Jean Andre Bruyns

Feasibility of robotic laparoscopic surgery: 146 cases.

Theoretically, in laparoscopic surgery, a computer interface in command of a mechanical system (robot) allows the surgeon: (1) to recover a number a number of lost degrees of freedom, thanks to intra-abdominal articulations; (2) to obtain better visual control of instrument manipulation, thanks to three-dimensional vision; (3) to modulate the amplitude of surgical motions by downscaling and stabilization; (4) to work at a distance from the patient. These advances improve the quality of surgical tasks in a perfect ergonomic position. The purpose of this paper is to evaluate the feasibility of utilizing a robot in laparoscopic surgery. The first robot-assisted procedure in humans was performed in March 1997 by our team. One hundred forty-six patients underwent robot-assisted laparoscopic surgery. Between March 1997 and February 2001 a nonconsecutive series was performed of 39 antireflux procedures, 48 cholecystectomies, 28 tubal reanastomoses, 10 gastroplasties for obesity, 3 inguinal hernias, 3 intrarectal procedures, 2 hysterectomies, 2 cardiac procedures, 2 prostactectomies, 2 arteriovenous fistulas, 1 lumbar sympathectomy, 1 appendectomy, 1 laryngeal exploration, 1 varicocele ligation, 1 endometriosis cure, 1 neosalpingostomy, 1 deferent canal. The robot (Da Vinci system, Intuitive Surgical, Mountain View, CA), consists of a console and a cart with three articulated robot arms. The surgeon sits in front of the console, manipulating joysticklike handles while observing the operative field through binoculars that provide a three-dimensional picture. This computer is capable of modulating these data by eliminating physiologic tremor and by downscaling the amplitude of motions by a factor 5 or 3 to one. This study has demonstrated the feasibility of several laparoscopic robotic procedures. There is no morbidity related to the system. Operating time and the hospital stay were within acceptable limits. The system seems most beneficial in intra-abdominal microsurgery or for manipulations in a very small space. Optimized ergonomics and increased mobility of the instrument tips are beneficial in many steps of abdominal surgical procedures.

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.

Conversions and complications in 185 laparoscopic adjustable silicone gastric banding cases

AbstractBackground: Kuzmaks gastric silicone banding technique is the least invasive operation for morbid obesity. The purpose of this study was to analyze the complications of this approach. Methods: Between September 1992 and March 1996, 185 patients underwent laparoscopic gastroplasty by the adjustable silicone band technique. A minimally invasive procedure using five trocars was performed. Results: In 11 patients exposure of the hiatus was impeded because of hypertrophy of the left liver lobe which led to conversion in eight patients and abortion of the procedure in three other patients. Anatomical complications: We observed two gastric perforations and one band slippage at the early stage, one infection and three rotations of the access port. Functional complications: There were eight (4%) cases of irreversible total food intolerance resulting in pouch dilation and eight cases (4%) of esophagitis. One fatality on the 45th day in a patient with a Prader-Willi syndrome. Conclusion: The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure.

Laparoscopic rectopexy according to Wells

AbstractBackground: The laparoscopic approach usually reduces the morbidity of procedures performed by laparotomy. The aim of this study was to demonstrate the usefulness of laparoscopic rectopexy. Methods: A total of 37 patients were included in this prospective study. The indication was true rectal prolapse in all patients. Incontinence was seen in 33% of the patients. A slightly modified Wells procedure was performed laparoscopically. Postoperatively, the patients were evaluated for resolution of the prolapse and incontinence. They were also questioned about their satisfaction with the procedure. Results: Laparoscopy was successful in all but one case. Follow-up is available in 32 of 37 patients. Prolapse was cured in all patients, and the incontinence resolved in 11 of 12. In addition, 38% of the patients experienced significant constipation preoperatively versus 5% postoperatively.

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.

Single-Access Transumbilical Laparoscopic Nissen Fundoplication Performed With New Curved Reusable Instruments

Introduction: The authors report a single-access laparoscopic Nissen fundoplication (SALN) performed with new curved reusable instruments. Case report: A 21-year-old woman sought care for symptomatic grade B esophagitis and hiatal hernia. A reusable 11-mm trocar was inserted in the umbilicus and a 10-mm, 30° angled, nonflexible, standard length scope was used. Curved reusable instruments (Karl Storz-Endoskope) were transumbilically introduced without trocars. The left hepatic lobe was retracted thanks to the distal curve of the grasper. The cruraplasty and wrap were performed using curved needle holder and intracorporeal sutures. Results: No extraumbilical trocar was necessary. Laparoscopic time was 108 minutes, and umbilical scar length was 16 mm. Discharge was allowed after 48 hours. Conclusions: SALN is feasible to be performed with curved reusable instruments, which avoid the conflict between the instruments’ tips inside the abdomen or between the surgeon’s hands outside. Cost of the procedure remains similar to standard laparoscopy because only reusable material is used.

A laparoscopic approach to left diaphragmatic rupture after blunt trauma.

Abstract Diaphragmatic rupture after blunt trauma is rare, but indicates a powerful external impact. Associated lesions are often life-threatening and require a rapid diagnosis and management. We report a case of a 24-year-old man, admitted to the emergency department after a serious car accident. He complained of a left sided thoraco-abdominal pain with breathing difficulties. Chest X-ray showed a left diaphragmatic elevation. Computed tomography demonstrated a left haemo-pneumothorax, herniation of the stomach in the chest and a haemoperitonium. Laparoscopically, herniated organs were re-integrated in the abdominal cavity; the diaphragmatic tear was repaired by both direct suture and synthetic prosthesis. Closure of a small bowel perforation found during the laparoscopic exploration was also performed. We consider this therapeutic modality to be an excellent approach in the management of acute left side diaphragmatic rupture in haemodynamically stable patients. Firstly, it permits an inspection of the thoracic cavity through the diaphragmatic tear and secondly, an easy repair of damaged structures in the abdominal cavity.

Duodenal duplication cyst in an adult: First simultaneous laparoscopic and endoscopic surgery

Duodenal duplication cysts are rare congenital anomalies. The symptoms may appear during the neonatal period or later in life, depending on the degree of gastrointestinal outlet obstruction. Classically, symptomatic cases have been treated by surgical resection or endoscopic marsupialization of the cyst. In this paper, we describe a new method of total laparoscopic resection and defect closure after precise localization of the lesion by simultaneous gastrointestinal endoscopy in a 24-year-old woman.

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.