Patient-side Cart Research Articles

Retroauricular thyroidectomy with a single-arm robotic surgical system: Preclinical cadaveric study.

In this study, we evaluate a new flexible, single-arm robotic system in performing thyroidectomy via a retroauricular approach. Four fresh cadavers were used. Technical details of the new system are discussed, and the comprehensive surgical procedures are described step by step. This single-port flexible system could be used to successfully perform retroauricular thyroidectomy. The ideal angle to dock the patient-side cart was at a 90° angle to the operating table. When the cannula tip was placed 10 to 15 cm away from the skin incision, positioning and full movement of all four instruments without collisions were possible. Three flexible instruments and an endoscope made the robotic dissection more efficient. We describe the first preclinical evaluation of an innovative, flexible, single-arm robotic surgical system for retroauricular thyroidectomy.

Single-docking robotic-assisted nephroureterectomy and extravesical bladder cuff excision without intraoperative repositioning: The technique and oncological outcomes

Background/Objective: Currently there are few report of oncologic outcomes following robotic-assisted radical nephroureterectomy (RRNU) based on long-term follow-up. To evaluate the therapeutic effect of RRNU for upper tract urothelial carcinoma (UTUC), a technique of single-docking RRNU was described and its oncological outcomes was evaluated. Patients and methodsThe data of 29 patients underwent RRNU for UTUC of Ta-T3 from July 2013 to June 2016 was analyzed. The data of 131 patients of UTUC underwent laparoscopic radical nephroureterectomy (LRNU) over the same period was analyzed as control. Kaplan-Meier analysis and Cox regression were used for prognosis evaluation. ResultsThe median follow-up time was 40.5 and 40.4 months in RRNU cohort and LRNU cohort. No difference in 5-year intravesical recurrence-free survival (IVRFS) (88.0% vs. 85.5%, p = 0.611) or distant metastasis-free survival (93.1% vs.96.7%, p = 0.323) between RRNU cohort and LRNU cohort. The 5-year retroperitoneal recurrence-free survival and cancer-specific survival (CS) were lower in RRNU cohort than in LRNU cohort (77.3% vs. 87.7%, and 71.2% v.s. 84.7%, respectively). ConclusionThe single-docking RRNU is an effective treatment for UTUC, avoiding the re-docking of patient-side cart or the intraoperative reposition of patient, and bringing equivalent 5-year IVRFS compared to LRNU. However, the lower 5-year retroperitoneal recurrence-free survival and CS in RRNU cohort warned the concern of higher chance of local tumor spillage during RRNU. The noninferiority of RRNU to LRNU still needed the confirmation of large sample sized, prospective randomized controlled study.

Robotic Surgery

Robots have revolutionized industrial production, from automobiles to pharmaceutical manufacturing, and offer an exciting, novel approach to surgical diseases. Robots employed in surgical use initially raised some concern related to malfunction and independent action. However, the surgeon’s decision-making capability is still crucial for each surgical procedure because of the anatomic or physiologic variables of each clinical situation. Currently, surgical robots consist of instruments that are remotely manipulated by a surgeon using an electromechanical interface and represent extensions of the surgeon’s mind and hands. This review provides an overview of robotic surgery, and covers the application of robotic surgery in general surgery. Figures show the AESOP 3000 robotic arm, the da Vinci robotic surgical system, the ZEUS Surgical System, the ZEUS robotic arms, the da Vinci Si, the da Vinci wristed endoscopic stapler, the da Vinci Xi patient side cart and robotic arms, the da Vinci Single-Site robotic instruments, and the da Vinci Single-Site port with instruments positioned and robotic arms docked. The video shows a robotic Rives-Stoppa retromuscular incisional hernia repair with bilateral transversus abdominis release. This review contains 9 highly rendered figures, 1 video, and 85 references Key words: Robotic, surgery, hernia, inguinal, ventral, incisional, fundoplication, paraesophageal hernia, myotomy, gastrectomy, cholecystectomy, pancreatectomy, splenectomy, bariatric, adrenalectomy, colon, colectomy, colorectal

