Advent Of Robotic Surgery Research Articles

Limitations and complications of robotic urological surgery in younger children: debunking old beliefs.

Even though certain technical limitations associated with the small size of the patients were taken for granted in the advent of pediatric robotic surgery, we could now be facing a paradigm shift challenging these old beliefs. A retrospective study of patients undergoing Da-Vinci-Xi(IS4000)-assisted urological surgery from May 2022 to October 2023 was carried out. Patients were divided into two groups -Group A <15 kg and Group B ≥15 kg. Operating times, hospital stay, and intra- and postoperative complications were compared. 17 patients (9 in Group A, 8 in Group B) underwent surgery. Median age was 29months (A) and 109 months (B) (p<0.001). Median weight was 12.0 kg (A) and 31.5 kg (p<0.001). Operating time was 162 min (A) and 130 min (p=0.203). Console time was 99 min (A) and 70 min (B) (p=0.065). Mean hospital stay was 2 days (A) and 3 days (B) (p=0.41). No differences were found in terms of intraoperative (p=0.453) or postoperative (p=0.485) complications. Even though operating on younger children seemed more complicated than on older ones in the advent of robotic surgery, the results in our series were similar. The fact patients under 12 months of age were not included means larger studies are required to prove this.

Current and Future of Robotic Surgery in Thyroid Cancer Treatment.

Thyroid cancer is among the most common endocrine malignancies, necessitating effective surgical interventions. Traditional open cervicotomy has long been the standard approach for thyroidectomy. However, the advent of robotic surgery has introduced new possibilities for minimally invasive procedures with benefits in terms of cosmetic outcomes, enhanced precision, comparable complication rates, and reduced recovery time. This study mainly reviewed the most widely used and well-known robotic thyroidectomy approaches: the transaxillary approach, the bilateral axillo-breast approach, and the transoral approach. This review examines the current status and future potential of robotic surgery in thyroid cancer treatment, comparing its efficacy, safety, and outcomes with those of conventional open cervicotomy. Challenges such as a longer operative time and higher costs exist. Future directions include technological advancements, tele-surgery, single-port surgery, and the integration of artificial intelligence. Robotic surgery holds promise in optimizing patient outcomes in thyroid cancer treatment.

Transoral Robotic Approach to Parapharyngeal Space Tumors: Changes in Paradigm of Surgery.

PPS space tumors are extremely rare, accounting for 0.5% of head and neck neoplasms. Trans-oral, Trans-cervical, Trans-parotid, Trans-cervical-trans-mandibular, and infratemporal are various surgical approaches that have been described for PPS tumors. Of late, with the advent of robotic surgery, Trans Oral Robotic Surgery (TORS) for PPS tumors is being increasingly advocated with promising results. To establish both efficacy and safety of Trans Oral Robotic Surgery, Five cases of pleomorphic adenoma of parapharyngeal space with sizes varying between 2.5 cm to 7.5 cm were evaluated and removed using Trans oral robotic approach using the Da Vinci system. Three were removed in toto and two in piecemeal fashion. There was capsule breach in 2 cases, no major complication was reported in any of the cases. Transoral Robotic Approach for PPS tumors can provide the much-required bridge between Transcervical and Trans mandibular Oral Approach. It provides a better direct approach. Carefully selected patients with well encapsulated tumors are more amenable to this approach.

Robotic versus laparoscopic total mesorectal excision with lateral lymph node dissection for advanced rectal cancer: A systematic review and meta-analysis.

