Τετάρτη, 17 Ιουλίου 2019

Robotic Surgery

Should we use virtual simulators for surgical resident selection?

New perspectives about the role of robot-assisted surgery for the treatment of endometriosis

Robot assisted intra-corporeal ileocalicostomy ureteral substitution for complex uretero-pelvic junction obstruction: a novel and feasible innovation


A 33-year-old female presented to the emergency department of our hospital with urosepsis and hematuria with clot retention secondary to a complicated pyelolithotomy for left-sided pelvic calculus. A percutaneous nephrostomy was placed for drainage as a DJ stent could not be traversed into the left renal pelvis with retrograde pyelography demonstrating complete cut-off at L4–L5 level. After stabilization, she was found to have uretero-pelvic junction obstruction (UPJO) in left solitary functioning kidney with long-segment upper ureteric stricture and nadir serum creatinine 1.5 mg/dL. Nephrostogram and CT scan revealed an intra-renal pelvis with no passage of contrast into the ureter. Primary hyperparathyroidism secondary to parathyroid adenoma was also detected and she underwent excision of the same. The long-segment ureteric stricture and need for a wide drainage ruled out pyeloplasty and ureterocalicostomy as treatment options. A wide-bore communication between the lower calyx and bladder was necessary and robot assisted ileocalicostomy was performed in this case. A 20-cm-long segment of ileum was used to replace the ureter with a suprapubic 16 Fr Foley’s catheter as splint. Postoperative course was uneventful with all tubes removed by third postoperative week. Nephrostogram demonstrated gravity-dependent drainage into the bladder with no leak or anastomotic narrowing. The patient is doing well at 6 months of follow-up with a stable renal function. Robot assisted ileocalicostomy is a safe and effective technique which provides wide gravity-dependent drainage in complex UPJO with long-segment ureteric stricture and intra-renal pelvis.

Techniques for developing and viewing stereoscopic three-dimensional teaching videos for transoral robotic surgery (TORS)


Advances in three-dimensional (3D) video recording and playback have expanded the availability of stereoscopic videos for consumption with specialized televisions, computer monitors, and virtual reality (VR) headsets. The built-in stereoscopic vision of the da vinci surgical system (Intuitive Surgical, Sunnyvale, CA) enables the recording of both camera views. However, medical-grade devices for direct stereoscopic video recording can be cost-prohibitive. We describe methods of producing and viewing 3D videos in transoral robotic surgery (TORS) without acquisition of dedicated 3D recording equipment. The video output from the left and right cameras of the da Vinci Si endoscope were recorded during a TORS radical tonsillectomy using non-stereoscopic media devices. Raw video was processed using commercially available video-editing software to create stereoscopic videos clips. 3D videos were successfully observed using a low-cost mobile phone VR headset. 3D stereoscopic surgical videos were successfully developed using widely available software, applications, computer peripherals, and mobile devices. The methods described confer significant cost savings when compared to the purchase of specialized recording equipment despite the requirements of time and intermediate computer skills. Future studies will investigate the utility of stereoscopic videos in medical student and resident education.

Wearable haptic interfaces for applications in gynecologic robotic surgery: a proof of concept in robotic myomectomy


Uterine fibromatosis is common in women, with an estimated prevalence of up to 15–50% after 35 years. About 80% of women affected by fibromatosis have symptoms and require medical or surgical treatment. Nowadays, the gold standard for the surgical treatment of uterine fibromatosis is the use of minimally invasive surgery. The surgical skills and improvements offered by robotic approach can be relevant in reproductive surgery, in particular in minimally invasive myomectomy. However, the lack of tactile feedback of robotic platform is an important technical drawback that can reduce the accuracy of surgical procedures. Here, we present the design and the preliminary test of the wearable fabric, yielding display wearable haptic interfaces able to generate a real-time tactile feedback in terms of stiffness for applications in gynecologic robotic surgery. We preliminarily tested the device in the simulation of a real scenario of conservative myomectomy with the final purpose of increasing the accuracy and precision during surgery. The future goal is the integration of a haptic device with the commercially available robotic surgical systems with the purpose of improving the precision and accuracy of the surgical operation, thus allowing a better understanding concerning the anatomical relationship of the target structures. This in turn could determine a change in the surgical strategy in some cases, letting some patients selected for a demolitive approach retaining their uterus. This could improve surgical outcomes in fertile women enrolled for minimally invasive surgery for uterine fibroids and may be a facilitation for young gynecological surgeons or during residency teaching plans and learning programs.

Costs–benefits of robot-assisted colorectal surgery: a different perspective


The costs of robot-assisted surgery (RAS) still represent a critical issue. Kulaylat et al. reported a propensity-matched study to compare the outcomes of colorectal surgery between a robotic and a laparoscopic group, concluding that RAS was burdened by higher costs. However, authors did not mention what da Vinci system, Si or Xi, they used and this could be crucial, as recently data published by our group on rectal resections showed that the use of the da Vinci Xi and the surgeon’s increased experience could improve the results and significantly reduce the costs of RAS.