Robotic Surgery

Robots have revolutionized industrial production, from automobiles to pharmaceutical manufacturing, and offer an exciting, novel approach to surgical diseases. Robots employed in surgical use initially raised some concern related to malfunction and independent action. However, the surgeon’s decision-making capability is still crucial for each surgical procedure because of the anatomic or physiologic variables of each clinical situation. Currently, surgical robots consist of instruments that are remotely manipulated by a surgeon using an electromechanical interface and represent extensions of the surgeon’s mind and hands. This review provides an overview of robotic surgery, and covers the application of robotic surgery in general surgery. Figures show the AESOP 3000 robotic arm, the da Vinci robotic surgical system, the ZEUS Surgical System, the ZEUS robotic arms, the da Vinci Si, the da Vinci wristed endoscopic stapler, the da Vinci Xi patient side cart and robotic arms, the da Vinci Single-Site robotic instruments, and the da Vinci Single-Site port with instruments positioned and robotic arms docked. The video shows a robotic Rives-Stoppa retromuscular incisional hernia repair with bilateral transversus abdominis release. This review contains 9 highly rendered figures, 1 video, and 85 references Key words: Robotic, surgery, hernia, inguinal, ventral, incisional, fundoplication, paraesophageal hernia, myotomy, gastrectomy, cholecystectomy, pancreatectomy, splenectomy, bariatric, adrenalectomy, colon, colectomy, colorectal

Evaluation of the ROSA™ Spine robot for minimally invasive surgical procedures

ABSTRACTThe ROSA® robot (Medtech, Montpellier, France) is a new medical device designed to assist the surgeon during minimally invasive spine procedures. The device comprises a patient-side cart (bearing the robotic arm and a workstation) and an optical navigation camera. The ROSA® Spine robot enables accurate pedicle screw placement. Thanks to its robotic arm and navigation abilities, the robot monitors movements of the spine throughout the entire surgical procedure and thus enables accurate, safe arthrodesis for the treatment of degenerative lumbar disc diseases, exactly as planned by the surgeon. Development perspectives include (i) assistance at all levels of the spine, (ii) improved planning abilities (virtualization of the entire surgical procedure) and (iii) use for almost any percutaneous spinal procedures not limited in screw positioning such as percutaneous endoscopic lumbar discectomy, intracorporeal implant positioning, over te top laminectomy or radiofrequency ablation.

Transoral endoscopic nasopharyngectomy with a flexible next-generation robotic surgical system.

To determine the feasibility of transoral endoscopic nasopharyngectomy without division of the soft plate using a flexible, next-generation robotic surgical system. Preclinical anatomic study using four human cadavers. Transoral resection of the nasopharyngeal wall with en-bloc resection of the cartilaginous Eustachian tube and dissection of the parapharyngeal fat space. The first flexible robotic surgical system has recently been described. We performed a series of laboratory experiments to determine whether this flexible system could be used to perform transoral robotic nasopharyngectomy. This novel system allowed docking of the patient-side cart at the side of the operating table. The cannula tip was placed approximately 12 cm from the edge of the retractor pointing superiorly toward the nasopharynx (NP). Retraction of the soft palate anteriorly and tonsillar pillars laterally with stay sutures expanded the velopharyngeal inlet, providing adequate space to deploy all four instruments (three surgical instruments and a camera) into the NP for dissection. All instruments could be deployed into the NP, without collision or restriction of joint movement in this cadaver model. Using this position and docking location, the new flexible surgical robot provided sufficient access, reach, and visualization to complete robotic nasopharyngectomy with en-bloc resection of the cartilaginous Eustachian tube. This feasibility study showed that transoral endoscopic nasopharyngectomy could be performed without compromising the integrity of the soft palate using a novel flexible robotic surgical system. N/A. Laryngoscope, 126:2257-2262, 2016.

A flexible, single-arm robotic surgical system for transoral resection of the tonsil and lateral pharyngeal wall: Next-generation robotic head and neck surgery.