Lateral pelvic node dissection (LPND) poses significant technical challenges. Despite the advent of robotic surgery, determining the optimal minimally invasive approach remains a topic of debate. This study aimed to compare postoperative outcomes between robotic total mesorectal excision with LPND (R-LPND) and laparoscopic total mesorectal excision with LPND (L-LPND). This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) 2020 and AMSTAR 2 (Assessing the Methodological Quality of Systematic Reviews) guidelines. Utilizing the RevMan 5.3.5 statistical package from the Cochrane Collaboration, a random-effects model was employed. Six eligible studies involving 652 patients (316 and 336 in the R-LPND and L-LPND groups, respectively) were retrieved. The robotic approach demonstrated favourable outcomes compared with the laparoscopic approach, manifesting in lower morbidity rates, reduced urinary complications, shorter hospital stays, and a higher number of harvested lateral pelvic lymph nodes. However, longer operative time was associated with the robotic approach. No significant differences were observed between the two groups regarding major complications, anastomotic leak, intra-abdominal infection, neurological complications, LPND time, overall recurrence, and local recurrence. In summary, the robotic approach is a safe and feasible alternative for Total Mesorectal Excision (TME) with LPND in advanced rectal cancer. Notably, it is associated with lower morbidity, particularly a reduction in urinary complications, a shorter hospital stay and increased number of harvested lateral pelvic nodes. The trade-off for these benefits is a longer operative time.

Outcomes of Robotic Surgery in a Single-institution, High-volume Hepatobiliary Oncology Unit.

Hepatobiliary surgery has traditionally been performed via an open approach. With the advent of robotic surgery, the minimal access approach in hepatobiliary oncology has gained impetus due to its technical superiority and favorable learning curve over laparoscopy. We present our experience with the Da Vinci Xi system in hepatobiliary oncology. This is a retrospective study from a prospectively maintained database. All patients who underwent surgery between June 2015 and July 2023 for suspected gallbladder cancer and primary or metastatic liver tumors were included. After excluding all inoperables and conversions, a total of 92 patients were included for analysis. There was a conversion rate of 15.6% (17 of 109 patients). Sixty-four (69.6%) patients underwent surgery for gallbladder-related pathologies that included 39 (60.9%) radical cholecystectomies, 24 (37.5%) simple cholecystectomies, and 1 (0.01%) revision cholecystectomy. Twenty-eight patients underwent surgeries for primary or metastatic liver tumors, which included 25 (92.9%) minor and 2 (7.1%) major hepatectomies. Significant morbidity (Clavien-Dindo grade III or more) was seen in 8 (8.6%). There was no postoperative mortality. In the group with gallbladder cancer, the median lymph nodal yield was 7 (2-22) in patients who underwent lymph nodal dissection. The median follow-up was 63.9 (0.49-100.67) (IQR = 37.76) months. The 5-year OS and DFS were 76.4 and 71.3%, respectively. Robotic hepatobiliary surgery is feasible and can be performed safely after adequate training. Patient selection is of utmost importance and is the key to establishing a robust robotic hepatobiliary oncosurgery program.

Revolutionary Advances of Robotic Surgery in Urology Field.

The advent of robotic surgery has significantly impacted various surgical fields, particularly urology, gynecology, general surgery, and cardiac surgery. While the da Vinci robotic platform has been predominant over the past two decades, recent years have witnessed the emergence of new robotic platforms in Japan, now actively used in clinical practice. Currently, the available systems in Japan, alongside the da Vinci, include the Hinotori, Senhance, Hugo Ras, and Saroa surgical systems. This review focuses on comparing the notable functions of each system in urologic surgery, emphasizing the areas in which they differ from the da Vinci robotic platform. The development of new robotic systems is ongoing, promising not only cost reductions but also the introduction of innovative devices and educational systems. Soft robotics, which constructs robotic devices using soft, adaptable materials, has the potential to become central to the next generation of robotic surgery. Moreover, the collaboration between Artificial Intelligence (AI) and robotic surgery significantly contributes to increasing efficiency, accuracy, and safety in the medical field, with more innovative applications expected in the future.

AB037. SOH23ABS_176. Evolution of robotic colorectal surgery: a 6-year single institutional experience

Background: The advent of robotic surgery has aimed to assist surgeons in the challenges posed by open and laparoscopic approaches. Implementation of any new technology that involves a multidisciplinary team can take time. The aim of this study was to assess the perioperative and short-term outcomes of a robotic colorectal surgery service over time.

