Da Vinci Surgical Robot Research Articles

High-fidelity, low-cost synthetic training model for fetoscopic spina bifida repair

Fetoscopic spina bifida repair is increasingly being practiced, but limited skill acquisition poses a barrier to widespread adoption. Extensive training in relevant models, including both ex vivo and in vivo models may help. To address this, a synthetic training model that is affordable, realistic, and that allows skill analysis would be useful. This study aimed to create a high-fidelity model for training in the essential neurosurgical steps of fetoscopic spina bifida repair using synthetic materials. In addition, we aimed to obtain a cheap and easily reproducible model. We developed a 3-layered, silicon-based model that resemble the anatomic layers of a typical myelomeningocele lesion. It allows for filling of the cyst with fluid and conducting a water tightness test after repair. A compliant silicon ball mimics the uterine cavity and is fixed to a solid 3-dimensional printed base. The fetal back with the lesion (single-use) is placed inside the uterine ball, which is reusable and repairable to allow for practicing port insertion and fixation multiple times. Following cannula insertion, the uterus is insufflated and a clinical fetoscopic or robotic or prototype instruments can be used. Three skilled endoscopic surgeons each did 6 simulated fetoscopic repairs using the surgical steps of an open repair. The primary outcome was surgical success, which was determined by water tightness of the repair, operation time <180 minutes and an Objective Structured Assessment of Technical Skills score of ≥18 of 25. Skill retention was measured using a competence cumulative sum analysis of a composite binary outcome of surgical success. Secondary outcomes were cost and fabrication time of the model. We made a model that can be used to simulate the neurosurgical steps of spina bifida repair, including anatomic details, port insertion, placode release and descent, undermining of skin and muscular layer, and endoscopic suturing. The model was made using reusable 3-dimensional printed molds and easily accessible materials. The 1-time startup cost was €211, and each single-use, simulated myelomeningocele lesion cost €9.5 in materials and 50 minutes of working time. Two skilled endoscopic surgeons performed 6 simulated, 3-port fetoscopic repairs, whereas a third used a Da Vinci surgical robot. Operation times decreased by more than 30% from the first to the last trial. Six experiments per surgeon did not show an obvious Objective Structured Assessment of Technical Skills score improvement. Competence cumulative sum analysis confirmed competency for each surgeon. This high-fidelity, low-cost spina bifida model allows simulated dissection and closure of a myelomeningocele lesion. VIDEO ABSTRACT.

PD30-05 AI-BASED VIDEO FEEDBACK TO IMPROVE NOVICE PERFORMANCE ON A ROBOTIC SUTURING TASK

You have accessJournal of UrologyCME1 Apr 2023PD30-05 AI-BASED VIDEO FEEDBACK TO IMPROVE NOVICE PERFORMANCE ON A ROBOTIC SUTURING TASK Jasper A. Laca, Dani Kiyasseh, Rafal Kocielnik, Taseen F. Haque, Runzhuo Ma, Anima Anandkumar, and Andrew J. Hung Jasper A. LacaJasper A. Laca More articles by this author , Dani KiyassehDani Kiyasseh More articles by this author , Rafal KocielnikRafal Kocielnik More articles by this author , Taseen F. HaqueTaseen F. Haque More articles by this author , Runzhuo MaRunzhuo Ma More articles by this author , Anima AnandkumarAnima Anandkumar More articles by this author , and Andrew J. HungAndrew J. Hung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003316.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Automated skills assessment can provide surgical trainees with objective, personalized feedback during training. Here, we measure the efficacy of artificial-intelligence (AI)-based feedback on a robotic suturing task. METHODS: 42 participants (no surgical experience) were randomized to control group (CG) or feedback group (FG) and video-recorded while completing 2 rounds (R1 and R2) of suturing tasks on a daVinci surgical robot. Participants were assessed on needle handling (NH) and needle driving (ND), and feedback was provided via a visual interface after R1 (Fig). For CG: participants were presented with randomly-selected video clips from R1. For FG: participants were informed of their AI-based skill assessment and presented with specific video clips from R1. Following the feedback, participants completed R2 where they repeated the suturing task. The ground-truth annotation of skill assessments of all suturing tasks was performed retrospectively by 3 blinded raters using a previously-validated tool (End-To-End Assessment of Suturing Expertise (EASE)). These ground-truth annotations were compared to AI-based assessments. Participants from each group were further labeled as under-performers (UP) or innate performers (IP), based on a median split of EASE scores from R1. Generalized estimating equation was used to compare performance between groups. RESULTS: Human raters achieved intraclass correlation coefficients of 0.84 for manual assessments (p<0.001). AI scoring achieved an AUC of 0.67 and 0.80 for NH and ND, respectively, using human scores as ground truth. By AI scores: R1 performance was statistically similar between CG (n=20) and FG (n=22) (p>0.05). Observing the median difference across rounds (R1 vs. R2), FG had a significantly larger improvement in NH skill (0.21 vs 0, p=0.032) and a larger improvement in ND skill (0.13 vs.-0.06, p=0.3) when compared to CG. All IP exhibited similar improvements across rounds, regardless of feedback (p>0.05). In contrast, UP in the FG improved more than CG counterparts in NH (p=0.015), suggesting that feedback was particularly valuable for UP. CONCLUSIONS: AI-based feedback facilitates the acquisition of robotic technical skills by surgical trainees, especially UPs. Future research will extend AI-based feedback to additional suturing skills, surgical tasks, and experience groups. Source of Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R01CA251579. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e832 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jasper A. Laca More articles by this author Dani Kiyasseh More articles by this author Rafal Kocielnik More articles by this author Taseen F. Haque More articles by this author Runzhuo Ma More articles by this author Anima Anandkumar More articles by this author Andrew J. Hung More articles by this author Expand All Advertisement PDF downloadLoading ...