To describe the application of a novel flexible robotic surgical system to transoral endoscopic head and neck surgery of the tonsillar fossa and lateral oropharyngeal wall. Preclinical anatomic study using three human cadavers. Transoral resection of the lateral oropharyngeal wall with mucosal and muscular resection of the tonsillar fossa. This single-port flexible robotic system could be used to successfully perform transoral resection of this region. The optimal angle to dock the patient-side cart was at a 90-degree angle to the operating room table. The placement of the remote center of the robotic instrument arm was evaluated in three positions. When the cannula tip was placed at 10 to 15 cm, all instruments could be deployed past the first and second joggle joint settings, without collision or restriction of arm movement. Using this position and docking location, all four arms were deployed inside the oral cavity without collision or restriction of movement in all three cadavers. The Da Vinci SP (Intuitive Surgical, Inc., Sunnyvale, CA) provided sufficient access, reach, and visualization in order to complete a transoral lateral oropharyngectomy. The first preclinical feasibility study of a novel, flexible, single-arm robotic surgical system is presented for its use in transoral endoscopic head and neck surgery. N/A.

Robotic surgery in gynecology.

FDA approved Da Vinci Surgical System in 2005 for gynecological surgery. It has been rapidly adopted and it has already assumed an important position at various centers where this is available. It comprises of three components: A surgeon's console, a patient-side cart with four robotic arms and a high-definition three-dimensional (3D) vision system. In this review we have discussed various robotic-assisted laparoscopic benign gynecological procedures like myomectomy, hysterectomy, endometriosis, tubal anastomosis and sacrocolpopexy. A PubMed search was done and relevant published studies were reviewed. Surgeries that can have future applications are also mentioned. At present most studies do not give significant advantage over conventional laparoscopic surgery in benign gynecological disease. However robotics do give an edge in more complex surgeries. The conversion rate to open surgery is lesser with robotic assistance when compared to laparoscopy. For myomectomy surgery, Endo wrist movement of robotic instrument allows better and precise suturing than conventional straight stick laparoscopy. The robotic platform is a logical step forward to laparoscopy and if cost considerations are addressed may become popular among gynecological surgeons world over.

A feasible and time-efficient adaption of the neurosafe intraoperative frozen section technique to robotic-assisted radical prostatectomy.

147 Background: In robotic-assisted radical prostatectomy (RARP) intraoperative frozen sections are often avoided due to suspected difficulties in harvesting the prostate during this procedure, loss in pneumoperitoneum, increased blood loss and lacking impact on functional outcome. We demonstrate the technique, feasibility and beneficial impact of our NeuroSAFE technique on the rate of nerve-sparing (NS) in RARP and analyse the oncological outcome. Methods: We analyzed 1,570 consecutive patients undergoing RARP from 2004 to 2012. NeuroSAFE was done in 1,178 pts. We compared OR-time, blood loss, frequency of nerve-sparing (NS) and PSM in non-NeuroSAFE versus NeuroSAFE-RARP. The prostate was intraoperatively harvested via an extension of the camera trocar incision without undocking the system. Instrument arms were not undocked. Blood spillage from the dorsal vein complex due to loss of pneumoperitoneum was avoided by upward traction on the transurethral catheter. After prostate removal, pneumoperitoneum was reestablished by closing the extended incision and repositioning of the optical trocar. NeuroSAFE-procedure consisted of intraoperative bilateral frozen sections covering the entire contact area of the prostate and the neurovascular bundles. Results: There was no significant difference in blood loss (253.5±204.4 ml vs. 265.8±246.7 ml, p=0.49) and OR-time. (220 min ± 51 vs. 224 min ± 64, p=0.22). No complications associated with specimen harvesting occurred. NS-rate increased significantly with vs. without NeuroSAFE (overall 97% vs. 81%, pT2 99% vs. 90%, pT3a 94% vs. 74%, pT3b 91% vs. 30). PSM rate dropped significantly with NeuroSAFE (overall 16% vs. 24%, pT2 8% vs. 15%, pT3a 22% vs. 39%, pT3b 49% vs. 67%, all p<0.05). Conclusions: We demonstrate a time-efficient adaption of the NeuroSAFE without patient side cart undocking, easy harvesting process, no increased blood loss or OR-time increased rate of nerve-sparing frequency and reduction of PSMs.

