in surgery. Domains range from general to urologic, cardiac, and gynecologic surgery. A decade after the first laparoscopic cholecystectomy, in 1987, the first telesurgical laparoscopic cholecystectomy formally opened the robotic era in general surgery. Since then, the robotic approach has been used in several general surgery procedures, such as cholecystectomy, gastroesophageal surgery, obesity surgery, and adrenalectomy. But despite early encouraging results and recent spectacular applications, robotics have not yet witnessed wide, large-scale diffusion among general surgeons and are still considered “experimental approaches.” THE ROBOTIC SYSTEM To reduce the limitations of laparoscopic surgery, robotic systems have been designed to give endoscopic surgeons the same quality of information and manipulation as they have when performing open surgery. These designs include: instruments and manipulators with all degrees of freedom, devices that provide surgeons with tactile feedback, and improved visual access. Until now, two robotic systems have been extensively tested in surgery: the Zeus (Computer Motion) and the Da Vinci (Intuitive Surgical) systems. Although both have shown to be effective and both are clinically promising, it appears that the Da Vinci system allows for shorter operating times and steeper learning curves. No comparison between these operative systems has yet been reported in general surgery procedures. To our knowledge, only the Mona-Da Vinci system has been used for robot-assisted laparoscopic fundoplication. Our experience refers to both the Da Vinci system and its precursor, the Mona prototype. The Mona-Da Vinci system introduces several technologic innovations aimed at improving a surgeon’s operating skills (Table 1). The greatest innovations of this system are the articulated arms. Whereas in open surgery the flexibility of the wrist and the hands inside the abdomen permits fully free movements, in laparoscopy, the presence of rigid, unarticulated instruments entering the abdomen through fixed openings (trocar sites) limits the number of degrees of freedom. Additional articulations inside and outside the abdomen may help recover the degrees of freedom that have been lost and regain some dexterity of the surgeon’s hand in open surgery. The robot downscales a surgeon’s movements (by a 10:1, 5:1, or 3:1 factor) and eliminates the physiologic tremor, increasing the accuracy of the surgeon’s action. A threedimensional monitor allows the surgeon to obtain more accurate visual control of the instruments and better motion coordination. Finally, because the robot is composed of two units, the patient’s station and the surgeon’s station, united by No competing interests declared.

How to avoid esophageal perforation while performing laparoscopic dissection of the hiatus

An increasing number of surgeons attempt advanced laparoscopic procedures, involving the distal esophagus such as Nissen fundoplication, truncal vagotomy, and Hellers myotomy. At this time, there are probably as many techniques as there are surgeons. The authors have tried to provide a “ready to use” universal strategy that details how to approach the distal esophagus while avoiding the dangerous pitfalls of surgery in that area.

A radionuclide study of regional gastric motility

SummaryThe aims of this research were to study some methodological aspects of radionuclide methods for assessing regional gastric motility and to determine the parameters that can be extracted along with their normal values or patterns. During the lag phase, the antral contraction curve showed three different patterns. At the beginning, the antral activity was too low to be analysed. Irregular variation of the count rate was then observed, followed by a more regular contraction. The application of Fourier transformation to the well-defined cyclical count rate variations revealed two areas with high amplitude values but with phase opposition. No peristaltic wave could be identified. After the lag phase, the antral curve showed cyclical variations of count rates with a frequency of about three cycles per minute. Slightly displaced curves but with a much lower amplitude were observed at different parts of the stomach. Several factors were found to influence the antral contraction curve, including the choice of region of interest and time since the last meal. Irregularities in the antral curve, both in terms of frequency and of amplitude, were not unusual in healthy subjects. These should be taken into account when interpreting antral contraction curves. The phase image showed a well-defined peristaltic contraction pattern. Three 360° cycles were usually observed throughout the stomach, suggesting that the time necessary for a peristaltic wave to sweep through from the upper part of the stomach to the antrum is about 1 min. Similar phase images were obtained in all subjects regardless of the amount of time since the meal containing the radioactive tracer, suggesting that gastric peristalsis can easily be assessed and interpreted. The amplitude image showed high amplitude in the antral area and in the greater curvature of the stomach. In the lesser curvature, the amplitude was much lower. Unlike the phase image, however, there was marked variability in the regional amplitude distribution. The value of the region amplitude distribution for evaluating regional gastric motility is therefore limited.