Is There a “One Size Fits All” Minimally Invasive Approach for Valve Surgery?

In this issue of The Annals of Thoracic Surgery, Wei and colleagues1 present a series of 50 sequential surgical aortic valve replacements (SAVRs) performed with the assistance of the DaVinci surgical robot (Intuitive Surgical), a procedure they term RAVR. Wei and colleagues1 performed routine femoral arterial cannulation, a total of 8 incisions, including the 4 robotic ports, and they used standard mechanical or standard stented tissue prostheses. Median cross-clamp and bypass times of 112 and 161 minutes, respectively, were reported for isolated aortic valve replacement (AVR).

Robot-assisted transthoracic first rib resection for venous thoracic outlet syndrome.

Venous thoracic outlet syndrome (vTOS) is caused by external compression of the subclavian vein at the costoclavicular junction. It can be subdivided in McCleery Syndrome and Paget-Schroetter Syndrome (PSS). To improve the venous outflow of the arm and to prevent recurrent thrombosis, first rib resection with venolysis of the subclavian vein can be performed. Open transaxillary, supraclavicular, infraclavicular or combined paraclavicular approaches are well known, but more recent robot-assisted techniques are introduced. We report our short- and long-term results of a minimal invasive transthoracic approach for resection of the anteromedial part of the first rib using the DaVinci surgical robot, performed through three trocars. We analyzed all patients with vTOS who were scheduled to undergo robot-assisted transthoracic first rib resection in the period July 2012 to May 2016. Outcomes were: technical success, operation time, blood loss, hospital stay, 30-day complications and patency. Functional outcomes were assessed using the "Disability of the Arm, Shoulder and Hand" (DASH) questionnaire. Fifteen patients (8 male, 7 female; mean age 32.9 years, range 20-54 years) underwent robot-assisted transthoracic first rib resection. Conversion to transaxillary resection was necessary in three patients. Average operation time was 147.9 min (range 88-320 min) with a mean blood loss of 79.5 cc (range 10-550 cc). Mean hospital stay was 3.5 days (range 2-9). In three patients, complications were reported (Clavien-Dindo grade 2-3a). Patency was 91% at 15.5 months' follow-up. DASH scores at one and three years showed excellent functional outcomes (7.1 (SD= 6.9, range 0-20.8) and 6.0 (SD= 6.4, range 0-25)) and are comparable to the scores of the normative general population. Robot-assisted transthoracic first rib resection with only three trocars is a feasible minimal invasive approach for first rib resection in the management of vTOS. This technique enables the surgeon to perform venolysis under direct 3D vision with good patency and long-term functional outcome. Studies with larger cohort size are needed to compare the outcomes of this robot-assisted technique with other more established approaches.

