Era Of Robotic Surgery Research Articles

Artificial intelligence and robotic surgery: current perspective and future directions.

This review aims to draw a road-map to the use of artificial intelligence in an era of robotic surgery and highlight the challenges inherent to this process. Conventional mechanical robots function by transmitting actions of the surgeon's hands to the surgical target through the tremor-filtered movements of surgical instruments. Similarly, the next iteration of surgical robots conform human-initiated actions to a personalized surgical plan leveraging 3D digital segmentation generated prior to surgery. The advancements in cloud computing, big data analytics, and artificial intelligence have led to increased research and development of intelligent robots in all walks of human life. Inspired by the successful application of deep learning, several surgical companies are joining hands with tech giants to develop intelligent surgical robots. We, hereby, highlight key steps in the handling and analysis of big data to build, define, and deploy deep-learning models for building autonomous robots. Despite tremendous growth of autonomous robotics, their entry into the operating room remains elusive. It is time that surgeons actively collaborate for the development of the next generation of intelligent robotic surgery.

Comparison of Robotic and Laparoscopic Partial Nephrectomy in Robotic Surgery Era

Comparison of Robotic and Laparoscopic Partial Nephrectomy in Robotic Surgery Era

Making the Jump: A Qualitative Analysis on the Transition From Bedside Assistant to Console Surgeon in Robotic Surgery Training

To determine barriers associated with the transition from bedside assistant to console surgeon for general surgery residents in the era of robotic surgery in general surgery training. Qualitative thematic analysis using one-on-one interviews of general surgery residents and attendings conducted between June 2018 and February 2019. An urban, academic, multihospital general surgery residency program with a robust robotic surgery program. Convenient and purposeful sampling was performed to ensure a variety of resident graduate-years and attending subspecialties were represented. Sample size was determined by data saturation, which occurred after 20 resident and 7 attending interviews. Residents identified the low volume of general surgery robotic cases, the infrequency of exposure to robotic surgery, and attending comfort with robotic surgery (and with teaching on the robot) as potential barriers in the transition from bedside assistant to console surgeon. Residents had to find a replacement bedside assistant in order to be the console surgeon, which was challenging. In addition, residents felt that the current culture surrounding robotic surgery is very hierarchal, limiting their exposure. Attendings' trust in the residents' console skills was a major determining factor in allowing residents on the console. Most robotic surgery education curricula are sequential, requiring the resident to progress from bedside assistant to console surgeon. Unfortunately, there are many potential barriers for residents in the transition from bedside assistant to console surgeon. Some barriers apply to general surgery training overall, but are amplified in robotic surgery, while others are unique to robotic surgery education. Recognition of, and rectifying, these barriers may increase resident participation as the console surgeon.

Reply to: The letter to the editor "Laparoscopic liver resection for malignancies confined to Couinaud's segment VII in the robotic surgery era" by Zizzo et al.-laparoscopic liver resection: a first choice for liver malignancies in Couinaud's segment VII in the robotic surgery era.

We are grateful for the comments of Maurizio Zizzo et al . referring to our review article focusing on the present and future of laparoscopic liver resection (LLR) (1). In fact, this comment and letter to the editor reflects the current debates on (I) the wide-spreading indication of LLR; (II) whether we should consider LLR as a first-choice for malignancies confined to segment VII; (III) the advantages and disadvantages of robotic hepatectomy.

Reply to: The letter to the editor "Laparoscopic liver resection for malignancies confined to Couinaud's segment VII in the robotic surgery era" by Zizzo et al.

We would like to thank you and other reviewers for reading our papers and sharing valuable comments. We are also appreciative of your conscientiousness and broad knowledge on relevant research fields. Recent advances in robotic hepatectomy (RH) were briefly summarized in your letter, especially its non-inferiority compared with the conventional laparoscopic liver resection (LLR). Here, we would like to address several points relevant to the comments.

General surgery training in the era of robotic surgery: a qualitative analysis of perceptions from resident and attending surgeons.