Cement-augmented pedicle screw insertion assisted by spinal robotic systems for widespread spinal metastases


Widespread spinal metastases can obscure bone landmarks and severely hinder surgical safety during pedicle screw insertion. Robot-assisted spinal surgery has demonstrated an excellent safety profile for pedicle screw insertion. Moreover, spinal surgery robotic systems can facilitate pedicle screw insertion with high-accuracy. We present a patient who had breast cancer with widespread spinal metastases, pathological vertebral fracture, and spinal cord compression with a challenge of intraoperative image recognition. To overcome this problem, she received surgical decompression and stabilization through the insertion of cement-augmented pedicle screws with the assistance of a spinal robotic system. At the 1-year follow-up, no implant loosening was observed, and the patient exhibited notable physical improvements, demonstrating that cement-augmented pedicle screw insertion with the assistance of spinal robotic systems is an effective method for treating widespread spinal metastases.

Magnetic-assisted robotic surgery: initial case series of reduced-port robotic prostatectomy


Minimally invasive radical prostatectomy has rapidly been adopted as the primary means of surgical intervention for prostate cancer. Intraoperative tissue retraction relies on either gravity (via positioning) or use of additional ports and instrumentation. We report the use of a novel trocar-less magnetic retractor system to aid with tissue retraction. Three patients underwent robotic-assisted radical prostatectomy in the treatment of prostatic adenocarcinoma at a single tertiary care institution. All surgeries utilized the Levita™ Magnetic Surgical System (San Mateo, CA) without the use of a fourth robotic arm. The magnetic grasper was used to manipulate the bowel, peritoneum, seminal vesicles, and prostatic capsule. Demographic, pre-operative, and perioperative information were collected. No cases required placement of any additional ports. No intraoperative or immediate post-operative complications occurred. No tissue tearing or subjective tissue damage was noted by placement or removal of the magnetic retractor. Mean operative time was 216 ± 17 min and mean blood loss was 333 ± 57 mL. All patients were discharged to home on post-operative day 1. Robotic prostatectomy utilizing a magnetically anchored tissue grasper appears to be safe and effective while reducing the number of ports (fourth robotic arm) needed. Further investigation is warranted.

Robotic harvesting of the omental flap: a case report and mini-review of the use of robots in reconstructive surgery


This study describes the robotic harvesting of a free omental flap. The patient was a 58-year-old man who had undergone several previous operations due to osteomyelitis caused by trauma. There was a non-healing wound and purulent discharge in the distal pretibial region. The flap was harvested based on the right gastroepiploic artery using robotic facilities only. The flap was then transferred to the debrided defect in the pretibial region. Anastomoses were performed between the posterior tibial vessels and the pedicle of the flap. A split thickness skin graft was used to cover the omental flap. The operation lasted 2.5 h in total, including flap harvesting, microvascular anastomoses, inset and skin grafting. The postoperative period was uneventful and the patient was discharged on the 12th day postoperatively. The reliability of the technique is discussed in this report, together with a brief review of the use of robot surgery in reconstructive surgery in the literature.

Robot-assisted stereotactic brainstem biopsy in children: prospective cohort study


Tumours located within the brainstem comprise approximately a tenth of all paediatric brain tumours. Surgical biopsy of these tumours is technically challenging and has historically been associated with considerable risk. To this end, robot-assisted surgery theoretically allows for increased accuracy and precision. In this study we report our experience using the Neuromate robot (Renishaw, Gloucestershire, UK) to perform robot-assisted stereotactic biopsy in children with tumours located within the brainstem. An uncontrolled prospective cohort study was performed (phase II) according to the IDEAL model for safe surgical innovation. All cases were recorded on a prospectively maintained database. The database was searched over a 2-year period between the 1st December 2015 and the 31st November 2017 to identify all children with brainstem tumours that underwent robot-assisted stereotactic brain biopsy. When accessible, the post-operative MRI scans and pre-operative plans were compared to assess the target point localisation error (TPLE). Adverse events were recorded prospectively according to whether they resulted in increased hospital stay, caused neurological injury, or lead to death. In all, 11 consecutive children were identified with brain tumours located within the brainstem. In 10/11 cases specimens were diagnostic; in the remaining case a further biopsy was successful. The most frequent pathology was DIPG (7/15). Seven patients underwent an early post-operative volumetric MRI; the calculated median TPLE was 2.7 mm (range 0.5–4.2 mm). There were no surgical complications noted. Robot-assisted stereotactic biopsy in children appears to be feasible and safe. Research databases and comparative studies are warranted to further assess the technique.

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