Robot-assisted Laparoscopic Procedures Research Articles

Robotic Assisted Endoscopic Surgery Practices in Pediatric Surgery, Single Center Experience

Objective: While robot-assisted laparoscopic surgery (RALS) is spreading rapidly all over the world, In pediatric surgery, this spread is slower than in adult surgery for many reasons. In this study, we discuss our initial experiences with pediatric robotic surgical cases. Material and Methods: Robotic-assisted endoscopic surgery between November 2017 and April 2022 was retrospectively reviewed. The medical records of the patients were reviewed retrospectively for some demographical features, surgical details, and follow-up time. Results: Of the 48 children, 27 were male and 21 were female. The youngest of the cases was 10 months old, while the oldest was 17 years old (mean 7.72±5.6, median 7). The shortest follow-up period after surgery was 5 months, while the longest follow-up was 60 months. A total of 63 surgical procedures were performed on 48 pediatric patients. 17 pyeloplasty (left 10, right 7), 9 Lich Gregoir operations (right 6, left 3), 4 ureteral reimplantation and tapering procedures due to left ureterovesical junction obstruction (UJO), 3 Hemi nephrectomy, one appendicovesicostomy, One right ureteral reimplantation, 11 Nissen fundoplication, 10 gastrostomy and one gastrojejunostomy, two ovarian sparing surgeries for ovarian cyst were performed. One urachal remnant excision, one adrenal mass excision, and one thoracic outlet mass excision were performed. Conclusion: This is the first study that includes a wide range of pediatric robotic surgical procedures in our country. Robotic-assisted laparoscopic procedures in pediatric surgery can be safely performed for many surgical pathologies. We think at the beginning some simple surgical procedures and then turning to the more complex procedures after at least 15 cases will be more appropriate.

Medial versus lateral camera port placement for robotic nephron-sparing surgery: evaluating surgical complications and outcomes.

As the growing popularity of robotic-assisted laparoscopic procedures for the treatment of renal cancer increases, there exists a variation in surgical technique among institutions and surgeons alike. One variation that exists in robotics is the anatomical placement of the camera port (medial versus lateral camera port placement). The purpose of this study is to evaluate surgical complications and outcomes in comparison to site of camera port placement during nephron-sparing surgery in an academic setting. Over a three-year period, outcomes for all robotic surgeries for renal cancer were examined. A total of 229 cases were discovered. Patient demographics and comorbidities were analyzed along with perioperative surgical data including location of camera port, surgery length, warm ischemia time, blood loss, pathological tumor margins, tumor size, length of stay and laboratory data. 134 patients had surgery performed with lateral camera port placement versus 95 patients with medial camera port placement. Operative time was significantly lower with an average operative time of 165.8min for the lateral group versus 209.1min in the medial group (p < 0. 0001). Warm ischemia time was also less in the lateral group with an average of 11min versus 15.5min for the medial group (p < 0. 0001).Blood loss was less in the lateral camera port group with an average of 158.2mL (± 196.5mL) versus 248.6mL in the medial group (± 252.6) (p = 0.0040). Drain use, positive surgical margin rate, transfusion rate, conversion to radical nephrectomy, change in pre-operative versus postoperative creatinine and glomerular filtration rate and length of hospital stay did not statistically differ. Lateral camera port placement is associated with decreased operative time and warm ischemia time in this series. There may be certain laparoscopic advantages through a better visualization of surgical anatomy, thus allowing for faster extirpation of renal lesions and decrease in surgical time. These advantages may result in better long-term renal function and decreased clinical sequela from chronic kidney disease.

Robotic Peritoneal Flap vs. Perineal Penile Inversion Techniques for Gender-Affirming Vaginoplasty.

To discuss perineal and robotic approaches to gender-affirming vaginoplasty. The Davydov peritoneal vaginoplasty has its origins in neovaginal reconstruction for vaginal agenesis. It has been adapted as a robotic-assisted laparoscopic procedure and provides an alternative to perineal canal dissection in gender-affirming vaginoplasty. Both techniques represent variations of penile inversion vaginoplasty with successful outcomes and overall low rates of major complications reported in the literature. However, there are differing advantages and considerations to each approach. A perineal approach has been the gold standard to gender-affirming vaginoplasty for many decades. Robotic peritoneal gender-affirming vaginoplasty (RPGAV) is an emerging alternative, with potential advantages including less reliance on extragenital skin grafts in individuals with minimal genital tissue, especially among patients presenting with pubertal suppression, and safer dissection in revision vaginoplasty for stenosis of the proximal neovaginal canal. Additional risks of RPGAV include those associated with robotic abdominal surgeries.

