I. A. M. J. Broeders

A consensus document on robotic surgery

“Robotic surgery” originated as an imprecise term, but it has been widely used by both the medical and lay press and is now generally accepted by the medical community. The term refers to surgical technology that places a computer-assisted electromechanical device in the path between the surgeon and the patient. A more scientifically accurate term for current devices would be “remote telepresence manipulators” because available technology does not generally function without the explicit and direct control of a human operator. For the purposes of the document, we define robotic surgery as a surgical procedure or technology that adds a computer technology–enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon. For example, in laparoscopic surgery, the surgeon directly controls and manipulates tissue, albeit at some distance from the patient and through a fulcrum point in the abdominal wall. This differs from the use of current robotic devices, whereby the surgeon sits at a console, typically in the operating room but outside the sterile field, directing and controlling the movements of one or more robotic arms. Although the surgeon still maintains control over the operation, the control is indirect and effected from an increased distance. This definition of robotic surgery encompasses micromanipulators, remotely controlled endoscopes, and console-manipulator devices. The key elements are enhancements of the surgeon’s abilities—be they vision, tissue manipulation, or tissue sensing—and alteration of the traditional direct local contact between surgeon and patient.

First experience with robot-assisted thoracoscopic esophagolymphadenectomy for esophageal cancer.

BackgroundTransthoracic esophagectomy with extended lymph node dissection is associated with higher morbidity rates than transhiatal esophagectomy. This morbidity rate could be reduced by the use of minimally invasive techniques. The feasibility of robot-assisted thoracoscopic esophagectomy (RTE) with mediastinal lymphadenectomy was assessed prospectively.MethodsThis study investigated 21 consecutive patients with esophageal cancer who underwent RTE using the Da Vinci™ robotic system. Continuity was restored with a gastric conduit and a cervical anastomosis.ResultsA total of 18 (86%) procedures were completed thoracoscopically. The operating time for the thoracoscopic phase was 180 min (range, 120–240 min), and the median blood loss was 400 ml (range, 150–700 ml). A median of 20 (range, 9–30) lymph nodes were retrieved. The median intensive care unit stay was 4 days (range, 1–129 days), and the hospital stay was 18 days (range, 11–182 days). Pulmonary complications occurred in 10 patients (48%), and one patient (5%) died of a tracheoneoesophageal fistula.ConclusionsIn this initial experience, robot-assisted thoracoscopic esophagectomy was found to be feasible, providing an effective lymphadenectomy with low blood loss. Standardization of the technique and increased experience should reduce the complication rate, which is in the range of the rate for open transthoracic dissection.

Construct validity of the LapSim: Can the LapSim virtual reality simulator distinguish between novices and experts?

BackgroundVirtual reality simulators may be invaluable in training and assessing future endoscopic surgeons. The purpose of this study was to investigate if the results of a training session reflect the actual skill of the trainee who is being assessed and thereby establish construct validity for the LapSim virtual reality simulator (Surgical Science Ltd., Gothenburg, Sweden).MethodsForty-eight subjects were assigned to one of three groups: 16 novices (0 endoscopic procedures), 16 surgical residents in training (>10 but <100 endoscopic procedures), and 16 experienced endoscopic surgeons (>100 endoscopic procedures). Performance was measured by a relative scoring system that combines single parameters measured by the computer.ResultsThe higher the level of endoscopic experience of a participant, the higher the score. Experienced surgeons and surgical residents in training showed statistically significant higher scores than novices for both overall score and efficiency, speed, and precision parameters.ConclusionsOur results show that performance of the various tasks on the simulator corresponds to the respective level of endoscopic experience in our research population. This study demonstrates construct validity for the LapSim virtual reality simulator. It thus measures relevant skills and can be integrated in an endoscopic training and assessment program.

Controversies in paraesophageal hernia repair; a review of literature

BackgroundThe surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure.MethodsAn electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome.ResultsA total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected.ConclusionTreatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.

Robot-assisted surgical systems: a new era in laparoscopic surgery.

