Patient-side Assistant Research Articles

Reproduction of modified Blumgart pancreaticojejunostomy in a robotic environment: a simple clipless technique.

Although modified Blumgart anastomosis (MBA) in robotic pancreaticoduodenectomy has been accepted as a simple and safe procedure that provides non-inferior surgical outcomes compared to open MBA, the details of the standardization of robotic MBAs have never been established. In this report, we detail the technical tips to reproduce MBA in the robotic environment. From January to December in 2021, 16 patients underwent our novel robotic MBA technique, which included clipless Blumgart suture and duct-to-mucosa anastomosis. To simplify the manipulation of sutures in robotic environment, short double-armed sutures in 15cm length were created and used for Blumgart suture. Duct-to-mucosa anastomosis were done by 5-0 monofilament of 6cm length. These tips enabled clipless anastomosis and minimized the burden of the patient-side assistant. Surgical and short-term outcomes were compared between patients with robotic MBA (Robo group) and those who underwent open MBA during 2021 (32 patients, Open group). The median operation time was significantly longer in the Robo group than in the Open group (551 vs. 485.5min, P = 0.0027). Estimated blood loss was significantly lower in the Robo group than in the open group (95 vs. 355mL, P < 0.0002). The median duration of clipless MBA in the Robo group was 56 (46-68) min. The incidence of POPF (grade B or C) was not significantly different among the groups (19% vs. 22%, P = 0.71). The mean length of hospital stay was significantly shorter in the Robo group than in the Open group (18 vs. 24days, P = 0.019). Clipless MBA in a robotic environment was safely performed with acceptable short-term outcomes and can be proposed as a standard technique for robotic pancreatojejunostomy.

Identifying curriculum content for a cross-specialty robotic-assisted surgery training program: a Delphi study.

Robotic-assisted surgery is increasing and there is a need for a structured and evidence-based curriculum to learn basic robotic competencies. Relevant training tasks, eligible trainees, realistic learning goals, and suitable training methods must be identified. We sought to develop a common curriculum that can ensure basic competencies across specialties. Two robotic surgeons from all departments in Denmark conducting robotic-assisted surgery within gynecology, urology, and gastrointestinal surgery, were invited to participate in a three-round Delphi study to identify learning goals and rank them according to relevance for a basic curriculum. An additional survey was conducted after the Delphi rounds on what training methods were considered best for each learning goal and who (console surgeon/patient-side assistant) should master each learning goal. Fifty-six robotic surgeons participated and the response rates were 86%, 89%, and 77%, for rounds 1, 2 and 3, respectively. The Delphi study identified 40 potential learning goals, of which 29 were ranked as essential, e.g., Understand the link between arm placement and freedom of movement or Be able to perform emergency un-docking. In the additional survey, the response rate was 70%. Twenty-two (55%) of the identified learning goals were found relevant for the patient-side assistant and twenty-four (60%) were linked to a specific suitable learning method with > 75% agreement. Our findings can help training centers plan their training programs concerning educational content and methods for training/learning. Furthermore, patient-side assistants should also receive basic skills training in robotic surgery.

Robotic cardiac surgery impact of a new patient-side assistant on outcomes

Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes. In 4/2016, the established patient-side assistant retired after spending 8months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared. Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups. We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.

Impact of assistant surgeon on outcomes in robotic surgery.

Introduction:It is believed that the outcomes of robotic surgery depends not only on the experience of the console surgeon but also the patient-side assistant. However, objective data supporting it is lacking. The aim of this study was to objectively determine change in operative outcomes with increasing experience of patient-side assistant.Materials and Methods:We performed a retrospective analysis of 222 urologic robotic procedures performed by two teams of surgeon-assistant and split the data into two chronological halves according to date of surgery. We considered that the assistant was inexperienced in the 1st half and had become experienced by the 2nd half, and we compared mean operative time and blood loss between these two halves of his experience.Results:We observed that with increasing experience of the assistant, the mean operative time reduced from 138.06 to 124.32 min (P = 0.001) and mean blood loss decreased from 191.93 to 187.61 ml (P = 0.57). On subset analysis, a consistent trend of reduction in the mean operative time was noted for both the assistants separately and for all surgical procedures included in the analysis. Maximum reduction was noted for pyeloplasty which was the most commonly performed surgery. The mean blood loss had a varied relation to the experience of the assistant and did not reach statistical significance in either direction.Conclusions:With increasing experience of the patient-side surgeon, the mean operative time for all robotic procedures showed a consistent trend of reduction across all types of surgery with greater reduction for commonly performed procedures.