The Impact of Steep Trendelenburg Position on Intraocular Pressure.

Intraocular pressure occurring during the Trendelenburg position may be a risk for postoperative visual loss and other ocular complications. Intraocular pressure (IOP) higher than 21 mmHg poses a risk for ocular impairment causing several conditions such as glaucoma, detached retina, and postoperative vision loss. Many factors might play a role in IOP increase, like peak expiratory pressure (PIP), mean arterial blood pressure (MAP), end-tidal CO2 (ETCO2) and surgical duration and some others (anaesthetic and neuromuscular blockade depth) contribute by reducing IOP during procedures requiring both pneumoperitoneum and steep Trendelenburg position (25–45° head-down tilt). Despite transient visual field loss after surgery, no signs of ischemia or changes to the retinal nerve fibre layer (RNFL) have been shown after surgery. Over the years, several studies have been conducted to control and prevent IOPs intraoperative increase. Multiple strategies have been proposed by different authors over the years to reduce IOP during laparoscopic procedures, especially those involving steep Trendelenburg positions such as robot-assisted laparoscopic prostatectomy (RALP), and abdominal and pelvic procedures. These strategies included both positional and pharmacological strategies.

Surgical Complications and Hospital Costs in Robot-Assisted Versus Conventional Laparoscopic Hysterectomy With Concurrent Sacrocolpopexy: Analysis of the Nationwide Readmissions Database.

Despite increasing use of robotic technology for minimally invasive hysterectomy with sacrocolpopexy, evidence supporting the benefits of these costly procedures remains inconclusive. This study aimed to compare differences in perioperative complications, 30-day readmissions, and costs between robot-assisted and conventional laparoscopic hysterectomy with concurrent sacrocolpopexy using a large national database. Using the 2009-2015 Nationwide Readmissions Database and procedure codes, we identified patients who underwent a robot-assisted or conventional laparoscopic hysterectomy with sacrocolpopexy. We measured in-hospital perioperative complications using diagnosis and procedure codes and measured 30-day readmissions based on patient linkages across hospitalizations. Hospital costs were estimated using charges and cost-to-charge ratios. These outcomes were compared between robot-assisted and conventional laparoscopic procedures using bivariate and multivariable regression analysis. Our weighted sample included a total of 7,675 patients. Major perioperative complications occurred in 6.7% of robot-assisted and 11.2% of conventional laparoscopic procedures (unadjusted P < 0.001; adjusted odds ratio, 0.69; 95% confidence interval, 0.51-0.93; P = 0.02). Hospital costs were higher in robot-assisted than in conventional laparoscopic procedures (respective median costs, $16,367 vs $13,898; P < 0.001), with an adjusted cost ratio of 1.24 (95% confidence interval, 1.17-1.31; P < 0.001). The risk of 30-day readmission was similar between robot-assisted and conventional laparoscopic procedures. Nationally representative data suggest that, in laparoscopic hysterectomy with sacrocolpopexy, the robot-assisted approach is associated with a lower risk of perioperative complications, despite higher costs, compared with the conventional one. The risk of 30-day readmission was similar between the robot-assisted and conventional laparoscopic approaches.