Robotic Surgery Systems

For many people, the term “robotic surgery” likely evokes one of two images. One is Asimo, the Honda robot, performing a complex heart-valve replacement with the precision and finesse of the most skilled surgeon. The other is more along the lines of an industrial robot found welding on an automotive assembly line—performing surgery by rote programming on scores of patients in a row, just like in a factory. Neither is the case. Robotic surgery is, by some accounts, the next level of minimally invasive surgery. Conventional invasive surgery involves a large incision in the body to gain access to the area and organ of interest. For example, in a conventional gallbladder removal, the surgeon first performs a laparotomy, which is an incision, usually a large one, through the abdominal wall to gain access to the interior of the torso. The problem with a laparotomy is that it is very stressful physiologically and exposes large portions of the patient’s abdominal cavity to infection. Additionally, because the incision is so large, and the surgeon needs access to a large part of the patient’s interior, the surgery is characterized by a relatively large amount of trauma to the surrounding tissue, blood loss, and postoperative pain and discomfort coupled with a prolonged healing period. To overcome the problems and side effects of the laparotomy, minimally invasive surgery was developed. Minimally invasive surgery accesses the chest or abdomen through several smaller incisions, each one typically half an inch long. Each smaller incision has a port, or a combination trocar/port is used to make the incision, to protect the surrounding tissue while a particular device is inserted through the hole. The most common items inserted are an endoscope connected to a camera, a light source (which may be part of the other devices), an insufflator, and an instrument with one or more operating channels. In the case of minimally invasive gallbladder removal, now called a laparoscopic cholecystectomy, all the associated steps (draining the gall bladder, severing it from the ducts, and removing the empty bladder) are performed through the operating channel using specially adapted instruments. In minimally invasive surgery, as few as three or four small incisions can take the place of the much larger laparotomy incision. Some surgeons also perform this procedure as “scarless surgery” by accessing the abdomen through the navel and using a specialized operating endoscope with integral illumination and operating channels. Although there technically is a scar, observers might be hard pressed to find it as it is hidden in the folds of the navel. As one would expect, the smaller incisions mean less trauma to the body as a whole, reduced blood loss, and minimal discomfort, all of which equate to a shorter healing period. Minimally invasive surgery techniques are THE FUNDAMENTALS OF ...

Global robotic experience and the type of surgical system impact the types of robotic malfunctions and their clinical consequences: an FDA MAUDE review

To assess annual rates of robotic system malfunctions and compare the da Vinci S(®) system (dVS) and da Vinci(®) surgical system (dV). To assess the types of malfunctions and associated outcomes for robotic cases and determine the extent to which experience and technological improvements impact these. This study is a retrospective review of the US Food and Drug Administration (FDA) MAUDE (Manufacturer and User Facility Device Experience) database, a publicly available, voluntary reporting system (http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm). The database was searched using the two phrases 'da Vinci' and 'Intuitive Surgical' from 2003 to 2009. Malfunctions of the instruments, console, patient-side cart, camera and cannula were recorded. Data on intraoperative injuries, case delays and conversions were also collected. In all, 1914 reports were reviewed (991 dVS and 878 dV, 45 unclassified) with peak years for reports of 2008 for dVS (571) and 2007 for dV (211), P < 0.001. With respect to time, the proportion of console and patient-side cart malfunctions declined from 2007 onward compared with the proportions prior to 2007 (5.1% vs 9.4% and 6.6% vs 10.9%). Patient injury did not change with year of surgery (0.5-5.4% of malfunctions, P= 0.358), open conversions declined (21.3% of malfunctions before 2007 vs 9.9% from 2007 onward, P < 0.001) and patient deaths increased (0.0013% of cases before 2007 vs 0.0061% of cases from 2007 onward, P < 0.001). With regard to robotic system, console and patient-side cart malfunctions were more frequent with the dV than the dVS: 82/878 vs 39/991 and 100/878 vs 48/991, P < 0.001. Open conversion was more frequent with dV than dVS (19.3% vs 7.7% of reported malfunctions, P < 0.001), while patient injury was less with dV than dVS (3.5% vs 5.9%, P= 0.021). The dVS decreased console and patient-side cart errors relative to total malfunctions, which were also influenced by surgical year. Open conversions were reduced by increased robotic experience and newer surgical system. Differences in patient injury may reflect changes in reporting or case complexity.