Effect of Postoperative Pain Management after Robot-Assisted Radical Prostatectomy: A Study on Reducing Hospital Length of Stay and Medical Costs Using Japanese Nationwide Database.

Prostate cancer has a high incidence rate. Many articles reported its usefulness with the advent of robotic surgery in 2001. However, epidural analgesia is declining due to the spread of minimally invasive treatment. There have been no studies using nationwide databases on the impact of epidural analgesia use on length of hospital stay and medical costs. Therefore, we used a Japanese national inpatient database from April 2016 to March 2020. The study population included 46,166 patients. We compared a postoperative analgesia management group using epidural analgesia [Epidural Analgesia Group (EA Group): 5,354] and a group not using epidural analgesia [non-Epidural Analgesia Group (non-EA Group): 40,812]. We found significant differences among the two groups regarding the length of stay, days from surgery to discharge, and inpatient cost of surgery to discharge. Hospital length of stay and postoperative hospital stay was statistically shorter in the EA group than in the non-EA group (11.3 ± 2.8 days vs. 12.1 ± 3.1 days, p < 0.001 and 8.9 ± 2.5 days vs. 9.3 ± 2.7 days, p < 0.001), respectively, and medical costs were also significantly lower in the EA group (84,566 JPY vs. 294,277 JPY, p < 0.001). Also, the activities of daily living (ADL) assessment at discharge determined a considerably higher score in the EA group than in the non-EA groups. Epidural analgesia for postoperative pain management largely depends on each medical institution's treatment policy. However, epidural analgesia is declining due to the spread of minimally invasive treatment. Therefore, epidural analgesia should be reconsidered because it can reduce hospital stays and hospitalization costs.

A Comparison of the Differences in Postoperative Chronic Pain Between Video-Assisted and Robotic-Assisted Approaches in Thoracic Surgery.

Background and objective In the last decade, there has been significant evolution in thoracic surgery with the advent of robotic surgery. In this study, we aimed to evaluate the incidence ofpostoperativechronic pain (for six months and beyond) in robotic and video-assisted approaches to analyze the long-term effects of the two different techniques. Methods This was a retrospective study involving 92 patients who underwent various thoracic operations betweensix months and two years preceding the study. Patients were classified into two groups based on the type of surgery: video-assisted (VATS) (n=51), and robotic-assisted (RATS) (n=41) thoracoscopic Surgery. We employed the EuroQol (EQ-5D-5L) questionnaire to assess the utility values in terms of five quality-of-life measures (self-care,pain/discomfort, mobility,anxiety/depression, and usual activities). Results In the VATS group, the median age was 68 years while it was 57 years in the RATS group(p=0.001). A higher proportion of patients in the VATSgroup had anatomical lung resection (lobectomy) compared to the RATS group: 61.2 vs. 41.6% respectively (p=0.005). However, the groups were well-matched on other patient characteristics such as relevant past medical history, underlying disease pathology, and final disease staging (if malignant), with no significant differences between groups observed regarding these traits. In the VATS group, 62.7% of patients were pain-free at the time of the questionnaire-based evaluation compared to 51.2% in the RATS group. Additionally, 25.5% vs. 39% of patients had mild pain in the VATS and RATS groupsrespectively. Neither of these differences was statistically significant. Conclusion Patients who undergo RATS are known to have better recovery and less pain compared to those who have VATS in the immediate postoperative period. However, our results did not find RATS to be superior toVATS in terms of long-term pain. Additionally, robotic surgery is associated with higher hospital costs. In light of these findings, further comparative studies between the two approaches are recommended, while strategies to reduce postoperative pain and financial cost should continue to be explored.

