Intuitive Surgical Inc Research Articles

Learning Curve of Robotic-Assisted Low Anterior Resection for Low and Mid Rectal Cancer.

Objective: The aim of our study was to assess the learning curve of robotic assisted low anterior resection with diverting loop ileostomy (LARDLI) for low and mid rectal cancer performed by novice in robotic-assisted surgery colorectal surgeon in a public hospital with limited access to the robotic platform. Methods: A retrospective analysis of all low and mid rectal cancer robotic-assisted operations was conducted. All procedures were performed by a single surgeon with a once per week access to the Da Vinci® Si™ Surgical System, Intuitive Surgical Inc. Demographic, clinical, and pathological data were reviewed. The cumulative sum (CUSUM) analysis was utilized to analyze learning curve for operative time. Results: A total of 107 consecutive patients who underwent LARDLI for lower and mid rectal cancer between November 2011 and July 2020 were included in the analysis. The median patients' age was 65 (range, 32-85) years, 72% were males (n = 77), and 91% (n = 97) received neoadjuvant therapy. Median operative time was 295.5 (range, 180-551) minutes. The conversion rate was 3.7% (n = 4). Median length of hospital stay was 6 (range, 1-41) days. There were 35 (32.7%) postoperative complications, of these 7 (6.5%) were major complications (≥Grade 3, according to the Clavien-Dindo classification). There was only one intraoperative complication (.9%). CUSUM analysis showed that the learning curve was 49 cases to achieve a plateau. Conclusions: The learning curve of robotic assisted low anterior resection for lower and mid rectal cancer for a novice in robotic surgery colorectal surgeon with limited access to the robotic platform is 49 cases. Surgeon and operative team dedication, alongside sufficient hospital support, may lower the number of cases of the learning curve.

P-092 EARLY OUTCOMES OF ROBOTIC-ASSISTED TRANSABDOMINAL PREPERITONEAL INGUINAL HERNIA REPAIR: A SINGLE-INSTITUTION EXPERIENCE

Abstract Purpose Since the introduction of the Da Vinci robot, robot-assisted hernia repairs have become more common. We aim to report our initial experience of robotic transabdominal preperitoneal (R-TAPP) inguinal hernia repair. Methods A retrospective chart review was performed in patients who underwent R-TAPP inguinal hernia repair with a prosthetic mesh using the Da Vinci platform (Intuitive Surgical Inc). Data were collected for patient characteristics and surgical outcomes. Results A total of 21 patients underwent R-TAPP repair consecutively. The mean age was 54.1 ±16.4 years. Twenty patients (95.2%) were male, and the mean body mass index was 23.8 ± 1.9. Bilateral hernia repairs were performed on 2 (9.5%) patients. Six cases (28.5%) of huge scrotal hernias were performed by R-TAPP. The operation time was 91.8 ± 20.4 min for unilateral inguinal hernia and 154.5 ± 26.2 min for bilateral inguinal hernia. The mean console operative time was 61.4 ± 16.9 min for unilateral inguinal hernia and 128 ± 25.5 min for bilateral inguinal hernia. Scrotal vein injury was identified in one patient intraoperatively. Two minor postoperative complications were reported: one with postoperative ileus and the other with umbilical wound seroma. The length of hospital stay was 3.8 ± 0.9 days. Neither mortality nor conversion to open surgery occurred. Conclusion Our early experience has demonstrated that the R-TAPP inguinal hernia repair is a safe and feasible approach. Cost-effectiveness, optimal procedural steps, and indications for the robotic approach remain to be further investigated.

One-year experience of robotic transabdominal preperitoneal approach in a single institute: 2 different surgeons with different levels of experience.

