Hubert Stein

Totally Robotic Low Anterior Resection with Total Mesorectal Excision and Splenic Flexure Mobilization

Some limitations of conventional laparoscopy have been overcome by the enhanced dexterity of the robotic da Vinci system, and its use in gastrointestinal procedures is evolving. However, difficulties accessing multiple quadrants of the abdomen with the first robotic system led to a rather slow introduction of the da Vinci into the field of abdominal surgery compared with its success with urologic and cardiac procedures. The new da Vinci S HD system offers improved range of motion that allows for easier access to a wider surgical field. The authors developed a new “one-step” setup to perform a low anterior resection with total mesorectal excision and splenic flexure mobilization for rectal cancer using a completely robotic approach. This technical report describes all the major aspects for successful performance of this complex minimally invasive procedure.

Facilitated endoscopic beating heart coronary artery bypass grafting using a magnetic coupling device.

BACKGROUND Suturing of a coronary anastomosis in totally endoscopic coronary artery bypass grafting on the beating heart is technically demanding. The potential benefits of the endoscopic Magnetic Vascular Positioner device (Ventrica, Inc, Fremont, Calif) to facilitate construction of a coronary anastomosis in a closed chest environment were evaluated. METHODS Totally endoscopic coronary artery bypass grafting on the beating heart was performed in 8 foxhound-beagle inbred dogs with the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif). A prototype of the endoscopic Magnetic Vascular Positioner device was used to facilitate construction of the coronary anastomosis. One pair of magnets was inserted in the internal thoracic artery and left anterior descending artery using robotic instruments to guide and place the endoscopic delivery platform. All animals underwent angiography; gross inspection of the anastomotic site was performed after excision of the hearts. RESULTS The procedure was accomplished in all animals in 169 minutes (155-190 minutes). Dissection of the left anterior descending coronary artery (6.5 minutes; 1-20 minutes), positioning of the stabilizer (8.5 minutes; 7-16 minutes), placement of occlusion tapes (6 minutes, 3-10 minutes), and arteriotomy 5.5 minutes (3-30 minutes) was achieved without problems. By use of the Magnetic Vascular Positioner device, the anastomosis at the graft site was performed with the graft still in situ. Except for 1 premature deployment, all other deployments were easily accomplished in 3 minutes (1-28 minutes). The following adverse events were encountered: bleeding from the right ventricle caused by occlusion tape (1), anastomotic leakage on reperfusion requiring repair stitches (2), and anastomotic occlusion as a result of thrombus (1). All except 1 animal with a patent graft and anastomosis survived the procedure. The overall patency was 7 of 8. DISCUSSION The combination of robotic technology allowing for dexterous manipulation in a closed chest environment and a simple yet effective and timesaving technique for anastomotic coupling may facilitate beating heart totally endoscopic coronary artery bypass grafting.

Endoscopic placement of multiple artificial chordae with robotic assistance and nitinol clip fixation

OBJECTIVE A totally endoscopic method of placing multiple premeasured artificial chordae with the assistance of the da Vinci surgical system (Intuitive Surgical Inc, Sunnyvale, Calif) and V60 U-clip devices (Medtronic Inc, Minneapolis, Minn) was evaluated. METHODS Totally endoscopic placement of multiple artificial chordae with robotic assistance and nitinol clips was performed in 30 patients. After subvalvular exposure with a robotically controlled Atrial Retractor (Intuitive Surgical Inc), artificial chordae constructed of 4-0 polytetrafluoroethylene (Gore-Tex; WL Gore & Associates Inc, Flagstaff, Ariz) were secured to the prolapsing leaflet edge with V60 U-clips. Transesophageal echocardiography to assess successful repair was performed. RESULTS Repairs of the anterior leaflet, the posterior leaflet, and combinations of both were performed. Crossclamp and cardiopulmonary bypass times were in the range of 78.63 +/- 17.03 minutes and 118.17 +/- 22.55 minutes, respectively. Transesophageal echocardiography showed grade 0 to less than grade 1 mitral regurgitation postoperatively. All patients had an uneventful recovery phase and were discharged within 5 days. CONCLUSION Endoscopic placement of premeasured artificial neochordae is greatly facilitated by applying robotic assistance and using nitinol clips for chordae fixation. The endoscopic robotic technique provides excellent functional and clinical outcomes.

Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system

Background:Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.Methods:The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.Results:The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 ± 58, 25 ± 10, and 18 ± 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.Conclusions:The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

Introduction to the Robotic System

The da Vinci® Surgical System is currently the most frequently used computer-enhanced endoscopic instrument control system capable of laparoscopic surgery. The system contains a surgical console, a surgical cart, and a vision cart. Core characteristics include the physical separation of the surgeon from the patient, a three-dimensional stereoscopic image with up to ten times magnification, wrist action of the instruments providing seven degrees of freedom with intuitive control, and several software features.

Totally endoscopic coronary artery bypass graft

BackgroundRobotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or counter-traction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.MethodsThe procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagnonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.ResultsThe mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195±58, 25±10, and 18±5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.ConclusionsThe additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

Universal suprapubic approach for complete mesocolic excision and central vascular ligation using the da Vinci Xi® system: from cadaveric models to clinical cases

There has been little enthusiasm for performing robotic colectomy for colon cancer in recent years due to multiple factors, one being that the previous robotic systems such as the da Vinci Si® (dVSi) were poorly designed for multi-quadrant surgery. The new da Vinci Xi® (dVXi) system enables colectomy with central mesocolic excision to be performed easily in a single docking procedure. We developed a universal port placement strategy to allow right and left hemicolectomies to be performed via a suprapubic approach and a Pfannensteil extraction site. This proof of concept paper describes the development and subsequent clinical application of this setup. After extensive training on the dVXi system concepts in collaboration with clinical development engineers, we developed a port placement strategy which was tested and adapted after performing experimental surgery in three cadaveric models. Subsequently our port placement was used for two clinical cases of suprapubic right and left hemicolectomy. With some modifications of port placements after the initial cadaveric colectomies, we have developed a potentially universal suprapubic port placement strategy for robotic colectomy with complete mesocolic excision and central vascular ligation using the dVXi robotic system. This port placement strategy was applied successfully in our first two clinical cases. Based on our cadaveric laboratory as well as our initial clinical application, the suprapubic port placement strategy for the dVXi system with its improved features over the dVSi can feasibly perform right and left hemicolectomy with complete mesocolic excision and central vascular ligation. Further studies will be required to establish efficacy as well as safety profile of these procedures.

Robotics in Cardiac Surgery: Basic Principles

The recent use of robotic surgical assistance has spawned an entirely new way of operating on many human systems. These devices provide the link to the least invasive cardiac operations, including coronary artery and mitral valve surgery. This chapter describes the evolution of robotic surgery as well as enabling robots in other areas of medicine. Moreover, the ergonomic aspects of complex surgical tele-manipulation systems are described in detail.