Fertility Preserving Robotic Surgery for Infiltrating Bladder Endometriosis

<h3>Study Objective</h3> The uterus is normally lined by endometrium, when any other site has endometriotic tissue it is known as pathological endometriosis. If this endometroitic tissue is found in the gynaecologist most feared organ the bladder it is bladder endometriosis which is a rare entity almost to the tune of 1-2%. <h3>Design</h3> Mrs V, nulligravida with primary infertility presented to Gyane OPD with complaints of dysmenorrhea, dyspareunia and heavy menstrual bleeding for last one and a half years. She had cyclical hematuria. On history a strong clinical suspicion of bladder endometriosis was confirmed by transvaginal ultrasound (TVS) and MRI <h3>Setting</h3> Cystoscopy performed by Urologist reaffirmed the diagnosis of bladder endometriosis. A 3.5 × 2cms nodule was visualized in bladder mucosa on posterior wall away from the uteric orifice. Using operative cystoscopy transurethral coring of the endometroitic nodule in the bladder was uptil the muscularis. <h3>Patients or Participants</h3> 1 <h3>Interventions</h3> Robotic Fertility Sparing Surgery for Infiltrating Bladder Endometriosis <h3>Measurements and Main Results</h3> Multidisciplinary approach towards bladder endometriosis and complete disease resection <h3>Conclusion</h3> Bladder endometriosis can be diagnosed both clinically & radiologically. With the advent of robotic surgery, it has now become easier to perform such complex surgeries with better postoperative

Total robotic choledochal cyst excision with Roux-en-Y hepaticojejunostomy in adults

Choledochal cyst (CDC) excision with bilio-enteric anastomosis has been reported by a laparoscopic approach. With the advent of robotic surgery, it is likely to simplify the performance of such complex procedures. Herein, we present our technique of total robotic CDC excision with intra-corporeal Roux-en-Y hepaticojejunostomy (RYHJ). The patient was placed in a reverse Trendelenburg position. The robotic ports were placed in a "C"-shaped manner, with the camera port placed ~2 cm below the umbilicus. A 12-mm assistant port was placed in between the camera and the left-sided robotic port. Robotic dissection and excision of extrahepatic part CDC were performed, and subsequently, intra-corporeal robotic RYHJ with jejunojejunostomy was completed. Intra-operatively, indocyanine green dye was used to delineate the biliary anatomy and to check the anastomotic integrity. All three patients were female with a median age of 21 (18-34) years. Two patients had type IVa, and one had a mixed variant of type I(C) with type VI. The median operative time was 420 min, whereas docking and console time was 22 (20-25) min and 400 (360-450) min, respectively. The median blood loss and length of hospital stay were 50 (50-100) ml and 6 (5-6) days, respectively. One patient has mild acute pancreatitis in the post-operative period, which was managed conservatively. Robotic CDC excision and reconstruction seem to be a safe, feasible, and effective surgical option that provides the benefits of minimal access surgery but also greatly aids in complex dissection and reconstruction.