The robotic platform, an extension of minimally invasive procedures, is distributed nationwide and readily available. However, its application in inguinal hernia repair seems rare in Korea. This report aims to share our initial experience with robotic inguinal hernia repair. The patients who underwent robotic inguinal hernia repair by 2 different surgeons with different experiences at a single center were retrospectively analyzed. The surgical procedures were performed on all patients using the Da Vinci Xi robotic platform (Intuitive Surgical Inc). Patient demographics, operation variables, and postoperative outcomes were analyzed. A total of 35 patients underwent robotic inguinal hernia repairs consecutively. The mean age was 55.03 ± 18.20 years. The majority of patients were male. The overall mean operation time was 103.98 ± 47.92 minutes for unilateral hernia surgery and 139.28 ± 46.07 minutes for bilateral surgery. None of the patients experienced intraoperative complications. However, postoperative complications were noticed in 8 patients: 3 with seroma formation, 1 with hematoma, 1 with superficial surgical site infection, and 3 with persistent pain at the operation site. This report demonstrates an early experience of hernia surgery using the robotic platform. The robotic approach for transabdominal preperitoneal hernia repair was completed without any significant intraoperative or postoperative complications. It may be a viable option as a minimally invasive technique. Cost-effectiveness, optimal procedural steps, and indications for the robotic approach remain to be further investigated.

233.9: The Sun Is Still Shining: Nature of Industry Payments to Transplant Surgeons From 2014-2019

Introduction: This study aims to characterize the nature of these payments made to transplant surgeons over the past six years of Open Payments Program (OPP) data, to better understand the nature of physician-industry relationships within transplant surgery. Methods: The study sample included all physicians (categorized under Urology, Surgery, Pediatric Urology, and Pediatric Surgery) who received at least one non-research payment as transplant surgeons to the OPP. To capture transplant surgeons who may be listed under their pipeline specialty, the American Society of Transplant Surgeons member directory as of January 2021 was queried. Physicians identified as residents in the ASTS member directory were excluded from analysis. Data was analyzed between 2014 and 2019. Results: Total number of transplant surgeons receiving payment 1335. Total amount in dollars paid, $15,661,536. The mean payment was $416.58 (SD $1684.60) and the median payment was $50.00 (IQR $17.44-$151.0). The top three categories include $3,910,288 (26.2%) paid for consulting fees, $4,668,147 (31.3%) paid for non-consulting fees (speaker and vendor fees), and $3,035,045 (20.3%) paid for travel and lodging. OPTN Region 5 received the most payment at 19.3%, and Region 1 received the least payment at 1.5%. The top five companies making payments include Intuitive Surgical Inc, Gilead, Norvartis, Astellas, Genzyme. Conclusions: There is a considerable financial relationship between medical device and pharmaceutical manufacturers and transplant surgeons. The majority of non-research payments to transplant surgeons by industry sponsors were for non-consulting services. There exist regional differences in the amount paid by industry to transplant surgeons in regards to median and total industry payment amounts.

MP39-04 COMPARISON OF ONE-YEAR HEALTHCARE EXPENDITURE AND UTILIZATIONS BETWEEN MINIMALLY INVASIVE AND OPEN SURGICAL APPROACHES AMONG PATIENTS UNDERGOING NEPHRECTOMY