The use of the surgical robot has increased annually since its introduction, especially in general surgery. Despite the tremendous increase in utilization, there are currently no validated curricula to train residents in robotic surgery, and the effects of robotic surgery on general surgery residency training are not well defined. In this study, we aim to explore the perceptions of resident and attending surgeons toward robotic surgery education in general surgery residency training. We performed a qualitative thematic analysis of in-person, one-on-one, semi-structured interviews with general surgery residents and attending surgeons at a large academic health system. Convenient and purposeful sampling was performed in order to ensure diverse demographics, experiences, and opinions were represented. Data were analyzed continuously, and interviews were conducted until thematic saturation was reached, which occurred after 20 residents and seven attendings. All interviewees agreed that dual consoles are necessary to maximize the teaching potential of the robotic platform, and the importance of simulation and simulators in robotic surgery education is paramount. However, further work to ensure proper access to simulation resources for residents is necessary. While most recognize that bedside-assist skills are essential, most think its educational value plateaus quickly. Lastly, residents believe that earlier exposure to robotic surgery is necessary and that almost every case has a portion that is level-appropriate for residents to perform on the robot. As robotic surgery transitions from novelty to ubiquity, the importance of effective general surgery robotic surgery training during residency is paramount. Through in-depth interviews, this study provides examples of effective educational tools and techniques, highlights the importance of simulation, and explores opinions regarding the role of the resident in robotic surgery education. We hope the insights gained from this study can be used to develop and/or refine robotic surgery curricula.

Development of an online, patient-centred decision aid for patients with oropharyngeal cancer in the transoral robotic surgery era.

Radiotherapy (rt) has been the standard treatment for early oropharyngeal cancer, achieving excellent outcomes, but with significant toxicities. Transoral robotic surgery (tors) has emerged as a promising alternative. A decision aid (da) can help to establish patient treatment preferences. A da was developed and piloted in 40 healthy adult volunteers. Assuming equal oncologic outcomes of the treatments, participants indicated their preference. The treatment trade-off point was then established, and participant perceptions were elicited. More than 80% of participants initially selected tors for treatment, regardless of facilitator background. For all participants, the treatment trade-off point changed after an average 15% cure benefit. Treatment toxicities, duration, novelty, and perceptions all influenced treatment selection. All subjects valued the da. A da developed for early oropharyngeal cancer treatment holds promise in the era of shared decision-making. Assuming equal cure rates, tors was preferred over rt by healthy volunteers.

Error reporting from the da Vinci surgical system in robotic surgery: A Canadian multispecialty experience at a single academic centre.

The goal of the study is to evaluate and report on the third-generation da Vinci surgical (Si) system malfunctions. A total of 1228 robotic surgeries were performed between January 2012 and December 2015 at our academic centre. All cases were performed by using a single, dual console, four-arm, da Vinci Si robot system. The three specialties included urology, gynecology, and thoracic surgery. Studied outcomes included the robotic surgical error types, immediate consequences, and operative side effects. Error rate trend with time was also examined. Overall robotic malfunctions were documented on the da Vinci Si systems event log in 4.97% (61/1228) of the cases. The most common error was related to pressure sensors in the robotic arms indicating out of limit output. This recoverable fault was noted in 2.04% (25/1228) of cases. Other errors included unrecoverable electronic communication-related in 1.06% (13/1228) of cases, failed encoder error in 0.57% (7/1228), illuminator-related in 0.33% (4/1228), faulty switch in 0.24% (3/1228), battery-related failures in 0.24% (3/1228), and software/hardware error in 0.08% (1/1228) of cases. Surgical delay was reported only in one patient. No conversion to either open or laparoscopic occurred secondary to robotic malfunctions. In 2015, the incidence of robotic error rose to 1.71% (21/1228) from 0.81% (10/1228) in 2014. Robotic malfunction is not infrequent in the current era of robotic surgery in various surgical subspecialties, but rarely consequential. Their seldom occurrence does not seem to affect patient safety or surgical outcome.

Performance of Adult Pyeloplasty Relative to Endourological Management in the Era of Robotic Surgery: Data from the Nationwide Inpatient Sample

IntroductionReports of robot-assisted pyeloplasty have increased. However, it is unclear if this change is due to increased diagnosis of adult ureteropelvic junction obstruction, a shift in management based on presumed efficacy, a desire to maximize robot use or some combination thereof. Therefore, we acquired and analyzed data on a national scale to determine the incidence of interventions to correct ureteropelvic junction obstruction in adults and to characterize trends in procedure selection. MethodsPatients older than 18 years with ICD-9 procedure codes 55.87 (pyeloplasty) and 55.11 (endopyelotomy) were included in the study, with attention to those designated laparoscopic robotic assistance (17.42). Data were collected for the period from January 2000 through December 2012, and weighted to a national average using Nationwide Inpatient Sample guidelines. ResultsA total of 47,992 pyeloplasties were identified. Pyeloplasty rates exhibited a significant increase during this period [F(1,11)=41.38, p <0.01] and endopyelotomy rates exhibited a significant decrease [F(1,11)=64.7, p <0.01]. A higher percentage of pyeloplasties were performed robotically in 2012 vs 2009 (54% vs 44%, p <0.010). ConclusionsRates of pyeloplasty appear to be increasing at the expense of endopyelotomy. The percentage of pyeloplasty cases performed robotically is increasing but it is unclear if this is due to superior results or a need for increased robot use.