V2-12 ROBOT-ASSISTED INTRACORPOREAL ILEAL NEOBLADDER: SIMPLIFIED STEP-BY-STEP TECHNIQUE AND SURGICAL OUTCOMES

You have accessJournal of UrologyReconstruction1 Apr 2014V2-12 ROBOT-ASSISTED INTRACORPOREAL ILEAL NEOBLADDER: SIMPLIFIED STEP-BY-STEP TECHNIQUE AND SURGICAL OUTCOMES Idir Ouzaid, Riccardo Autorino, Dinesh Samarasekera, Vishnuvardhan Ganesan, Jayram Krishnan, and Georges-Pascal Haber Idir OuzaidIdir Ouzaid More articles by this author , Riccardo AutorinoRiccardo Autorino More articles by this author , Dinesh SamarasekeraDinesh Samarasekera More articles by this author , Vishnuvardhan GanesanVishnuvardhan Ganesan More articles by this author , Jayram KrishnanJayram Krishnan More articles by this author , and Georges-Pascal HaberGeorges-Pascal Haber More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To detail our simplified technique for robotic intracorporeal ileal neobladder (NB) after robot assisted radical cystectomy (RARC). METHODS Between January 2012 and July 2013, 12 consecutive RARC with intracorporeal NB were performed. A transperitoneal five-port approach using a 4-arm da Vinci® robot (Intuitive Surgical, Sunnyvale, CA, USA) and one patient-side assistant was employed. Outcomes as well as surgical technique are reported. The enclosed video details the steps of the procedure including the bowel segment selection and anastomosis, the ileourethral anastomosis, the detubularization and neobladder reconstruction, and finally the ureteroileal anastomoses. RESULTS All procedures were successfully completed. Main surgical parameters were as follows: average operative time 442±57 min, estimated blood loss 420±213 ml, and hospital stay 8.4±2.8 days. Complications occurred in 66.6% of the cases of which, 58.3 % were postoperative with 41.6% and 16.7% of the patients experiencing minor (grade 1-2) and major (grade 3-5) complications respectively. Readmission and secondary procedure were 25% and 16.7% respectively. CONCLUSIONS Robotic intracorporeal NB represents a challenging surgical task. A simplified step-by-step approach allows a practical standardization of the procedure and ultimately facilitates its safe implementation. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e361 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Idir Ouzaid More articles by this author Riccardo Autorino More articles by this author Dinesh Samarasekera More articles by this author Vishnuvardhan Ganesan More articles by this author Jayram Krishnan More articles by this author Georges-Pascal Haber More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Da Vinci robotic single‐incision cholecystectomy and hepatectomy using single‐channel GelPort access

Minimally invasive surgery including laparoscopic and robotic surgery was recently approved for clinical use in hepatobiliary surgery. The purpose of this article is to evaluate the feasibility and technical aspects of robotic single incision for hepatobiliary surgery using the GelPort laparoscopic system in a preliminary animal study. We performed eight robotic single-incision laparoscopic surgery (SILS) procedures, including four cholecystectomies and four lateral segmentectomy of the liver, in a porcine study using the da Vinci S-HD Surgical System. A single-channel GelPort access was placed through a 2.5-cm single incision for robotic access. A 12-mm camera port, two 8-mm ports for the robotic arms and one 5-mm port for the patient-side assistant were inserted. A Mini Loop Retractor was applied to retract the fundus of the gallbladder. The EndoWrist dissector and grasping forceps was introduced to fine-dissect Calot's triangle. The instruments were crossed to avoid "sword fighting" and clashing of instruments in the abdomen. The cystic duct was divided after double ligation and the gallbladder was removed. Hepatic transection was performed with bipolar Harmonic shears and LigaSure for vascular pedicles. All robotic SILS procedures were completed (8/8, 100%). The cholecystectomies and hepatectomies were safely performed in average operating times of 70min (±15) and 60min (±20), respectively, with minimal blood loss. There were no conversions, re-interventions or extension of the skin incision. Robotic hepatobiliary SILS is technically feasible and safe using GelPort as a single-incision access platform. Robotic SILS is becoming established and is enormously advantageous to the patient.

Transoral Robotic Surgery (TORS) for Parapharyngeal and Retromolar Trigone Tumors

 Robotic console time for the first resection was 40 minutes and 54 minutes for the second TORS. The traditional approaches to the parapharyngeal space allow for a maximum of two-handed surgery within the narrow operative field. TORS affords an approach in which the retraction/dissection carried out by the patient side assistant translates into four-handed surgery. Although the majority of dissection in the parapharyngeal space is carried out bluntly, the patient side assistant provides the exposure and tension required for precise electrocautery. Additionally the magnified view also allows for placement of surgical clips for hemostasis.

Assistant-Less Urethrovesical Anastomosis During Robot-Assisted Radical Prostatectomy Using a Unidirectional Barbed Wound Closure Device