Review of automated performance metrics to assess surgical technical skills in robot-assisted laparoscopy

Robot-assisted laparoscopy is a safe surgical approach with several studies suggesting correlations between complication rates and the surgeon's technical skills. Surgical skills are usually assessed by questionnaires completed by an expert observer. With the advent of surgical robots, automated surgical performance metrics (APMs)-objective measures related to instrument movements-can be computed. The aim of this systematic review was thus to assess APMs use in robot-assisted laparoscopic procedures. The primary outcome was the assessment of surgical skills by APMs and the secondary outcomes were the association between APM and surgeon parameters and the prediction of clinical outcomes. A systematic review following the PRISMA guidelines was conducted. PubMed and Scopus electronic databases were screened with the query "robot-assisted surgery OR robotic surgery AND performance metrics" between January 2010 and January 2021. The quality of the studies was assessed by the medical education research study quality instrument. The study settings, metrics, and applications were analysed. The initial search yielded 341 citations of which 16 studies were finally included. The study settings were either simulated virtual reality (VR) (4 studies) or real clinical environment (12 studies). Data to compute APMs were kinematics (motion tracking), and system and specific events data (actions from the robot console). APMs were used to differentiate expertise levels, and thus validate VR modules, predict outcomes, and integrate datasets for automatic recognition models. APMs were correlated with clinical outcomes for some studies. APMs constitute an objective approach for assessing technical skills. Evidence of associations between APMs and clinical outcomes remain to be confirmed by further studies, particularly, for non-urological procedures. Concurrent validation is also required.

Appropriate Preoperative Planning Leads to Successful Removal of the Small Volume Ovarian Remnant

<h3>Study Objective</h3> To review the ovarian remnant syndrome characteristics and risk factors. To describe the correct surgical technique to prevent this condition. To demonstrate the appropriate preoperative evaluation and surgical resolution of the small volume ovarian remnant. <h3>Design</h3> Educational video. <h3>Setting</h3> Robotic assisted laparoscopic procedure. Patient in dorsal lithotomy position. Bilateral double ended tiger tail prophylactic ureteral stents used. <h3>Patients or Participants</h3> We describe a case of a 40-year-old patient who presented with a pelvic cystic mass and pelvic pain. She had a history of multiple laparotomies including an abdominal hysterectomy and bilateral salpingo-oophorectomy. She had a known BRCA 1 mutation and a strong family history of ovarian cancer. Her estradiol and follicle-stimulating hormone (FSH) levels were in the premenopausal range. Ovarian remnant syndrome was suspected. <h3>Interventions</h3> Robotic assisted removal of bilateral small volume ovarian remnants. <h3>Measurements and Main Results</h3> An overview of the preoperative evaluation and management of small volume ovarian remnant syndrome is described. The surgical technique to prevent ovarian remnant syndrome is discussed. The preoperative evaluation including hormone levels, ovarian stimulation, and imaging studies are discussed. Surgical planning including discussion with radiology and pathology are reviewed. Relying on anatomical landmarks, ureterolysis, proximal ligation of the infundibulopelvic ligament, and other surgical tips for the successful removal of the small volume ovarian remnant are presented. <h3>Conclusion</h3> Appropriate surgical technique prevents ovarian remnant syndrome. Serial MRIs may help identify cyclic changes of the ovarian remnant. Ovarian stimulation and hormone levels may assist with diagnosis and treatment planning. Preoperative discussion with Radiology to look for anatomical landmarks is important to successfully excise small volume lesions.

Inguinal hernia TAPP repair using Senhance® robotic platform: first multicenter report from the TRUST registry.

The purpose of this article was to provide feasibility and safety results of robotic transabdominal preperitoneal inguinal hernia repair (Robotic TAPP). We included 271 cases of robotic inguinal hernia TAPP repair using the Senhance® robotic platform from four different centers between March 2017 and March 2020. Key data points were intraoperative and postoperative complication rate, operating time, length of hospital stay, postoperative pain score and time required to get back to a daily routine that were inserted in the TransEnterix European Patient Registry for Robotic assisted Laparoscopic Procedures in Urology, Abdominal Surgery, Thoracic and Gynecologic Surgery (TRUST). We report 203 cases of unilateral and 68 cases of bilateral inguinal hernia repairs. Mean operative time was 74 ± 35min (range 32-265min), postoperative complications occurred in five (1.85%) cases, the intraoperative complication rate was five (1.85%). The average subjective patient-related pain score after the procedure was 3 ± 1.9 (range 1-9), length of hospital stay was 39 ± 28h (range 4-288h), and recovery time was 9.65 ± 8days (range 1-36days). Robotic inguinal hernia TAPP repair shows inspiring results. It is a safe and doable procedure. However, cost analysis should be performed in future to show the superiority over other techniques.