You have accessJournal of UrologyCME1 May 2022MP39-04 COMPARISON OF ONE-YEAR HEALTHCARE EXPENDITURE AND UTILIZATIONS BETWEEN MINIMALLY INVASIVE AND OPEN SURGICAL APPROACHES AMONG PATIENTS UNDERGOING NEPHRECTOMY Kennedy Okhawere, Gediwon Milky, I-Fan Shih, Yanli Li, and Ketan Badani Kennedy OkhawereKennedy Okhawere More articles by this author , Gediwon MilkyGediwon Milky More articles by this author , I-Fan ShihI-Fan Shih More articles by this author , Yanli LiYanli Li More articles by this author , and Ketan BadaniKetan Badani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002599.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the widespread adoption of minimally invasive surgical approaches for partial and radical nephrectomy, its long-term cost-benefit is still heavily criticized. We aim to compare total health care utilization and costs up to one year after minimally invasive surgery (MIS) and open surgery (OS) for radical (RN) and partial nephrectomy (PN). METHODS: A retrospective cohort study of patients who had nephrectomy for kidney cancer was conducted using the IBM® MarketScan® Databases between 2013 and 2018. Outcomes included length of stay and expenditure for index surgery, post-operative 1-year total healthcare expenditure, healthcare utilizations, and total missed workdays due to healthcare utilization. Inverse probability of treatment weighting (IPTW) based on baseline patient characteristics was applied to compare MIS versus OS. RESULTS: Of 5,104 patients, 2,639 had PN (2,008 MIS vs 631 OS) and 2,465 had RN (1,816 MIS vs 649 OS). MIS patients had lower index length of stay than OS (PN: 2.4 vs 3.8, p <0.001; and RN: 2.8 vs 4.6, p <0.001), and lower index expenditure for RN ($28,999 vs $31,977, p=0.013). For PN, index expenditure was lower for OS ($27,480 vs $30,380 for MIS, p=0.012). MIS was associated with lower post-operative expenditure than OS (PN: $17,116 vs. $19,686, p=0.020; and RN: $22,504 vs. $30,791, p=0.009). MIS patients had lower or comparable readmission rate than OS (PN: 15% vs 21%, p=0.024; and RN: 15.6% vs 18.9%, p=0.063). Following RN, MIS patients had fewer resource utilizations than OS (inpatient days: 1.0 vs 1.4 days, p=0.041; hospital outpatient visits: 5.5 vs 6.7, p <0.001), translating to fewer missed workdays (2.3 vs. 2.8, p=0.019). CONCLUSIONS: Irrespective of the cost of the index surgery for both PN and RN, the total cumulative cost in one-year post-discharge was lower for MIS when compared to OS. Several factors might contribute to cost savings after MIS in the post-operative period including reduction in re-admission rate and number of outpatient visits. Our findings suggest that impact on downstream cost and resource utilization should be considered when evaluating surgical approach for both partial and radical nephrectomy. Source of Funding: Intuitive Surgical Inc © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e665 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kennedy Okhawere More articles by this author Gediwon Milky More articles by this author I-Fan Shih More articles by this author Yanli Li More articles by this author Ketan Badani More articles by this author Expand All Advertisement PDF DownloadLoading ...

Accelerating Surgical Robotics Research: A Review of 10 Years With the da Vinci Research Kit

Robotic-assisted surgery is now well established in clinical practice and has become the gold-standard clinical treatment option for several clinical indications. The field of robotic-assisted surgery is expected to grow substantially in the next decade, with a range of new robotic devices emerging to address unmet clinical needs across different specialties. A vibrant surgical robotics research community is pivotal for conceptualizing such new systems as well as for developing and training the engineers and scientists to translate them into practice. The da Vinci Research Kit (dVRK), an academic and industry collaborative effort to repurpose decommissioned da Vinci surgical systems [Intuitive Surgical Inc. (ISI), California, USA] as a research platform for surgical robotics research, has been a key initiative for addressing a barrier to entry for new research groups in surgical robotics. In this article, we present an extensive review of the publications that have been facilitated by the dVRK over the past decade. We classify research efforts into different categories and outline some of the major challenges and needs for the robotics community to maintain and build upon this initiative.

Endoscopic Image-Based Skill Assessment in Robot-Assisted Minimally Invasive Surgery.

Objective skill assessment-based personal performance feedback is a vital part of surgical training. Either kinematic—acquired through surgical robotic systems, mounted sensors on tooltips or wearable sensors—or visual input data can be employed to perform objective algorithm-driven skill assessment. Kinematic data have been successfully linked with the expertise of surgeons performing Robot-Assisted Minimally Invasive Surgery (RAMIS) procedures, but for traditional, manual Minimally Invasive Surgery (MIS), they are not readily available as a method. 3D visual features-based evaluation methods tend to outperform 2D methods, but their utility is limited and not suited to MIS training, therefore our proposed solution relies on 2D features. The application of additional sensors potentially enhances the performance of either approach. This paper introduces a general 2D image-based solution that enables the creation and application of surgical skill assessment in any training environment. The 2D features were processed using the feature extraction techniques of a previously published benchmark to assess the attainable accuracy. We relied on the JHU–ISI Gesture and Skill Assessment Working Set dataset—co-developed by the Johns Hopkins University and Intuitive Surgical Inc. Using this well-established set gives us the opportunity to comparatively evaluate different feature extraction techniques. The algorithm reached up to 95.74% accuracy in individual trials. The highest mean accuracy—averaged over five cross-validation trials—for the surgical subtask of Knot-Tying was 83.54%, for Needle-Passing 84.23% and for Suturing 81.58%. The proposed method measured well against the state of the art in 2D visual-based skill assessment, with more than 80% accuracy for all three surgical subtasks available in JIGSAWS (Knot-Tying, Suturing and Needle-Passing). By introducing new visual features—such as image-based orientation and image-based collision detection—or, from the evaluation side, utilising other Support Vector Machine kernel methods, tuning the hyperparameters or using other classification methods (e.g., the boosted trees algorithm) instead, classification accuracy can be further improved. We showed the potential use of optical flow as an input for RAMIS skill assessment, highlighting the maximum accuracy achievable with these data by evaluating it with an established skill assessment benchmark, by evaluating its methods independently. The highest performing method, the Residual Neural Network, reached means of 81.89%, 84.23% and 83.54% accuracy for the skills of Suturing, Needle-Passing and Knot-Tying, respectively.

