Jacques Marescaux

Transcontinental Robot-Assisted Remote Telesurgery, Feasibility and Potential Applications

ObjectiveTo show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology. Summary Background DataTechnical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances. MethodsTo verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service). ResultsThe operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery. ConclusionsRemote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide.

Single-Access Laparoscopic Sigmoidectomy as Definitive Surgical Management of Prior Diverticulitis in a Human Patient

HYPOTHESISnSingle-access laparoscopic surgery should offer minimal scarring without compromising surgical outcome. It is enhanced by both innovative port technology and technical expertise learned by developing natural orifice transluminal endoscopic surgery (NOTES).nnnDESIGNnSigmoidectomy in a human via a single laparoscopic port.nnnSETTINGnUniversity hospital. Patient A 40-year-old woman with previously documented diverticular abscess.nnnINTERVENTIONSnThe multichannel single port (Triport; Advanced Surgical Concepts, Wicklow, Ireland) was placed at the umbilicus. The sigmoid was retracted by both intraluminal sigmoidoscopy and magnetic anchoring. Mesenteric dissection between the mid-descending colon and the colorectal junction was carried out close to the colon using a Ligasure Advance (Covidien, Valley lab, Norwalk Connecticut). The stapler anvil was passed retrogradely per ano to lie within the descending colon. A linear stapler effected proximal and distal sigmoidal transection. Magnetic attraction then delivered the in situ anvil pike into a colotomy placed adjacent to the proximal staple line. After its position was secured with an endoloop, the pike was mated with its stapler head positioned in the rectal stump. This allowed creation of a double-stapled colorectal anastomosis 10 cm from the anal verge. Specimen retrieval was performed via the umbilical port site.nnnMAIN OUTCOME MEASURESnExtent of scarring, occurrence of surgical complications, technical adequacy, and clinical outcome.nnnRESULTSnNo intraoperative complications occurred during the 90-minute procedure. A total of 40 cm of sigmoid was resected. The patient convalesced without complication and went home 4 days after surgery. At the 1-month review, she was fully recovered and her single umbilical scar was well healed.nnnCONCLUSIONSnWith advancing surgical technology and technique, truly minimally invasive surgical procedures are feasible. Understanding of NOTES can therefore extend beyond its experimental application into contemporary surgical practice.

Laparoscopy not recommended for routine appendectomy in men: Results of a prospective randomized study

BACKGROUNDnLaparoscopic appendectomy has now gained wider acceptance in clinical practice, particularly in the treatment of women with right iliac fossa pain. However, the precise role of laparoscopic appendectomy in men is unclear, and this study was therefore undertaken to examine this specific issue in a prospective randomized trial.nnnMETHODSnOne hundred men between the ages of 16 and 65 years who had suspected appendicitis were recruited and randomized to undergo either open or laparoscopic appendectomy. Both groups were compared in terms of their clinical parameters, duration of anesthetic and operation times, postoperative pain, duration of ileus, and length of hospital stay.nnnRESULTSnThe histologic confirmation of appendicitis was present in 94% of the cases for both groups of patients. Laparoscopic appendectomy required significantly longer anesthetic time (72.5 minutes versus 55 minutes) and actual operating time (45 minutes versus 25 minutes) compared with open appendectomy. Postoperative pain as measured by visual analog scale on postoperative days 1 and 2 were not significantly different between the patients who underwent laparoscopic and open surgery with values of 4.7 versus 4.4 and 2.1 versus 2.2, respectively. Also no significant difference was seen between the laparoscopic and open appendectomy groups in the recovery of bowel function (24.7 hours versus 21 hours) and in the length of hospital stay (4.9 days versus 5.3 days).nnnCONCLUSIONSnThe results of this prospective randomized trial showed that there were no significant advantages of laparoscopic appendectomy over open appendectomy for the treatment of male patients with suspected appendicitis. We recommend that the use of laparoscopy be limited to men with atypical pain of uncertain diagnosis and in obese patients.

Stereoscopic vision provides a significant advantage for precision robotic laparoscopy.

Current surgical robots provide no sense of touch and rely solely upon vision. This study evaluated the effect of new stereoscopic technology on the performance of robotic precision laparoscopy.

Laparoscopic resection with transanal specimen extraction for sigmoid diverticulitis

This prospective study evaluated the technical aspects and microbiological consequences of laparoscopic resection with transanal specimen extraction and per ano transcolonic stapler anvil insertion in patients requiring elective operation for previous diverticulitis.

Laparoscopic Total Mesorectal Excision for Rectal Cancer Surgery

The introduction of total mesorectal excision in the early 1980s has improved local control and survival in patients with rectal cancer. Laparoscopic resections for colonic malignancies are gaining acceptance in the light of the recent evidence of oncologic adequacy from randomized clinical trials. Technical difficulties and the difference in the natural history of the disease have excluded rectal cancer from major clinical trials comparing laparoscopic to conventional rectal surgery. This review examined the feasibility, safety and oncologic outcomes of reported laparoscopic total mesorectal excision for surgical treatment of operable rectal cancer.

