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A Systematic Review of Virtual Reality Simulators for Robot-assisted Surgery
By: Andrea Mogliaa*, Vincenzo Ferrariab, Luca Morelliac, Mauro Ferraria, Franco Moscad and Alfred Cuschierief
European Urology, October 2015
Published online: 01 October 2015
No single large published randomized controlled trial (RCT) has confirmed the efficacy of virtual simulators in the acquisition of skills to the standard required for safe clinical robotic surgery. This remains the main obstacle for the adoption of these virtual simulators in surgical residency curricula.
To evaluate the level of evidence in published studies on the efficacy of training on virtual simulators for robotic surgery.
In April 2015 a literature search was conducted on PubMed, Web of Science, Scopus, Cochrane Library, the Clinical Trials Database (US) and the Meta Register of Controlled Trials. All publications were scrutinized for relevance to the review and for assessment of the levels of evidence provided using the classification developed by the Oxford Centre for Evidence-Based Medicine.
The publications included in the review consisted of one RCT and 28 cohort studies on validity, and seven RCTs and two cohort studies on skills transfer from virtual simulators to robot-assisted surgery. Simulators were rated good for realism (face validity) and for usefulness as a training tool (content validity). However, the studies included used various simulation training methodologies, limiting the assessment of construct validity. The review confirms the absence of any consensus on which tasks and metrics are the most effective for the da Vinci Skills Simulator and dV-Trainer, the most widely investigated systems. Although there is consensus for the RoSS simulator, this is based on only two studies on construct validity involving four exercises. One study on initial evaluation of an augmented reality module for partial nephrectomy using the dV-Trainer reported high correlation (r = 0.8) between in vivo porcine nephrectomy and a virtual renorrhaphy task according to the overall Global Evaluation Assessment of Robotic Surgery (GEARS) score. In one RCT on skills transfer, the experimental group outperformed the control group, with a significant difference in overall GEARS score (p = 0.012) during performance of urethrovesical anastomosis on an inanimate model. Only one study included assessment of a surgical procedure on real patients: subjects trained on a virtual simulator outperformed the control group following traditional training. However, besides the small numbers, this study was not randomized.
There is an urgent need for a large, well-designed, preferably multicenter RCT to study the efficacy of virtual simulation for acquisition competence in and safe execution of clinical robotic-assisted surgery.
We reviewed the literature on virtual simulators for robot-assisted surgery. Validity studies used various simulation training methodologies. It is not clear which exercises and metrics are the most effective in distinguishing different levels of experience on the da Vinci robot. There is no reported evidence of skills transfer from simulation to clinical surgery on real patients.
Take Home Message
This review critically appraises the evidence published regarding virtual simulators for robot-assisted surgery and addresses key aspects that are currently unsolved for which research should be conducted.
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Minimally Invasive and Robotic Thyroid and Parathyroid Surgery is the first textbook which includes a comprehensive review of both minimally invasive and robotic thyroid and parathyroid techniques. Over the last several years there has been a rapid expansion in the number of different surgical approaches available to patients undergoing thyroid and parathyroid surgery.
This book consolidates these in one source and focuses on both the philosophy and techniques of these procedures. For thyroid surgery, the text covers the full range of minimally invasive procedures and several of the most widely adopted remote access techniques. Several related procedures are also discussed, including minimally invasive approaches to central and lateral neck dissection. For parathyroid surgery, several minimally invasive techniques are covered, including radioguided surgery.
Written by experts in the field of thyroid and parathyroid surgery, Minimally Invasive and Robotic Thyroid and Parathyroid Surgery serves as a critical resource for both experienced and less experience surgeons, fellows, residents, and students interested in understanding the breadth of this field or learning the specific steps of a particular technique.
Distribution of innate ability for surgery amongst medical students assessed by an advanced virtual reality surgical simulator
Authors: Andrea Moglia, Vincenzo Ferrari, Luca Morelli, Franca Melfi, Mauro Ferrari, Franco Mosca, Alfred Cuschieri
Abstract: Surgery is a craft profession requiring individuals with specific, well-documented innate aptitude for manipulative skills. Yet in most countries, the current selection process of surgical trainees does not include aptitude testing for the psychomotor and manipulative skills of candidates.
Methods: A total of 125 participants (121 medical students and four expert surgeons) performed all 26 exercises of the da Vinci Skills Simulator, with six exercises being identified as metrics of aptitude for manipulative and psychomotor skills. The expert surgeons were enrolled as the control group to validate the performance of the most talented students.
Results: Eight students (6.6 %) significantly outperformed the remaining 113, obtaining a median value of the sum of weighted overall score on the six selected exercises of 52.7 % versus 21.0 % (p < 0.001). In contrast, 14 students (11.6 %) performed significantly worse and well below the performance of the other 107, with a median value of overall score of 8.7 % versus 24.1 (p < 0.001). There was no statistically significant difference between expert surgeons (control group) and the eight talented students (62.1 % vs. 52.7 %, respectively; p = 0.368). No significant correlation between exposure to video games and overall score (ρ = 0.330) was observed.
Conclusions: In terms of innate aptitude for manipulative and psychomotor abilities, the present investigation has documented two subpopulations that fall outside the norm for the group of medical students recruited for the study: (i) a small group (6.6 %) with a high level and (ii) a larger cohort (11.6 %) with low level (significantly below the norm) innate aptitude for surgery. Exposure to video game experience did not appear to influence performances on the da Vinci Skills Simulator.
By: Salem I. Noureldine, Jeremy D. Richmon, Ralph P. Tufano, Salah Mohamed, Emad Kandil
Posted on AARS: July 24, 2013
Over the last decade, robotic surgery has evolved from a medical curiosity, with anticipated potential to overcome the limitations of surgical endoscopy, to the favored procedure in several surgical specialties such as urology and gynecology. The application of robotic technology in head and neck endocrine surgery has recently expanded. Different approaches have lately been described that are intended to preserve the safety of these operations, while avoiding visible neck scars. This article aims to provide the reader with an overview of the current robotic approaches and their capability to assist surgeons in accomplishing remote-access thyroid and parathyroid surgery.
Essentials of Robotic Surgery: The Present and Potential Future of Surgical Techniques
Essentials of Robotic Surgery: The Present and Potential Future of Surgical Techniques May 14, 2013, Ann Arbor, MI. For Immediate Release
Drs. Manak Sood and Stefan W. Leichtle with Spry Publishing today announced the release of Essentials of Robotic Surgery, a groundbreaking new book that provides comprehensive analysis of the current developments in robotically assisted surgery.
Essentials of Robotic Surgery details the history of robotic surgical technologies and techniques, while looking ahead to the possibilities contained within future applications. Covered in the book are the most notable, current surgical applications, from coronary revascularization to prostate surgery, from the lungs and esophagus to the uterus, from sleep apnea to head and neck cancer.....read more
Robotic Cardiothoracic Surgery (Current Cardiac Surgery)
Robotic Cardiothoracic Surgery (Current Cardiac Surgery)
Robotic Surgery is similar to minimally invasive surgery, also known as laparascopy, in which surgeons operate through small ports rather than large incisions. This text will provide a comprehensive review of the historical, engineering, surgical and economic aspects of robotically assisted cardiothoracic surgery. This book will be of interest and use to a wide variety of readers from mechanical and biomedical engineers to cardiologists.
Pediatric Robotic and Reconstructive Urology: A Comprehensive Guide John Wiley and Sons Ltd, Pages: 368 This title is pre-publication and is due to be released in April 2012. Order now at this special pre-publication price.
This comprehensive guide provides specialist and trainees with an innovative text and video guide to this dynamic area, in order to aid mastery of robotic approaches and improve the care of pediatric patients.
Full-color throughout and including over 130 color images, this comprehensive guide covers key areas including:
• Training, instrumentation and physiology of robotic urologic surgery • Surgical planning and techniques involved • Adult reconstructive principles applicable to pediatrics • Management of complications, outcomes and future perspectives for pediatric urologic surgery
Also included are 30 high-quality surgical videos illustrating robotic surgery in action, accessed via a companion website, thus providing the perfect visual tool for the user.
With chapters authored by the leading names in the field, and expertly edited by Mohan Gundeti, this ground-breaking book is essential reading for all pediatric urologists, pediatric surgeons and general urologists, whether experienced or in training.
The axial position sensing and signal processing in maglev artificial heart pump January 7, 2011
This paper describes a newly developed position sensor system. The position sensing system is designed to be combined with the radial permanent magnetic bearing and used for the control of the axial active magnetic bearing. The rotor ring of the radial magnetic bearing is used as field source, which shortens the rotor and saves space for artificial heart design. Linear hall sensor is selected due to its low cost and miniature size. The principle of the position sensing system is based on the analysis of the magnetic field of the permanent magnetic bearing and the sensor module is designed via finite-element analysis to optimize sensitivity and accuracy of the measured signal. An applied primary amplifier circuit for the position sensing is designed and its performance is tested. The experimental results demonstrate that the position sensing system has a satisfactory performance and is effective for axial control. Source: ieeexplore.org
Robotics in reproductive medicine Edward E. Wallach, M.D. Associate Editor Sejal P. Dharia, M.D.(a) and Tommaso Falcone, M.D.(b) a Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama; b Department of Obstetrics and Gynecology, Cleveland Clinic Foundation, Cleveland, Ohio
The Surgical Assistant Workstation (SAW) modular software framework provides integrated support for robotic devices, imaging sensors, and a visualization pipeline for rapid prototyping of telesurgical research systems. Subsystems of a telesurgical system, such as the master and slave robots and the visualization engine, form a distributed environment that requires an efficient inter-process communication (IPC) mechanism. This paper describes the extension of the component-based framework provided by the cisst libraries, on which the SAW depends, from a multi-threaded (local) to a multi-process (networked) environment. The current implementation uses the Internet Communication Engine (ICE) middleware package, but the design does not depend on ICE and can accomodate other middleware choices. A telesurgical robot system based on the da Vinci hardware platform is used as a test case, with a research application that requires coordination between the left and right robot arms (a bimanual knot tying task). Performance measurements on this platform indicate minimal overhead due to the networking.
Comparison of robotic and nonrobotic thoracoscopic thymectomy: A cohort study Jens C. Rückert, MD, PhD*, Marc Swierzy, MD, Mahmoud Ismail, MD
Department of General, Visceral, Vascular and Thoracic Surgery, Universitätsmedizin Berlin, Charité Campus Mitte, Berlin, Germany.
Objective: Radical thymectomy has become more popular in the comprehensive treatment of myasthenia gravis. Minimally invasive techniques are increasingly used for thymectomy. The most recent development in robotic thoracoscopic surgery has been successfully applied for mediastinal pathologies. To establish robotic technique as a standard, the results of high-volume centers and comparison with traditional surgery are mandatory. Methods: In a retrospective cohort study, the results of 79 thoracoscopic thymectomies (October 1994 to December 2002) were compared with the results of 74 robotic thoracoscopic thymectomies (January 2003 to August 2006). Data from both series were collected prospectively. In both groups, all patients had myasthenia gravis. Both cohorts were compared with respect to severity of disease, gender, age, histology, and postoperative morbidity. All patients were analyzed for quantification of improvement of disease according to the Myasthenia Gravis Foundation of America. Results: There were no differences in age distribution and severity of myasthenia gravis. The dominant histologic finding was follicular hyperplasia of the thymus in both groups with a significantly higher percentage in the thoracoscopic thymectomy series (68% vs 45%, P < .001). After a follow-up of 42 months, the cumulative complete remission rate of myasthenia gravis for robotic and nonrobotic thymectomy was 39.25% and 20.3% (P = .01), respectively. Conclusions: There is an improved outcome for myasthenia gravis after robotic thoracoscopic thymectomy compared with thoracoscopic thymectomy.