Robotic cyst gastrostomy &amp; Roux-en-Y cyst jejunostomy for a bilobed walled-off pancreatic necroma

Presenter: Samer AlMasri MD | University of Pittsburgh Medical Center Background: Walled-off pancreatic necrosis (WON) represents delayed sequelae of necrotizing pancreatitis and is characterized by a well-circumscribed, encapsulated collection of necrotic parenchyma with variable degree of gland liquefaction. This is seen following 5-15% of acute pancreatitis episodes. Although a significant number of WONs are asymptomatic and resolve spontaneously, some require endoscopic or surgical intervention. In this video, we demonstrate a robotic cyst gastrostomy and roux-en-y cyst jejunostomy performed for two simultaneous complex WONs. Methods: A 71-year-old female presented with a history of drug-induced necrotizing pancreatitis 2 years prior to surgical referral. This was complicated by the development of two separate WONs in the head and the body of the pancreas measuring 6.5x6.5cm and 9.7x7.3cm respectively, with significant necrotic debris. Due to the continued growth of the WONs, the decision was made to pursue simultaneous internal surgical drainage of both lesions using a minimally invasive approach. Results: The procedure was performed using the DaVinci Si HD robotic Surgical System (Intuitive Surgical Inc) and lasted 180 minutes with a total blood loss of approximately 25ml. A cyst gastrostomy and a roux-en-y cyst jejunostomy with debridement was performed for the body and head WONs respectively. The patient tolerated the procedure well, had an uneventful postoperative course and was discharged on post-operative day 7. Conclusion: This case demonstrates that the robotic approach can be a safe and effective approach to the management of technically challenging complex WONs.

The impact of surgical learning curve on survival – reopening the door for minimally invasive surgery in the management of cervical cancer?

Minimally invasive surgery has been widely adopted in gynaecological oncology with a significant surge since 2010 associated with the introduction of robot-assisted surgery. Up until 2018, virtually all testimonials of minimally invasive surgery for cervical cancer indicated equal oncological outcomes compared with laparotomy. The unexpected results from the only randomised controlled trial (Ramirez et al. N Engl J Med 2018;379:1895–904) seriously challenge the use of minimally invasive surgery for cervical cancer. However, the lack of plausible explanations for the inferior survival has made it hard for many gynaecological oncologists to accept the results at face value. Suggested causes such as the use of intrauterine manipulators and intracorporeal colpotomy may to some extent account for the detrimental outcomes but as practice differs widely worldwide, none of these factors seem convincing. In the current paper by Baeten et al., a different aspect of novel surgical technologies has been explored (BJOG 2020; https://doi.org/10.1111/1471-0528.16399). The adoption of any new modality/technology is clearly associated with a learning curve and it is well known from surgery that procedural outcomes, such as operative time, improve with increasing case numbers. However, the potential impact of learning curve on hard outcomes such as survival has scarcely been reported. Baeten et al. convincingly demonstrate that a substantial number of robot-assisted radical hysterectomies are required to overcome an initial harm. The authors point out that the learning curve should be considered institutional; suggesting that an individual learning curve may benefit from previous experiences at the specific institution. Intriguingly, similar data have not been presented for endometrial cancer, which may be related to the higher complexity of radical hysterectomy for cervical cancer. Although no specific changes were made over time in the current study, a learning curve may include modifications of surgical routines based on early experiences. Which specific improvements during the learning curve account for the increased survival are unclear but reduction of complications that could delay adjuvant treatment may be one. The data presented by Baeten et al. signify a solid effort to elucidate the underlying cause of the outcomes from the LACC trial, especially as the trial was launched at a time when most surgeons had limited experience from laparoscopic/robotic radical hysterectomy. The study should raise the awareness of surgical learning curve in the context of survival in oncological surgery. It also brings us to the most important question – how do we avoid harming our patients when novel technologies are adopted? The authors suggest that centralisation and structured training represent two of the most important strategies to mitigate the effects of early errors. Interestingly, recent population-based studies from countries with high levels of centralisation do not corroborate the findings from the LACC trial (Alfonzo et al. Eur J Cancer 2019;29:1072–6; Jensen et al. Eur J Cancer 2020;128:47–56). Although the current study may reopen the door for robotic surgery in the management of cervical cancer, prospective randomised trials are needed to ensure its safety. The impact of surgical learning curve should be considered in any future trial exploring oncological safety for procedural interventions. HF is a proctor for Intuitive Surgical Inc. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Intuitive Surgical Inc.