Is Robotic Partial Nephrectomy Safe for T3a Renal Cell Carcinoma? Experience of a High-Volume Center.

To compare the oncological and functional outcomes of robotic partial nephrectomy (RPN) with radical nephrectomy (RN) in renal-cell carcinoma (RCC) cases with pT3a staging. A retrospective analysis of our IRB-approved nephrectomy database from 2005 to 2015 was performed. RPN and RN cases with confirmed RCC and pT3a staging were matched. Preoperative variables, functional, and oncological outcomes were compared between the groups, as well as Kaplan-Meier estimated overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS). A multivariable Cox proportional hazards regression model for overall mortality rate was generated to evaluate hazard ratios (HRs) of potential risk factors. Seventy patients with pT3a tumors composed each group. Preoperative variables were comparable between groups. The median follow-up time for the cohort was 20 (9-38) months and the renal function preservation was higher in the RPN group (86% vs 70%; p < 0.001). The estimated 3 years of OS (90% vs 84%; p = 0.42), CSS (94% vs 95%; p = 0.78), and RFS (95% vs. 100%; p = 0.06) were similar between RPN and RN groups, respectively. On multivariable Cox regression model, the presence of ≥2 aggressive tumor features was the only factor associated with increased risk of overall mortality rate (HR 4.01 95% confidence interval [1.13, 14.27)]; p = 0.03). Patients with localized pT3a RCC treated with RPN had similar short-term oncological and better renal functional outcomes compared with similar cases treated by RN. In the minimally invasive robotic surgery era, renal masses suspicious for pathological T3a disease should not be a deterring factor for performing nephron-sparing surgery when technically feasible by skilled surgeons.

Neoadjvant hormone therapy for localized prostate cancer: Initial experiences in intermittent-and high-risk patients in the robotic surgery ERA

Neoadjvant hormone therapy for localized prostate cancer: Initial experiences in intermittent-and high-risk patients in the robotic surgery ERA

Transoral surgery for laryngo-pharyngeal cancer - The paradigm shift of the head and cancer treatment.

Transoral surgery is a less invasive treatment that is becoming a major strategy in the treatment of laryngo-pharyngeal cancer. It is a minimally invasive approach that has no skin incision and limits the extent of tissue dissection, disruption of speech and swallowing muscles, blood loss, damage to major neurovascular structures, and injury to normal tissue. Transoral approaches to the laryngo-pharynx, except for early glottis cancer, had been limited traditionally to tumors that can be observed directly and manipulated with standard instrumentation and lighting. Since the 1990s, transoral laser microsurgery (TLM) has been used as an organ preservation strategy with good oncological control and good functional results, although it has not been widely used because of its technical difficulty. Recently, transoral robotic surgery (TORS) is becoming popular as a new treatment modality for laryngo-pharyngeal cancer, and surgical robots are used widely in the world since United States FDA approval in 2009. In spite of the global spread of TORS, it has not been approved by the Japan FDA, which has led to the development of other low-cost transoral surgical techniques in Japan. Transoral videolaryngoscopic surgery (TOVS) was developed as a new transoral surgery system for laryngo-pharyngeal lesions to address the problems of TLM. In TOVS, a rigid endoscope is used to visualize the surgical field instead of a microscope and the advantages of TOVS include the wide operative field and working space achieved using the distending laryngoscope and videolaryngoscope. Also, with the spread of narrow band imaging (NBI), endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), which are widely used for superficial cancers in the gastrointestinal tract, have been applied for the superficial laryngo-pharyngeal cancer. Both EMR and ESD are performed mainly by gastroenterologists with a sharp dissector and magnifying endoscopy (ME)-NBI with minimal surgical margin. Endoscopic laryngo-pharyngeal surgery (ELPS) was developed to treat laryngo-pharyngeal superficial cancer by modifying the ESD procedure. The concept of ELPS is the same as that of ESD, however, the resection procedure is performed by a head and neck surgeon with both hands using a ME-NBI and rigid curved laryngo-pharyngoscope. These four procedures are low cost with similar oncological and functional outcomes to TORS. TORS may be less expensive than chemoradiotherapy, but the number of hospitals that can afford da Vinci surgical systems is limited. Even in the era of robotic surgery, these four procedures will be good options for laryngo-pharyngeal cancer.