The introduction of laparoscopic surgery offers clear advantages to patients; to surgeons, it presents the challenge of learning new remote operating techniques quite different from traditional operating. Telemanipulation, introduced in the late 1990s, was a major advance in overcoming the reduced dexterity introduced by laparoscopic techniques. This paper reviews the development of robotic systems in surgery and their role in the operating room of the future.

Virtual reality training for endoscopic surgery: voluntary or obligatory?

IntroductionVirtual reality (VR) simulators have been developed to train basic endoscopic surgical skills outside of the operating room. An important issue is how to create optimal conditions for integration of these types of simulators into the surgical training curriculum. The willingness of surgical residents to train these skills on a voluntary basis was surveyed.MethodsTwenty-one surgical residents were given unrestricted access to a VR simulator for a period of four months. After this period, a competitive element was introduced to enhance individual training time spent on the simulator. The overall end-scores for individual residents were announced periodically to the full surgical department, and the winner was awarded a prize.ResultsIn the first four months of study, only two of the 21 residents (10%) trained on the simulator, for a total time span of 163 minutes. After introducing the competitive element the number of trainees increased to seven residents (33%). The amount of training time spent on the simulator increased to 738 minutes.ConclusionsFree unlimited access to a VR simulator for training basic endoscopic skills, without any form of obligation or assessment, did not motivate surgical residents to use the simulator. Introducing a competitive element for enhancing training time had only a marginal effect. The acquisition of expensive devices to train basic psychomotor skills for endoscopic surgery is probably only effective when it is an integrated and mandatory part of the surgical curriculum.

Robot-assisted laparoscopic choledochojejunostomy

Background: Endoscopic stenting is the treatment of choice for palliative relief of biliary obstruction by a periampullary tumor. If treated surgically, a choledochojejunostomy and Roux-en-Y diversion is still performed by laparotomy in a large number of cases due to technical challenges of the biliodigestive anastomosis in the laparoscopic approach. Robotic systems may enhance dexterity and vision and might therefore support surgeons in delicate laparoscopic interventions. The purpose of this study is to assess the efficacy and safety of performing a laparoscopic choledochojejunostomy and Roux-en-Y reconstruction with the aid of a robotic system. Methods: Ten laparoscopic procedures were performed in pigs with the da Vinci robotic system and compared to 10 procedures performed by laparotomy (controls). Operation room time, anastomoses time, blood loss, and complications were recorded. The effectiveness of the anastomoses was evaluated by postoperative observation for 14 days and by measuring passage, circumference, and number of stitches. Results: Operating room time was significantly longer for the robot-assisted group than for controls (140 vs 82 min, p < 0.05). The anastomoses times were longer in the robot-assisted cases but not statistically significant (biliodigestive anastomosis, 29 vs 20 min; intestinal anastomosis, 30 vs 15 min), Blood loss was less than 10 cc in all robot-assisted cases and 30 cc (10–50 cc) in the controls. In both groups, there were no intraoperative complications. In the control group, one pig died of gastroparesis on postoperative day 6. In the robot-assisted group, one pig died on postoperative day 7 due to a volvulus of the jejunum. At autopsy, a bilioma was found in one pig in the robot-assisted group. In all pigs, the biliodigestive and intestinal anastomoses were macroscopically patent with an adequate passage. Circumference and number of stitches were similar. Conclusion: The safety and efficacy of robot-assisted laparoscopic choledochojejunostomy was proven in this study. The procedure can be performed within an acceptable time frame.