The International Journal of Medical Robotics and Computer Assisted Surgery
Side-docking in robotic-assisted gynaecologic cancer surgery
Background The majority of previous experience with the robotic-sssisted laparoscopic technique for gynaecological procedures has utilized a method in which the robot is centrally located (CD) between the patient's legs.
Methods Twelve consecutive patients undergoing robotic-assisted procedures for gynaecological malignancies were positioned in a side-docking (SD) fashion, in which the robot is positioned lateral to the patient. The relevant clinical parameters were collected and compared to the previous 12 patients undergoing surgery using the conventional, centre-docking (CD) technique.
Results Specimen retrieval time for larger uteri was reduced in the SD group compared to the CD group (p = 0.03). Total operative times were slightly lower in the SD group and specimen retrieval times for all uterine weights were unchanged when compared to the CD group. Statistical significance was not observed.
Robotic systems were first used to remove prostate cancer, then adapted for kidney cancer and bladder cancer procedures, which are more complex because of the variation in surgical anatomy, size and shape of tumors. The benefits of robotic surgery for a patient include decreased blood loss, nerve sparing and shorter hospital stay. This talk will focus on the latest advances in robotic surgery for the treatment of these cancers.This product is manufactured on demand using DVD-R recordable media.
Robotic Surgery for Aortoiliac Occlusive Disease
Chapter 30. Robotic Surgery for Aortoiliac Occlusive Disease
Sections: Robotic Surgery for Aortoiliac Occlusive Disease: Introduction, Laparoscopic Vascular Surgery, Robot-Assisted Vascular Surgery, Operative Technique, Conclusion, References.
Excerpt: "Diseases of the abdominal aorta can be classified primarily as aneurysmal or occlusive and account for significant morbidity and mortality worldwide, with more than 16,000 deaths annually in the United States alone.1 The tenets of operative repair, whether for abdominal aortic aneurysms (AAAs) or aortoiliac occlusive disease, have remained relatively stable in the setting of rapid technological change. Aneurysms are excluded from the circulation and blood flow continuity restored,2,3 while in aortoiliac occlusive disease, blood flow is reestablished beyond the site of occlusion via aortoiliac bypass.4 Endovascular options now exist in both the diagnosis and the treatment of abdominal vascular disease, but again the surgical principles remain unchanged.5 Vascular surgeons and patients have embraced the move toward endovascular approaches to the abdominal aorta, as these typically result in less postoperative pain, improved cosmesis, and a quicker recovery time.6..."
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Transoral Robotic Surgery for Advanced Oropharyngeal Carcinoma
Gregory S. Weinstein, MD; Bert W. O’Malley Jr, MD; Marc A. Cohen, MD; Harry Quon, MD
Arch Otolaryngol Head Neck Surg. 2010;136(11):1079-1085. doi:10.1001/archoto.2010.191
Objectives: To determine the oncologic and functional outcomesin patients undergoing primary transoral robotic surgery followedby adjuvant therapy as indicated with a minimum of 18-monthfollow-up for advanced oropharyngeal carcinoma.
Design: Prospective single-center cohort study.
Setting: Academic university health system and tertiaryreferral center.
Patients: Forty-seven adults with newly diagnosed and previouslyuntreated advanced oropharyngeal carcinoma.
Intervention: Transoral robotic surgery with staged neckdissection and adjuvant therapy as indicated.
Main Outcome Measures: Margin status, recurrence, disease-specificand disease-free survival, gastrostomy tube dependence, andsafety and efficacy end points.
Are there advantages to robotic-assisted surgery over laparoscopy from the surgeon’s perspective?
The advantages of a robotic approach are often difficult to quantify for surgical procedures that can be performed laparoscopically. Using a novel subjective rating scale, this study demonstrates a methodology to measure surgeon assessment of ease of use, comparing complex operations performed robotically and laparoscopically.
A subjective assessment scale for robotic surgery was developed that included 13 task-related factors assessing operative challenges and ease of use. As part of a larger study comparing outcomes of laparoscopic and robotic biliary-enteric anastomosis, a surgeon performing 20 choledochojejunal anastomoses in an ex vivo pig model completed this scale after each procedure. Ten anastomoses were performed laparoscopically and ten using da Vinci robot assistance. Overall difficulty was also assessed using a 10-cm visual analog scale.
Robotic surgery was associated with superior ease to laparoscopy in 8 of the 13 factors, including image quality, depth perception, comfort, eye fatigue, dexterity, precision of motion, speed of motion, and range of motion. The visual analog scale also showed a significant benefit in overall ease of the robotic over laparoscopic procedure. Nonsignificant trends favoring robotics were seen with fluidity of motion and equipment setup. Based on these results this study suggest that surgeon ease of use may be quantified using this assessment scale and that robot assistance may be advantageous over laparoscopy when performing complex surgical tasks in an ex vivo model from the surgeon’s perspective.
Robotic-assisted laparoscopic surgery in urology:a historical perspective REVIEW ARTICLE Year : 2005 | Volume : 21 | Issue : 2 | Page : 79-82 Nikhil L Shah, AK Hemal, Mani Menon Vattikuti Urology Institute, Henry Ford Health Systems, Detroit, USA
Significant improvements in the surgical approaches and management of disease have been made since the advent of antiseptic surgical technique and the widespread use of antibiotics. During the last quarter century, especially in the last decade, however, there has been an indisputable paradigm shift toward the use of minimally invasive surgery for treatment of a variety of diseases. This has benefited the patient in terms of lower morbidity and mortality through less violation of the body's natural protective boundaries. The morbidity in terms of pain, discomfort, and disability often associated with open surgery is due to the process of gaining access to the specific organ or region of interest as opposed to the actual procedure itself. Put another way, the move toward minimally invasive approaches for surgical disease has resulted in superior outcomes, fewer complications, and an overall improvement in health-related quality of life (HRQOL).
Robotic surgery in gynecologic oncology fellowship programs in the USA: a survey of fellows and fellowship directors. Int J Med Robot. 2010 Sep 17 Authors: Sfakianos GP, Frederick PJ, Kendrick JE, Straughn JM, Kilgore LC, Huh WK
BACKGROUND: In order to understand how robotic surgery impacts gynecologic oncology fellowship training and surgical practices, a survey of fellows and fellowship directors was conducted.
METHODS: Questionnaires designed to determine the prevalence, application, and acceptance of robotics were sent to fellows and fellowship directors in approved U.S. programs.
RESULTS: Of the respondents, 95% have a robot at their institution and 95% utilize it. Most responding fellowship directors (70%) reported that fellow education is enhanced by robotic surgery. Most fellows (65%) who responded feel comfortable using the robot, and 94% plan on performing robotic surgery upon completion of fellowship training.
CONCLUSIONS: This survey demonstrates that robotic surgery is utilized in the majority of responding gynecologic oncology fellowship programs for a wide array of indications. Fellowship directors and fellows-in-training generally have a favorable view of this evolving technology. Based on these responses, robotic surgery will play an increasingly important role in the future.
Impact of Robotics and Laparoscopy on Surgical Skills: A Comparative Study
Background:This study objectively surveyed and compared the ability of participants to perform laparoscopic and robotic tasks, and attempted to determine the key advantages of each modality.
Study design:A task-based training course was developed that included laparoscopic and robotic task modules. Twenty-two participants (6 faculty members, 6 fellows, and 10 residents) completed a pretask and posttask questionnaire concerning 3 tasks, using both laparoscopy trainer and the daVinci robotic system (Intuitive Surgical, Inc). All tasks were timed and values were recorded. The surveys were completed by each participant to assess both pre- and posttask experiences.
Results:In the pretask survey, 55% of subjects reported participating in more than 20 laparoscopic cases, and only 27% had ever worked at a robotic console. The median number of beads threaded in 5 minutes was similar for the 2 methods, but the median time to complete 5 beads was 98 seconds for the laparoscope compared with 160 seconds using the robot (p=0.001). The median number of loops completed in 5 minutes was greater (p < 0.001) using the robot (7.5 versus 2). Only 9% of subjects completed 9 loops in 5 minutes using the laparoscope; 50% did so using the robot (p < 0.05). The percentage of subjects completing 3 knots in 5 minutes was similar when using the laparoscope (45%) and robot (68%). Familiarity and tactile feedback were the primary advantages with laparoscopy, and EndoWrist (Intuitive Surgical, Inc) and stereoscopic visualization were perceived as advantages of the robot.
Conclusions:As with any new technology, skills must be mastered to use robotic technology for the most benefit. The EndoWrist action and stereoscopic visualization were the most valued advantages of the robot. Most fellows and residents would seek additional training in robotics if given the opportunity.