Virtual Surgical Planning in the Era of Robotic Surgery

Virtual Surgical Planning in the Era of Robotic Surgery

Analgesic opioid dose is an important indicator of postoperative ileus following radical cystectomy with ileal conduit: experience in the robotic surgery era.

PurposePostoperative ileus (POI) is common following bowel resection for radical cystectomy with ileal conduit (RCIC). We investigated perioperative factors associated with prolonged POI following RCIC, with specific focus on opioid-based analgesic dosage.Materials and MethodsFrom March 2007 to January 2013, 78 open RCICs and 26 robot-assisted RCICs performed for bladder carcinoma were identified with adjustment for age, gender, American Society of Anesthesiologists grade, and body mass index (BMI). Perioperative records including operative time, intraoperative fluid excess, estimated blood loss, lymph node yield, and opioid analgesic dose were obtained to assess their associations with time to passage of flatus, tolerable oral diet, and length of hospital stay (LOS). Prior to general anaesthesia, patients received epidural patient-controlled analgesia (PCA) consisted of fentanyl with its dose adjusted for BMI. Postoperatively, single intravenous injections of tramadol were applied according to patient desire.ResultsMultivariate analyses revealed cumulative dosages of both PCA fentanyl and tramadol injections as independent predictors of POI. According to surgical modality, linear regression analyses revealed cumulative dosages of PCA fentanyl and tramadol injections to be positively associated with time to first passage of flatus, tolerable diet, and LOS in the open RCIC group. In the robot-assisted RCIC group, only tramadol dose was associated with time to flatus and tolerable diet. Compared to open RCIC, robot-assisted RCIC yielded shorter days to diet and LOS; however, it failed to shorten days to first flatus.ConclusionReducing opioid-based analgesics shortens the duration of POI. The utilization of the robotic system may confer additional benefit.

Approaches to the Cervical Spine- A Special Emphasis on the Forgotten Trotter’s Approach

Approaches to the Cervical Spine- A Special Emphasis on the Forgotten Trotter’s Approach In this paper the anatomy and applied anatomy of the cervical spine with approaches to the cervical spine are discussed. In the era of Robotic surgery some age old techniques may be forgotten, but however some still remain invaluable to us and should remain in the armamentarium of the Head & Neck and Spinal/ Neurosurgeon. The labiomandibuloglossotomy or the Trotter’s approach was first described in the 1920’s. This approach to the skull base/ upper cervical spine is not universally well known to the Spinal/ Neurosurgeons.

Long term follow-up of benign functional adrenocortical tumors in the era of robotic surgery

Long-term outcome after operation for benign functional adrenal tumours [aldosteronoma (PA), subclinical (SCS) or clinical Cushing ́s syndrome (CS)] has not been reported extensively, especially not in the era of robotic-assisted laparoscopic surgery why pheochromocytomas has not been included in the group of benign functional masses? We have excluded pheocromocytoma because it is well known that it is very difficult to distinguish between malignant and benign pheocromocytomas. Since our aim was to evaluate benign lesions, we excluded pheocromocytomas. The purpose of this study was to investigate the clinical outcome for patients having undergone adrenalectomy for non-malignant clinical or subclinical functional adrenocortical tumors. The records of 65 patients with benign functional adrenocortical tumors treated with laparoscopic adrenalectomy (80% robotic assisted) were surveyed retrospectively. Clinical and biochemical data were evaluated at baseline and follow-up data was collected by a survey distributed to referring endocrinology centers. Cure was defined both in objective measurements and in the subjective validation of the endocrinologists referring the patients for surgery. According to our definition, 83% of patients with PA were either cured (normotension without anti-hypertensive medication), or improved (better blood pressure control with equal or fewer medications). For CS, 89% of patients were cured (biochemical normalization and lack of or significant improvement in co-morbidities). With the same definition, 73% of SCS patients were cured. The endocrinologists considered 86% of PA patients, 100% of CS and 64% of SCS patients as cured. Complications were few and there was no mortality. Robotic assisted adrenalectomy provides safe and effective treatment for PA, CS and SCS. Our objective definition of cure matched the assessment of cure of the endocrinologists in patients with PA and CS.

