Bimanual Surgery Research Articles

Currently Recommended Small Incision Vitrectomies and Bimanual Surgery in Diabetic Vitrectomy

In recent years, retinal specialists have benefited from significant advances in the surgical treatment of proliferative diabetic retinopathy, including improved preoperative planning, vitreoretinal instrumentation, and new surgical maneuvers. In light of these developments, surgical indications in proliferative diabetic retinopathy patients have been expanded, success rates have increased, and complication rates have decreased over the years. Transconjunctival small-incision surgery, vitrectomes with high cutting speed, and bimanual approaches allowed by chandelier lighting have been preferred by more and more surgeons. In this review, we will discuss the benefits of small incision surgery and the clinical results of bimanual surgery in the treatment of PDR patients with historical development steps.

Surgical Treatment of Diabetic Combined Tractional-Rhegmatogenous Retinal Detachment

Diabetic macular edema, tractional retinal detachment (TRD) and combined rhegmatogenous retinal detachment (CTRRD) are important causes of vision loss in eyes with proliferative diabetic retinopathy. CTRRD is less common than TRD but has a worse prognosis. Therefore, the treatment of CTRRD is one of the issues that await solutions in current ophthalmology practice. In recent years, it has been shown that the risk of intraocular bleeding during and after the operation is reduced by the use of vascular endothelial growth factor inhibitors before the operation. In addition to bimanual surgery, there are current developments that enable the effective and safe application of segmentation and delamination of proliferative membranes with customized rapid cutters from vitreoretinal small incisions. In addition, the preference for silicone oil as an intraocular tamponade and intraoperative real-time follow-up of vitrectomy with optical coherence tomography has the potential to provide more successful anatomical and functional results.

Minimally Invasive Bimanual Fetal Surgery-A Review.

Background: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of the surgeon (bimanual minimally invasive fetal surgery). Methods: a print and electronic literature search was performed; the titles and abstracts were screened and included reports were reviewed in a two-step approach. First, reports other than minimally invasive fetal surgery were excluded, then a full text review and analysis of the reported data was performed. Results: 17 reports were included. The heterogeneity of the included reports was high. Although reports on human fetoscopic surgical procedures can be found, most of them do not pick out bimanual fetal surgery as a central theme but rather address interventions applying a fetoscope with a working channel for a laser fiber, needle or flexible instrument. Most reports were on experimentation in animal models, the human application of minimally invasive fetoscopic bimanual surgery is rare and has at best been explored for the prenatal treatment of spina bifida. Some reported bimanual fetoscopic procedures were performed on the exteriorized uterus via a maternal laparotomy and can therefore not be classified as being truly minimally invasive. Discussion: our results demonstrate that minimally invasive fetoscopic bimanual surgery is rare, even in animal models, excluding many other techniques and procedures that are loosely termed ‘minimally invasive fetal surgery’ which we suggest to better label as ‘interventions’. Thus, more research on percutaneous minimally invasive bimanual fetoscopic surgery is warranted, with the aim to reduce the maternal, uterine and fetal trauma for correction of congenital malformations.

Minimally Invasive Resection of Intraventricular Pilocytic Astrocytoma Using the Aurora Surgiscope in an Adult Patient: Technical Note

Pilocytic astrocytomas account for approximately 5%-6% of all gliomas and are most commonly diagnosed between the ages of 8 and 13 years. Although they may occur throughout the neuraxis, approximately two thirds arise from the cerebellum and optic pathway. Other locations of origin include midline structures such as thalamus, hypothalamus, and periventricular regions. Surgical approaches to lateral or third ventricular tumors include anterior transcallosal, subfrontal translamina terminalis, and anterior transcortical approaches. The Aurora Surgiscope is a single-use, disposable minimally invasive neurological endoscope designed for intraparenchymal hemorrhage evacuation. We present the successful use of this system to aid resection of a large intraventricular pilocytic astrocytoma. A 29-year-old man presented with signs of developing hydrocephalus and was found to have a large intraventricular tumor, which was later identified to be a rare intraventricular pilocytic astrocytoma. A ventriculostomy was performed as a temporizing measure, and he was transferred to our tertiary care facility for surgical management. Sulcal dissection was performed, and the endoscope was inserted to create a minimally invasive corridor to the lateral ventricle. Using the endoscope, bimanual surgery using multiple instruments simultaneously was possible and enabled gross total resection of the tumor. The patient tolerated the procedure well and was discharged at his neurological baseline level. Extensive sulcal dissection preceding placement of the endoscope allowed access to the intraventricular space with minimal passage of parenchymal tissue. High-definition visualization was provided and allowed the operating surgeon to freely use both hands during surgery.