Intuitive Surgical Inc.

Single-port robotic surgery: the next generation of minimally invasive urology.

The da Vinci Single-Port (SP) platform (Intuitive Surgical Inc, Sunnyvale CA) is a recently approved robotic surgical platform which features several novel modifications from previously available single trocar models including a flexible camera, articulating instruments, and navigator guidance for real-time monitoring of instrument position. We sought to describe our clinical experience with this device as well as to review the current literature related to the use of the SP platform. We provide a narrative review of clinical data related to single-port robotic surgery within the field of urology. In addition, we report our initial clinical experience for surgical procedures performed with the SP platform between December 2018 and April 2019 following installation of the system at our institution. Currently, the presently available literature for single-port robotic urological surgery consists of single-center case reports and series. Most major robotic urologic operations appear technically feasible using the da Vinci SP platform; however, additional multi-center studies and randomized trials are needed to determine what role the SP platform will play. Rather than an iterative step or a niche system, the SP platform provides for a new approach to single-site laparoscopic or robotic techniques and is demonstrated as a feasible approach for several major robotic urological operations. While comparative studies will be required to evaluate perioperative and long-term outcomes between SP and multi-port platforms, further technological advances will continue to push surgeons towards less morbid and more minimally invasive approaches for surgery.

Robotic Instrument Failure—A Critical Analysis of Cause and Quality Improvement Strategies

ObjectiveTo introduce a quality improvement initiative tracking robotic instrument failures on a per case basis. It is imperative to understand rates of failure, financial implications of failures, and identify factors suggesting common mechanisms of failure. Materials and MethodsStarting in January 1, 2014 a quality reporting system for failed robotic equipment began. Staff was instructed to submit an incident report when a robotic instrument failed and the instrument returned to central processing. Instruments were then returned to the manufacturer (Intuitive Surgical Inc, Sunnyvale, CA) for analysis and reimbursement. Results of failure analysis by the manufacturer, including reimbursement rates, were recorded and correlated with the procedure and surgical specialty. ResultsA total of 3935 robotic cases were performed during the study period with a reported instrument failure incidence of 6.2% (247 total instruments). Etiology of instrument failure was as follows: tip or wrist (46.9%), cable (30.0%), unknown (12.6%), control housing (5.3%), and shaft (3.2%). Highest instrument failure incidence was seen in colorectal surgery cases at 4.0%, Urology had the lowest at 2.7%. Manufacturer reimbursement rate was 57.9%; the most common reason for denial being mishandling/misuse of equipment, determined by manufacturer analysis. ConclusionHerein, we have demonstrated that improved process flow of reporting is necessary to better track incidence and etiology of instrument failures. Cost savings comes from improved training of not only surgeons but operating room and central processing staff in handling equipment to prevent high rates of reimbursement denial.