Introduction: Urethrovesical anastomosis (UVA) is a critical and technically demanding step during robot-assisted radical prostatectomy (RARP). The commonly used Van Velthoven stitch has limitations relating to slippage and unraveling of the monofilament suture. This necessitates constant traction by an assistant or repeated tightening of suture by the surgeon, necessitating an experienced assistant, prolonging UVA time, and increasing risk of instrument clashes and urethral tears. We present a novel technique of UVA utilizing unidirectional barbed suture that overcomes these limitations. Materials and Methods: The UVA suture is pre-prepared from two 6-inch 3-0 polyglyconate barbed sutures by running the needle of each suture through the loop of the other suture, creating a sturdy, bidirectional, barbed suture. This 12-inch composite suture is used to perform UVA as previously described. However, the patient side assistant does not follow the suture or provide any help with the UVA and the two sutures are not tied at the conclusion of UVA, but merely continued across for one additional throw. Fifty-one consecutive patients undergoing RARP at our institution underwent a dual-layer UVA using the barbed suture. Integrity of anastomosis was tested intraoperatively by instilling 240 mL of saline in the bladder. Cystogram was performed at 7 days. Preoperative, demographic, and perioperative data were recorded prospectively. Intraoperative adverse events (including anastomotic leaks) and post-operative complications (urinary retention and anastomotic strictures) were recorded. Follow-up was at least 1 month. Results and Conclusions: Median time for UVA was 11 min, with 45% performed in <10 min. Eight (16%) required anterior bladder neck reconstruction by extending the suture across in figure of eight pattern. No patients had cystogram-detected urinary leaks, urinary retention, or anastomotic strictures. Not having an assistant who follows the suture minimizes instrument clashes, suture entanglement, inadvertent suture breakage, and urethral tears, and makes UVA faster and efficient. This advantage translates into avoiding an assistant for an inexperienced surgeon and faster UVA for an experienced one. We noted 25% reduction in UVA time in a comparative study performed at our institution. It is postulated that because of the barbs, each throw becomes an independent interrupted suture and holds itself in place, making knot tying unnecessary. Hypothetical concerns include strangulation of urethra causing strictures or urinary retention; neither occurred in our cohort. Since the barbs do not allow the suture to be retracted once placed, any mistake in placing throws necessitates the UVA to be redone. However, the first inch of the suture is without barbs, and if a misstep is recognized early, the suture may be readjusted easily. No patients required UVA to be redone for this reason. Although there have been no short-term sequelae, long-term results are awaited. This technique has become the standard of care at our institution. We present a novel technique of UVA during RARP that is safe and efficient, and overcomes the limitations of current techniques. Utilizing barbed self-locking suture obviates the need for assistance, prevents slippage, and allows for knotless anastomosis. No competing financial interests exist. Runtime of video: 5 mins 50 secs

The decisive role of the patient-side surgeon in robotic surgery

Minimally invasive technology literature is mainly concerned about the feasibility of the robotic procedures and the performance of the console surgeon. However, few of these technologies could be applied without a well-trained team. Our goal was to demonstrate that robotic surgery depends more on the patient-side assistant surgeon's abilities than has been previously reported. In our department, 280 interventions in digestive, thoracic, and gynecological surgery were performed since the acquisition of the robotic equipment. There are three teams trained in robotic surgery with three console surgeons and four certified patient-side surgeons. Four more patient-side assistants were trained at our center. Trocar placement, docking and undocking of the robot, insertion of the laparoscopic instruments, and hemostatic maneuvers with various devices were quantified and compared. Assistants trained by using animal or cadaver surgery are more comfortable with the robotic instruments handling and with docking and undocking of the robot. Assistants who finalized their residency or attend their final year are more accurate with the insertion of the laparoscopic instrument to the targeted organ and more skillful with LigaSure or clip applier devices. Interventions that require vivid participation of the assistants have shorter assistant-depending time intervals at the end of the learning curve than at the beginning. Robotic surgery is a team effort and is greatly dependant on the performance of assistant surgeons. Interventions that have the benefit of a trained team are more rapid and secure.

Robotic atrial septal defect repair and endoscopic treatment of atrial fibrillation

Computer (robotic) enhancement has emerged as a facilitator of minimally invasive cardiac surgery and has been used to perform portions of intracardiac procedures via thoracotomy incisions. This report describes the use of the da Vinci surgical system in two totally endoscopic (“closed chest”) cardiac operations: atrial septal defect closure and pulmonary vein isolation of atrial fibrillation. ASD closure: Fifteen patients underwent repair of a secundum-type atrial septal defect or patent foramen ovale by a totally endoscopic approach, utilizing the da Vinci robotic system. Cardiopulmonary bypass (CPB) was achieved peripherally. Cardioplegia was administered via the distal port of the arterial cannula after endoballoon inflation. Via three port incisions in the right chest, the entire operation including pericardiotomy; bicaval occlusion; atriotomy; atrial septopexy; and atrial closure was performed by a surgeon seated at a computer console. A fourth 15 mm port was utilized for suction and suture passage by a patient-side assistant. In one case, a recurrent shunt was identified and repaired on POD 5. Median ICU length of stay (LOS) was 20 hours, and median hospital LOS was 4 days. Atrial fibrillation surgery: This report also describes the pathway that we have pursued in the development of a totally endoscopic operation for atrial fibrillation. Beginning with animal models, we tested various ablative energy sources; methods of ablation; and minimally invasive approaches. This work has led to the development of a variety of minimally invasive surgical approaches including a totally endoscopic, robotically assisted beating heart procedure for the treatment of atrial fibrillation. © 2003 Elsevier Inc. All rights reserved.