Postoperative assessment of nosocomial transmission of COVID-19 after robotic surgical procedures during the pandemic

ObjectivesTo assess potential nosocomial coronavirus disease-2019 (COVID-19) transmission in patients who underwent robot-assisted laparoscopic procedures during the pandemic.Material and methodsProspective study in patients undergoing robot-assisted laparoscopy in urology or gynaecology within 2 academic hospitals. Patients underwent local preoperative COVID-19 screening using a symptoms questionnaire. Patients with suspicious screening underwent coronavirus real time-polymerase chain reaction (RT-PCR) and were excluded from robotic surgery if positive. Patients with symptoms postsurgery were systematically tested for coronavirus by RT-PCR. One-month postsurgery, all patients had a telephone consultation to evaluate COVID-19 symptoms.ResultsSixty-eight patients underwent robotic surgery during the study period (median age: 63-years [IQR: 53–70], 1.8 male: female ratio). Oncology was the main indication for robotic surgery (n = 62, 91.2%) and 26 patients (38.2%) received a chest CT-scan prior to surgery. Eleven patients (16.2%) were symptomatic after surgery of whom only 1 tested positive for coronavirus by RT-PCR (1.5%) and was transferred to COVID-19 unit with no life-threatening condition. No attending surgeon was diagnosed with COVID-19 during the study.ConclusionsRobot-assisted laparoscopic surgery seemed safe in the era of COVID-19 as long as all recommended precautions are followed. The rate of nosocomial COVID-19 transmission was extremely low despite the fact that we only used RT-PCR testing in symptomatic patients during the preoperative work-up. Larger cohort is needed to validate these results.

Robotic versus Laparoscopic Cholecystectomy: Case-Control Outcome Analysis and Surgical Resident Training Implications.

BackgroundThe robotic approach in surgery is becoming more widely used in many subspecialties. Robot-assisted laparoscopic procedures provide potential improvements in clinical outcomes due to improved visualization and enhanced surgical ergonomics. In this study, we measured and compared outcomes of robot-assisted laparoscopic cholecystectomy with the conventional laparoscopic technique, as well as the implications for the training of surgical residents.MethodWe compared a total of 244 patients undergoing minimally invasive cholecystectomies performed by one surgeon between July 2013 and June 2016 examining relevant clinical outcomes including operative room (OR) time, length of hospital stay (LOS), readmission to the hospital, post-operative emergency department (ED) visits, and post-operative pain between laparoscopic single-incision cholecystectomy and robot-assisted laparoscopic cholecystectomy. A chi-square test and Student’s t-test were used to compare these variables between the two groups. Propensity score matching (PSM) was used using gender, age, and body mass index (BMI) as variables.ResultsFrom the total number of procedures of 244, 144 were included in the laparoscopic group and 100 in the robot-assisted group. The robot-assisted patients had a shorter post-operative LOS (mean: 0.8 vs. 1.6 days; p = 0.002). There was no significant difference in the OR time (mean: 64.8 vs. 65.0 minutes; p = 0.945), readmissions (4.0% vs. 3.5%; p = 0.830), post-operative ED visits (7.0% vs. 7.6%; p = 0.851), or post-operative pain (13.0% vs. 21.3%; p= 0.137). Robotic cholecystectomy patients were younger (mean: 46 vs. 52 years; p = 0.023) and had lower BMIs (mean: 31 vs. 33; p = 0.038). Because of these differences, we compared the two groups using PSM that confirmed the shorter LOS in the robotic group (mean: 0.9 vs. 1.9; p = 0.009).ConclusionsThese results demonstrate that robotic cholecystectomies can reduce LOS for patients undergoing laparoscopic cholecystectomy, without increasing OR time. Increased surgeon experience with robotic procedures and improved OR efficiency will allow greater opportunities for resident participation. Robotic training curricula need to be employed and objectively evaluated to improve surgical resident skill acquisition and provide earlier and progressive clinical participation in robotic procedures.

Effective intracorporeal space in robot-assisted multiquadrant surgery in a pediatric inanimate model.