Robot-assisted thoracoscopic esophagectomy for a giant upper esophageal leiomyoma

This is the first report of a thoracoscopic esophagectomy for a giant leiomyoma of the upper esophagus aided by a robotic system. A 37-year-old man presented with progressive dysphagia and nocturnal aspiration. Endoscopic ultrasound and CT scan of the chest revealed an upper esophageal tumor of 9 x 4 cm arising from the muscularis mucosae. A fine needle aspiration showed clustering of mesenchymal cells, confirming the diagnosis of a stromal cell tumor. A mesenchymal malignancy was suspected because the tumor was located in the upper esophagus and was arising from the muscularis mucosae, both uncommon for a leiomyoma. Moreover, tumor size, an indicator of potential malignancy if >3 cm, was 9 cm. Therefore, an esophagectomy was performed thoracoscopically with the formation of a gastric conduit via laparotomy and a hand-sewn end-to-side cervical anastomosis. The thoracoscopic phase was performed with support of the da Vincitrade mark robotic system, which allowed for an excellent 3-dimensional view and a precise dissection of the esophagus along the vital mediastinal structures. The duration of the thoracoscopic part was 115 min and that of the total procedure was 270 min. Blood loss during the thoracoscopic phase was 50 mL; total blood loss was 200 mL. The patient was ventilated for 1 day; his total intensive care stay was 2 days. He left the hospital in good condition on the 11th postoperative day. Histopathological examination combined with immunohistochemistry revealed a leiomyoma of 9.0 x 5.0 x 2.5 cm. After 3 years of follow-up, the patient is in good health.

Robotic Surgery in a Routine Procedure An Evaluation of 40 Robot-Assisted Laparoscopic Cholecystectomies

SummaryBackground: Laparoscopic surgery offers distinct benefits to patients but places a burden on surgeons regarding manoeuvrability of instruments and visualization of the operating field. The introduction of robotic telemanipulation systems offers a solution to these problems in videoscopic surgery. Methods: In this study, the feasibility of robot-assisted laparoscopic surgery was assessed by performing 40 laparoscopic cholecystectomies with the da Vinci™ robotic system. Time necessary for system set-up and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity and mortality. Results: 39/40 procedures were completed laparoscopically with the da Vinci™ system. There were no intraoperative complications and only minor technical problems. Median hospitalization was 2 days. System set-up time decreased with increasing experience of the operating team. Operating time was at least comparable to times reported for standard laparoscopic cholecystectomy in the literature. There was neither postoperative mortality nor morbidity at the time of discharge and during short-term follow-up. Conclusions: Robot-assisted surgery was repeatedly proven as a safe and feasible approach to laparoscopic cholecystectomy.ZusammenfassungGrundlagen: Während die laparoskopische Chirurgie den Patienten mehrere entscheidende Vorteile bietet, wird das Operieren für den Chirurgen hinsichtlich des Gesichtsfeldes und der Bewegungsfreiheit der Instrumente erschwert. Durch die Anwendung eines Operationroboters können diese Probleme gelöst werden. Methodik: In dieser Studie wurde die Eignung des da Vinci™-Operationsroboters für die laparoskopische Chirurgie an 40 laparoskopischen Cholezystektomien untersucht. Neben der Aufrüstzeit des Systems und der reinen Operationszeit wurden Komplikationen, technische Probleme, stationäre Aufenthaltsdauer sowie Morbidität und Mortalität evaluiert. Ergebnisse: 39 von 40 Eingriffen wurden mit dem Operationsroboter vollendet. Es kam lediglich zu geringfügigen technischen Problemen, intraoperative Komplikationen traten nicht auf. Die Aufrüstzeit verkürzte sich mit der wachsenden Erfahrung des Teams. Die Operationszeit war mit der für das konventionelle laparoskopische Verfahren vergleichbar. Die mediane stationäre Aufenthaltsdauer betrug 2 Tage. Im bisherigen Beobachtungszeitraum waren die Morbidität und Mortalität 0. Schlußfolgerungen: Das Roboter-assistierte Verfahren hat sich für die laparoskopische Cholezystektomie als sicher und geeignet erwiesen.

Feasibility of Laparoscopic Surgery Assisted by a Robotic Telemanipulation System

Robotic telemanipulation systems have recently been introduced to enhance the surgeons dexterity and visualisation in laparoscopic surgery. Technical feasibility of robot-assisted surgery was evaluated in 30 laparoscopic cholecystectomies.