Robot-assisted Laparoscopic Fundoplication Research Articles

СРАВНИТЕЛЬНЫЙ АНАЛИЗ ЛАПАРОСКОПИЧЕСКОЙ И РОБОТ-АССИСТИРОВАННОЙ ФУНДОПЛИКАЦИИ ПРИ ГРЫЖАХ ПИЩЕВОДНОГО ОТВЕРСТИЯ ДИАФРАГМЫ

Elaparoscopic fundoplication has gained rapid surgery and is the gold standard in the treatment of hiatal hernia and gastroesophageal reflux disease. However, with the invention of robot-assisted laparoscopic technologies, disputes over this or that minimally invasive technology have not subsided. Methods. A group of authors from 2015 to 2019 y.e. 363 surgical treatments was performed for the treatment of hiatal hernia and gastroesophageal reflux disease. Patients were stratified on laparoscopic fundoplication or robot-assisted laparoscopic fundoplication. Intraoperative and postoperative results were evaluated. Results. All 363 patients completed Nissen fundoplication: laparoscopic fundoplication - 291 (80.17%) patients, robot-assisted laparoscopic fundoplication - 72 (19.83%) patients. Intraoperative and postoperative results are comparable with each other. Complications of Clavien-Dindo Classification >3 were observed in 3 patients in the laparoscopic fundoplication group. The follow-up period for patients of the laparoscopic fundoplication group ranged from 1 to 53 months (median - 19 months), for patients of the robot-assisted laparoscopic fundoplication group ranged from 1 to 41 months (median - 13 months). Conclusion. The observed values demonstrate that robot-assisted laparoscopic fundoplication is comparable to laparoscopic fundoplication in terms of a workable result.

Refractory gastroesophageal reflux disease as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication

Some patients with typical (heartburn/regurgitation) symptoms of gastroesophageal reflux disease (GERD) are refractory to proton pump inhibitor (PPI) therapy. Impedance-pH monitoring can identify PPI-refractory patients who could benefit from laparoscopic fundoplication, but outcome data are scarce. We aimed to assess whether PPI-refractory GERD as diagnosed by impedance-pH monitoring can be cured by laparoscopic fundoplication. Forty-four consecutive GERD patients with heartburn/regurgitation refractory to high-dose PPI therapy entered a 3-year outcome assessment following robot-assisted laparoscopic fundoplication. Preoperative on-PPI impedance-pH diagnostic criteria consisted of positive symptom association probability (SAP)/symptom index (SI), and/or abnormal percentage esophageal acid exposure time (%EAET), and/or abnormal number of total refluxes. GERD cure was defined by 3-year postoperative off-PPI normal impedance-pH findings with persistent symptom remission. Preoperatively, 24 of 38 (63 %) patients who completed the outcome assessment had a positive SAP/SI, 20 of 38 (53 %) for weakly acidic refluxes; 3 of 38 (8 %) patients had an abnormal %EAET, 11 of 38 (29 %) an abnormal number of total refluxes only. Postoperatively, heartburn/regurgitation recurred in 3 patients; abnormal impedance-pH findings were found in two of them, and they responded to PPI therapy. GERD cure was achieved in 34 of 38 (89 %) patients, 11 of 11 with an abnormal number of total refluxes as the only preoperative abnormal impedance-pH finding. Postoperatively, there was a significant decrease of the %EAET (1 vs. 0.1 %, P = 0.002) and of the number of total refluxes (68 vs. 8, P = 0.001), with the latter finding mainly due to a decrease in the number of weakly acidic refluxes. Normal reflux parameters and persistent symptom remission at 3-year follow-up can be achieved with laparoscopic fundoplication in the majority of patients with PPI-refractory GERD as diagnosed by impedance-pH monitoring. On-PPI impedance-pH diagnostic criteria should include SAP/SI positivity, an abnormal %EAET, and an abnormal number of total refluxes. Weakly acidic refluxes have a major role in the pathogenesis of PPI-refractory GERD.

Is there a Future for Robot-assisted Laparoscopic Nissen Fundoplication (RALF)...?

Introduction: Gastroesophageal reflux disease (GERD) has been the main health concern in the last few years, both in term of quality of life and symptomatology and also causing longterm health concern like cancer. In our current practice laparoscopic Nissen fundoplication is the most commonly performed operative procedure for reflux disease. Aim and methodology: We performed our review to predict the future of robot-assisted laparoscopic fundoplication (RALF) by looking at this new technology from different angles namely, comparison with conventional laparoscopic Nissen fundoplication (CLF), in term of operative complications and postoperative outcome, training aspect of RALF, application in complicated cases and difficult tasks, and also in pediatric population. Conclusion: We are in the opinion that there is a promising future for RALF, despite the increased cost and longer operation time. It has been found that RALF can function better in smaller spaces and more capable in finer dissection and it has shorter and steeper learning curve. The time and the cost issue is expected to reduce with further development and upgrades of the robotic surgery, and increase in surgeons experience in RALF. Therefore, we think the trend should be more toward RALF as a future of antireflux surgery.