Robotic Surgery of the Mediastinum: A Review

Background: The mediastinum is a complex anatomical region which contains many vital structures. Many aspects of mediastinal surgery, like that for other anatomic regions, have evolved from a maximally invasive approach involving a median sternotomy, anterior mediastinotomy, mediastinoscopy or thoracotomy, to a minimally invasive video-assisted approach. Robotic surgery is presently the most advanced form of minimally invasive surgery. Methods: We reviewed our experience with a robotic approach to mediastinal pathology. In addition, an extensive search was conducted using PubMed, in order to extract references for the application of robotics to surgical conditions of the mediastinum. Results: The first robotic procedure by our group was a mediastinal procedure in 2003. In the past eighteen years, 203 patients have undergone robotic surgery for mediastinal pathology. There were 119 procedures for the Anterior Mediastinum, 33 procedures for the Middle Mediastinum, and 51 procedures for the Posterior Mediastinum. 78 patients underwent robotic thymectomy using a left-sided approach. 43/78 (55%) patients underwent radical thymectomy for Myasthenia Gravis. Thymoma was histologically identified in 32% of patients with Myasthenia Gravis. In patients with thymoma, there was no tumor recurrence. In patients with Myasthenia Gravis, the overall improvement rate after robotic radical complete thymectomy was 91% (39/43). Following robotic surgery for the mediastinal disease, the median hospitalization was 3 days, major complications occurred in 0.9% of patients and there was no mortality. Conclusion: With the advent of robotic surgery, many of the current surgical approaches to diseases of the mediastinum will likely be replaced over time by robotic surgery. When applied to the mediastinum, robotics has a number of benefits when compared to conventional Video-Assisted Thoracic Surgery (VATS) including three-dimensional visualization, magnification of the operative field, precise instrument movement, and improved dexterity. Much of the mediastinal disease encountered in an adult is benign, making it especially suited to a minimally invasive approach. With the use of the robot, a complete anatomical and oncological procedure can be performed through a number of small incisions or ports, while at the same time providing the patient with minimally invasive benefits including shorter hospitalizations, quicker returns to preoperative activity, less pain, less inflammatory response and better cosmesis. The excellent range of motion of the robotic instruments makes them particularly suitable to maneuver around the vital structures and the rigid axial skeleton encountered in various compartments of the mediastinum, and for reaching those “distant” areas of the mediastinum that are difficult to explore and dissect with conventional Video-Assisted Thoracic Surgery (VATS).

Orthotopic urinary diversions after radical cystectomy for bladder cancer: lessons learned last decade.

Orthotopic urinary diversion (OUD), or neobladder, is believed to be the gold standard for surgical bladder reconstruction following radical cystectomy though it is performed far less often than ileal conduits. As both a continent and intracavitary diversion, OUDs offer unique advantages for patients. Their utilization has decreased overall though, especially with the advent of robotic surgery. In this review, we will cover patient selection for OUD, functional outcomes (i.e., continence, sexual activity, quality of life [QoL]), and robotic orthotopic diversions. OUDs have seen a proportionally greater decline in utilization compared with ileal conduits as the number of robotic radical cystectomies being performed with intracorporeal diversions increases. Multiple robotic series have demonstrated less perioperative blood loss and shorter hospital stays when compared with the open approach though operative times are longer, the learning curve is steeper, and overall costs may be higher in some settings. Perioperative safety and short-term oncological outcomes appear comparable. Since robotic OUDs are relatively new, functional outcomes are not yet well established. Patient satisfaction with urinary diversion is associated with informed decision-making tailored to the patient. A thorough understanding of expected short- and long-term functional outcomes and the care required to maintain an OUD improves QoL and satisfaction with diversion choice. Given the potential advantages of OUD, its decreasing use is a remarkable trend. Shared decision-making and a patient-centered approach should be used when selecting the type of urinary diversion.

A Bibliometric Analysis of Overall and Top 100 Most-Cited Studies About Robotic Surgery Versus Open Surgery.

In the last 30years, significant progress in the field of surgery has been achieved with the advent of robotic surgery. In this study, we aimed to conduct a bibliometric analysis to identify the distribution and characteristics overall and of the top 100 most-cited studies about robotic surgery versus open surgery. A systematic search was conducted on March 26, 2021 using Web of Science Core Collection. Two reviewers independently screened documents, and the top 100 most-cited studies were identified. Excel 2019 and VOSviewer were used to collect the data, and visual information was obtained. A total of 2306 documents were searched from the Web of Science Core Collection, and 1065 journals and 2913 institutes were extracted. A significant growth was observed in the last 15years. The number of citations from the United States accounted for 33.31% of the total number of citations. There were nine American institutes and one Swedish institute in the top 10 institutes. Four journals in the field of urology or gynecology were present in the top 10 published journals. Few global communications between authors, institutes, and countries authors were observed. The lack of close cooperation among scientific research institutions may have affected the industrialization process of surgical robots. Some developing countries, including South America and Africa, should seize the development opportunity of robotic surgery to improve the level of domestic research on robotic surgery.