Pediatric robot-assisted surgery is technically challenging, but it is becoming the most desirable approach for most of the pediatric urological abdominal surgical procedures. Distance between ports has been adopted based on adult surgery experience. Currently, there is scarce information and literature about effective trocar position and distance between ports for highly complex pediatric multiquadrant surgery. The aim of this study is to evaluate the most effective way of port placement for pediatric multiquadrant robot-assisted surgery using an inanimate model. Two inanimate models simulating the abdominal area of an older infant were created: model (1) 33.3 × 29.6 × 11.5cm and model (2) 15 × 13 × 8 cm. A simulation of a robot-assisted laparoscopic Mitrofanoff procedure was performed in both models simulating appendix procurement and subsequent anastomosis to the bladder dome. In the first model, the simulation was performed in two ways: (a) adult trocars were placed with a distance of 4cm between them and placed longitudinally and (b) ports were placed by triangulating the camera 2cm in a cephalic fashion. In the second model, (a) scenario was used as described above (c) single port crossing the arms. Volume of the first model was 11,335.32cm3. Simulation (b) reached higher percentage of volumes without arm clash (30.19 vs. 41.92%, p = 0.021). In the second model with a volume of 1560cm3, simulation (a) reached a volume percentage of 65.15% without arm clash and allowing the multiquadrant advance, while simulation (c) could not be performed due to arm collision and the inability to advance and see the four quadrants. Triangulation and increasing the distance away from the point of interest improve intracorporeal EWS for multiquadrant complex pediatric surgery.

90: Assessing activity and recovery following benign gynecologic surgery using an activity monitor and validated tool sets: A pilot study

Assessment of recovery after surgery in women following benign gynecologic surgery remains highly subjective and elusive, as the majority of patient recovery is taking place at home and outside of the hospital. However, advances in wearable technology present an opportunity for clinicians to have an objective assessment of postoperative recovery. The aims of this pilot study are to 1) feasibility of the use of an activity monitor in a gynecologic surgical patient population, 2) use activity monitor data to characterize the recovery trajectory of physical activity for laparoscopic and open surgeries. Women aged 18-51 years old undergoing elective inpatient and outpatient surgical procedures at an academic tertiary medical center, specifically myomectomy and hysterectomy, were invited to participate. Physical activity was measured using an Actigraph GT3X wrist worn activity monitor. Participants wore the activity monitor a week before the surgery to assess preoperative baseline activity and they were asked to wear them for a minimum 6 weeks postop. The total number of steps was measured for each patient per day, and the time (in days) to baseline recovery activity was measured. Of the 15 patients enrolled, 13 patients completed the study procedures and were included in the analysis. 9 underwent a laparoscopic or robot-assisted laparoscopic procedure; 4 underwent a laparotomy. Of the 9 minimally invasive procedures, 7 were hysterectomies and 2 were myomectomies. Of the laparotomies, 2 were hysterectomies and 2 were myomectomies. The mean number of days the activity monitor was worn was 45 days (SD 27) for all procedures. For minimally invasive outpatient procedures, the total number of steps per day reached preoperative average levels on postoperative day (POD) 7.8 (SD 7.5). For laparotomies that required inpatient stay, the total number of steps per day reached preoperative average levels on POD 33.5 (SD 24.5). An adverse event in 1 patient was associated with a decline in activity. This study demonstrates that objective monitoring of postoperative physical activity using activity monitors is feasible in the benign gynecologic surgical population. Recovery trajectories for inpatient laparotomies and outpatient minimally invasive procedures differ. Activity monitors present clinicians with a new potential tool for assessing and managing surgical recovery, and for determining if women are not recovering as expected.