BACKGROUND: Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery. METHODS: A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords "surgical robotics," "robotic surgery," "robotics," "computer assisted surgery," and "vascular surgery" or "endovascular" for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken. RESULTS: Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited. CONCLUSIONS: Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery. For more information Click here
Christos Katsios and Georgios Baltogiannis
Advances and high demands in totally robotic surgery for rectal cancer
Open low anterior resection for tumors located in the lower third of the rectum has three goals: precision of total mesorectal excision (TME), safe distal margins to prevent local recurrence after a sphincter-preserving procedure, and high ligation of the inferior mesenteric artery with splenic flexure mobilization. Can these surgical aims be achieved with a minimally invasive approach such as laparoscopic or robotic surgery? Park et al. highlight this question in their report on robotic surgery for rectal cancer in the March issue of Surgical Endoscopy....read more
Incidence of Surgical Site Infection Associated with Robotic Surgery
Elizabeth D. Hermsen, PharmD, MBA; Tim Hinze, PharmD; Harlan Sayles, MS; Lee Sholtz, RN; Mark E. Rupp,MD
From Pharmacy Relations and Clinical Decision Support (E.D.H.), the Department of Pharmaceutical and Nutrition Care (T.H.), and the Department of Healthcare Epidemiology and Infection Control (L.S.), Nebraska Medical Center, and the Department of Pharmacy Practice, College of Pharmacy (E.D.H.), the Section of Infectious Diseases, Department of Internal Medicine, College of Medicine (E.D.H., M.E.R.), and the Biostatistics Department, College of Public Health (H.S.), University of Nebraska Medical Center, Omaha, Nebraska....read more
Transoral Robotic Surgery of the Skull Base: A Cadaver and Feasibility Study John Y.K. Leea, Bert W. O’Malley, Jr.b, Jason G. Newmanb, Gregory S. Weinsteinb, Bradley Legaa, Jason Diazb, M. Sean Gradya
Departments of aNeurosurgery and bOtolaryngology, University of Pennsylvania, Philadelphia, Pa., USA
Objective: The goal of this study was to determine the potential role as well as the current limitations of the da Vinci Surgical System robot in transoral surgery of the skull base. Methods: The da Vinci robot was used to perform dissections of the skull base on 7 cadaver heads with their neck and clavicles intact. Neurosurgeons and otolaryngologists familiar with all facets of the open microscopic, minimally invasive, endoscopic and transoral robotic surgical procedure proceeded with the approach to and dissection of the human skull base. Results: The da Vinci robot provided superb illumination and 3-dimensional depth perception. The 30- degree endoscope improved cephalad visualization, and the ‘intuitive’ nature of the da Vinci surgical robot arms provided an advantage by their ability to suture the dura at the level of the clivus. An entirely transoral route provides access to the middle and lower clivus as well as the infratemporal fossa, but access to the sellar region and anterior cranial fossa is limited via a purely transoral route. Tremor-free dural closure was successfully performed. Conclusion: Our findings suggest that transoral robotic surgery utilizing the da Vinci robot system holds great potential for skull base surgical resection of extradural and intradural tumors of the middle and lower clivus and infratemporal fossa. A collaborative approach with neurosurgeon and otolaryngologist alternating at the master console and bedside is a successful strategy. Further instrument development is necessary, and continued investigation is warranted. Source
Surgical performance in a virtual environment
Surgical performance in a virtual environment
Purpose – The purpose of this paper is to determine the effect of video game and surgical experience on the ability to adapt to and use the neuroArm virtual reality (VR) simulator. Design/methodology/approach – A total of 48 participants, comprising video gamers, medical students, surgical residents, and qualified surgeons, were recruited. Subjects played three video games and completed a questionnaire. Three pre-determined tasks simulating surgical procedures were performed using the simulator. Performance was measured by time for task completion, number of errors, and quality of outcome. Findings – Gamers outperformed other groups on all measures of performance at almost every task on the VR simulator. All groups showed interval improvement in performance. As age of participants increased, irrespective of their sex and group, their quality of performance decreased and time to complete tasks increased. Initially, the men outperformed the women at every task, however, the difference decreased with repetition. Research limitations/implications – More participants are needed to increase statistical significance of the results, in particular female participants. Practical implications – This study showed that gamers adapted rapidly to the neuroArm trainer, which could be attributed to enhanced visual attention and spatial distribution skills from video game play. Therefore, visuospatial skills may become strong elements in the selection criterion for future generations of surgical trainees. Originality/value – This study evaluated performance on the neuroArm trainer for the first time. The results provide insight into the design of a training program that helps select and prepare future surgeons for robotic surgery.
Robotics May Overcome Technical Limitations of Single-Trocar Surgery
An Experimental Prospective Study of Nissen Fundoplication
Pierre Allemann, MD; Joel Leroy, MD; Mitsuhiro Asakuma, MD; Fahad Al Abeidi, MD; Bernard Dallemagne, MD; Jacques Marescaux, MD, PhD, FRCS
Objective To 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 surgeon's 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. Design Prospective study consisting of 18 randomly performed porcine STA Nissen fundoplications with and without robotic assistance. Setting A research institute. Participants Three surgeons with different experience. Main Outcome Measures Operative time, intraoperative complications, and the number of conflicts between the instruments and/or hands of the surgeons. Results All 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. Conclusions Use 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. Author Affiliation
Haptics: Generating and Perceiving Tangible Sensations
VerroTouch: High-Frequency Acceleration Feedback for Telerobotic Surgery
Katherine J. Kuchenbecker, Jamie Gewirtz, William McMahan, Dorsey Standish, Paul Martin, Jonathan Bohren, Pierre J. Mendoza and David I. Lee
The Intuitive da Vinci system enables surgeons to see and manipulate structures deep within the body via tiny incisions. Though the robotic tools mimic one’s hand motions, surgeons cannot feel what the tools are touching, a striking contrast to non-robotic techniques.
We have developed a new method for partially restoring this lost sense of touch. Our VerroTouch system measures the vibrations caused by tool contact and immediately recreates them on the master handles for the surgeon to feel. This augmentation enables the surgeon to feel the texture of rough surfaces, the start and end of contact with manipulated objects, and other important tactile events. While it does not provide low frequency forces, we believe vibrotactile feedback will be highly useful for surgical task execution, a hypothesis we we will test in future work.
Artificial Tactile Sensing in Biomedical Engineering By: Siamak Najarian
This definitive guide details the design and manufacturing of artificial tactile systems and their applications in surgical procedures.
Artificial Tactile Sensing in Biomedical Engineering explains the fundamentals of the human sense of touch and the latest techniques for artificially replicating it.
The book describes the mechanistic principles of static and dynamic tactile sensors and discusses cutting-edge biomedical applications, including minimally invasive surgery, tumor detection, robotic surgery, and surgical simulations. Artificial Tactile Sensing in Biomedical Engineering covers: Capacitive, magnetic, inductive, conductive elastomeric, optical, and thermal sensors Strain gauge and piezoelectric sensors Tactile sensing in surgery and palpation...read more
Duty-split Approach in Robotic Surgery
Minimally-invasive surgery deserves increasing attention to lower post-operative stays in hospitals and to lessen fall-off complications. This new book is devoted to surgical robotics, with a focus on technology and design issues of the remote-mode operation assistants. The investigation leads to define the technical characteristics of a CRHA, co-robotic handling appliance, to be purposely developed, to support the duty-split approach surgical planner.
Complications of Laparoscopic and Robotic Urologic Surgery
There has been a huge rise in minimally invasive surgery (MIS) in urology. This has led for an urgent need for a textbook specifically dedicated to the issues and complications arising from laparoscopic and robotic procedures.
With contributions from recognized urologic experts in MIS, Complications of Laparoscopic and Robotic Urologic Surgery fills this need by familiarizing the modern urologist with the common and the more eccentric complications of laparoscopic and robotic urologic surgery. Brief descriptions of the procedures are pred, as well as an in-depth discussion of the diagnosis and management of complications associated with that particular procedure.
The book is divided into three specific sections. The first section covers medical and general considerations. The second section pres a generalized discussion of common surgical complications. Complications specific to robotic surgery in general are emphasized in a separate chapter. The third section is dedicated to procedure specific complications. Complications of upper tract and lower tract laparoscopic and robotic procedures are discussed in different sub-sections. Ample illustrations and images are pred throughout the text. As more urologists embrace laparoscopy and robotics, and more fellows and residents are trained in this subspecialty, the use of MIS technology in the field of urology is expanding. This unique volume will of great value to the practicing urologist adept at performing laparoscopy and...read more
Institute for Process Control and Robotics
SAFROS - Patient Safety in Robotic Surgery
This Large-scale integrating project (IP) addresses the development of technologies for patient safety in robotic surgery. We define patient safety metrics for surgical procedures and then develop methods that abide by safety requirements, formulated in terms of our metrics. We aim at demonstrating that a properly controlled robotic surgery carried out in accordance to our safety criteria can improve the level of patient safety currently achievable by traditional surgery.
The main innovative aspects of this project are:
Research driven by patient-safety requirements
Emphasis on methodological rigor: development of a methodology founded in evidence-based medicine
Scope: the entire surgical workflow is considered for development and validation.
Along with considering the entire surgical workflow, SAFROS focuses on innovative development of methods for the following technologies:
Soft organ modeling and calibration, considering patient pathologies and anatomical variants
Simulation planning in deformable environments
Intra-operative registration and workflow monitoring
Robot modeling and performance monitoring
Operator interface with integrated stereovision and haptics
New methods are integrated and validated on two distinct surgical robots (MIRO and RAMS), with respect to two inherently different contexts (pancreatic and vascular surgery). We quantitatively validate the adherence of our methods to the safety criteria, using surgical phantoms and animals. By comparing across robots and surgical contexts we draw conclusions about the generality of our approach...read more
Estimation of environmental force for the haptic interface of robotic surgery
Background The success of a telerobotic surgery system with haptic feedback requires accurate force-tracking and position-tracking capacity of the slave robot. The two-channel force-position control architecture is widely used in teleoperation systems with haptic feedback for its better force-tracking characteristics and superior position-tracking capacity for the maximum stability margin. This control architecture, however, requires force sensors at the end-effector of the slave robot to measure the environment force. However, it is difficult to attach force sensors to slave robots, mainly due to their large size, insulation issues and also large currents often flowing through the end-effector for incision or cautery of tissues.
Methods This paper provides a method to estimate the environment force, using a function parameter matrix and a recursive least-squares method. The estimated force is used to feed back the force information to the surgeon through the control architecture without involving the force sensors...read more
Robotics in Surgery
Robotics in Surgery: History, Current and Future Applications
Minimally-invasive surgical techniques are rapidly becoming the desired standard, in keeping with our “first do no harm” mandate. The consensus of the contributing authors is that surgical robots represent the next level in our minimally-invasive evolution. These authors are pioneers in minimally-invasive techniques, and have discovered that surgical robotic systems can augment and extend our human capabilities as surgeons. They enable us to operate in increasingly smaller spaces, through increasingly smaller incisions, resulting in decreased morbidity and more rapid recovery times. Due to miniaturization and addition of the “wrist” to robotic endoscopic instruments, surgical robots have enabled procedures to be performed that are otherwise not possible with manually-controlled endoscopic instruments. This book brings together a review of how these surgeon-scientists have come to this early stage in robot-assisted surgery, how this technology is improving patient care in multiple surgical fields, and what we can expect in the near future from surgical robotics.
Robotic single-incision transabdominal and transvaginal surgery: initial experience with intersecting robotic arms
Background: Single-incision laparoscopic and natural orifice translumenal endoscopic surgery (NOTES) are technically challenging methods. Robotics might have the potential to overcome such hurdles with computer technology. Methods: The da Vinci® Standard and S System (Intuitive, Sunnyvale, USA) were used in human cadavers and pigs to perform single-incision transabdominal and transvaginal surgery. Robotic arms were crossed and control-switched to achieve intuitive control. Results: It was possible to perform robotic single-incision laparoscopy in the typical, intuitive fashion. Transvaginal set-up, including docking of the system and introduction of instruments into the abdominal cavity, was possible but no useful manipulation could be performed Conclusions: While robotic NOTES with the da Vinci surgical system was not successful, robotic single-incision surgery is feasible using the above set-up. This new approach seems to offer the advantages of single-incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified.
World Journal of Surgery
Robot-Assisted Pediatric Surgery: How Far Can We Go?
Background: The purpose of this study was to assess the safety and feasibility of performing robot-assisted pediatric surgery using the da Vinci Surgical System in a variety of surgical procedures. Methods: A retrospective review of 144 robot-assisted pediatric surgical procedures performed in our institution between June 2004 and December 2007 was done. The procedures included the following: 39 fundoplications; 34 cholecystectomies; 25 gastric bandings; 13 splenectomies; 4 anorectal pull-through operations for imperforate anus; 4 nephrectomies; 4 appendectomies; 4 sympathectomies; 3 choledochal cyst excisions with hepaticojejunostomies; 3 inguinal hernia repairs; two each of the following: liver cyst excision, repair of congenital diaphragmatic hernia, Heller’s myotomy, and ovarian cyst excision; and one each of the following: duodeno-duodenostomy, adrenalectomy, and hysterectomy. Results: A total of 134 procedures were successfully completed without conversion; 7 additional cases were converted to open surgery, and 3 were converted to laparoscopic surgery. There were no system failures (e.g., setup joint, arm, or camera malfunction; power error; monocular or binocular loss; metal fatigue or break of surgeon’s console hand piece; software incompatibility). There was one esophageal perforation and two cases of transient dysphagia following Nissen fundoplication. The mean patient age was 8.9 years, and the mean patient weight was 57 kg. Conclusions: Robot-assisted surgery appears to be safe and feasible for a number of pediatric surgical procedures. Further system improvement and randomized studies are required to evaluate the benefits, if any, and the long-term outcomes of robotic surgery.