Laparoscopic versus robotic hysterectomy in obese and extremely obese patients with endometrial cancer: A multi-institutional analysis

ObjectiveThe aim of this study was to evaluate the surgical and oncological outcome of robotic surgical staging with hysterectomy (RH) plus or less pelvic and aortic lymphadenectomy, compared to the same procedures performed by laparoscopic surgery (LH) in obese patients (BMI≥30 kg/m2) with endometrial cancer. Material and methodsFrom October 2001 to April 2017, obese patients (BMI > 30 kg/m2) with primary, histologically confirmed endometrial carcinoma who underwent LH or RH using the Da Vinci Si or Xi Surgical System® (Intuitive Surgical Inc®, 1266 Kifer Road, Building 101 Sunnyvale, CA) were eligible for the study. ResultsWe identified 655 women with endometrial cancer and BMI >30 kg/m2. Out of 655 patients, 249 (38%) underwent RH and 406 (62%) underwent LH plus or less pelvic and aortic lymphadenectomy. Our study showed that, compared to the 406 patients treated in LPS, 249 patients treated in robotics have a statistically significant difference in terms of increased operating time and a decreased conversion rate. In addition, the rate of pelvic lymphadenectomies in robotic surgeries is twice the one reported in LPS surgeries. Furthermore, a reduction in hospital stay was observed in the robotic group. We observed that the oncological outcomes do not vary according to the surgical approach and BMI variation.Conclusions: robotic surgery in severely obese women with endometrial cancer is feasible, safe, and reproducible and could be a valid alternative to laparoscopy in the treatment of these patients. Prospective studies could confirm our results.

Intuitive Surgical Inc. Payments to Ob/Gyns Compared to Other Specialties: Analysis from 2014 Open Payments Database [4D

INTRODUCTION: Study Objective: To determine the payments made to Obstetricians and Gynecologists (OBGYNs) compared to other surgical specialties by the makers of the Da Vinci robot-Intuitive Surgical, Inc. in 2014. METHODS: Design: Retrospective cross-sectional study (Canadian Task force classification- II-3). Setting: Payments to OBGYNs in the United States compared to the total Intuitive Surgical payment amount in each state as analyzed from Centers for Medicare &amp; Medicaid Services (CMS)’ Open Payments website. Subjects: General OBGYNs, OBGYN subspecialists (Gynecologic Oncology, Reproductive Endocrinology, Female Pelvic Medicine and Reconstructive Surgery, Gynecology), and providers in other specialties nationwide. Interventions: Compare Intuitive Surgical Inc. payments to OBGYNs versus other surgical specialties as analyzed from publicly available CMS Open Payments database. RESULTS: A total of 50 states received money from Intuitive Surgical Inc. in 2014. Payments to general OBGYNs totaled $5,061,439, OBGYN subspecialties received $1,591,556, and other surgical specialties that use the Da Vinci platform received $33,011,657. Total payments per state can be represented in a map diagram. The state of Texas got the highest amount. Payments to OBGYNs divided by total payments in each state can be depicted in a similar fashion, Wyoming state had the highest value. CONCLUSION: OBGYNs received a significant proportion of funding from Intuitive Surgical Inc. as compared to other surgical specialties in 2014. We recommend that OBGYNs update or declare any conflicts when required.

Robotic versus laparoscopic stapling during robotic Roux-en-Y gastric bypass surgery: a case-matched analysis of costs and clinical outcomes