Эффективность бимануального хирургического лечения отслоек сетчатки при тяжелых формах пдр с предоперационной подготовкой анти-vegf препаратами в сочетании с использованием системы 3d визуализации

As a result of the study, it was found that visual acuity before the treatment was 0.03 [0.01; 0.1], and 4–6 months after the surgical treatment, 0.3 [0.15; 0.5]. The performed statistical analysis made it possible to establish a statistically significant increase in visual acuity 4–6 months after the treatment (p = 0.001) Complete anatomical retinal attachment with increased visual acuity was achieved. There were 5 complications in the postoperative period. Recurrent hemophthalmos was diagnosed in 3 cases, which required repeated surgical intervention. In 2 patients diabetic macular edema (DME) has developed, which required intravitreal injection of biodegradable dexamethasone implant. Key words: proliferative diabetic retinopathy; vitrectomy; 3D imaging; bimanual surgery; anti-VEGF drugs.

Клинический анализ и эффективность бимануального хирургического лечения отслоек сетчатки при тяжелых формах ПДР с предоперационной подготовкой анти-VEGF препаратами в сочетании с использованием системы 3D-визуализации Ngenuity ALCON

The purpose of the study was to evaluate the effectiveness of bimanual surgery with anti-VEGF preparation of patients with severe forms of PDR complicated by traction retinal detachment, with intraoperative use of 3D visualization. Material and methods. Operated on 18 patients with a diagnosis of PDR complicated by traction retinal detachment. Of these, there were 7 patients with type 1 diabetes, type 2 diabetes. There were 5 men and 13 women. The average age was 58 + -2 years. All patients underwent a three-port vitrectomy, using an additional light source, with preoperative preparation with anti-VEGF drugs, using bimanual technique and 3D visualization, using air tamponade. Results and its discussion. As a result of the study, it was found that the visual acuity before the treatment was 0.03 [0.01; 0.1], and 4-6 months after the surgical treatment, 0.3 [0.15; 0.5]. The performed statistical analysis made it possible to establish a statistically significant increase in visual acuity 4-6 months after the treatment. (p = 0.001) Achieved complete anatomical retinal fit. With increased visual acuity. There were 5 complications in the postoperative period. Recurrent hemophthalmos was diagnosed in 3 people, which required repeated surgical intervention. In 2 patients in the postoperative period, DMO developed, which required IVI biodegradable dexamethasone implant. Conclusion. Bimanual, surgical treatment of traction retinal detachments, in severe forms of PDLP, with preoperative preparation with anti-VEGF drugs, and the use of the Ngenuity ALCON 3D imaging system, is one of the effective methods of treatment in this group of patients, and is aimed at reducing both intra and postoperative complications. Key words: рroliferative diabetic retinopathy, vitrectomy, 3D imaging, bimanual surgery, anti-VEGF drugs.

Advanced Vitrectomy Surgery in Rhegmatogenous Retinal Detachment; Indications and Techniques

The main goal in the treatment of rhegmatogenous retinal detachment (RRD) is the localization of retinal tears, removal of tractions, and closure of retinal tears. Despite the use of pneumatic retinopexy, scleral buckling, and vitrectomy as standard treatment modalities, the preference for pars plana vitrectomy (PPV) in the treatment of RRD has increased steadily in recent years. The reason for this increase is the widespread use of small-sized transconjunctival surgery, improvement of bimanual surgery, use of liquid perfluorocarbons, improved vitrectomy devices and more safe and successful removing of peripheral vitreous bases, visualization of membranes with vital dyes, safe retinopexy with use of curved laser probe even with phakic cases. Besides these, PPV and advanced surgical techniques are more needed in complicated detachments. Nevertheless, the surgeon has a specially important role in the surgical technique of choice. Although the control of the procedures can be performed much more successfully with the PPV in the case of complicated RRD patients during surgery, anatomical success rates are still not very high. In this article, the applications of advanced vitrectomy surgery in RRD are discussed in detail.

Evaluation of Haptic Feedback on Bimanually Teleoperated Laparoscopy for Endometriosis Surgery.