Robotic surgery and resident training
Robotic surgery and resident training
Background: Robotic technology promises to have an important future in surgery, but few residency programs incorporate robotics into surgical training. We sought to compare the speed and accuracy with which junior residents could perform laparoscopic tasks using both a robotic surgical device (Zeus MicroWrist) and conventional laparoscopic instruments. Methods: Twelve residents performed exercises of progressive difficulty in an inanimate model using both the robot and conventional laparoscopy. Analysis of variance statistical analysis was used to compare task time and suturing accuracy scores. Results: Grasping and suturing exercises were performed significantly faster with conventional laparoscopic instruments than with the robot. However, no difference in task time was noted for intracorporeal knot tying. Accuracy scores for suturing were higher for the robot. Conclusions: Junior residents can be instructed easily and quickly in both robotic and conventional advanced laparoscopic skills. The utility of robotic surgical devices in resident training requires further investigation.
Legal and ethical issues in robotic surgery
AIM: With the rapid introduction of revolutionary technologies in surgical practice, such as computer-enhanced robotic surgery, the complexity in various aspects, including medical, legal and ethical, will increase exponentially. Our aim was to highlight important legal and ethical implications emerged from the application of robotic surgery. METHODS: Search of the pertinent medical and legal literature. RESULTS: Robotic surgery may open new avenues in the near future in surgical practice. However, in robotic surgery, special training and experience along with high quality assessment are required in order to provide normal conscientious care and state-of-the-art treatment.
While the legal basis for professional liability remains exactly the same, litigation with the use of robotic surgery may be complex. In case of an undesirable outcome, in addition to physician and hospital, the manufacturer of the robotic system may be sued. In respect to ethical issues in robotic surgery, equipment safety and reliability, provision of adequate information, and maintenance of confidentiality are all of paramount importance. Also, the cost of robotic surgery and the lack of such systems in most of the public hospitals may restrict the majority from the benefits offered by the new technology.
CONCLUSION: While surgical robotics will have a significant impact on surgical practice, it presents challenges so much in the realm of law and ethics as of medicine and health care......Fulltext
European Archives of Oto-Rhino-Laryngology
The AESOP robot system for video-assisted rigid endoscopic laryngosurgery
Abstract: Surgeons may occasionally encounter difficulty in visualizing the whole larynx with a direct laryngoscope. In such cases, rigid endoscopic laryngosurgery using a direct laryngoscope is an optimal solution. Multidirectional examination of the larynx using rigid endoscopes during direct laryngoscopy, leads to better control and management of the ventricle, inferior surface of the vocal fold and subglottis, and the anterior commissure.
Currently, 0°, 30°, 70° and 120° angled rigid telescopes are used worldwide. Our experience in telescopic endolaryngeal surgery provided us the opportunity to work with AESOP 3000 (automated endoscope system for optimal positioning), coupling a robotic arm to a rigid endolaryngeal telescope. The use of this device allows the surgeon to control the field of view and operate with both hands. A total of 20 patients presenting a laryngeal lesion were randomly selected and included in this study undergoing a robot-assisted procedure....read more
Initiation of a pediatric robotic surgery program: institutional challenges and realistic outcomes
Background: Few institutions have reported their experience initiating a pediatric robot-assisted laparoscopic (RAL) program, and results vary regarding the outcomes for robotic surgery in children. We present the initiation of our pediatric robotic surgery program, provide suggestions for overcoming institutional challenges, and perform a comparative analysis to illustrate realistic outcomes during the learning curve. Methods: Outcomes from consecutive children who underwent RAL surgery since the 2006 acquisition of the da Vinci® surgical system were retrospectively reviewed. To evaluate the safety and outcomes during the introduction of this new technology, we performed an outcome analysis of ureteral reimplantations comparing RAL cases to matched open controls. Results: The first 50 RAL cases were performed over 20 months by two general and two urologic surgeons. Fourteen different procedures were performed successfully. The average patient age was 8.6 ± 5.7 years with 10 patients weighing less than 10 kg (20%). Three urologic cases were converted to traditional laparoscopy and two general surgery cases were converted to open. There were five mechanical failures. Initial outcomes comparing RAL and open ureteral reimplantations revealed similar length of stay, complications, and success with lower estimated blood loss in the RAL group. Overall OR time was 53% longer in the RAL reimplant group (361 ± 80 vs. 236 ± 58 min, p < 0.0001). Conclusion: Robotic surgery appears to be safe in pediatric patients for many procedures. Proper instruction and training precedes technological proficiency. The institutional learning curve may be magnified when there are multiple participating surgeons. Operative times for initial RAL cases can be expected to be greater than their open correlates.
Robotic surgery setup simulation with the integration of inverse-kinematics computation and medical imaging
ABSTRACT: At present, there are representative robot operation systems such as da Vinci and ZEUS which have realized minimally invasive surgery by the use of dexterous manipulators. In the operating room, medical staff must prepare and set up an environment in which the robot has optimal freedom of motion and its functions can be fully demonstrated for every case.
The range of motion in which the robot can reach and be maneuvered is restricted by the fixed point of the trocar site. We have developed a preoperative planning system with the function of volume rendering of medical images and automatic positioning by applying an inverse-kinematics computation of surgical robot.
The motion of a surgical robot can be simulated in advance with the intuitive interface and kinematics computation program running in the background of the system. If robotic surgery planning with volume rendering of DICOM images is possible, the discussion of a surgical plan can be directly made just after the diagnosis considering the patient-specific structure. This kind of setup platform would be essential for the future introduction of surgical robotics into an operating room. For more information Click here
Farid Gharagozloo, Farzad Najam
Robotic Surgery: Theory and Operative Technique
Synopsis: Look ahead to the future of surgery, with the first comprehensive robotic surgery reference representing a landmark in the medical literature, Robotic Surgery is the first complete robotic surgery source book. In its pages, you'll explore the new frontiers of robotic and remote technologies, which bring us closer to the goal of achieving the benefits of traditional surgery with the least disruption to the normal functions of the human body. The authors take you through the fundamental principles of robotic surgery and provide clear instruction on their clinical application.
American Medical Association Complete Medical Encyclopedia
Complete Medical Encyclopedia, From the Most Trusted Name in Medicine: The American Medical Association
The only new major medical encyclopedia of the century, completely written by the American Medical Association, America’s top medical authority.
Organized in easy-to-use A-Z format, it covers thousands of medical terms from the common cold to the Lyme Disease. Hundreds of different surgical procedures and tests are explained, as well as the benefits and potential side effects of drugs and treatments.
Also includes timely information on issues such as bioterrorism, genetic research, robotic surgery, brain imaging, and bionic people. Includes cutting-edge topics in alternative medicine, nutrition, mental health, and cosmetic surgery.
Written and reviewed by top medical doctors and specialists, the Complete Medical Encyclopedia sets a new standard for consumer medical reference.
Medical editors for this AMA-authored book were Jerrold B. Leikin, MD, and Martin S. Lipsky, MD, both on the faculty of Northwestern University medical school.
Abstract: The first generation of surgical robots are already being installed in a number of operating rooms around the world. Robotics is being introduced to medicine because it allows for unprecedented control and precision of surgical instruments in minimally invasive procedures. So far, robots have been used to position an endoscope, perform gallbladder surgery and correct gastroesophogeal reflux and heartburn. The ultimate goal of the robotic surgery field is to design a robot that can be used to perform closed-chest, beating-heart surgery. The use of robotics in surgery will expand over the next decades without any doubt.
The aim of this book is to provide an overview of the state-of-art, to present new ideas, original results and practical experiences in this expanding area. Nevertheless, many chapters in the book concern advanced research on this growing area. The book provides critical analysis of clinical trials, assessment of the benefits and risks of the application of these technologies. This book is certainly a small sample of the research activity on Medical Robotics going on around the globe as you read it, but it surely covers a good deal of what has been done in the field recently, and as such it works as a valuable source for researchers interested in the involved subjects, whether they are currently "medical roboticists" or not.
Survey of obstetrics and gynecology residents’ training and opinions on robotic surgery
Abstract: To investigate obstetrics and gynecology residents’ access to training in robotics and their opinions of its utility and future in gynecologic surgery a 31-item questionnaire was developed and distributed to Ob/Gyn residents in the United States via email.
Results were tabulated via SurveyMonkey.com. A total of 470 residents representative of all ACOG districts and PGY levels responded. A total of 72% of residents reported ≥3 staff surgeons performing robotic gynecologic surgery at their institution and 70% had participated in robotic surgery in the past 12 months. Robotic hysterectomy (81%) and oncologic surgery (76%) were the most frequently performed procedures.
A total of 79% believe their institution should provide formal training in robotics, but only 38% report access to it. A total of 23% have operated at the surgeon console, and 44% plan to incorporate robotic surgery into their practice after completing residency. A total of 3.6% feel equipped to perform robotic surgery without additional training. A total of 63% believe robotic surgery in gynecology will continue to increase in popularity.
Exposure to gynecologic robotic procedures during residency is increasing. Although residents believe robotics has a place in gynecology, many feel formalized training has not been successfully implemented into their residency. Development of a structured program for training residents in robotics merits further investigation.
Conquer Prostate Cancer: How Medicine, Faith, Love and Sex Can Renew Your Life
This inspiring physical, emotional, and spiritual guide empowers patients and survivors, including Boomers and Seniors, to face diagnosis with dignity, explore their options realistically, and tackle recovery with optimism and determination.
The first book to emphasize robotic surgery for prostate cancer from an informed layman’s perspective, CONQUER PROSTATE CANCER discusses the latest research and advances in treatment, and profiles twenty patients who chose various treatment options.
As the author and his wife share the most intimate details of their prostate cancer journey, readers learn how to:
— Become an active member of their medical team — Reduce pain and stress and renew vitality — Overcome impotence and incontinence — Enhance intimate relationships — Draw strength from faith, family, and friends.
Prominent robotic surgeon Dr. Robert Carey discusses medical and patient-care concerns and the author’s wife provides a running commentary, sharing her thoughts about how she and her family coped with the disease and its effects.
Three-dimensional Motion Tracking for Beating Heart Surgery Using a Thin-plate Spline Deformable Model
Source: International Journal of Robotics Research archive Volume 29 , Issue 2-3 (February 2010) table of contents Pages: 218-230
Year of Publication: 2010
Authors: Rogério Richa: LIRMM, UMR 5506 CNRS, UM 2, 161, rue Ada, 34392 MontpellierCedex 5, France Philippe Poignet: LIRMM, UMR 5506 CNRS, UM 2, 161, rue Ada, 34392 MontpellierCedex 5, France Chao Liu: LIRMM, UMR 5506 CNRS, UM 2, 161, rue Ada, 34392 MontpellierCedex 5, France
Minimally invasive cardiac surgery offers important benefits for the patient but it also imposes several challenges for the surgeon. Robotic assistance has been proposed to overcome many of the difficulties inherent to the minimally invasive procedure, but so far no solutions for compensating physiological motion are present in the existing surgical robotic platforms.