The purpose of this analysis is to compare the robotic EndoWrist Stapling System (EWSS) 45mm (Intuitive Surgical Inc. Sunnyvale, CA, USA) and the ECHELON FLEX™ ENDOPATH® Staplers (EFES) 60mm (Ethicon, Cincinnati, OH, USA) for gastric pouch formation during robotic gastric bypass surgery. Patients who underwent robotic gastric bypass surgery with stapling using EWSS were matched with patients who underwent the same procedure with the EFES. Demographic, intra- and postoperative, and cost data were collected and analyzed. A total of 49 patients were identified who had undergone robotic gastric bypass surgery using EWSS. They were matched with 49 patients who underwent the equivalent procedure using EFES. With similar demographic parameters, corrected operating room time without cholecystectomy took longer for the patients that underwent surgery with EWSS (+22min, p=0.1042). Stapler clamping was unsuccessful in 19.0% of all recorded attempts with EWSS. Two intra-operative complications unrelated to stapling and one complication due to stapling were observed in the EWSS cohort, while none was observed for the EFES group. Significantly, more recharges were needed with EWSS to complete the gastric pouch (4.9 vs. 4.1, p=0.0048) and overall stapling costs for the procedure were significantly higher (2212.2 vs. 1787.4 USD, p=0.0001). Gastric pouch formation using EWSS during robotic gastric bypass surgery is feasible. Due to the shorter length of EWSS compared to EFES, more stapling recharges are required to complete gastric pouch formation and the stapling costs for gastric bypass surgery are higher. Further systematic research should be conducted to precisely determine the value of the robotic EWSS for gastric bypass surgery.

Laparobotic Duodenal Diverticulectomy: A Case Series and Operative Technique

Objective: Duodenal diverticulum is not uncommon but most are asymptomatic. Surgery is recommended only for the patients with symptoms. Although laparoscopic diverticulectomy can be done, it is often with significant difficulties due to inherent limitations of the laparoscopic technique and posterior location of the lesion. The advent of the robotic surgical technology with superior imaging and instrumentation may provide an alternative minimally invasive approach for this situation. We herein report our case series utilizing the daVinci Surgical System (dVSS) for duodenal diverticulectomy. Methods: We retrospectively reviewed our robotic database for all duodenal procedures performed at a single institution (the Valley Hospital: VH). Only patients who underwent laparobotic duodenal diverticulectomy (LRDD) were included and their recorded videos reviewed. Data analyzed were patients’ demographic, perioperative outcomes, and technical details. We used the daVinci Si (Intuitive Surgical Inc. Sunny Vale, Calif.) for all cases. Results: 4 female patients underwent LRDD. All presented with abdominal pain. Diagnosis was made by CT scans or MRI with or without EGD. 3 patients had diverticula located in the second part of the duodenum (75%). Concomitant procedures (choledochoduodenostomy and CBD exploration) were performed in two patients. Mean operative time was 142.5 min. There was one complication but no mortality. Average length of stay was 4 days. Conclusion: LRDD is feasible, efficient, and safe. The dVSS provides the surgeon improved visualization and enhanced dexterity to perform complex procedure.

Robot-assisted Laparoscopic Transplantation of Frozen-thawed Ovarian Tissue

Study ObjectiveTo show a new approach for orthotopic human ovarian tissue transplantation via robot-assisted laparoscopic surgery. DesignA step-by-step video explanation of the surgical technique (Canadian Task Force classification III). SettingAcademic medical center. InterventionsThe robot-assisted transplantation approach consisted of 3 steps: (1) reconstruction of the ovarian tissue graft, (2) preparation of the contralateral menopausal ovary as the recipient site, and 3) transplantation of the reconstructed graft to the bivalved contralateral ovary. Institutional review board approval was obtained. Measurements and Main ResultsAlthough still experimental, cryopreservation and subsequent transplantation of frozen-thawed ovarian tissue are currently the only available methods for prepubertal girls and young women with cancer who are not eligible for established fertility preservation options such as oocyte or embryo cryopreservation [1]. We performed the first reported autologous ovarian transplantation with a conventional laparoscopic technique [2]. To date, over 60 babies have been born after the orthotopic transplantation of cryopreserved ovarian tissue, and this number is growing [3,4]. Until recently, all of these children were born from ovarian transplants that were performed via laparotomy or conventional laparoscopy [5]. We have recently developed a robot-assisted ovarian transplantation procedure that uses an extracellular matrix scaffold to facilitate ovarian reconstruction, handling, and revascularization. Both of the procedures resulted in robust ovarian function and births [6]. The purpose of this video reports the surgical technique in detail, which uses the da Vinci Xi (Intuitive Surgical Inc, Sunnyvale, CA) robotic system for transplantation, and a decellularized human extracellular tissue matrix (Alloderm; LifeCell Corp, Branchburg, NJ) for graft reconstruction. ConclusionRobotic ovarian transplantation may have several advantages, which include precision, more delicate graft handling, and reduced time from tissue thawing to transplantation. The collective usefulness of the extracellular tissue matrix may enhance this technique by enabling a niche for ovarian reconstruction and potentially enhanced revascularization. The feasibility and comparative advantages of this technique are currently being studied in ongoing trials.