Minimal invasive single-site surgery in colorectal procedures: Current state of the art.

BACKGROUND: Minimally invasive single-site (MISS) surgery has recently been applied to colorectal surgery. We aimed to assess the current state of the art and the adequacy of preliminary oncological results. METHODS: We performed a systematic review of the literature using Pubmed, Medline, SCOPUS and Web of Science databases. Keywords used were “Single Port” or “Single-Incision” or “LaparoEndoscopic Single Site” or “SILS™” and “Colon” or “Colorectal” and “Surgery”. RESULTS: Twenty-nine articles on colorectal MISS surgery have been published from July 2008 to July 2010, presenting data on 149 patients. One study reported analgesic requirement. The final incision length ranged from 2.5 to 8 cm. Only two studies reported fascial incision length. There were two port site hernias in a series of 13 patients (15.38%). Two “fully laparoscopic” MISS procedures with preparation and achievement of the anastomosis completely intracorporeally are reported. Future site of ileostomy was used as the sole access for the procedures in three studies. Lymph node harvesting, resection margins and length of specimen were sufficient in oncological cases. CONCLUSIONS: MISS colorectal surgery is a challenging procedure that seems to be safe and feasible, but the existing clinical evidence is limited. In selected cases, and especially when an ileostomy is planned, colorectal surgery may be an ideal indication for MISS surgery leading to a no-scar surgery. Despite preliminary oncological results showing the feasibility of MISS surgery, we want to stress the need to standardize the technique and carefully evaluate its application in oncosurgery under ethical committee control.

Single port sigmoidectomy in an experimental model with survival.

Introduction. Single port laparoscopic access could reduce morbidity associated with additional trocar placement and, through the development of a hybrid intermediate, facilitate the clinical adoption of evolving techniques such as natural orifice transluminal endoscopic surgery. Advanced trocar technology, as much as adapted surgical technique, seems necessary to best facilitate this, however. Methods. A novel port (Airseal, Surgiquest) that uses vortex technology to create an air-curtain seal to maintain the pneumoperitoneum while facilitating the simultaneous passage of multiple working instruments was trialed. For this, 6 pigs (30 kg each) underwent sigmoid resection and reanastomosis using the port as the sole laparoscopic access for conventional instrumentation. All animals were thereafter survived for observation during a 2-week convalescence before undergoing repeat general anesthesia, sigmoidoscopy for anastomotic assessment, and forensic laparotomy for determination of intraperitoneal healing and complications. Results. The operation was technically feasible via a single port within a short time in every animal (mean duration 12.3 minutes). One anastomosis had to redone because of staple misfire but this too was accomplishable without additional port placement. All animals survived and convalesced normally without evincing clinical complication. At follow-up, all anastomoses were patent at sigmoidoscopy and only 1 animal had evidence of complicated anastomotic healing (the same animal that had needed anastomotic refashioning). Conclusions. Single port colonic resection and reanastomosis is readily achievable in this animal model. As an operative approach, it may both advance in its own right as much as facilitate the evolution and clinical incorporation of other developmental access routes.

Transgastric hybrid cholecystectomy

Clinical application of natural orifice transluminal endoscopic surgery is under investigation. Preliminary results of transvaginal cholecystectomy in women and associated technical issues have been described. The technique and initial results of hybrid transgastric cholecystectomy are now reported.

Robotics may overcome technical limitations of single-trocar surgery: an experimental prospective study of Nissen fundoplication.

OBJECTIVEnTo compare laparoscopic and robotic-assisted single-trocar access (STA) Nissen fundoplication in a porcine model. The STA procedure is an emerging concept in minimally invasive surgery that presents technical difficulties and challenges compared with traditional laparoscopy. Using multiple instruments inserted through a single trocar generates internal and external conflicts. Achieving triangulation requires the instruments and surgeons hands to cross over at the point of entry. Robotic-assisted surgery may overcome these difficulties owing to its capability of dissociating the hands of the surgeon from the instruments.nnnDESIGNnProspective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance.nnnSETTINGnA research institute.nnnPARTICIPANTSnThree surgeons with different experience.nnnMAIN OUTCOME MEASURESnOperative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons.nnnRESULTSnAll of the procedures were successfully completed. Mean operative time (45.6 +/- 11.2 vs 65.4 +/- 10.7 minutes; P = .03) and number of conflicts (1.0 +/- 0.9 vs 3.8 +/- 1.2; P < .001) were significantly reduced in the robotic series.nnnCONCLUSIONSnUse of the robotic platform allows the surgeon to select which hand will move which instrument. Inverting the control allows crossing of the instruments without any consequences to the surgeon. Moreover, this system offers instruments with multiple degrees of freedom. These factors could explain the clear improvement demonstrated in this study. As a result, robotics may play an essential part in the diffusion of STA surgery.