In beating heart surgery, cardiac and respiratory motions are important sources of disturbance, hindering the surgeons gestures and limiting the types of procedures that can be performed in a minimally invasive fashion.
In this context, computer vision techniques can be used for retrieving the heart motion for active motion stabilization, which improves the precision and repeatability of the surgical gestures. However, efficient tracking of the heart surface is a challenging problem due to the heart surface characteristics, large deformations and the complex illumination conditions.
In this article, we present an efficient method for active cancellation of cardiac motion where we combine an efficient algorithm for 3D tracking of the heart surface based on a thin-plate spline deformable model and an illumination compensation algorithm able to cope with arbitrary illumination changes. The proposed method has two novelties: •the thin-plate spline model for representing the heart surface deformations •an efficient parametrization for 3D tracking of the beating heart using stereo images from a calibrated stereo endoscope.
The proposed tracking method has been evaluated offline on in vivo images acquired by a DaVinci surgical robotic platform. For more information Click here
Minimally Invasive Therapy and Allied Technologies
Robotic manipulators in cardiac surgery: the computer-assisted surgical system ZEUS
Abstract: Minimally invasive strategies continue to evolve in cardiac surgery. Robotic-assisted systems have been introduced recently, to increase the precision of endoscopic coronary surgery.
This report describes the experimental and clinical use of the computer-assisted robotic system ZEUS for endoscopic coronary artery bypass anastomoses. The ZEUS system consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled-down mode. The third arm (AESOP) positions the endoscope under voice control.
The present study demonstrates the feasibility of endoscopic coronary artery bypass grafting using a computer-assisted surgical robotic system on the arrested heart, as well as on the beating heart in selected patients. However, robotic-assisted cardiac surgery is still developing, and tremendous efforts are still required to establish a routine procedure.
Bloodless Surgery in Gynecologic Oncology
Bloodless Surgery in Gynecologic Oncology Nimesh P. Nagarsheth, MD, Fahimeh Sasan, DO
Bloodless medicine and surgery is an evolving field in the practice of medicine designed to avoid allogeneic transfusions. Although this field has largely developed in response to the growing needs of Jehovah's Witness patients refusing transfusions, all patients may potentially benefit from the avoidance of transfusions.
The applications of bloodless techniques and strategies in the field of gynecologic oncology have been limited until recently, in part because of the generally large blood loss associated with gynecologic cancer surgeries. However, as advances in our understanding of bloodless surgery have developed and surgical techniques have been refined, the gynecologic oncology patient can now benefit from the avoidance of allogeneic transfusions.
Early experiences of endoscopic procedures in general surgery assisted by a computer-enhanced surgical system
We performed a variety of complete total endoscopic general surgical procedures, including colon resection, distal gastrectomy, and splenectomy, successfully with the assistance of the da Vinci computer-enhanced surgical system. The robotic system allowed us to manipulate the endoscopic instruments as effectively as during open surgery. It enhanced visualization of both the operative field and precision of the necessary techniques, as well as being less stressful for the endoscopic operating team. This technological innovation can therefore help surgeons overcome many of the difficulties associated with the endoscopic approach and thus has the potential to enable more precise, safer, and more minimally invasive surgery in the future.
BJUI Mini Reviews
BJUI Mini Reviews - Robotic-assisted radical prostatectomy: A review of current outcomes Friday, 30 October 2009
This review provides an examination of the perioperative, oncological and functional outcomes of the largest RALP series recently published.
With the widespread diffusion of the screening for prostate cancer, the disease has been diagnosed more commonly in the organ-confined stage, and in younger and healthier men. For these patients, radical prostatectomy (RP) is still the standard treatment. In an effort to decrease the morbidity associated with open RP, minimally invasive approaches have been described, including robotic-assisted RP (RALP). Almost one decade after the introduction of RALP, large and mature series have now been reported.
We reviewed the outcomes of the largest series of RALP published recently. We searched Medline for reports published between 2006 and 2009, to identify articles describing intraoperative data, surgical complications, oncological outcomes, continence and potency rates after RALP. Relevant articles were selected and the outcomes evaluated....continue reading
General Thoracic and Cardiovascular Surgery
Robot-assisted thoracoscopic lung resection aimed at solo surgery for primary lung cancer
The surgical robotic system has been advanced as a tool that enables surgeons to perform precision operations of high quality. Many reports have been presented in cardiovascular surgery using the robotic system, but its use is uncommon in general thoracic surgery.
We describe our two experiences with single-surgeon video-assisted thoracoscopic surgery lobectomy for primary lung cancer using a remote-controlled robot, named Naviot, to manipulate an endoscope. We believe that Naviot might be one of the robotic devices whose use could lead to solo surgery, even for complicated thoracoscopic procedures such as anatomical pulmonary resections with lymph node dissection
Springer New York
16th International Congress of the European Association for Endoscopic Surgery (EAES) Stockholm, Sweden, 11–14 June 2008 Video Presentation
Preview: LAPAROSCOPIC TRANSGASTRIC ACCESS TO THE COMMON
BILE DUCT AFTER ROUX-EN-Y GASTRIC BYPASS
G. Dapri, J. Himpens, M. Buset, G. Vasilikostas, G.B. Cadie` re
European School of Laparoscopic Surgery, BRUSSELS, Belgium
Rapid weight loss following Roux-en-Y gastric bypass (RYGBP) is often associated with gallstones formation which can lead to cholecystitis and/or choledocholithiasis. Difficult access to the biliary tract is one of the disadvantages after RYGBP. We report a useful technique of laparoscopic transgastric access to the remnant stomach for an endoscopic retrograde cholangiopancreatography (ERCP).
A 40- years-old women, sweet eater and with a BMI of 48 kg/m2, was submitted to a laparoscopic RYGBP in December 2003. At that time the abdominal ultrasound was negative for gallbladder lithiasis. On April 2007 she was admitted to the Emergency for an upper right side abdominal pain, vomiting episodes, fever and jaundice.....
Robotic Equipment and Instrumentation Armine K. Smith and Jeffrey S. Palmer
Abstract: The advancement of laparoscopic roboticsurgery largely depends on the development of innovative laparoscopic instrumentation. The most widely used system, the da Vinci surgical robot (Intuitive Surgical Inc., Sunnyvale, California), was introduced in 1998 and received FDA approval in 2000. Its popularity may largely be attributed to the development of EndoWrist instruments with increased degrees of freedom and improved stereoscopic vision. The electronics integrated into the system allow motion scaling of surgeon hand movement into smaller instrument tip movements in the field, reducing natural tremor of surgeon’s hands. Instruments have a total of six degrees of freedom plus grip, mimicking the up and down and side-to-side flexibility of human wrist. The introduction of the da Vinci S system by Intuitive Surgical Inc., features easier docking, added system feedback and high-definition telemonitoring. Another feature of the new S system is the additional 2 inches of length of the instruments.
The combination of pure laparoscopic and robot-assisted tools constitutes a standard approach to the advanced endourological techniques. There are many available tools at the disposal of the robotic surgeon. Similar to the surgeon performing open surgery, a robotic surgeon’s familiarity with available equipment and technology is essential. This knowledge of all the available tools is essential to the surgeon in maximizing the outcomes of the surgery and shortening the procedure times.
Springer Berlin Heidelberg
History of Stereotactic Surgery in France A. L. Benabid, S. Chabardes and E. Seigneuret
Abstract: The history of stereotaxy is part of a larger perspective of a methodological approach that is therapeutic and focuses on the search for precision. The search for precision implies the recognition and marking of targets (taxonomic version of the etymology of the word Stereotaxy, from taxis: order) as well as to the tactic act, which is the achievement, at least in human stereotaxy, of this approach (tactic version of the etymology of the word stereotaxy).
The common denominator of these two definitions is the space (from the Greek Stereos: solid, volume), which by itself would define the methodology, based on the spatial coordinates of a point that will be called the target. This etymological duality corresponds in fact to a historical perspewctive, as for the first time, in 1917, the need to precisely recognize and localize the various spatial structures of the brain led Horsley and Clark to design an instrumental method aimed at quantifying cerebral space, in order to attribute precise coordinates to the different structures that the anatomo physiologists were studying at that time. This taxonomy approach led to the development of an instrument and a method, and then to the elaboration of the concept of the surgical act based on exact location.
This corresponded in fact to the tactic version of the etymological definition of stereotaxy, even if it has been, historically, only secondary. Having designed an apparatus and developed a method, one tended to build on these two concrete elements a philosophy, or at least a state of mind. This constitutes the most interesting, maybe the most noble, part of the history of stereotaxy. This history has been the reflection of the complex interaction, depending upon circumstances, between the technical means of the moment and the therapeutic needs, as well as on pharmacological alternatives.
This process is not specific to stereotaxy. It characterizes every approach of Homo Faber, which tries to solve his current problems, on the bases of the know-how which is available. He often stumbles on technological bottlenecks, which impede the development of methods, and even make it transitorily disappear, until the advance of knowledge in other domains provides the key, which will open the lock. A new momentum of development is therefore observed until the time when a new obstacle stops the process again, or when the need disappears, often because advancements of knowledge in other domains have brought more satisfactory solutions. Stereotaxy is at the crossroads of industrial technology, of surgical technology and therapeutic needs, themselves strongly enclosed in the domain of neurosciences, which, as we know, is undergoing rapid evolution. It is therefore not surprising to see that its history has been chaotic, and it can be foreseen that it will become even more complicated.
Necrotic mass after transurethral resection of a bladder tumor: novel management with robotic partial cystectomy
AbstractA 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed.
Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months.
To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.
Publisher: Springer Verlag
Manual Endourology: Training For Residents [with Dvd] By Rudolf Hohenfellner, Jens-Uwe Stolzenburg
Endourology Step by Step. This manual is intended to help residents in urology learn the basic techniques of endourology. All authors are experts in this field and experienced teachers. Each chapter includes: indications, limits, risks and contraindications, a step-by-step procedure.The book is completed by extensive illustrations and a DVD with surgery video clips.
Robot-assisted surgery in children: current status
Abstract:The horizon of robotic paediatric surgery has grown in leaps and bounds with advances in technology. The aim of this study was to analyse the extent of robotic involvement in paediatric surgical practice. A systematic database search was performed. Data about children who had undergone robot-assisted procedures were reviewed retrospectively from all published reports up to October 2007. Success rates were defined in term of completion of the procedures, their complications, and the time taken. These results were further studied in comparison with the procedures performed by open and laparoscopic methods.
A total of 31 studies were identified describing 566 patients. Of these, four studies were case control, comparing with either laparoscopic or open procedures, one study was a prospective trial, and the rest of the studies were either case reports or series.
The most common robotic system used was the da Vinci (23 studies) followed by the Zeus (four studies).