Robotic living donor hepatectomy: Is it the future?

Donor liver hepatectomy has always been associated with significant risks and complications affect up to 1/3 of patients. The vast majority are related to large incisions, severe postoperative pain, lung atelectasis, extensive intrabdominal adhesions as well as intraoperative blood loss and biliary injuries. The advent of robotic surgery can improve outcomes through minimally invasive approaches and use of superb technological instruments, but its use for donor hepatectomy is still in infancy. This review summarises its current state and challenges. Review of published literature. Robotic liver surgery offers significant advantages: small access wounds, stable magnified 3-D intraabdominal views, multidimensional instrument articulation. For liver donor resection this allows close individual biliary and vascular dissection, improved haemostasis by ligating vascular pedicles precisely, parenchymal transection facilitated by better views and reduced blood loss. Even in the challenging right donor hepatectomy, a fourth robotic arm allows for identification of accessory veins and venous reconstruction if necessary. Published studies show longer operative time for the robotic population but comparable intraoperative blood loss and similar incidence of early allograft dysfunction, vascular complications (hepatic artery thrombosis, portal vein thrombosis or stenosis), and 1-year liver regeneration and liver function tests. Robotic hepatectomy has the potential to revolutionize living donor liver surgery and to minimize major complications and their associated morbidity. However it is still limited to few highly expert centers and requires extensive operative experience in robotic and liver resections. As exposure to minimally invasive techniques grows, it could become the mainstay of practice in the next decade.

The Artisential® Articulated Laparoscopic Forceps: A Dry Lab Study to Examine Dexterity and Learning Effects in Operators with Different Levels of Laparoscopic Experience

Purpose: The advent of robotic surgery has highlighted the advantages of articulation. This dry-lab study examined the dexterity and learning effect of a new articulated laparoscopic instrument: the ArtiSential® forceps (LIVSMED, Seongnam, Republic of Korea). Methods: A peg board task was designed. Three groups of volunteers with varying levels of laparoscopic expertise were organized to perform the task: expert, intermediate and novice. The participants performed the task using articulated and straight instruments, once before a 30-min training session and once afterwards. The times required to perform the task were recorded. The performances were analyzed and compared between the groups as well as between the straight and articulated instruments. Results: The experts were significantly faster than the novices with both instruments before the 30-min training session (p = 0.0317 for each instrument). No significant time difference was found among the three groups after the 30-min training session. The decrease in the time required to perform the peg-transfer task with the articulated instrument was significantly greater in the novice and intermediate groups (p = 0.0159 for each group). No significant difference in time reduction was observed between the groups with the straight instrument. Regardless of the user, the articulated device was associated with faster task performance than the straight device after 8 hours of training (p = 0.0039). Conclusion: The ArtiSential® articulated device can improve dexterity. A significantly greater learning effect was observed in the novice and intermediate groups in comparison with experts. A plateau in the learning curve was observed after a few hours of training.

Pediatric Robotic Adrenalectomy for Virilizing Adrenal Tumor in a 4-year-old Female

Adrenocortical tumors in children are rare, with approximately 90% of children presenting with endocrine syndromes, most commonly virilization. The standard treatment remains an open resection, although there is increasing use of the minimally invasive approach. With the advent of robotic surgery, its advantages over open and conventional laparoscopy make it a viable option in select patients. Despite the adoption of robot-assisted surgery in pediatric urology, limited literature regarding robotic pediatric adrenal surgery exists, with only a few small case series. We present a female child with virilizing features due to a large functional adrenal tumor managed by robot-assisted adrenalectomy.

Neoplastic Myelopathies.