Robotic minimal invasive surgery is gaining acceptance in surgical care. In contrast with the appreciated three-dimensional vision and enhanced dexterity, haptic feedback is not offered. For this reason, robotics is not considered beneficial for delicate interventions such as the endometriosis. Overall, haptic feedback remains debatable and yet unproven except for some simple scenarios such as fundamentals of laparoscopic surgery exercises. Objective: This work investigates the benefits of haptic feedback on more complex surgical gestures, manipulating delicate tissue through coordination between multiple instruments. Methods: A new training exercise, “endometriosis surgery exercise” (ESE) has been devised approximating the setting for monocular robotic endometriosis treatment. A bimanual bilateral teleoperation setup was designed for laparoscopic laser surgery. Haptic guidance and haptic feedback are, respectively, offered to the operator. User experiments have been conducted to assess the validity of ESE and examine possible advantages of haptic technology during execution of bimanual surgery. Results: Content and face validity of ESE were established by participating surgeons. Surgeons suggested ESE also as a mean to train lasering skills, and interaction forces on endometriotic tissue were found to be significantly lower when a bilateral controller is used. Collisions between instruments and the environment were less frequent and so were situations marked as potentially dangerous. Conclusion: This study provides some promising results suggesting that haptics may offer a distinct advantage in complex robotic interventions were fragile tissue is manipulated. Significance: Patients need to know whether it should be incorporated. Improved understanding of the value of haptics is important as current commercial surgical robots are widely used but do not offer haptics.

An Innovate Robotic Endoscope Guidance System for Transnasal Sinus and Skull Base Surgery: Proof of Concept.

Objective Advanced transnasal sinus and skull base surgery remains a challenging discipline for head and neck surgeons. Restricted access and space for instrumentation can impede advanced interventions. Thus, we present the combination of an innovative robotic endoscope guidance system and a specific endoscope with adjustable viewing angle to facilitate transnasal surgery in a human cadaver model. Materials and Methods The applicability of the robotic endoscope guidance system with custom foot pedal controller was tested for advanced transnasal surgery on a fresh frozen human cadaver head. Visualization was enabled using a commercially available endoscope with adjustable viewing angle (15-90 degrees). Results Visualization and instrumentation of all paranasal sinuses, including the anterior and middle skull base, were feasible with the presented setup. Controlling the robotic endoscope guidance system was effectively precise, and the adjustable endoscope lens extended the view in the surgical field without the common change of fixed viewing angle endoscopes. Conclusion The combination of a robotic endoscope guidance system and an advanced endoscope with adjustable viewing angle enables bimanual surgery in transnasal interventions of the paranasal sinuses and the anterior skull base in a human cadaver model. The adjustable lens allows for the abandonment of fixed-angle endoscopes, saving time and resources, without reducing the quality of imaging.

Development and preliminary results of bimanual smart micro-surgical system using a ball-lens coupled OCT distance sensor.

Bimanual surgery enhances surgical effectiveness and is required to successfully accomplish complex microsurgical tasks. The essential advantage is the ability to simultaneously grasp tissue with one hand to provide counter traction or exposure, while dissecting with the other. Towards enhancing the precision and safety of bimanual microsurgery we present a bimanual SMART micro-surgical system for a preliminary ex-vivo study. To the best of our knowledge, this is the first demonstration of a handheld bimanual microsurgical system. The essential components include a ball-lens coupled common-path swept source optical coherence tomography sensor. This system effectively suppresses asynchronous hand tremor using two PZT motors in feedback control loop and efficiently assists ambidextrous tasks. It allows precise bimanual dissection of biological tissues with a reduction in operating time as compared to the same tasks performed with conventional one-handed approaches.

Surgical Management of Tractional Retinal Detachments in Proliferative Diabetic Retinopathy

There have been significant recent advances in the management of diabetic tractional retinal detachments. Pre-operative intravitreal bevacizumab causes regression of active vessels and less intraoperative hemorrhage, small-gauge vitrectomy has dramatically changed how segmentation and delamination are performed, and bimanual surgery and viscodissection offer additional options. Intraoperative bevacizumab may decrease the incidence of postoperative vitreous hemorrhage. Single surgery success rates are generally >85 % with final anatomic success rates approaching 100 %. Useful vision (VA ≥ 20/100) is attained in <40 % of patients in most series while ambulatory vision (VA ≥ 5/200) is attained in <80 % patients in most series. No light perception/light perception only vision occurs in <10 % patients while recurrent hemorrhage occurs in approximately one-third of patients.