V01-10 ROBOTIC-ASSISTED SALVAGE PARTIAL NEPHRECTOMY AFTER CRYOABLATION FAILURE

You have accessJournal of UrologyKidney Cancer I: Partial Nephrectomy & Kidney Preservation Strategies (V01)1 Apr 2020V01-10 ROBOTIC-ASSISTED SALVAGE PARTIAL NEPHRECTOMY AFTER CRYOABLATION FAILURE Candice Debard*, Clément Michiels, Grégoire Capon, Henri Bensadoun, Jean-Marie Ferrière, Grégoire Robert, and Jean-Christophe Bernhard Candice Debard*Candice Debard* More articles by this author , Clément MichielsClément Michiels More articles by this author , Grégoire CaponGrégoire Capon More articles by this author , Henri BensadounHenri Bensadoun More articles by this author , Jean-Marie FerrièreJean-Marie Ferrière More articles by this author , Grégoire RobertGrégoire Robert More articles by this author , and Jean-Christophe BernhardJean-Christophe Bernhard More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000826.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: This case illustrates the difficulty of a salvage PN after cryoablation. The objective is to show that Image Guided Robot-Assisted Partial Nephrectomy (IGRAPN) with 3D model assistance, intraoperative US, and indocyanine green, as a salvage treatment, allows an excellent renal function preservation without morbidity METHODS: The surgery was performed with the Da-Vinci surgical robot, by using 3 operatives arms, a 30-degree endoscope and 2 ports for the assistant. We used a 3D model image, intraoperative ultrasound (US) and indocyanine green fluorescence. Clinical data, collected after consent, were extracted from the french national database on kidney cancer UroCCR. RESULTS: A 5cm upper and mid pole, posterior and mostly endophytic tumor was discovered in a 72 years old woman with CDK (GFR 34mL/min MDRD) and anticoagulant treatment, and treated by cryoablation. 4 months CT scan showed an extended residual disease in sinusal part of the tumor. It was a highly complex tumor: RENAL score 10ph, PADUA score 12p. Ablated zone was very difficult to dissect because of a sticky fat. Hilum was deeply dissected to enable selective clamping, arterial branchs were encircled with vessel loops. We made hemostasis of feeding tumor veins with Hemolocs. It was difficult to find the tumor plan around the hilum. Intraoperative US was performed to identify the limits of the tumor. An anterior feeding arteria was clamped and the tumorectomy started, dissecting step by step, with no real enucleation plan because of cryoablation. To continue the dissection, we practiced sequential clampage, taking off the bulldog clamp on anterior artery to clamp a more posterior arterial branch. Collecting system was opened, necessary step to permit a complete excision. The tumor was finally removed, and put in an endobag. Collecting system was closed with 4.0 PDS and the tumor bed with a 3.0 Veloc overlock. Patient was discharged at home post-operative day 2, with an unchanged renal function. Tumor was a Renal Cell Carcinoma of 3,5 cm Fuhrman grade 3 staging pT3aR0. 8 months later, renal function was still stable, with no recurrence on CTscan. CONCLUSIONS: A complex PN would become even more complex if performed as a salvage indication. Elect the right treatment option at first. In situations with risk factors for ablation failure, even in case of comorbidities or CKD, PN remains standard treatment Source of Funding: 0 © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e93-e93 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Candice Debard* More articles by this author Clément Michiels More articles by this author Grégoire Capon More articles by this author Henri Bensadoun More articles by this author Jean-Marie Ferrière More articles by this author Grégoire Robert More articles by this author Jean-Christophe Bernhard More articles by this author Expand All Advertisement PDF downloadLoading ...

The Human Agency Driverless Cars Must Preserve

In 2016, we set out to understand the future of driverless mobility — and specifically, how a mobility company can build products and services that will optimize the relationships between people and advanced assistive systems in an increasingly automated future. This case study will shed light on how an ethnographic approach inspired by actor‐network theory allowed us to look closely at human‐system interactions, build a unique perspective on the forms of agency people value most, and understand how mobility companies can harness this understanding to build automated systems that strengthen their relationships with consumers.Drawing from the core tenets of actor‐network theory, our research placed an emphasis not on individuals or even broader social ecologies — but rather, shifting networks of relationships between humans, objects, ideas, and processes. We divided our resources between two research tracks: i) human mobility, studying the complex network of relationships that gives shape to it, and ii) technology, studying networks of relationships surrounding six analogous advanced assistive technologies that are likely to prove pre‐cursors to the relationship between people and driverless cars, ranging from the DaVinci surgical robot to the driverless tractor. While the objective of the former track was to understand the relationship between human agency and mobility, the latter was designed to help us understand how advanced assistive technologies might aid or impede this relationship going forward.Studying human‐system interactions within broader, complex networks allowed us to uncover an insight about agency that is core to how mobility companies should approach automation. Agency doesn't have a single, fixed value to individuals; rather, people derive greater meaning from and thus value agency over higher‐order tasks and responsibilities — often revolving around role determination and fulfillment, such as “being a good father” or “being a precision farmer” — much more than they enjoy and value agency over lower‐order tasks — like paying the household bills, or keeping track of contracts with farm suppliers. The people studied aspired to preserve their enjoyable agency over higher‐order tasks, and thus perceived automation as most helpful when it liberated them to higher‐order responsibilities by removing the burden of lower‐order ones.This understanding allowed us to see that mobility companies can reframe mobility as much more than about getting between destinations. Instead, they should see mobility as a broader and more valuable system within which automation can be used to lessen users' burden of control over lower‐order tasks, while augmenting people's agency over the most meaningful tasks. This could mean, for example, using automation to remove the lower‐order task of navigation, so drivers can focus on curating a unique set of destinations through a city for their passengers; or removing pain points around parking that might dissuade a driver from driving to see a friend, so drivers can focus on higher‐order social tasks like setting the mood for a great dinner. Since this study, this focus on unlocking the higher‐order value of mobility has become a part of our client company's approach to driverless cars and advanced automated systems. This case study will invite social scientists to consider how we might refine and continue to apply this actor‐network inspired approach to build an even more granular ambition for the future of automation in mobility.