Impact of previous abdominal surgery on the outcome of laparoscopy-assisted open appendicovesicostomy (Mitrofanoff) creation in children: a comparative study

For patients who require self-intermittent catheterization, a continent catheterizable stoma is a viable option. This patient population often has had previous abdominal surgery (PAS), a risk factor for complicated laparoscopic procedures. Therefore, the authors aim to determine whether PAS has an impact on the peri-operative outcomes of the laparoscopic-assisted Mitrofanoff procedure in children. A research ethics board-approved retrospective review was performed to assess peri-operative outcomes amongpediatric patients who underwent laparoscopic-assisted Mitrofanoff procedures in the authors institution from May 2000 to March 2016. Patients with no PAS were compared with those with intraperitoneal PAS. Demographic/baseline characteristics and peri-operative outcomes such as operative time, estimated blood loss, hospital stay, unanticipated additional operations, stomal stenosis, and urinary continence were compared. To ensure there is no confounding based on PAS characteristics, subgroups were created to compare the recency (PAS <1 year ago) and extent (ventriculoperitoneal (VP) shunt vs non-VP shunt PAS) to assess their peri-operative outcomes. Fisher's exact test and Mann-Whitney U test were used to determine statistical significance. Thirty-four patients (15 no PAS and 19 PAS) were included in the analysis. No significant difference in demographics and baseline characteristics was noted between the patient groups. The median age was 6.5 years (interquartile range [IQR] 4.8-14.0) and 9.9 years (4.2-14.3), respectively (NS). Peri-operative outcomes of operative time, estimated blood loss, and hospital stay were similar between the PAS and no PAS groups. There was no statistical difference in complications requiring surgical intervention (n=3, 20.0%; n=9, 47.4%). The median follow-up period was 25.9 (IQR 7.7-47.2) months and 28.0 (IQR 13.0-53.0) months, respectively (NS). Patients with VP shunts as their only PAS had higher estimated blood loss compared with no PAS group (50 [IQR 25-150], 25 [IQR 25-50], respectively) but without other differences in peri-operative outcomes. Findings support the use of a minimally invasive approach in this patient population as it is feasible, comparable, and safe but with careful consideration for risk factors that may predispose PAS patients to postsurgical complications requiring intervention. Although limited by small sample size, this study provides valuable insight into performing laparoscopic operations in children who have undergone prior surgeries and invites future studies to compare the outcomes between patients undergoing open, pure laparoscopic, and robotic-assisted laparoscopic Mitrofanoff procedures for children with PAS. Laparoscopic-assisted Mitrofanoff creation may be safely performed in children with PAS.

Néphrectomie laparoscopique assistée par robot dans le cadre du donneur-vivant : étude chez les donneurs et les receveurs à partir de 155 cas

To evaluate morbidity and renal function of the donor and recipient during a robotic-assisted laparoscopic nephrectomy procedure. It is a retrospective study of 155 consecutive patients by robot-assisted laparoscopy in the living donor. Mean operating time, warm ischemia time, blood loss, complications according to the Clavien classification and evolution of creatinine clearance were analyzed in the donors. Recovery of graft function, complications and changes in creatinine clearance were observed in recipients. The mean operating time was 176 (±23) minutes. The mean warm ischemia time was 4.8 (±0.6) minutes. Twenty seven complications were noted. The loss of renal function was 19% at 5 years in donors. Renal recovery was immediate for 153 recipients. Two were delayed due to sepsis. Two patients lost their graft at 15 and 18 months. Seventeen complications have been identified. The mean kidney function of the recipients is measured at 63ml/min at 5 years. Robotic-assisted laparoscopic nephrectomy procedure appears to provide the donor with low morbidity and a moderate decrease in creatinine clearance at 19% at 5 years. Morbidity is also low in recipients with very satisfactory 5-year mean renal function. The technique should promote donation. 4.

Retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy in adult patients with duplex kidneys.

Background: To report our experience with retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy in adult patients with duplex kidneys.Methods: We retrospectively reviewed the medical records of 7 patients who underwent retroperitoneal robot-assisted laparoscopic upper pole heminephrectomy at our institution between September 2014 and July 2017. Of the robot-assisted laparoscopic procedures, 5 were on the left and 2 on the right side.Results: All patients underwent robot-assisted laparoscopic surgery successfully in a totally retroperitoneal manner without conversion to open surgery. The mean operative time was 175 mins (range 140–270). The mean estimated blood loss was 84 mL (range 20–200). The mean postoperative hospital stay was 7 days (range 5–9). No major intraoperative and postoperative complications occurred. All patients had a resolution of their presenting symptoms after surgery at a mean follow-up of 24 months (range 14–38).Conclusion: Our initial clinical experience suggests that robot-assisted laparoscopic upper pole heminephrectomy using a retroperitoneal approach for a duplex kidney appears to be safe with acceptable perioperative outcomes.