Whether robot-assisted laparoscopic fundoplication is better for gastroesophageal reflux disease in adults: a systematic review and meta-analysis

Although laparoscopic fundoplication is an effective, minimally invasive surgical technique for gastroesophageal reflux disease (GERD) that failed to be treated with medicine, with wide implementation its technical limitations have become increasingly clear. Recently, robot-assisted laparoscopic fundoplication (RALF) was considered a new approach that makes up for the deficiency of conventional laparoscopic fundoplication (CLF). This systematic review aimed to assess the feasibility and efficiency of robot-assisted laparoscopic fundoplication for GERD. Two reviewers independently searched and identified seven randomized controlled trials (RCTs) and four clinical controlled trials (CCTs) of RALF versus CLF for GERD in the Cochrane database, Medline, Embase, and Science citation index between 2001 and 2009. The main outcomes were operating time, complication rate, hospital stay, and costs. The meta-analysis was performed by Review Manager 5.0 software. The effect size of the clinical outcomes was evaluated by odds ratio (OR), weighted mean difference (WMD), and standard mean difference (SMD) according to different data type. Heterogeneity and sensitivity analysis were used to account for rationality of pooling data and sources of heterogeneity. Of 483 studies found, a total of 11 trials were included in this review; among 533 patients, 198 patients underwent RALF and 335 patients underwent CLF. The results of meta-analysis showed that the postoperative complication rate (OR = 0.35, 95% CI = [0.13, 0.93], p = 0.04) is lower for RALF, but the total operating time (WMD = 24.05, 95% CI = [5.19, 42.92], p = 0.01) is longer for RALF compared with those for CLF. Statistically, there was no significant difference between the two groups with regard to perioperative complication rate (OR = 0.67, 95% CI = [0.30, 1.48], p = 1.00) and length of hospital stay (WMD = 0.00, 95% CI = [-0.25, 0.26], p = 0.04). Systematic review of the literature indicates that RALF is a feasible and safe alternative to surgical treatment of GERD. However, since it lacks obvious advantages with respect to operating time, length of hospital stay and cost, RALF has limitations for its extensive application in clinics.

Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study

We read with great interest the recent Surgical Endoscopy publication entitled ‘‘Robot assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled study’’. The authors come to the conclusion that—besides shortened operation time—the application of the operation robot does not reveal a further benefit in laparoscopic fundoplication. In 2002 we were able to perform a pilot study on robot-assisted laparoscopic Toupet fundoplication with the DaVinci surgical system (Intuitive Surgical, Mountain View, Calif., USA) with a 6month follow-up and came to the same conclusion except for an even longer set-up and operating time in our series [1]. Despite demanding experience of the surgeon in order to obtain a good functional outcome the performance of a laparoscopic fundoplication does not require the four main advantages of robot assisted laparoscopic surgery: it is not an operation that cannot be performed laparoscopically without the robot [2]; it does not require microscopic view and movements of the arms; anatomically it is not an operation in a remote or narrow operating field [3, 4]; and in a normal laparoscopic fundoplication no complex manoeuvres such as creation of an intracorporeal anastomosis or complex suturing [5] are needed. Improved ergonomics for the surgeon and a shorter set-up and operation time as a matter of training (as demonstrated in the above mentioned paper) do not outweigh higher operative costs as long as no further clear advantage is proven. Laparoscopic redo fundoplications [6] often consist of an even more demanding intraoperative situation where the operation robot could allow for a more precise dissection, avoiding inadvertent lacerations (e.g., lacerations of the vagus nerve), and therefore lead to a better outcome. For training purposes in order to be prepared for such more demanding applications the performance of robot-assisted laparoscopic fundoplications seems justified.

Robotic fundoplication in children

Since January 2006, robotic assistance has been used for performing minimal invasive laparoscopic fundoplications in children. These patients were compared with those operated on with either the open surgical technique or the laparoscopic procedure. The first six children operated on with a fundoplication using the operation robot, da Vinci Surgical System from Intuitive Surgical, were included prospectively. As controls, data from the latest six children operated on using the open surgical procedure and the latest six children operated on using the minimal invasive laparoscopic technique were selected retrospectively. All the patients were operated on due to gastroesophageal reflux and were comparable in the De Meester score. The main outcome measures were the operating time, the use of postoperative analgesics, the duration of the postoperative hospital stay and the short-term outcome. There was no significant difference between the three groups concerning age, body weight and preoperative 24 h pH measurement. The mean operating time for the robotic group, 213 min, was the longer one, but the operating time for the latest four patients in the robotic group was similar to that for the laparoscopic group, 189 min. The postoperative hospital stay was shorter and a reduction in the use of analgesics postoperatively was noted. The reduction in the postoperative hospital stay and in the use of analgesics had been already noted with the introduction of the minimal invasive laparoscopic technique. There was no difference in short-term clinical outcome; the gastroesophageal reflux symptoms disappeared in all the patients. Robot-assisted laparoscopic fundoplication is comparable with the standard laparoscopic surgical procedure in terms of duration of operation, postoperative hospital stay, use of postoperative analgesics and short-term clinical outcome. The robotic surgery adds qualities to the surgical work when compared with open or laparoscopic surgery. These include better visualisation for the surgeon and greater precision in the movements of the instruments used.