The mean age of the children was 8.3 years. The commonest operation was pyeloplasty (141 cases), followed by fundoplication (122 cases) and patent ductus arteriosus ligation (50 cases). The mean operation time for robot-assisted pyeloplasty was 221 min (open pyeloplasty 214 min). The mean operation times for fundoplication were robotic, 170 min, laparoscopic, 158 min, and open, 121 min. The mean operation times for patent ductus arteriosus ligation were 166 min (robotic) and 83 min (open). Overall conversion rate for all paediatric robotic procedures was 4.7% and complications ranged from 0 to 15%. For robotic fundoplications the conversion and complication rates were 0.8 and 3.3%, respectively. For robotic pyeloplasties the conversion and complication rates were 2.1 and 3.5%, respectively. Many other major operations were performed successfully.
All studies recommended robotic procedure as safe and feasible. Currently, the most common robotic operations in practice are pyeloplasties and fundoplications. Most of the authors concluded that, despite taking more time, roboticsurgery enables more refined hand–eye coordination, superior suturing skills, better dexterity, and precise dissection with minimal conversion and complication rates. The widespread acceptance of this technology largely depends on solving the issues: learning curve; suitable machine size for neonates and infants; ensuring efficacy and safety in all operations; and, most importantly, making this procedure cost effective, so as to cater for the needs of most, if not all, children.
Wolfgang Dorschner, Jens-Uwe Stolzenburg, Jochen Neuhaus
Structure and function of the bladder neck By Wolfgang Dorschner, Jens-Uwe Stolzenburg, Jochen Neuhaus
The studies described here are based on histological serial sections of the entire bladder neck region of 50 male and 15 female deceased of all age groups. For the first time, a Musculus vesicoprostaticus et vesicovaginalis, a Musculus dilator urethrae and a Musculus ejaculatorius are defined. The bipartite Musculus sphincter urethrae (glaber et transversostriatus) is the morphologcal basis for the maintentance of the rest and stress continence. New findings lead to new interpretations of the basic functions of the lower urinary tract. The results presented here prove that the corresponding morphological substrate differs in many respects from the descriptions in the literature.
The AESOP robot system in laparoscopic surgery: Increased risk or advantage for surgeon and patient?
BackgroundThe aim of this study was to examine the advantages and risks of the Automated Endoscopic System for Optical Positioning (AESOP) 3000 robot system during uncomplicated laparoscopic cholecystectomies or laparoscopic hernioplasty.
MethodsIn a randomized study, we examined two groups of 120 patients each with the diagnosis cholecystolithiasis respectively the unilateral inguinal hernia. We worked with the AESOP 3000, a robotic arm system that is voice-controlled by the surgeon. The subjective and objective comfort of the surgeon as well as the course and length of the operation were measured.
ResultsThe robot-assisted operations required significantly longer preparation and operation times. With regard to the necessary commands and manual camera corrections, the assistant group was favored. The same was true for the subjective evaluation of the surgical course by the surgeon.
ConclusionsOur study showed that the use of AESOP during laparoscopic cholecystectomy and hernioplasty is possible in 94% of all cases. The surgeon must accept a definite loss of comfort as well as a certain loss of time against the advantage of saving on personnel.
Current Urology Reports
AbstractIn addition to the classic open surgery, a variety of minimally invasive therapeutic options have been developed for the treatment of ureteropelvic junction obstruction, including an endoscopic antegrade or retrograde ureteropelvic junction obstruction visually controlled incision or radioscopically controlled Acucise (Applied Medical, Laguna Hills, CA), which does not share the high success rate that results from open-surgical dismembered pyeloplasty.
Laparoscopic pyeloplasty, which duplicates the open technique and differs only by the mode of access, has proven to have positive results when performed by experts, but remains a demanding technique that requires a long learning curve. Providing a three-dimensional vision, an unprecedented control of the endocorporeal instruments, and an ergonomic surgeon’s position, robots may allow urologists with limited laparoscopic experience to rapidly master the endocorporeal management of ureteropelvic junction obstruction. They likely will propel minimally invasive urology forward in the next several years.
Robotic endoscopic surgery in a porcine model of the infant neck
Abstract:Minimally invasive surgery is rapidly becoming the desired surgical standard, especially for pediatric patients. Infants and children are a particular technical challenge, however, because of the small size of target anatomical structures and the small surgical workspace. Computer-assisted robot-enhanced surgical telemanipulators may overcome these challenges by facilitating surgery in a small workspace.
We studied the feasibility of performing robotic endoscopic neck surgery on a porcine model of the human infant neck. The study design was a prospective, feasibility pilot study of a small cohort for proof of concept and for a survival model. Sixteen non-survival piglets weighing 4.5–10 kg were used to develop the surgical approach and operative technique. Eight piglets aged 3–6 weeks old and weighing 4.0–9.1 kg underwent survival thyroidectomy by a cervical endoscopic approach using the Zeus surgical robot, which includes the Aesop endoscope holder and “Microwrist” microdissecting instruments.
We succeeded in performing endoscopic robotic neck surgery on a piglet as small as 4 kg, in an operative pocket as small as 2 cm3. Total incision length for all three ports was ≤23 mm. There were no major complications, no major robotic instrument malfunctions or breakages, and no procedures required conversion to open surgery. These results support the feasibility of robotic endoscopic neck surgery on a neck the size of a human infant’s. From Springerlink.com
Lecture Notes in Computer Science
Laparoscope Self-calibration for Robotic Assisted Minimally Invasive Surgery
For robotic assisted minimal access surgery, recovering 3D soft tissue deformation is important for intra-operative surgical guidance, motion compensation, and prescribing active constraints.
We propose in this paper a method for determining varying focal lengths of stereo laparoscope cameras during roboticsurgery. Laparoscopic images typically feature dynamic scenes of soft-tissue deformation and self-calibration is difficult with existing approaches due to the lack of rigid temporal constraints.
The proposed method is based on the direct derivation of the focal lengths from the fundamental matrix of the stereo cameras with known extrinsic parameters. This solves a restricted self-calibration problem, and the introduction of the additional constraints improves the inherent accuracy of the algorithm. The practical value of the method is demonstrated with analysis of results from both synthetic and in vivo data sets.
Reaching the rural world through robotic surgical programs
BACKGROUND: For patients living in rural and remote areas, access to advanced surgical care is frequently limited or even nonexistent. Establishment of telementoring and remote telesurgical networks would enable patients in these areas to benefit from the knowledge of expert surgeons in distant urban centres.
METHODS: Literature review and personal experience.
RESULTS: Telementoring provides a convenient and effective means for community surgeons to learn new surgical techniques. Although still in its infancy, initial experience with routine clinical use of remote telepresence surgery indicates that it can be used to safely offer surgery to patients in a rural community. However, a number of technical, ethical, and legal challenges still exist.
CONCLUSIONS: As telecommunications and robotic technology evolve, remote telesurgical programs will play an increasing role in providing high-quality surgical care in rural communities and may even facilitate emergency surgical care in remote areas in the absence of a local physician.
Surgical Cartographic Navigation System for Endoscopic Bypass Grafting
Endoscopic bypass grafting with the da Vinci system is still challenging and needs high level of experience and skill of the surgeon. Therefore, it is necessary to support the surgeon with enhanced vision and augmented reality. The augmentation of the patient model into the view of the endoscope is a direct approach to enhance support. The results of a preclinical study are shown in this paper. The method applied is suitable for endoscopic bypass grafting and in general applicable to minimal invasive surgery. The system was designed as an open architecture to facilitate easy transfer of the methodology into other surgical domain applications.
Journal of Robotic surgery
Roboticsurgery versus laparoscopy; a comparison between two robotic systems and laparoscopy
AbstractLaparoscopy has found a role in standard urologic practice, and with training programs continuing to increase emphasis on its use, the division between skill sets of established non-laparoscopic urologic practitioners and urology trainees continues to widen. At the other end of the spectrum, as technology progresses apace, advanced laparoscopists continue to question the role of surgical robotics in urologic practice, citing a lack of significant advantage to this modality over conventional laparoscopy.
We seek to compare two robotic systems (Zeus and DaVinci) versus conventional laparoscopy in surgical training modules in the drylab environment in the context of varying levels of surgical expertise.
A total of 12 volunteers were recruited to the study: four staff, four postgraduate trainees, and four medical student interns. Each volunteer performed repeated time trials of standardized tasks consisting of suturing and knot tying using each of the three platforms: DaVinci, Zeus and conventional laparoscopy. Task times and numbers of errors were recorded for each task.
Following each platform trial, a standardized subjective ten-point Likert score questionnaire was distributed to the volunteer regarding various operating parameters experienced including: visualization, fluidity, efficacy, precision, dexterity, tremor, tactile feedback, and coordination. Task translation from laparoscopy to Zeus robotics appeared to be difficult as both suture times and knot-tying times increased in pairwise comparisons across skill levels.
Advantages of Robotic-Assisted Laparoscopy Walid A. Farhat and Pasquale Casale
Abstract: The introduction of robotic surgical systems represents a further step in the evolution of endoscopic instrumentation. Initially, the robot was thought to be bulky for children, but the delicate robotic movements are ideal for the reconstructive surgeries children require, hence pediatric urology has embraced robotic technology.
The systems enhance dexterity using internal software that filters out the natural tremor of a surgeon’s hand, which becomes particularly evident under high magnification and may be problematic when attempting fine maneuvers in very small fields. The introduction of the da Vinci system to perform precise laparoscopic manipulations offers an opportunity to spread reconstructive laparoscopic skills among pediatric surgeons.
However, despite its numerous advantages, the surgical robotic has a number of general limitations. In pediatric surgery, the size and variety of available robotic instrumentation remains limited compared with those offered for standard minimal invasive surgery (MIS) and the huge size discrepancy between the typical pediatric patient and the size of the robotic system (i.e., its “footprint”) can restrict the anesthesiologist’s access to the patient. Herein we are providing the benefits of robotic technology in children.
Haptic Feedback a.k.a. Tactile Feedback.
The International Journal of Medical Robotics and Computer Assisted Surgery.
Evaluation of flexible endoscope steering using haptic guidance
Background Steering the tip of a flexible endoscope relies on the physician's dexterity and experience. For complex flexible endoscopes, conventional controls may be inadequate.
Methods A steering method based on a multi-degree-of-freedom haptic device is presented. Haptic cues are generated based on the endoscopic images. The method is compared against steering using the same haptic device without haptic cues, and against conventional steering. Human-subject studies were conducted in which 12 students and 6 expert gastroenterologists participated.
Results Experts are significantly faster when using the conventional method compared with using the haptic device, either with or without haptic cues. However, it is expected that the performance of the subjects with the haptic device will increase with experience.
From The Journal of Laparoendoscopic & Advanced Surgical Techniques Brought to you by: Liebert Online
Robotic surgical systems have greatly contributed to the advancement of minimally invasive endoscopic surgery. However, current robotic systems do not provide tactile or haptic feedback to the operating surgeon. Under certain circumstances, particularly with the manipulation of delicate tissues and suture materials, this may prove to be a significant irritation. We hypothesize that haptic feedback, in the form of sensory substitution, facilitates the performance of surgical knot tying. This preliminary study describes evidence that visual sensory substitution permits the surgeon to apply more consistent, precise, and greater tensions to fine suture materials without breakage during robot-assisted knot tying.........Continue reading
Haptics for Robot-Assisted Minimally Invasive Surgery
Haptics for Robot-Assisted Minimally Invasive Surgery A. M. Okamura, L. N. Verner, C. E. Reiley and M. Mahvash
Robot-assisted minimally invasive surgery (RMIS) holds great promise for improving the accuracy and dexterity of a surgeon while minimizing trauma to the patient. However, widespread clinical success with RMIS has been marginal and it is hypothesized by engineers and surgeons alike that the lack of haptic feedback presented to the surgeon is a limiting factor.