98: Do attending physicians and trainees agree about what happens in the operating room during robot-assisted laparoscopic hysterectomy procedures?

The objective in this study was to determine agreement between attending and trainee surgeons on important aspects of what happened in the operating room during robot-assisted laparoscopic hysterectomy (RALH) procedures, which are essential for teaching and assessment, e.g., case participation for accurate case logs, intraoperative skill assessment for performance evaluation and feedback. Attending and trainee surgeons performing 56 RALH procedures responded to questionnaires postoperatively concerning: 1) who performed each of 11 steps (L/R excise infundibulopelvic ligament, excise utero-ovarian ligament, skeletonize uterine vessel, electrodessicate uterine vessels, dissect bladder, colpotomy or amputate uterus, close vaginal cuff or cervical stump), 2) vaginal cuff closure technique (VCCT) and suture device (SD) used, 3) trainees’ self-assessed skill and attending assessment of trainees’ skill using GEARS, and difficulty of surgery. For bladder dissection, colpotomy, and vaginal cuff closure, we asked what percentage (0%, 25%, 50%, 75%, or 100%) was performed by the trainee. We analyzed agreement between attending and trainee surgeons using Cohen’s kappa for categorical variables and Krippendorff’s alpha (KA) for ordinal variables, as well as Spearman’s correlation (rho). Kappa was greater than 0.6 for 8 surgical steps (kappa = 0.71, 0.62, 0.82, 0.85, 0.71, 0.78, 0.86, 0.86), suggesting strong agreement between attending and trainee surgeons. We observed kappa values of 0.79 and 0.79 for VCCT and SD, indicating strong agreement. There was weak agreement for depth perception and bimanual dexterity criteria of the GEARS scale (rho = 0.21, 0.29 and KA = 0.158, 0.007, respectively). Skill assessments by attending and trainee surgeons on the domains of efficiency, force sensitivity, autonomy, and robotic control exhibited moderate correlation and agreement (rho = 0.468, 0.534, 0.440, 0.495; KA = 0.473, 0.506, 0.412, 0.484, respectively). There was a moderate level of agreement (kappa = 0.484) on estimating difficulty of surgical case. Our findings show that there is imperfect agreement between attending and trainee surgeons even with who performed parts of the procedure, which intuitively, should be unambiguous. They also disagreed on case difficulty and technical skill. This incongruency on critical aspects of what happened in the operating room poses a significant challenge to teach and learn hysterectomy.

Robotic-Assisted Urologic Surgery in Infants: Positioning, Trocar Placement, and Physiological Considerations.

Pediatric robotic-assisted laparoscopic procedures are becoming increasingly common. They have been shown to be safe in younger patients, including infants. Successful adoption of robotic-assisted surgery in infants requires an understanding of the technical factors unique to this patient population. This review will delineate the specific considerations to safely perform robotic-assisted laparoscopic procedures in infants, including physiological changes associated with pneumoperitoneum in infants, positioning, trocar placement, and docking.

Évaluation du niveau sonore dans un bloc opératoire d’urologie

In the operating room, a high sound level is associated with a higher risk of complications and affects the communication between the various workers. The objective of this study was to assess the sound level at the operating room during urological procedures. A monocentric cross-sectional study was carried out in 100 procedures in urology. They were divided into four groups: open surgical procedures, endoscopic procedures, pure laparoscopic procedures, and robotic-assisted laparoscopic procedures. The sound level was measured with the Sound Metter by Examobile application (Bielsko-Biała, Poland) for i-phone®. For all procedures, mean sound level, mean minimum sound level and mean maximum sound level were 60.31±3.3 db, 52.42±2.6 db and 81.73±2.8 db, respectively. For endourological procedures, they were 61.6±4.1 db, 53.4±4.1 db and 81.3±3.1 db, respectively. For open surgery, they were 59.0±1.0 db, 51.6±1.8 db and 81.4±1.5 db, respectively. For laparoscopic surgery, they were 58.33±0.6 db, 50.66±1.2 db and 83.33±1.5 db, respectively. Robotic-assisted laparoscopic surgery, they were 60.0±2.4 db, 52.5±2.3 db and 83.56±1.8 db, respectively. No difference was found according to the type of surgical approach. However, the sound level in the operating room was increased for endourological procedures using the laser technology as compared to endourological procedures without laser used (58.7±1.1 vs. 66.3±0.1 db, P=0.01, respectively). The sound level in the operating room during urological procedures was high. For the endourological procedures, the sound level was the highest when the laser technology was used. 3.