Robotic Roux-en-Y Gastric Bypass as a Revisional Bariatric Procedure: a Single-Center Prospective Cohort Study

Roux-en-Y gastric bypass (RYGB) is the procedure of choice to manage the failure of primary bariatric surgery. However, the current evidence on the role of the robotic technology in revisional bariatric surgery is very limited. The aim of this study is to report safety and effectiveness of revisional RYGB performed with the DaVinci Robotic Surgical System (R-rRYGB) after failed primary bariatric surgery. Clinical data of consecutive patients undergoing R-rRYGB were included in a prospectively collected database. Intraoperative findings, early postoperative outcomes, and 1-year follow-up results were considered. Primary outcome was postoperative morbidity rate. Secondary outcomes were conversion to open surgery, length of stay, percentage of excess weight loss (%EWL), resolution of complications, and costs. A total of 68 patients underwent R-rRYGB at our department from 2011 to 2016. Primary procedures were laparoscopic adjustable gastric banding (n = 10), vertical banded gastroplasty (n = 43), and sleeve gastrectomy (n = 15). Conversion rate to open surgery was 2.9%. Postoperative morbidity rate was 8.8%, with no anastomotic leaks reported. Total cost for surgical procedure was 14,334.7 ± 2920.4 €. Revisional RYGB is a complex procedure but can be performed with the robotic approach with a low morbidity rate. Weight loss outcomes and resolution of complications of the index procedure are satisfactory.

V07-01 ROBOT-ASSISTED HEMINEPHRECTOMY USING AN IMAGE-GUIDED ANATOMICAL TUMOR DEVASCULARIZATION TECHNIQUE

You have accessJournal of UrologyRenal Oncology I1 Apr 2018V07-01 ROBOT-ASSISTED HEMINEPHRECTOMY USING AN IMAGE-GUIDED ANATOMICAL TUMOR DEVASCULARIZATION TECHNIQUE Astrid de Hauteclocque, Souleymane Maiga, Clément Michiels, Clément Allenet, Thibault Marquette, Grégoire Capon, Grégoire Robert, Henri Bensadoun, Nicolas Grenier, Jean-Marie Ferrière, and Jean-Christophe Bernhard Astrid de HauteclocqueAstrid de Hauteclocque More articles by this author , Souleymane MaigaSouleymane Maiga More articles by this author , Clément MichielsClément Michiels More articles by this author , Clément AllenetClément Allenet More articles by this author , Thibault MarquetteThibault Marquette More articles by this author , Grégoire CaponGrégoire Capon More articles by this author , Grégoire RobertGrégoire Robert More articles by this author , Henri BensadounHenri Bensadoun More articles by this author , Nicolas GrenierNicolas Grenier More articles by this author , Jean-Marie FerrièreJean-Marie Ferrière More articles by this author , and Jean-Christophe BernhardJean-Christophe Bernhard More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1760AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Conservative management of high volume kidney tumors has several goals : optimal sparing of healthy parenchyma, free margin tumoral excision and avoidance of extended ischemia. The objective of this video was to illustrate the image-guided anatomical tumor devascularization technique through an heminephrectomy case. METHODS Synapse 3D Software (Fujifilm) was used for pre-operative CT Scan segmentation. The resulting 3D-model of the kidney displaying the vascular and collecting system anatomy allowed the selection of third and forth-order clamping spots with prediction of the related parenchymal ischemia. The surgery was performed with the Da-Vinci surgical robot (Intuitive Surgical) and intra-operative assistance for image-guidance comprised 3D model and ultrasound, both relayed on the console screen. Clinical data were collected in the French kidney cancer prospective database UroCCR after patient consent. RESULTS The patient, a 41 year-old male, BMI 38, presented with a 8cm hilar tumor on the upper and mid-pole of the right kidney. It was rated as a highly complex tumor regarding RENAL (10ph) and PADUA (13p). Pre-operative screening of third and fourth-order tumor-feeding arterial branches permitted to plan the devascularization of the tumor with a minor effect on the healthy parenchyma. The tumor limits were compared with the pattern of ischemia using an intra-operative doppler ultrasound. Once all tumor-feeding arteries were clipped, an off-clamp minimal margin tumor excision was performed. The length of surgery was 240 minutes and blood loss was 150ml. Pathologic examination confirmed a Fuhrman grade 4 clear-cell renal carcinoma, stage pT3a with negative surgical margin. The patient was discharged on post-operative day one without any complication. Based on post-operative month 3 CT-scan, the volume of spared parenchyma was 95ml and 82% of tumor-free parenchymal volume (115ml). The CT-scan showed a harmonious enhancement of the spare kidney. CONCLUSIONS The anatomical tumor devascularization technique for high-volume tumors combines safe tumor removal with minimal ischemia. Intra-operative image-guidance with endoscopic US and 3D model make the surgery achievable. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e741 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Astrid de Hauteclocque More articles by this author Souleymane Maiga More articles by this author Clément Michiels More articles by this author Clément Allenet More articles by this author Thibault Marquette More articles by this author Grégoire Capon More articles by this author Grégoire Robert More articles by this author Henri Bensadoun More articles by this author Nicolas Grenier More articles by this author Jean-Marie Ferrière More articles by this author Jean-Christophe Bernhard More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