The objective of our research is to acquire, display, and determine the utility of haptic information during RMIS. This overview paper examines the design, analysis, practicality, and effectiveness of various force estimation and display methods. In particular, we describe our experience in adding force feedback to an experimental version of the da Vinci surgical system, a commercially available teleoperated RMIS system.
Artificial Tactile Sensing in Biomedical Engineering
Filled with high-quality photographs and illustrations, including some in color, this definitive guide details the design and manufacturing of artificial tactile systems and their applications in surgical procedures.
Artificial Tactile Sensing in Biomedical Engineering explains the fundamentals of the human sense of touch and the latest techniques for artificially replicating it. The book describes the mechanistic principles of static and dynamic tactile sensors and discusses cutting-edge biomedical applications, including minimally invasive surgery, tumor detection, robotic surgery, and surgical simulations.
The Dexterous human-arm like manipulator for Laparoscopic Surgery
This paper describes design of the dexterous manipulator for laparoscopic surgery that performs like a human whole arm and the FEM simulation result to measure the force of its tool-tip for including force-feedback loop. Though a human whole arm has 7 degrees of freedom, we have designed overall 8 degrees of freedom because of considering one dof translation motion that corresponds with human body movement. Some researchers reported that if we could develop either mechanical or electromechanical tele-operators which enable surgeons to move a MIS system in a manner analogous to an open instrument, we could potentially reduce the time of current laparoscopic procedures by at least 15% and we could perhaps also enable surgeons to perform procedures which are currently too difficult. Accordingly, we are expecting that the suggested design provides surgeon with improved dexterity during minimally invasive surgery.
Robotic urology in the United Kingdom: experience and overview of robotic-assisted cystectomy
Abstract:In this article we look at the evolution of robotic technology in operative urology and the significant early contribution of Mr John Wickham. We explore the ergonomics of robotic technology and discuss financial issues from a British perspective. We share our clinical experience, describe the authors’ robotic-assisted cystectomy technique, and conclude by exploring the patients’ perception of this new treatment modality.
Surgical Endoscopy Journal.
The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review
Background Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation.
Methods A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive SurgeryAND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education.
Results The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence.
Conclusions In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.
The International Journal of Medical Robotics and Computer Assisted Surgery.
An integrated pneumatic tactile feedback actuator array for robotic surgery
Background A pneumatically controlled balloon actuator array has been developed to provide tactile feedback to the fingers during robotic surgery. Methods The actuator and pneumatics were integrated onto a robotic surgical system. Potential interference of the inactive system was evaluated using a timed robotic peg transfer task. System performance was evaluated by measuring human perception of the thumb and index finger. Results No significant difference was found between performance with and without the inactive mounted actuator blocks. Subjects were able to determine inflation location with > 95% accuracy and five discrete inflation levels with both the index finger and thumb with accuracies of 94% and 92%. Temporal tests revealed that an 80 ms temporal separation was sufficient to detect balloon stimuli with high accuracy. Conclusions The mounted balloon actuators successfully transmitted tactile information to the index finger and thumb, while not hindering performance of robotic surgical movements. For complete article Click here
Haptic Feedback in a Telepresence System for Endoscopic Heart Surgery
The implementation of telemanipulator systems for cardiac surgery enabled heart surgeons to perform delicate minimally invasive procedures with high precision under stereoscopic view. At present, commercially available systems do not provide force-feedback or Cartesian control for the operating surgeon. The lack of haptic feedback may cause damage to tissue and can cause breaks of suture material. In addition, minimally invasive procedures are very tiring for the surgeon due to the need for visual compensation for the missing force feedback. While a lack of Cartesian control of the end effectors is acceptable for surgeons (because every movement is visually supervised), it prevents research on partial automation.
In order to improve this situation, we have built an experimental telemanipulator for endoscopic surgery that provides both force-feedback (in order to improve the feeling of immersion) and Cartesian control as a prerequisite for automation. In this article, we focus on the inclusion of force feedback and its evaluation.
We completed our first bimanual system in early 2003 (EndoPAR Endoscopic Partial Autonomous Robot). Each robot arm consists of a standard robot and a surgical instrument, hence providing eight DOF that enable free manipulation via trocar kinematics. Based on the experience with this system, we introduced an improved version in early 2005. The new ARAMIS system (Autonomous Robot Assisted Minimally Invasive Surgery) has four multi-purpose robotic arms mounted on a gantry above the working space. Again, the arms are controlled by two force-feedback devices, and 3D vision is provided. In addition, all surgical instruments have been equipped with strain gauge force sensors that can measure forces along all translational directions of the instrument's shaft.
Force-feedback of this system was evaluated in a scenario of robotic heart surgery, which offers an impression very similar to the standard, open procedures with high immersion. It enables the surgeon to palpate arteriosclerosis, to tie surgical knots with real suture material, and to feel the rupture of suture material. Therefore, the hypothesis that haptic feedback in the form of sensory substitution facilitates performance of surgical tasks was evaluated on the experimental platform described in the article (on the EndoPAR version). In addition, a further hypothesis was explored: The high fatigue of surgeons during and after robotic operations may be caused by visual compensation due to the lack of force-feedback (Thompson, J., Ottensmeier, M., & Sheridan, T. 1999. Human Factors in Telesurgery, Telmed Journal, 5 (2) 129–137.).
The American Laryngological, Rhinological and Otological Society, Inc.,
Applications of image-directed robotics in otolaryngologic surgery
This report will evaluate the feasibility of applying image-directed robotic technology to the field of otolaryngologic surgery. Image-directed robotic surgery uses a three-dimensional image to guide a robot in the removal of tissue. To demonstrate the future use of image-directed robotics in otolaryngologic surgery, five antrostomies will be performed on temporal bones. The accuracy of the surgical defect will be measured. It is the goal of this pilot study to achieve an average surgical error of less than 1.0 mm. Future applications of image-directed robotic surgery will be presented, along with technical modifications, and future areas of research necessary to adapt this technique to otology and rhinosinus surgery.
A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution
PATIENTS AND METHODS The study was a single-institution, prospective, unrandomized comparison of histopathological, and functional outcomes, at baseline and during and after surgery, in 100 patients undergoing RRP and 200 undergoing VIP. RESULTS While the variables before surgery, the operative duration (163 vs 160 min) and pathological stages were comparable, there were significant differences in the measured outcomes. The blood loss was 910 and 150 mL for RRP and VIP, respectively, and transfusion was greater after RRP (67% vs none; both P < 0.001). There were four times as many complications after RRP (20% vs 5%, P < 0.05), the haemoglobin level at discharge was lower (100 vs 130 g/L, P < 0.005) and the hospital stay longer (3.5 vs 1.2 days; P < 0.05). Most (93%) of VIP and none of the RRP patients were discharged within 24 h (P < 0.001); the duration of catheterization was twice as long after RRP (15.8 vs 7 days; P < 0.05). Positive margin was more frequent after RRP (23% vs 9%, P < 0.05). After VIP, patients achieved continence and return of erections more quickly than after RRP (160 vs 44, and 180 vs 440 days, both P < 0.5). The median return to intercourse was 340 days after VIP but after RRP half the patients have as yet not resumed intercourse at 700 days (P < 0.05). CONCLUSIONS The VIP procedure appears to be safer, less bloody and requires shorter hospitalization and catheterization. The oncological and functional results were favourable in patients undergoing VIP.
The Leipzig Experience with Robotic Valve Surgery
AbstractObjectives: The study describes the single-center experience using robot-assisted videoscopic mitral valve surgery and the early results with a remote telemanipulator-assisted approach for mitral valve repair. Material and Methods: Out of a series of 230 patients who underwent minimally invasive mitral valve surgery, in 167 patients surgery was performed with the use of robotic assistance. A voice-controlled robotic arm was used for videoscopic guidance in 152 cases. Most recently, a computer-enhanced telemanipulator was used in 15 patients to perform the operation remotely. Results: The mitral valve was repaired in 117 and replaced in all other patients. The voice-controlled robotic arm (AESOP 3000) facilitated videoscopic-assisted mitral valve surgery. The procedure was completed without the need for an additional assistant as "solo surgery." Additional procedures like radiofrequency ablation and tricuspid valve repair were performed in 21 and 4 patients, respectively. Duration of bypass and clamp time was comparable to conventional procedures (107 Å 34 and 50 Å 16 min, respectively). Hospital mortality was 1.2%. Using the da Vinci telemanipulation system, remote mitral valve repair was successfully performed in 13 of 15 patients. Conclusion: Robotic-assisted less invasive mitral valve surgery has evolved to a reliable technique with reproducible results for primary operations and for reoperations. Robotic assistance has enabled a solo surgery approach. The combination with radiofrequency ablation (Mini Maze) in patients with chronic atrial fibrillation has proven to be beneficial. The use of telemanipulation systems for remote mitral valve surgery is promising, but a number of problems have to be solved before the introduction of a closed chest mitral valve procedure.
Journal of Interventional Cardiac Electrophysiology
Experience of robotic catheter ablation in humans using a novel remotely steerable catheter sheath
BackgroundA novel remotely controlled steerable guide catheter has been developed to enable precise manipulation and stable positioning of any eight French (Fr) or smaller electrophysiological catheter within the heart for the purposes of mapping and ablation.
ObjectiveTo report our initial experience using this system for remotely performing catheter ablation in humans.
MethodsConsecutive patients attending for routine ablation were recruited. Various conventional diagnostic catheters were inserted through the left femoral vein in preparation for treating an accessory pathway (n = 1), atrial flutter (n = 2) and atrial fibrillation (n = 7). The steerable guide catheter was inserted into the right femoral vein through which various irrigated and non-irrigated tip ablation catheters were used. Conventional endpoints of loss of pathway conduction, bidirectional cavotricuspid isthmus block and four pulmonary vein isolation were used to determine acute procedural success.
ResultsTen patients underwent remote catheter ablation using conventional and/or 3D non-fluoroscopic mapping technologies. All procedural endpoints were achieved using the robotic control system without manual manipulation of the ablation catheter. There was no major complication. A radiation dosimeter positioned next to the operator 2.7 m away from the X-ray source showed negligible exposure despite a mean cumulative dose area product of 7,281.4 cGycm2 for all ten ablation procedures.
Conclusions Safe and clinically effective remote navigation of ablation catheters can be achieved using a novel remotely controlled steerable guide catheter in a variety of arrhythmias. The system is compatible with current mapping and ablation technologies Remote navigation substantially reduces radiation exposure to the operator......
Journal of Robotic Surgery
Proceedings of the First Annual Worldwide Robotic Renal Symposium: lessons learned for future robotic renal surgeons
AbstractThe First Annual Worldwide Robotic Renal Symposium was held on 26–27 June 2008 at Washington University in Saint Louis. The symposium featured numerous live surgeries and lectures on all aspects of robotic renal surgery. Several innovations were discussed, which may allow participants to perform robotic renal surgery with greater efficiency and precision.