Feasibility of robotic inguinal hernia repair, a single-institution experience

With the growth of the discipline of laparoscopic surgery, technology has been further developed to facilitate the performance of minimally invasive hernia repair. Most of the published literature regarding robotic inguinal hernia repair has been performed by urologists who have dealt with this entity in a concomitant way during radical prostatectomies. General surgeons, who perform the vast majority of inguinal herniorrhaphies worldwide, have yet to describe the role of robotic inguinal hernia repair. Here, we describe our initial experience and create the foundation for future research questions regarding robotic inguinal hernia repair. A retrospective chart review was performed in 78 patients who underwent robotic transabdominal preperitoneal TAPP inguinal hernia repair with a prosthetic mesh using the da Vinci platform (Intuitive Surgical Inc). Data collected included patient demographics, past medical history, previous surgeries, details related to the surgical procedure, perioperative outcomes and complications. A total of 123 hernias were repaired. Forty-five patients had bilateral robotic inguinal herniorrhaphies, and the mean age was 55.1years (SD 15.1), with a mean BMI of 27.6 (SD 6.1). There were 71 male and 7 female patients. Surgical complications included hematoma in three patients (3.9%), two seromas (2.6%) and one superficial surgical site infection at a trocar site (1.3%), which resolved with oral antibiotics. Chronic postoperative complications (>30days post-surgery) included the persistence of hematomas in two patients (2.6%). Same day discharge was achieved in 60 patients (76.9%) with a mean length of stay of 8h (SD 2.65). Neither mortality nor conversion to open surgery occurred. Our early experience has demonstrated that the robotic transabdominal preperitoneal (TAPP) inguinal hernia repair is a safe and versatile approach that allows the general surgeon to perform this procedure in more complex cases such as those involving incarcerated and/or recurrent hernias.

Laparoscopic Robot-Assisted Diaphragm Plication

Minimally invasive approaches to diaphragm plication for eventration include thoracoscopic and laparoscopic techniques. The elevated hemidiaphragm and ribs limit thoracoscopic techniques. We report our modification of the laparoscopic approach using robotic assistance with the da Vinci Surgical System, (Intuitive Surgical Inc, Sunnyvale, CA) to avoid single-lung ventilation, facilitate exposure, and allow more precise placement of plication sutures to achieve an even tension and maximum plication. Critical steps include creation of a small defect in the diaphragm to equalize pressures between cavities and placement of multiple, pledgeted interrupted horizontal mattresses.

A multicenter study of initial experience with single-incision robotic cholecystectomies (SIRC) demonstrating a high success rate in 465 cases.

Recently, the robotic single-site platform has been used to ameliorate the difficulties seen in single-incision laparoscopic surgery (SILC) while preserving the benefits of standard laparoscopic cholecystectomy. The purpose of this study is to describe the clinical outcomes of a large series of single-incision robotic cholecystectomy (SIRC). Medical records of consecutive patients who underwent SIRC were retrospectively reviewed. All procedures were performed by six surgeons at five different North American centers involved in the study. All patients included in the study underwent a cholecystectomy attempted through single site at the umbilicus, using the da Vinci(®) Surgical System (Intuitive Surgical Inc. Sunnyvale, CA). A total of 465 patients met study criteria. Median age was 48years (range 18-89); 351 (75.5%) were female and 304 (66.4%) were overweight or obese. Except for gender, case characteristics differed significantly by surgeon/site. Previous abdominal surgery was reported for 226 (48.6%) cases. SIRC was successfully completed in 455 (97.8%) cases, and there were no conversions to open surgery. Median surgical time was 52min with a decreasing trend after 55-85 cases. Male gender, obesity and diagnoses other than biliary dyskinesia were independent predictors of longer surgical times. The complication rate was 2.6%. Our large, multicenter study demonstrates that robotic single-site cholecystectomy is safe and feasible in a wide range of patients.