V08-10 DESIGN AND VALIDATION OF A LOW-COST, HIGH-FIDELITY MODEL FOR RALP URETHROVESICAL ANASTOMOSIS

You have accessJournal of UrologyProstate & Renal Oncology II1 Apr 2018V08-10 DESIGN AND VALIDATION OF A LOW-COST, HIGH-FIDELITY MODEL FOR RALP URETHROVESICAL ANASTOMOSIS Brett Johnson, Matthew Timberlake, Igor Sorokin, Jeffrey Cadeddu, and Jeffrey Gahan Brett JohnsonBrett Johnson More articles by this author , Matthew TimberlakeMatthew Timberlake More articles by this author , Igor SorokinIgor Sorokin More articles by this author , Jeffrey CadedduJeffrey Cadeddu More articles by this author , and Jeffrey GahanJeffrey Gahan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1976AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surgical simulation is a critical component of surgical training, and urology trainees lack procedure-specific simulation models which allow repetitive practice of robotic skills during case preparation. We sought to develop and validate a low-cost, high fidelity robotic surgical simulator for the urethrovesical anastomosis component of robotic assisted laparoscopic radical prostatectomy. METHODS A novel urethrovesical anastomosis simulation model was constructed with silicone molds and a 3D-printed model of the male boney pelvis. Using a DaVinci surgical robot, urology faculty and trainees operated on the simulation. Each participant viewed a 4-minute instructional video and was then was given 12 minutes to complete the simulation. A survey was issued to establish face validity, content validity, and acceptability. Simulation runs were recorded, evaluated by three blinded reviewers, and given a GEARS (global evaluative assessment of robotic skills) and PACE (prostatectomy assessment and competency evaluation) score. The quality of the anastomosis was graded by two reviewers. These factors were compared to robotic experience to establish construct validity. ANOVA statistical analysis was performed. RESULTS Seventeen participants took part in the initial validation of this model (1 faculty, 4 fellows, 2 chief residents, and 10 residents). Median console experience was 10 years, 4.0 years, 1.5 years, and 0 years for faculty, fellows, chief residents, and residents, respectively. Likert (1-5) scores for face validity, content validity, and acceptability were 3.56 (SD 0.42), 4.17 (SD 0.21), and 4.24 (SD 0.15), respectively. Construct validity was excellent. Mean time to completion, mean percent completion, mean anastomosis inspection score, mean GEARS score, and mean PACE score all correlated to robotic experience (p < 0.01, see table 1). Total material cost was $2.50 per model. CONCLUSIONS We present a novel high-fidelity, low-cost robotic simulation of the urethrovesical anastomosis. Initial evaluation demonstrates good face validity, content validity, and acceptability. Construct validity is excellent, and the model is able to discern robotic skill level across all levels of training. Further studies are needed to evaluate longitudinal effect of the model on surgical training. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e822 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Brett Johnson More articles by this author Matthew Timberlake More articles by this author Igor Sorokin More articles by this author Jeffrey Cadeddu More articles by this author Jeffrey Gahan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robotic paraesophageal hernia repair: a single-center experience and systematic review