Current Urology Reports
Telesurgery, telementoring, virtual surgery, and telerobotics
Abstract:With the advent of laparoscopic surgery, a method characterized by a surgeon’s lack of direct contact with the patient’s organs and tissue and the availability of magnified video images, it has become possible to incorporate computer and robotic technologies into surgical procedures. Computer technology has the ability to enhance, compress, and transmit video signals and other information over long distances. These technical advances have had a profound effect on surgical procedures and on the surgeons themselves because they are changing the way surgery is taught and learned. This article provides an overview of the most important advances and issues developing from the use of computer and robotic technologies in surgery.
Springer New York
Roboticsurgery, telerobotic surgery, telepresence, and telementoring
G.H. Ballantyne; Minimally Invasive & Telerobotic Surgery Institute, Hackensack University Medical Center, 20 Prospect Avenue, Hackensack, NJ, USA, US
Although laparoscopic cholecystectomy rapidly became the standard of care for the surgical treatment of cholelithiasis, very few other abdominal or cardiac operations are currently performed using minimally invasive surgical techniques. The inherent limitations of traditional laparoscopic surgery make it difficult to perform these operations.
We, and others, have attempted to use robotic technology to:
•Provide a stable camera platform •Replace two-dimensional with three-dimensional (3-D) imaging •Simulate the fluid motions of a surgeon's wrist to overcome the motion limitations of straight laparoscopic instruments, •Offer the surgeon a comfortable, ergonomically optimal operating position.
In this article, we review the early published clinical experience with surgical robotic and telerobotic systems and assess their current limitations. The voice-controlled AESOP robot replaces the cameraperson and facilitates the performance of solo-surgeon laparoscopic operations. AESOP provides a stable camera platform and avoids motion sickness in the operative team. The telerobotic Zeus and da Vinci surgical systems permit solo surgery by a surgeon from a remote sight. These telerobots hold the camera, replace the surgeon's two hands with robotic instruments, and serve in a master–slave relationship for the surgeon. Their robotic instruments simulate the motions of the surgeon's wrist, facilitating dissection. Both telerobots use 3-D imaging to immerse the surgeon in a three-dimensional video operating field.
These robots also provide operating positions for the surgeon console that are ergonomically superior to those required by traditional laparoscopy. The technological advances of these telerobots now permit telepresence surgery from remote locations, even locations thousands of miles away. In addition, telepresence permits the telementoring of novice surgeons who are performing new procedures by expert surgeons in remote locations. The studies reviewed here indicate that robotics and telerobotics offer potential solutions to the inherent problems of traditional laparoscopic surgery, as well as new possibilities for telesurgery and telementoring. Nonetheless, these technologies are still in an early stage of development, and each device entails its own set of challenges and limitations for actual use in clinical settings.
SUO 2008 - Outcomes Research in Prostate Surgery: How Should We Evolve from Open Surgery? - Session Highlights
BETHESDA, MD (UroToday.com) - In this discussion by Dr. Peter Scardino, he stressed the importance of focusing on the best operation for the patient, not the modality of surgery. He cited level 1 evidence that radical prostatectomy (RP) is better than watchful waiting for significant CaP in the Scandinavian study. Even in high-risk patients, 10-year BFS in RP patients is 45-75% and disease-specific survival is over 85%. Based on these good oncologic outcomes, he shifted his focus to the morbidity of RP.
Patients treated by high-volume RP surgeons have fewer early and late complications. Urinary complications in patients, among surgeons with varying surgical volume, did not show a difference. This suggested that surgeons with suboptimal outcomes who performed a high volume of surgery were consistently making the same surgical errors. He showed that with open RP it takes about 1,000 cases to get a low and stable positive margin rate. In multivariable analysis, the surgeon remains an independent risk factor for a positive surgical margin.
He compared the positive surgical margin rates of his open series to the Memorial Sloan-Kettering Cancer Center lap series, and the lap series was twice as high. By watching videos of his surgeries and changing technique, the positive surgical margin rate is now the same as the open series. The same outcome and process was apparent for continence as well. The heterogeneity of outcomes among minimally invasive surgeons was greater than among open surgeons. If one assesses the three critical aspects of recurrence, potency, and continence there is significant room for improvement. In his series, at 24 months, only 60% of patients were deemed successful in all three areas.
Presented by Peter Scardino, MD at the 9th Annual Winter Meeting of the Society of Urologic Oncology (SUO) - December 4 - 6, 2008 - Natcher Conference Center, National Institutes of Health, Bethesda, Maryland
SUO 2008 - Transition from Laparoscopic to Robotic Prostatectomy - Session Highlights
BETHESDA, MD (UroToday.com) - In his presentation, Dr. Edouard Trabulsi discussed his transition from training as a laparoscopic radical prostatectomy (LRP) surgeon to a robotic prostatectomy (RALP) surgeon. LRP is more economical, has tactile feedback, but is technically challenging. He started his post-fellowship practice doing LRP. However, his outcomes were suboptimal especially in obese patients and the urethral anastomosis was difficult. He then switched to RALP and performed the first 40 cases together with a RALP trained surgeon. As a result, the surgical volume has increased.
He stated that RALP is easier to teach residents. He presented his results, and the positive surgical margin rate was 16%. Ninety-four percent were deemed continent by use of 0-1 pads per day at 12 months. The potency rate was 81% at 12 months. His outcomes, learning curve and increase in volume are similar to studies he presented from the literature. Knowledge of surgical anatomy from his previous open and LRP experiences were instrumental in his success with RALP.
He concluded that cost still remains an issue with RALP.
Presented by Edouard Trabulsi, MD at the 9th Annual Winter Meeting of the Society of Urologic Oncology (SUO) - December 4 - 6, 2008 - Natcher Conference Center, National Institutes of Health, Bethesda, Maryland
SUO 2008 - Experience with Robotic Prostatectomy: Progression in Three Programs - Session Highlights
BETHESDA, MD (UroToday.com) - In his presentation, Dr. Vipul Patel pointed out that while open prostatectomy techniques evolved over 100 years, robotic assisted laparoscopic prostatectomy (RALP) has very recently evolved over only 8 years.
Approximately 300,000 RALP procedures have been performed globally. RALP accounts for 63% of all types of radical prostatectomy cases performed in the US. The goals of RALP have evolved to focus on high-end outcomes and to improve potency and continence. The challenges of robotic surgery include lack of tactile feedback, building a qualified team, and overcoming the steep learning curve.
He felt the basic learning curve was 25-50 cases, and the intermediate learning curve was 300 cases. He presently performs about 700 cases per year. He emphasized principles of open surgery, avoidance of thermal energy during nerve sparing and measuring surgical outcomes with use of video to improve technique. He showed a video of the urethral anastomosis that supported his contention of excellent optics and ability to suture. For nerve sparing, an athermal, interfascial, retrograde approach is best. There are some technical advantages to RALP such as vision and pneumoperitoneum, but beyond that it is still surgical experience that drives outcomes.
His positive surgical margin rate is 9.5% in 2,000 patients. His potency rate in patients age 55 or younger, at 12 months who have excellent SHIM scores preoperatively is 91%. Potency decreased to 75% in men with preoperative SHIM scores of 17-21.
He concluded that institutional commitment to putting together a successful RALP program with good patient volume is key to good outcomes.
Presented by Vipul Patel, MD at the 9th Annual Winter Meeting of the Society of Urologic Oncology (SUO) - December 4 - 6, 2008 - Natcher Conference Center, National Institutes of Health, Bethesda, Maryland
Robotic Surgery in Ophthalmology
Robotic Surgery in Ophthalmology
Innovations in ophthalmology have expanded greatly in recent years. Miniaturization of operating instruments, refinements in surgical technique, and use of laser delivery systems have all been recognized as key contributions to the realm of ocular surgery. Increased precision, decreased operating time, and improved surgical outcomes have directly resulted from these advances. We feel that the next major advancement in ophthalmology is the integration of robotic surgery.
Robotics in microsurgery: Use of a surgical robot to perform a free flap in a pig Abstract:We present the concept that a surgical robot may be used to successfully perform a free flap. To study different microsurgical techniques, a porcine free flap model was developed in our laboratory. Dissection of the free flap model and isolation of the vessels were completed under traditional loupe magnification. The da Vinci® robot was then used to perform vessel adventitiectomy and microanastomoses. The model was observed for 4 h postoperatively, noting flap color, temperature, capillary refill, and Doppler signal. At the end of this period, the flap was noted to be viable; anastomoses were evaluated and found to be grossly and microscopically patent. Advantages conferred by the da Vinci® robot include elimination of tremor, scalable movements, fully articulating instruments with six degrees of spatial freedom, and a dynamic three-dimensional visualization system. Drawbacks include the cost and the absence of true microsurgical instruments.
Springer New York
Performance of basic manipulation and intracorporeal suturing tasks in a robotic surgical system: single- versus dual-monitor views
Background: Technical advances in the application of laparoscopic and robotic surgical systems have improved platform usability. The authors hypothesized that using two monitors instead of one would lead to faster performance with fewer errors.
Methods:All tasks were performed using a surgical robot in a training box. One of the monitors was a standard camera with two preset zoom levels (zoomed in and zoomed out, single-monitor condition). The second monitor provided a static panoramic view of the whole surgical field. The standard camera was static at the zoomed-in level for the dual-monitor condition of the study. The study had two groups of participants: 4 surgeons proficient in both robotic and advanced laparoscopic skills and 10 lay persons (nonsurgeons) who were given adequate time to train and familiarize themselves with the equipment. Running a 50-cm rope was the basic task. Advanced tasks included running a suture through predetermined points and intracorporeal knot tying with 3–0 silk. Trial completion times and errors, categorized into three groups (orientation, precision, and task), were recorded.
Results:The trial completion times for all the tasks, basic and advanced, in the two groups were not significantly different. Fewer orientation errors occurred in the nonsurgeon group during knot tying (p = 0.03) and in both groups during suturing (p = 0.0002) in the dual-monitor arm of the study. Differences in precision and task error were not significant.
Conclusions:Using two camera views helps both surgeons and lay persons perform complex tasks with fewer errors. These results may be due to better awareness of the surgical field with regard to the location of the instruments, leading to better field orientation. This display setup has potential for use in complex minimally invasive surgeries such as esophagectomy and gastric bypass. This technique also would be applicable to open microsurgery.
Springer New York
Roboticsurgery training and performance Identifying objective variables for quantifying the extent of proficiency
Background:To understand the process of skill acquisition in roboticsurgery and to allow useful real-time feedback to surgeons and trainees in future generations of robotic surgical systems, robotic surgical skills should be determined with objective variables. The aim of this study was to assess skill acquisition through a training protocol, and to identify variables for the quantification of proficiency.
Methods:Seven novice users of the da Vinci Surgical System engaged in 4 weeks of training that involved practicing three bimanual tasks with the system. Seven variables were determined for assessing speed of performance, bimanual coordination, and muscular activation. These values were compared before and after training.
Results:Significant improvements were observed through training in five variables. Bimanual coordination showed differences between the surgical tasks used, whereas muscular activation patterns showed better muscle use through training. The subjects also performed the surgical tasks considerably faster within the first two to three training sessions.
Conclusions:The study objectively demonstrated that the novice users could learn to perform surgical tasks faster and with more consistency, better bimanual dexterity, and better muscular activity utilization. The variables examined showed great promise as objective indicators of proficiency and skill acquisition in roboticsurgery.
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