Kinematics Based Safety Operation Mechanism for Robotic Surgery extending the JHU SAW Framework

As robotic surgery gains popularity [1, 2, 3], methods for improving situational awareness during tele- operation have become an active area of research. Literature has attempted to incorporate haptic feedback displays to enhance and improve user performance. For example, Massimino et al. [4] showed that a combi- nation of vibrotactile and auditory substitutions lead to task performance (peg-in hole task) comparable to that using a force feedback. Kitagawa et al. [5] extended this approach by using visual force displays and and auditory cues, in experiments showing comparable performance in surgical tasks (knot-tying). Reiley et al. [6] used a visual force display in a teleoperated knot-tying task to demonstrate lower forces and reduced suture breakage by trainees. The above art demonstrates the need for information overlays in telerobotic surgical tasks. However, this literature also used prototype software and tools intended only for the specic experiments. By contrast, we use the Surgical Assistant Workstation (SAW) [7, 8] in development at Johns Hopkins University to create a general information overlay, and demonstrate its utility by creating a visual warning display for telerobotic surgery that detects instruments being operated outside of the eld of view of the endoscopic camera. SAW is a modular framework for rapid prototyping of new tools and methods for robotic surgery. It includes methods for image guidance, registration with pre-operative and intra-operative images, and ability to interact with the graphical objects rendered within the display with the master or slave manipulators in a teleoperation environment. The common telesurgical system in use is the da Vinci Surgical System (Intuitive Surgical Inc.). It consists of a surgeon’s console containing the two master manipulators, a patient side cart with up to four robotic arms - three for the slave instrument manipulators which can be equipped with the removable instruments and an endoscope camera manipulator connected to a high-performance stereo vision system. The da Vinci also provides a research and development application programming interface (DiMaio, et al., [9]) that streams kinematics data and system events at congurable rates of up to 100Hz. The SAW/cisst framework also contains an interface to the da Vinci API. We present an overlay architecture (Figure 1) implemented using the cisst/SAW libraries to integrate contextual procedure and system information for improving safety, and situational awareness during these delicate and complex manipulations. While the presented methods can be modied for use with any robotic system, we used our da Vinci S Surgical System (Intuitive Surgical Inc.) for the validation experiments (Figure 2) here. Results from validation experiments with 17 users and a total of 50 training sessions totaling 214350 image frames are presented.

Training in Robotic Surgery Using the da Vinci® Surgical System for Left Pneumonectomy and Lymph Node Dissection in an Animal Model

In Japan, as of March 2010, only 13 hospitals were using the da Vinci® system and only for selected cases. Few clinical robotic lung surgery has been done in Japan, and there are no standardized training programs, although some exist in the U.S. and are under consideration by the Japanese society for thoracic surgery. We have used the da Vinci S® Surgical System for pneumonectomy and lymph node dissection in pigs. We report and review future possibilities and problems of robotic surgery, especially concerning education, training, safety management and ethical considerations for pneumonectomy and lymph node dissection in clinical practice. The da Vinci® system consists of a surgeon's console connected to a patient-side cart, a manipulator unit with three instrument arms and a central arm to guide the endoscope. The surgeon, sitting at the console, triggers highly sensitive motion sensors that transmit the surgeon's movements to the instrument arm. We experienced exactly the same sensation as when performing standard open thoracotomy. Visual recognition is 3-D, and the high manipulation potential allows free movement of the various accessory instruments, exceeding the capacity of a surgeon's hands in video-assisted thoracic surgery (VATS) or even standard thoracotomy. Robotic surgery achieves at least the same level of operation technique for pneumonectomy and lymph node dissection under standard open thoracotomy, and it seemed as safe and easily performed as conventional VATS. The training program using pigs was effective and holds promise as a system to train thoracic surgeons in robotic lung surgery.

An overview of the intuitive system: The surgeon's perspective

An overview of the intuitive system: The surgeon's perspective