Robotic Surgery is becoming increasingly used in general surgery. The objective of this study is to evaluate the safety, effectiveness and short-term (less than 1year) outcomes of Robotic Paraesophageal Hernia (RPEH) Surgery using the DaVinci Surgical Robot system (Intuitive Surgical, CA) in a large community hospital. This is a retrospective cohort study of 28 consecutive patients who underwent robotic paraesophageal hernia repair January 2011-March 2013 in this institution. Data and outcomes collected for analysis include patient demographics, operating times, conversion, complications, mortality and recurrence. The mean age of the patients was 68.7+/-12.7years, 82% were females and the mean BMI was 29+/-6.3. The mean operative time, including the robot docking time, was 83.6+24min. The average length of hospital stay (LOS) was 2.8+/-1.9days. There were no conversions to open or laparoscopic procedures. Postoperative complications were noted in 3 patients (10.7%), including one mortality (3.4%). One symptomatic recurrence (3.4%) was noted during the 12-month follow-up period. Robotic Paraesophageal repair is a safe (similar rate of complication and mortality to literature for laparoscopic procedure) and an effective (paraeshopageal hernia repaired without high recurrence) procedure with acceptable complication rates even in older patients with high operative risks.

Application of Da Vinci surgical robot in the dissection of splenic hilar lymph nodes for gastric cancer patients with total gastrectomy

To investigate the feasibility and safety of Da Vinci surgical robot in the dissection of splenic hilar lymph nodes for gastric cancer patients with total gastrectomy. Clinical data of two cases who underwent total gastrectomy for cardia cancer at our department in January 2016 were analyzed retrospectively. Two male patients were 62 and 55 years old respectively, with preoperative diagnosis as cT2-3N0M0 and cT1-2N0M0 gastric cancer by gastroscope and biopsy, and both received robotic total gastrectomy spleen-preserving splenic hilar lymph node dissection successfully. The operative time for splenic hilar lymph node dissection was 30 min and 25 min respectively. The intraoperative estimated blood loss was both 100 ml, while the number of total harvested lymph node was 38 and 33 respectively. One dissected splenic hilar lymph node and fatty tissues in two patients were proven by pathological examinations. There were no anastomotic leakage, pancreatic fistula, splenic infarction, intraluminal bleeding, digestive tract bleeding, aneurysm of splenic artery, and other operation-associated complications. Both patients suffered from postoperative pneumonia, and were cured by conservative therapy. The robotic spleen-preserving splenic hilar lymph node dissection is feasible and safe, but its superiority needs further evaluation.

Pre‐operative Eligibility for Minimally Invasive Coronary Artery Bypass Grafting Using the DaVinci Robot: An Examination of Anatomical Parameters using Computed Tomography

IntroductionMinimally invasive coronary artery bypass procedures have been shown to reduce morbidity, 30‐day complication rates, and length of hospital stays, as well as increasing patient quality of life scores post‐operatively. The robotic‐assisted endoscopic single‐vessel small thoracotomy (endo‐SVST) bypass procedure is a minimally invasive procedure that confers similar benefits to the more invasive conventional full‐sternotomy revascularization approach. A limitation to the endo‐SVST procedure that still requires attention is the pre‐operative selection criteria. Inappropriate selection can result in intra‐operative conversions from the endo‐SVST to a conventional full‐sternotomy resulting in increased patient morbidity, and both operative and general anesthetic times along with increased costs. One of the primary intraoperative concerns, necessitating conversion to a conventional full‐sternotomy, is the inability of the endoscopic camera to visualize the left anterior descending (LAD) coronary artery, the target vessel, under the surrounding epicardial adipose tissue. The purpose of this study is to determine if anatomical and anthropometric parameters, examined using both patient data and pre‐operative computed tomography (CT) images, are able to predict and thus reduce the need for conversion based on effective pre‐operative exclusion criteria.MethodsRetrospective analysis of patient pre‐operative CT angiography scans from both converted (N=13) and robotic‐assisted (N=13) procedures using the DaVinci Surgical Robot was performed. Patient scans were anonymized and measurements were made using 3D Slicer 4.4.0. Where possible, measurements of thoracic cavity dimensions and epicardial adipose depths were acquired from axial slices, at the most accessible segment of the LAD, in the fourth anterior intercostal space. An independent‐samples Student T Test (∝=0.05) and Pearson Correlation (∝=0.05) were performed using SPSS.ResultsPreliminary results indicate that patients who successfully underwent the endo‐SVST procedure had significantly less epicardial adipose tissue (p=0.03) overlying the LAD in the transverse measurement than those who were converted to the full‐sternotomy intra‐operatively. This data also suggests that there are no significant differences between the two groups with respect to the remaining epicardial adipose tissue and anthropometric measurements. A moderate, but non‐significant, positive correlation R=0.36 (p=0.07) appears to exist between body mass index (BMI) and the depth of epicardial adipose tissue within the anterior inter‐ventricular sulcus.DiscussionThese data suggest that a transverse depth measurement of epicardial adipose tissue overlying the LAD of 7.6±3.3mm may indicate a greater risk for conversion to the full‐sternotomy. Preliminary findings also indicate that the relationship between the depth of epicardial adipose tissue and conversion to full‐sternotomy may not be fully explained by a patient's BMI. However, future studies with a larger sample size need to be conducted in order to examine the relationship between these anatomical and anthropometric parameters and to also assess whether their combined use may further enhance the precision of pre‐operative exclusion criteria.