Hemodynamic and Respiratory Effects of Robot‐assisted Laparoscopic Fundoplication in Children

Laparoscopic fundoplication is increasingly used for treating gastro-esophageal reflux disease in children. Mechanical and pharmacological effects may contribute to hemodynamic and respiratory changes during carbon dioxide pneumoperitoneum. The aim of the present study was to evaluate the hemodynamic and respiratory effects of pneumoperitoneum (PP) with an intra-abdominal pressure (IAP) of 12 mmHg in children undergoing robot-assisted laparoscopic fundoplication during total intravenous anesthesia. Ten children, aged 8-16 years, American Society of Anesthesiologists physical status II-III, scheduled for robot-assisted laparoscopic fundoplication in the reverse Trendelenburg position were investigated. Minute ventilation (MV), peak inspiratory pressure (PIP), IAP, heart rate (HR), mean arterial blood pressure (MAP) were recorded, together with pH, base excess, HCO3-, P(et)CO2, PaCO2, and PaO2 at six time points: before insufflation, 10, 30, 60, 90 minutes after creating PP and after desufflation. The IAP was maintained at 12 mmHg. During insufflation MAP increased significantly from 70.6 (+/-9.0) to 84.8 (+/-10.4) mmHg, MV was increased from 4.6 (+/-0.8) to 5.5 (+/-0.9) l min(-1), PIP increased, PaO2 and pH decreased. P(et)CO2 increased from 33.1 (+/-1.6) to 36.6 (+/-1.6) mmHg together with PaCO2. Hemodynamic and respiratory effects due to the intra-abdominal insufflation of CO2 with an IAP of 12 mmHg are well tolerated, and anesthesia with remifentanil, propofol and mivacurium facilitates extubation immediately at the end of surgery.

Robotic fundoplication: from theoretic advantages to real problems.

ROBOTICS IN LAPAROSCOPIC SURGERY During the past decade, laparoscopy, through a dramatic worldwide diffusion, has become the gold standard in the surgical treatment of several conditions. Currently, it is still spreading and gaining popularity in new fields of surgery. Nevertheless, the laparoscopic technique has shown peculiar disadvantages and limitations intrinsic to this approach. Unlike traditional open surgery, in laparoscopy, the action of the surgeon’s hand is mediated by rigid, unarticulated instruments, and the visual access is not direct, but is mediated by a camera. Obviously, these limitations reduce the laparoscopic surgeon’s possibilities and increase technical difficulty, operative times, and risk of complications. In an effort to improve surgical technique by avoiding some of the disadvantages of laparoscopy while maintaining the advantages brought by the miniinvasive approach (less postoperative pain, shorter hospital stay, and early return to normal activities, robotics have been introduced in surgery. Domains range from general to urologic, cardiac, and gynecologic surgery. A decade after the first laparoscopic cholecystectomy, in 1987, the first telesurgical laparoscopic cholecystectomy formally opened the robotic era in general surgery. Since then, the robotic approach has been used in several general surgery procedures, such as cholecystectomy, gastroesophageal surgery, obesity surgery, and adrenalectomy. But despite early encouraging results and recent spectacular applications, robotics have not yet witnessed wide, large-scale diffusion among general surgeons and are still considered “experimental approaches.” THE ROBOTIC SYSTEM To reduce the limitations of laparoscopic surgery, robotic systems have been designed to give endoscopic surgeons the same quality of information and manipulation as they have when performing open surgery. These designs include: instruments and manipulators with all degrees of freedom, devices that provide surgeons with tactile feedback, and improved visual access. Until now, two robotic systems have been extensively tested in surgery: the Zeus (Computer Motion) and the Da Vinci (Intuitive Surgical) systems. Although both have shown to be effective and both are clinically promising, it appears that the Da Vinci system allows for shorter operating times and steeper learning curves. No comparison between these operative systems has yet been reported in general surgery procedures. To our knowledge, only the Mona-Da Vinci system has been used for robot-assisted laparoscopic fundoplication. Our experience refers to both the Da Vinci system and its precursor, the Mona prototype. The Mona-Da Vinci system introduces several technologic innovations aimed at improving a surgeon’s operating skills (Table 1). The greatest innovations of this system are the articulated arms. Whereas in open surgery the flexibility of the wrist and the hands inside the abdomen permits fully free movements, in laparoscopy, the presence of rigid, unarticulated instruments entering the abdomen through fixed openings (trocar sites) limits the number of degrees of freedom. Additional articulations inside and outside the abdomen may help recover the degrees of freedom that have been lost and regain some dexterity of the surgeon’s hand in open surgery. The robot downscales a surgeon’s movements (by a 10:1, 5:1, or 3:1 factor) and eliminates the physiologic tremor, increasing the accuracy of the surgeon’s action. A threedimensional monitor allows the surgeon to obtain more accurate visual control of the instruments and better motion coordination. Finally, because the robot is composed of two units, the patient’s station and the surgeon’s station, united by No competing interests declared.