Development of the dual SMART micro-surgical system using common-path swept source optical coherence tomography.

Manual micro-surgical tasks are fundamentally divided into grasping, cutting and injecting maneuvers performed on biological tissues. Efficient dissection of fibrous tissue from the surface of the retina often requires grasping and cutting maneuvers carried out simultaneously. True bimanual surgery requires that the surgeon contend with the innate hand tremor of two hands at once as well as unpredicted patient's movement. In this study, we develop and test a dual SMART micro-surgical system to suppress bimanual hand tremor during micro-surgical dissection.

FBG-based sensorized light pipe for robotic intraocular illumination facilitates bimanual retinal microsurgery.

In retinal surgery, microsurgical instruments such as micro forceps, scissors and picks are inserted through the eye wall via sclerotomies. A handheld intraocular light source is typically used to visualize the tools during the procedure. Retinal surgery requires precise and stable tool maneuvers as the surgical targets are micro scale, fragile and critical to function. Retinal surgeons typically control an active surgical tool with one hand and an illumination source with the other. In this paper, we present a "smart" light pipe that enables true bimanual surgery via utilization of an active, robot-assisted source of targeted illumination. The novel sensorized smart light pipe measures the contact force between the sclerotomy and its own shaft, thereby accommodating the motion of the patient's eye. Forces at the point of contact with the sclera are detected by fiber Bragg grating (FBG) sensors on the light pipe. Our calibration and validation results demonstrate reliable measurement of the contact force as well as location of the sclerotomy. Preliminary experiments have been conducted to functionally evaluate robotic intraocular illumination.

A comparative study of 23 G vitrectomy and bimanual surgery in the management of epiretinal membranes in diabetic eyes

PurposeThe purpose of the study was to compare the anatomical and functional outcome of the use of high-speed 23 G vitreous cutters shaving versus bimanual surgery in the management of epiretinal membranes (ERMs) in eyes with diabetic tractional retinal detachment (TRD).DesignProspective comparative double-blind study.SettingModern Ophthalmology Center, Alexandria, Egypt.Patients and methodsThe study was conducted on 60 eyes with diabetic TRD, divided blindly into two equal groups. Informed consent was obtained from all patients before participation in the study. Group I was operated upon with the Twinac cutter on Oertli OS3 NovitreX using the foot-controlled peristaltic pump. Group II was operated upon with a chandelier light using twinlight on BrightStar. The ERM was operated upon using curved 23 G scissors and end-gripping forceps. All eyes were followed up for 6 months after surgery.ResultsComplete removal of ERM was achieved in 20 (66.7%) eyes and 30 (100%) eyes, iatrogenic breaks in 10 (33.4%) eyes and five (16.7%) eyes, postvitrectomy bleeding in five (16.7%) eyes and two (6.7%) eyes, retinal tamponade was not needed in six (20%) eyes and eight (26.7%) eyes, in groups I and II, respectively. There was significant difference between the two groups in complete removal of ERM, use of gas or air as a tamponade, and use of silicone tamponade.ConclusionAlthough the advent of high-speed 23 G vitreous cutter facilitates dissection of ERM in eyes with diabetic TRD, bimanual surgery is associated with statistically significant more complete removal of ERM, more use of temporary tamponade as gas or air, and less use of silicone oil.

Combined choroidal biopsy and cytology for diagnosis of intraocular tumour

Clinical caseNo intraocular biopsy technique is free of risk and all have the possibility of giving false negatives due to the difficulty in obtaining a sufficient sample.A modified chorioretinal biopsy was performed on a patient with suspected choroidal melanoma after negative biopsy with 25G vitrectomy. In addition to removing a solid fragment of tumor material using bimanual surgery, material from the lesion was obtained with the vitreotome to perform cytology, which confirmed the diagnosis of melanoma. DiscussionCytology obtained through the vitreotome in association with removing a solid sample of the choroidal lesion may improve the efficiency of intraocular biopsy.