Long term follow-up of benign functional adrenocortical tumors in the era of robotic surgery

Long-term outcome after operation for benign functional adrenal tumours [aldosteronoma (PA), subclinical (SCS) or clinical Cushing ́s syndrome (CS)] has not been reported extensively, especially not in the era of robotic-assisted laparoscopic surgery why pheochromocytomas has not been included in the group of benign functional masses? We have excluded pheocromocytoma because it is well known that it is very difficult to distinguish between malignant and benign pheocromocytomas. Since our aim was to evaluate benign lesions, we excluded pheocromocytomas. The purpose of this study was to investigate the clinical outcome for patients having undergone adrenalectomy for non-malignant clinical or subclinical functional adrenocortical tumors. The records of 65 patients with benign functional adrenocortical tumors treated with laparoscopic adrenalectomy (80% robotic assisted) were surveyed retrospectively. Clinical and biochemical data were evaluated at baseline and follow-up data was collected by a survey distributed to referring endocrinology centers. Cure was defined both in objective measurements and in the subjective validation of the endocrinologists referring the patients for surgery. According to our definition, 83% of patients with PA were either cured (normotension without anti-hypertensive medication), or improved (better blood pressure control with equal or fewer medications). For CS, 89% of patients were cured (biochemical normalization and lack of or significant improvement in co-morbidities). With the same definition, 73% of SCS patients were cured. The endocrinologists considered 86% of PA patients, 100% of CS and 64% of SCS patients as cured. Complications were few and there was no mortality. Robotic assisted adrenalectomy provides safe and effective treatment for PA, CS and SCS. Our objective definition of cure matched the assessment of cure of the endocrinologists in patients with PA and CS.

Preoperative Criteria to Select Patients for Bilateral Nerve-sparing Robotic-assisted Radical Prostatectomy

To date, no study has analyzed the predictors of potency recovery in a robot-assisted laparoscopic radical prostatectomy (RALP) series. A novel risk stratification for erectile function recovery after retropubic radical prostatectomy (RRP) has been proposed recently by Briganti et al. from the University Vita-Salute San Raffaele in Milan, Italy. To evaluate the potency rate in a series of consecutive patients who underwent bilateral nerve-sparing RALP, to identify the preoperative predictors of erectile function recovery, and to validate the risk-group stratification of Briganti et al. The clinical records of all patients who underwent RALP for clinically localized prostate cancer between April 2005 and April 2009 were prospectively collected in the Prostate Cancer Padua Database. For the present study, we extracted all consecutive cases receiving a bilateral nerve-sparing technique with a minimum follow-up > or =12 months. Twelve-month potency rate after RALP, defined as an International Index of Erectile Function 6 (IIEF-6) score > or =18. Data showed that 129 out of 208 enrolled patients (62%) were potent 12 months after surgery. Age (hazard ratio [HR]: 2.8; P < 0.001), Charlson score (HR: 2.9; P = 0.007), and baseline IIEF-6 score (HR: 0.8; P < 0.001) were independent predictors of potency recovery at multivariate analysis. According to Briganti et al.'s risk-group stratification, the 12-month potency rate following RALP was 81.9% in the low-risk group, 56.7% in the intermediate-risk group, and 28.6% in the high-risk group (P < 0.001). In the era of robotic surgery, the key point for the success of the nerve-sparing technique remains the accurate selection of patients. Age < or =65 years, absence of associated comorbidities, and good preoperative erectile function are the most important preoperative factors to select those patients for whom bilateral nerve-sparing RALP can achieve the best results.

The twenty-first century role of Piver-Rutledge type III radical hysterectomy and FIGO stage IA, IB1, and IB2 cervical cancer in the era of robotic surgery: a personal perspective

Type III radical hysterectomy reported in 1974 by Piver, Rutledge, and Smith is considered worldwide by many as the standard surgical therapy for invasive cervical carcinoma stage IB and IIA. With the increasing number of robotic surgeries being performed for early stage cervical cancer worldwide, the purpose of the paper is to present our personal perspective of the 21st century role of Piver-Rutledge type III radical hysterectomy for stage IB cervical cancer in the era of robotic surgery using the da Vinci robot.

Prostatectomie totale robot-assistée

The beginning of the 21st century has ushered the new era of robotic surgery that now challenges conventional open surgery. Robotic surgery has been embraced by urologists who have applied it to complex surgical procedures such as radical prostatectomy. The revolutionary improvements provided by the Da Vinci Surgical System combines superior 3D visualization along with enhanced dexterity such as the endowrist allowing distal supranatural rotation of instruments, precision and control in an intuitive, ergonomic interface with breakthrough surgical dissection and suturing capabilities in confined spaces. Da Vinci Surgical System allows to perform nerve sparing radical prostatectomy techniques in various surgical plans (inter, intra and extrafascial) with a shorter learning curve and probably outcomes more rapidly reproducible by a less experienced laparoscopic surgeon.