Robotic Nissen Fundoplication

SummaryBackground: Laparoscopic surgery is beneficial to the patient but challenging for the surgeon. The visual axis is not the same as the operative axis. The surgeon must manipulate long, sharp instruments through a fixed opening under the control of a two-dimensional monitor and without the help of any tactile sensation. The body cavity is penetrated by cannulas, which cannot be interchanged, so that the surgeon is obliged to move around the patient in order to reach the best position for every step of the procedure. Methods: A computer interface in command of a mechanical system (robot) makes it possible: 1) To regain several lost degrees of freedom through intra-abdominal articulations; 2) to obtain better visual control of instrument manipulation thanks to three-dimensional vision; 3) to modulate amplitude of surgical motions by downscaling and stabilization; 4) to operate at distance from the patient.These possibilities lead to improved surgical performance. In addition, the surgeon operates in an ergonomically correct position. The robot (da Vinci™ System, Intuitive Surgical, Mountain View, CA, USA) consists of a console and a surgical cart, which supports three articulated robotic arms. The surgeon sits at the console where he or she manipulates joystick-like handles while observing the operating field through binoculars that provide a three-dimensional image. This computer is capable of modulating data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor of 5 or 3 to 1. Results: The first robot-assisted procedure in a human was performed in March 1997 by our team. Since then, we have used robot-assisted laparoscopic surgery for 147 procedures, including 39 anti-reflux operations. Our study demonstrates the feasibility of telesurgery on humans in a variety of procedures including robotic Nissen fundoplication, with no morbidity specifically related to the use of robotics, and with acceptable operative times. Conclusions: In its present embodiment, the system seems most efficient when involved in microsuturing within the abdomen or in very confined spaces. Improved ergonomic conditions and improved instrument mobility at the level of distal articulation seem beneficial in routine abdominal procedures. More research is necessary for further improvement in tool configuration and visualization. The robotic approach implies new operative strategies, including specific trocar placement.ZusammenfassungGrundlagen: Während das laparoskopische Vorgehen für den Patienten Vorteile mit sich bringt, überwiegen für den Chirurgen gewisse Nachteile. Blickrichtung und operative Ausführung liegen auf verschiedenen räumlichen Ebenen. Der Chirurg führt lange, scharfe — durch Trokare fix positionierte — Instrumente. Dabei kontrolliert er seine Bewegungen lediglich über ein zweidimensionales Monitorbild und verfügt über kein taktiles Feedback. Da das Wechseln der Trokare nicht ganz unproblematisch ist, muß der Chirurg seine Position dem jeweiligen Akt anpassen. Methodik: Durch ein Computer-gesteuertes mechanisches System (Roboter) wird folgendes ermöglicht: 1) Wettmachen der Bewegungseinschränkung durch intraabdominelle Gelenke; 2) bessere visuelle Kontrolle der Manipulationen durch dreidimensionale Darstellung des Operationsfeldes; 3) die Amplituden der Bewegungen der Hand des Chirurgen können moduliert und stabilisiert werden; 4) es kann abseits vom Patienten operiert werden.Die Performance und die ergonomischen Bedingungen für den Chirurgen wurden verbessert. Der Roboter (da Vinci™ System, Intuitive Surgical, Mountain View, CA, USA) besteht aus einer Konsole und einem Wagen mit drei Roboterarmen. Der Chirurg sitzt an der Konsole, bewegt Joystick-ähnliche Handgriffe und schaut in ein dreidimensionales Operationsfeld. Durch den Computer können Zitterbewegungen eliminiert und die Bewegungsamplituden um den Faktor 5 bzw. 3 zu 1 moduliert werden. Ergebnisse: Weltweit der erste roboter-assistierte Eingriff am Menschen erfolgte durch unser Team 1997. Seitdem haben wir insgesamt 147 Eingriffe, darunter 39 Antirefluxoperationen mit dem Roboter durchgeführt. Unsere Studie zeigt, daß verschiedene Eingriffe am Menschen, darunter auch Nissenfundoplikationen, ohne Roboter-assoziierte Morbidität bei akzeptablen Operationszeiten machbar sind. Schlußfolgerungen: In der jetzigen Ausstattung bietet sich der Roboter für feines Nähen im Abdomen oder in engen Räumen an. Die verbesserten ergonomischen Bedingungen sowie die bessere Beweglichkeit der Instrumente sind für den Allgemeinchirurgen von Nutzen. Weitere Anstrengungen zur Verbesserung von Instrumentenkonfiguration und Visualisierung sind notwendig. Das Arbeiten mit dem Roboter verlangt spezielle operative Strategien und angepaßte Trokarplazierungen.