Patient positioning, port placements setting and robot cart docking in pediatric robot-assisted laparoscopic upper urinary tract operation

Objective To summarize the experience of patient positing, port placements setting and robot cart docking in pediatric robot-assisted laparoscopic upper urinary tract operations. Methods From March 2017 to December 2017, 140 robot-assisted laparoscopic upper urinary tract procedures were performed in our institution, including 110 cases of pyeloplasty, 15 upper pole heminephroureterectomy, 12 simple nephrectomy and 3 adrenalectomy.There were 103 males and 37 females with a range age from 1 month to 18 years. The assistant surgeon was adjacent to the instrument nurse, and patients were placed in a supine position with 60°- 80° inclination and keep the legs low to the body. Room setup and patient positioning were similar to the traditional laparoscopic surgery. Semi-hidden incision technique was used in 140 patients: the camera port was placed umbilicus, two additional arm ports (one 5 mm and one 8 mm) were placed under direct vision, the 8 mm arm port was placed on the line of a Pfannenstiel incision and the 5 mm arm port was placed below the Xiphoid along the midline. Finally, a 3 or 5 mm assistant port was placed approximately 3 cm lateral to the inferior arm port, the line of a Pfannenstiel incision. Results The average time was (11.5±3.2) min (10.5-16.5 min) from skin incision to robot cart docking completed.All surgeries were successfully completed without open conversion. One patient required an additional assist port for severe adhesion after the previously open surgery, there was no injury to other viscera.Average operative time was (146.9±48.7)min(78-259 min) and average post-operative hospitalization time was (5.7±1.4) d(4-10 d), respectively. There was no visual scar on abdominal 6 weeks postoperatively, and all parents made comments about their satisfaction with the cosmetic appearance. All operations got complete success at a mean follow up of 6(1-9)months. Conclusions A good room setup, patient positioning and the semi-hidden incision technique port placements are maintaining the safety of the patient, avoiding compression injuries, allowing maximum mobility of the robotic arms, and facilitating a smooth and efficient surgery, and improving post-operative recovery. Key words: Robot; Laparoscopic; Pediatric; Upper urinary tract

The Effect of Steep Trendelenburg Positioning on Retinal Structure and Function during Robotic-Assisted Laparoscopic Procedures.

Purpose Robotic-assisted laparoscopic radical prostatectomy (RALP) has become a standard treatment choice for localized prostate cancer. RALP requires a steep Trendelenburg position, which leads to a significant increase in intraocular pressure (IOP). This study evaluated the effect on the retinal structure and function in patients undergoing RALP. Methods Standard automated perimetry (SAP) and optical coherence tomography (OCT) were performed in 20 males scheduled for RALP at 1 month and 1 day before the operation and at 1 and 3 months after the operation. IOP measurements were made in the supine position at 5 min after intubation under general anesthesia (T1), at 6 discrete time points (5, 30, 60, 120, 180, and 240 min; T2-7), and at 5 min after returning to a horizontal supine position (T8). Serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression were assessed using the guided progression analysis software program. RNFL thickness progression and visual field progression were evaluated by event analysis. Results Average IOP (mmHg) for each time point was as follows: T1 = 12.3 ± 2.6, T2 = 20.4 ± 4.2, T3 = 23.3 ± 3.8, T4 = 24.0 ± 3.2, T5 = 24.3 ± 3.4, T6 = 27.1 ± 7.2, T7 = 29.8 ± 8.7, and T8 = 20.1 ± 4.4. During RALP, IOP significantly increased. There was no progression of the visual field and RNFL thickness after surgery or any other ocular complications found. Conclusions Although IOP significantly increased during RALP, there were no significant changes in the retinal structure and function between the pre- and postoperation observations.