C37 Vesico-vaginal fistula repair assisted by the davinci surgical robot; Our initial experience

C37 Vesico-vaginal fistula repair assisted by the davinci surgical robot; Our initial experience

Robotic‐Assisted Lingual Tonsillectomy in the Pediatric Population

Objectives: Assess the feasibility and outcomes of robotic-assisted lingual tonsillectomy (RALT) in the pediatric population. Methods: Retrospective medical chart review performed using a tertiary care children’s hospital database identified 16 pediatric patients who underwent RALT from March 2011 through December 2012. Demographic data, comorbidities, robot docking time, operative time, surgical blood loss, and postoperative course, including complications in the immediate and longer-term postoperative period, were collected and analyzed. Results: All patients successfully underwent RALT using the daVinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). Endotracheal intubation was used in all cases and did not interfere with visualization of the oropharynx. Optimal retraction allowed visualization of pertinent structures and maximized transoral access. A significant learning curve from the first 5 surgical cases to subsequent cases with respect to robot docking time and surgical blood loss was observed (9 versus 3 minutes and 7.4 versus 3.2 ml respectively, P &lt; .05). Operative time, estimated blood loss, and postoperative complication profile are within the expected and acceptable limitations for performing lingual tonsillectomy in the pediatric population. Conclusions: Technologic advances have allowed miniaturization of robotic instrumentation and have expanded the scope of surgical options for the pediatric airway. RALT is well-tolerated and can be performed in the pediatric population with excellent success. It should be considered a feasible option for implementation at an institution-based level.

Robot-assisted thyroidectomy: early experience.

The numbers of thyroid surgeries have been increasing recently. Robot-assisted thyroidectomy allows for a better cosmetic outcome in comparison with conventional open thyroidectomy. We performed two robot-assisted endoscopic thyroidectomies by a gasless unilateral axillo-breast approach using the da Vinci surgical robot system. We performed right thyroid lobectomies in both patients. The pathologic reports were: micropapillary carcinoma without extracapsular invasion in patient 1 and a benign cyst in patient 2. The operation times were 165 minutes in patient 1 and 110 minutes in patient 2. No postoperative complications occurred. Regarding our early experience, robotic thyroidectomy using the gasless axillo-breast approach is a safe, feasible, and cosmetically good procedure.

Mesh Erosion in Robotic Sacrocolpopexy

This study aimed to compare the incidence of mesh erosion after robotic sacrocolpopexy between women undergoing total and those undergoing supracervical hysterectomy (SH). This is a retrospective cohort study of women who underwent sacrocolpopexy and concomitant hysterectomy using the DaVinci surgical robot between May 2007 and December 2010 at 2 sites. Baseline data were gathered before surgery. The primary outcome was mesh erosion identified during 3 months of follow-up. A total of 102 women underwent sacrocolpopexy, of whom 45 were with concomitant SH and 57 were with total hysterectomy (TH). Their mean age was 58 years, mean body mass index was 26.8 kg/m, 98% were white, 6% smoked, and 25% were on systemic hormone replacement therapy. Mean preoperative Ba = +1.4, C = -2.2. These were not different between the 2 groups or by site. Within 3 months of surgery, mesh erosion was diagnosed in 8 women, all of whom had TH. No mesh erosions occurred in the SH group (14% vs 0%). Total hysterectomy mesh erosion rate at site 1 was 37% compared with 3% [corrected] at site 2. Mesh type was the only identifiable difference between sites: self-cut polypropylene at site 1, precut polypropylene at site 2. Two women in the SH had abnormal uterine pathology: 1 endometrial adenocarcinoma and 1 focus of hyperplasia with atypia. No mesh erosions were associated with SH within the first 3 months. In TH, the graft material used may be a modifiable factor needing further investigation. Unexpected abnormal uterine pathologic diagnosis remains a possibility with SH. Longer-term follow-up and a randomized trial are warranted to answer these questions.

