Kunal Shetty

The first decade of robotic surgery in children

BACKGROUND Robotic surgery offers technological solutions to current challenges of minimal access surgery, particularly for delicate and dexterous procedures within spatially constrained operative workspaces in children. The first robotic surgical procedure in a child was reported in April 2001. This review aims to examine the literature for global case volumes, trends, and quality of evidence for the first decade of robotic surgery in children. METHODS A systematic literature search was performed for all reported cases of robotic surgery in children during the period of April 2001 to March 2012. RESULTS Following identification of 220 relevant articles, 137 articles were included, reporting 2393 procedures in 1840 patients. The most prevalent gastrointestinal, genitourinary, and thoracic procedures were fundoplication, pyeloplasty, and lobectomy, respectively. There was a progressive trend of increasing number of publications and case volumes over time. The net overall reported conversion rate was 2.5%. The rate of reported robot malfunctions or failures was 0.5%. CONCLUSIONS Robotic surgery is an expanding and diffusing innovation in pediatric surgery. Future evolution and evaluation should occur simultaneously, such that wider clinical uptake may be led by higher quality and level of evidence literature.

Gaze contingent cartesian control of a robotic arm for laparoscopic surgery

This paper introduces a gaze contingent controlled robotic arm for laparoscopic surgery, based on gaze gestures. The method offers a natural and seamless communication channel between the surgeon and the robotic laparoscope. It offers several advantages in terms of reducing on-screen clutter and efficiently conveying visual intention. The proposed hands-free system enables the surgeon to be part of the robot control feedback loop, allowing user-friendly camera panning and zooming. The proposed platform avoids the limitations of using dwell-time camera control in previous gaze contingent camera control methods. The system represents a true hands-free setup without the need of obtrusive sensors mounted on the surgeon or the use of a foot pedal. Hidden Markov Models (HMMs) were used for real-time gaze gesture recognition. This method was evaluated with a cohort of 11 subjects by using the proposed system to complete a modified upper gastrointestinal staging laparoscopy and biopsy task on a phantom box trainer, with results demonstrating the potential clinical value of the proposed system.

Disparity in Frontal Lobe Connectivity on a Complex Bimanual Motor Task Aids in Classification of Operator Skill Level

Objective metrics of technical performance (e.g., dexterity, time, and path length) are insufficient to fully characterize operator skill level, which may be encoded deep within neural function. Unlike reports that capture plasticity across days or weeks, this articles studies long-term plasticity in functional connectivity that occurs over years of professional task practice. Optical neuroimaging data are acquired from professional surgeons of varying experience on a complex bimanual coordination task with the aim of investigating learning-related disparity in frontal lobe functional connectivity that arises as a consequence of motor skill level. The results suggest that prefrontal and premotor seed connectivity is more critical during naïve versus expert performance. Given learning-related differences in connectivity, a least-squares support vector machine with a radial basis function kernel is employed to evaluate skill level using connectivity data. The results demonstrate discrimination of operator skill level with accuracy ≥0.82 and Multiclass Matthews Correlation Coefficient ≥0.70. Furthermore, these indices are improved when local (i.e., within-region) rather than inter-regional (i.e., between-region) frontal connectivity is considered (p = 0.002). The results suggest that it is possible to classify operator skill level with good accuracy from functional connectivity data, upon which objective assessment and neurofeedback may be used to improve operator performance during technical skill training.

Automated Task Load Detection with Electroencephalography: Towards Passive Brain–Computer Interfacing in Robotic Surgery

Automatic detection of the current task load of a surgeon in the theatre in real time could provide helpful information, to be used in supportive systems. For example, such information may enable the system to automatically support the surgeon when critical or stressful periods are detected, or to communicate to others when a surgeon is engaged in a complex maneuver and should not be disturbed. Passive brain–computer interfaces (BCI) infer changes in cognitive and affective state by monitoring and interpreting ongoing brain activity recorded via an electroencephalogram. The resulting information can then be used to automatically adapt a technological system to the human user. So far, passive BCI have mostly been investigated in laboratory settings, even though they are intended to be applied in real-world settings. In this study, a passive BCI was used to assess changes in task load of skilled surgeons performing both simple and complex surgical training tasks. Results indicate that the introduced methodo...

Persistent Prefrontal Engagement Despite Improvements in Laparoscopic Technical Skill

Persistent Prefrontal Engagement Despite Improvements in Laparoscopic Technical Skill Teaching and assessment of laparoscopic skills are currently essential components of surgical training. The Fundamentals of Laparoscopic Surgery (FLS) is a widely adopted training program based on expert-derived benchmarks; technical skills are assessed and completion is a mandatory criterion for general surgery board certification in the United States.1 However, is attainment of technical proficiency synonymous with being a safe surgeon? Intraoperative errors persist and are thought to be related to errors in cognition2 as opposed to technical failure per se. The prefrontal cortex (PFC) is a brain region associated with attention and executive function serving as a scaffold to support novel task demands during effortful unrefined performance.3 Studies examining cortical correlates of technical skills acquisition have observed predictable attenuation in PFC response alongside improvement in technical performance4,5; however, this has not been adequately tested for challenging laparoscopic skills. Methods | The National Research Ethics Service Committee London-Fulham approved the study, and written informed consent was obtained from participants. Forty-five participants of varying surgical experience were studied using a 44-channel optical-topographic device (ETG-4000; Hitachi Medical Corp) to monitor prefrontal responses during a laparoscopic suturing drill depicted in the Figure. To characterize frontal brain behavior over the time course from early learning to automation, both cross-sectional and longitudinal studies were conducted as follows: (1) a cross-sectional study compared PFC excitation in 35 surgeons (novices with 2 hours of training: n = 12; residents: n = 12; and experts: n = 11) and (2) a longitudinal study that tracked changes in PFC responses across 4 points as a second cohort of novices (n = 13) acquired suturing skills over a fortnight of practice (8 hours). Laparoscopic suturing skill was evaluated using the FLS framework (time and accuracy). Brain activation was inferred from task-evoked changes in cortical oxygenated (ΔHbO2) and deoxygenated hemoglobin.

Robotic-assisted total mesorectal excision: should it be considered as the technique of choice in the management of rectal cancer?

The feasibility of robotic surgery has been extensively explored over the past decade with a more recent shift towards defining focused clinical applications for which quantifiable patient benefits can be directly attributed to its use. The aim of this article is to review the current literature on the use of daVinci robotic surgery for the management of rectal cancer and identify the potential benefits, if any, that robotic-assisted total mesorectal excision (RTME) may provide over the current conventional approach. A comprehensive search strategy was used to identify relevant evidence in order to explore the oncological, operative and functional outcome measures for the RTME in addition to quantifying the level of evidence which describes the clinical effectiveness of the daVinci robot in oncological surgery. Both robotic assisted techniques and the primary outcomes are discussed. In total, 23 studies were reviewed across 11 institutions, including one pilot randomised control trial. When data repetition is disregarded, a total of 452 robotic assisted laparoscopic anterior resections and 60 robotic-assisted laparoscopic abdomino-perineal excision of the rectum have been published since the introduction of the daVinci into clinical practice. Feasibility of the daVinci robotic assisted total mesorectal excision is demonstrated, with comparable oncological outcomes presented for rectal cancer excision. A demonstration of a reduced open conversion rate as well as of reduced hospital stay with the use of the robot is highlighted, although further trials are required to confirm both these findings. No functional benefit in using the daVinci could be confirmed due to the lack of focused trials in this area.