This article reviews the current classification system of primary spinal cord tumors and explores evolving diagnostic and therapeutic strategies for both primary tumors and metastatic tumors to various compartments of the spinal cord. The 2016 World Health Organization classification system allows for more precise prognostication of and therapy for spinal cord tumors and has identified new entities, such as the diffuse midline glioma, H3 K27M mutant. Whole-exome sequencing reveals that the genetic background of primary glial spinal cord neoplasms differs from that of their intracranial histologic counterparts in ways that can potentially influence therapy. Targeted and immune checkpoint therapies have improved survival for patients with melanoma and lung cancer and have simultaneously produced novel complications by enhancing radiation toxicity in some cases and by facilitating the emergence of novel autoimmune and paraneoplastic syndromes involving the spinal cord, such as neuromyelitis optica spectrum disorder and syndromes associated with anti-Hu and collapsin response mediator protein-5 (CRMP-5) antibodies. These conditions must be distinguished from tumor or infection. Epidural spinal cord compression treatment paradigms have changed with the advent of robotic surgery and advances in radiation therapy. Neoplastic myelopathies subsume a wide spectrum of pathologies. Neoplastic cord involvement may be primary or secondary and may be approached diagnostically by the particular spinal cord compartment localization. Primary spinal cord tumors account for only 2% to 4% of primary central nervous system tumors, ranging from low-grade glial neoplasms to malignant tumors. Metastatic malignancy to the epidural or leptomeningeal spaces is more common than primary cord tumors. Differential diagnoses arising in the course of evaluation for cord tumors include myelopathies related to radiation or chemotherapy and paraneoplastic syndromes, all of which are sources of significant morbidity. Knowledge of genetic syndromes and the biologic behavior of diverse histologies together with selective application of surgery, radiation, and targeted therapies can facilitate diagnosis, minimize surgical morbidity, and prolong quality of life.

Robotic thoracic surgery in children and adolescents—technology and adaptability

The advent of robotic surgery has ushered in new and exciting innovations in all aspects of thoracic surgery—from mediastinal procedures to esophageal and lung cancer operations. While the bulk of robotic thoracic surgery today is performed on adult patients, the robotic platform also offers opportunity to provide minimally-invasive procedures to selected pediatric patients. In this article we will review the most common robotic thoracic surgical operations that are appropriate for pediatric patients.

Evaluating Pedicle-Screw Instrumentation Using Decision-Tree Analysis Based on Pullout Strength.

Study DesignA biomechanical study of pedicle-screw pullout strength.PurposeTo develop a decision tree based on pullout strength for evaluating pedicle-screw instrumentation.Overview of LiteratureClinically, a surgeon’s understanding of the holding power of a pedicle screw is based on perioperative intuition (which is like insertion torque) while inserting the screw. This is a subjective feeling that depends on the skill and experience of the surgeon. With the advent of robotic surgery, there is an urgent need for the creation of a patient-specific surgical planning system. A learning-based predictive model is needed to understand the sensitivity of pedicle-screw holding power to various factors.MethodsPullout studies were carried out on rigid polyurethane foam, representing extremely osteoporotic to normal bone for different insertion depths and angles of a pedicle screw. The results of these experimental studies were used to build a pullout-strength predictor and a decision tree using a machine-learning approach.ResultsBased on analysis of variance, it was found that all the factors under study had a significant effect (p <0.05) on the holding power of a pedicle screw. Of the various machine-learning techniques, the random forest regression model performed well in predicting the pullout strength and in creating a decision tree. Performance was evaluated, and a correlation coefficient of 0.99 was obtained between the observed and predicted values. The mean and standard deviation of the normalized predicted pullout strength for the confirmation experiment using the current model was 1.01±0.04.ConclusionsThe random forest regression model was used to build a pullout-strength predictor and decision tree. The model was able to predict the holding power of a pedicle screw for any combination of density, insertion depth, and insertion angle for the chosen range. The decision-tree model can be applied in patient-specific surgical planning and a decision-support system for spine-fusion surgery.