Robotic rectovaginal fistula repair.

Minimally invasive surgery for diseases in the pelvic region is gaining popularity due to advances in technology and increased benefit to the patient. As indications for such surgeries increase, the known boundaries for minimal access are being extended by a few teams. We report a patient who underwent robotic-assisted transabdominal repair of a high rectovaginal fistula which developed following a vaginal hysterectomy. Vaginography revealed a communication between the vaginal vault and the upper rectum. After evaluation of the colon and the vagina, the patient was planned for a robotic-assisted rectovaginal fistula repair. The three-arm daVinci(®) surgical robot was used. A total of five ports were used to complete the entire procedure, which included adhesiolysis, re-creation of the vaginal vault, repair of the fistula and omental interposition. This is the first robotic-assisted rectovaginal fistula repair reported to date. Besides the advantages of minimally invasive surgery for the patient, the surgeon benefits from the ease of suturing deep in the pelvis afforded by the articulated robotic arms.

Visual Measurement of Suture Strain for Robotic Surgery

Minimally invasive surgical procedures offer advantages of smaller incisions, decreased hospital length of stay, and rapid postoperative recovery to the patient. Surgical robots improve access and visualization intraoperatively and have expanded the indications for minimally invasive procedures. A limitation of the DaVinci surgical robot is a lack of sensory feedback to the operative surgeon. Experienced robotic surgeons use visual interpretation of tissue and suture deformation as a surrogate for tactile feedback. A difficulty encountered during robotic surgery is maintaining adequate suture tension while tying knots or following a running anastomotic suture. Displaying suture strain in real time has potential to decrease the learning curve and improve the performance and safety of robotic surgical procedures. Conventional strain measurement methods involve installation of complex sensors on the robotic instruments. This paper presents a noninvasive video processing-based method to determine strain in surgical sutures. The method accurately calculates strain in suture by processing video from the existing surgical camera, making implementation uncomplicated. The video analysis method was developed and validated using video of suture strain standards on a servohydraulic testing system. The video-based suture strain algorithm is shown capable of measuring suture strains of 0.2% with subpixel resolution and proven reliability under various conditions.

Tandem-robot Assisted Laparoscopic Radical Prostatectomy to Improve the Neurovascular Bundle Visualization: A Feasibility Study

To examine the feasibility of image-guided navigation using transrectal ultrasound (TRUS) to visualize the neurovascular bundle (NVB) during robot-assisted laparoscopic radical prostatectomy (RALP). The preservation of the NVB during radical prostatectomy improves the postoperative recovery of sexual potency. The accompanying blood vessels in the NVB can serve as a macroscopic landmark to localize the microscopic cavernous nerves in the NVB. A novel, robotic transrectal ultrasound probe manipulator (TRUS Robot) and three-dimensional (3-D) reconstruction software were developed and used concurrently with the daVinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) in a tandem-robot assisted laparoscopic radical prostatectomy (T-RALP). After appropriate approval and informed consent were obtained, 3 subjects underwent T-RALP without associated complications. The TRUS Robot allowed a steady handling and remote manipulation of the TRUS probe during T-RALP. It also tracked the TRUS probe position accurately and allowed 3-D image reconstruction of the prostate and surrounding structures. Image navigation was performed by observing the tips of the daVinci surgical instruments in the live TRUS image. Blood vessels in the NVB were visualized using Doppler ultrasound. Intraoperative 3-D image-guided navigation in T-RALP is feasible. The use of TRUS during radical prostatectomy can potentially improve the visualization and preservation of the NVB. Further studies are needed to assess the clinical benefit of T-RALP.

Robotic Transperitoneal Recto-Vaginal Fistula Repair

Minimally invasive surgery for diseases in the pelvis are gaining popularity due to advancesin technology and the benefit to the patient. We report a patient who underwentrobotic transabdominal repair of a high rectovaginal fistula. The patient developed the high fistula following a vaginal hysterectomy. Vaginography revealed a communication between the vaginal vaultand the upper rectum. After evaluation of the colon and the vagina, the patient was planned for a robotic repair. The DaVinci Surgical robot was used. A total of 5ports were used to complete the entire procedure which included adhesiolysis, recreation of thevaginal vault, repair of the fistula and omental interposition. Besides the advantages of minimally invasive surgery for the patient, the surgeon benefits by the ease of suturing deep in the pelvis afforded by the articulating robotic arms.