Exploratory Visualization of Surgical Training Databases for Improving Skill Acquisition

A new visualization system analyzes multidimensional surgical performance databases of information collected via emerging surgical robot and simulator technologies. In particular, it has visualized force, position, rotation, and synchronized video data from 300 bimanual laparoscopic surgery tasks performed by more than 50 surgeons. To explore data, the system uses a multiple-coordinated-views framework. It provides techniques to select and filter multivariate time series data, visualize animated force plots in conjunction with contextual videos, encode multivariate bimanual tool trace data in 3D visualizations, and link visualizations to a database management system via a new generalizable data model. Insights and feedback from an interdisciplinary iterative design process and use case studies support the utility of visualization in this emerging area of data-driven surgical training.

Técnica combinada de vitrectomía con biopsia y citología en el diagnóstico de tumor intraocular

Clinical caseNo intraocular biopsy technique is free of risk and all have the possibility of giving false negatives due to the difficulty in obtaining a sufficient sample.A modified chorioretinal biopsy was performed on a patient with suspected choroidal melanoma after negative biopsy with 25G vitrectomy. In addition to removing a solid fragment of tumor material using bimanual surgery, material from the lesion was obtained with the vitreotome to perform cytology, which confirmed the diagnosis of melanoma. DiscussionCytology obtained through the vitreotome in association with removing a solid sample of the choroidal lesion may improve the efficiency of intraocular biopsy.

OSSICULAR CHAIN PRESERVATION IN EPITYMPANIC CHOLESTEATOMA SURGERY

To the Editor: We read the recent article by Marchioni et al. (1) about ossicular chain preservation using the endoscopic transcanal tympanoplasty approach with great interest. We agree with the authors that when it does not compromise cholesteatoma removal, the entire ossicular chain should be preserved to achieve optimum hearing results. Even the best prosthetic ossicular reconstruction cannot consistently match the hearing possible with an intact, mobile ossicular chain. However, the endoscopic technique for addressing epitympanic cholesteatoma only allows for ossicular chain preservation in 56.5% of cases and was much less successful when the cholesteatoma involved multiple subsites, especially the medial attic and antrum. Additionally, the reported recurrence rate in the middle ear is 13%. We believe the modified Bondy technique is the procedure of choice in cases of uncomplicated, epitympanic cholesteatoma with an intact ossicular chain and pars tensa (2). In our series of 230 consecutive cases (3), we were able to preserve an intact ossicular chain in all cases and were able to eradicate disease in 1 stage, regardless of location in the epitympanum. There was no recurrent disease in the middle ear after a follow-up period exceeding 7 years. Postoperatively, 88% of our patients had preserved or improved hearing by air conduction. This technique allows for bimanual surgery and is not limited by external canal size or bleeding, which makes an endoscopic approach difficult. Of course, cholesteatoma surgery is complex, and no one surgical approach can be applied to all circumstances. No single surgical technique can substitute for sound surgical decision making and mastery of a variety of surgical approaches. We commend the authors for their work in exploring novel ways of addressing a challenging problem. Mario Sanna, M.D. Trac M. Duong, M.D. Gruppo Otologico Piacenza, Italy

Pneumatic tools for vitreoretinal surgery

One of the difficulties of microsurgery is learning how to control physiological tremors. The pneumatic tool eliminates the physiological tremor, but no tactile feedback is provided. The manual tremor when closing the forceps is completely eliminated and the exact target can be more easily grabbed. Forceps closure pressure can rise up to 50 psi, whereas the scissors can be used in two modes: multicut and proportional. When performing bimanual surgery the pedal range is divided into two steps: in the first step, the forceps are controlled, and in the second step, the forceps remain closed. At the same time the scissors start to work in the preselected mode. No adverse events occurred and no iatrogenic retinal breaks were produced. Precision and control sensation were a grateful surprise.

A robotic assistant for trans-oral surgery: the robotic endo-laryngeal flexible (Robo-ELF) scope.

This paper describes the continued development of the Robotic EndoLaryngeal (Robo-ELF) Scope System, a simple clinically usable robot for manipulating flexible endoscopes, particularly in laryngeal surgery. The system includes a robot with three active and two passive degrees of freedom, a five degree of freedom passive positioning arm, a malleable scope shaft support, and a custom joystick controller. The Robo-ELF Scope allows a surgeon to control a flexible endoscope with only one hand and also to release the controls and perform bimanual surgery if desired. We have evaluated the Robo-ELF Scope system in both phantom and cadaver studies and found it superior to hand manipulation of flexible endoscopes and conventional rigid endoscopes.