Robotic Abdominal Surgery Research Articles

Novel single-layer continuous suture of pancreaticojejunostomy for robotic pancreaticoduodenectomy

Introduction: Robotic pancreaticoduodenectomy (RPD) is one of the most technically challenging procedures in robotic abdominal surgery. The best technique for pancreatic anastomosis after PD remains controversial, and the procedure for performing this anastomosis by a robotic approach has not been previously reported. This study aimed to evaluate the safety and feasibility of a novel technique of pancreaticojejunostomy (PJ) for RPD. Method: The demographics and perioperative outcomes of a consecutive series of RPD patients who underwent single-layer continuous suture (SCS) for PJ between September 2018 and November 2018 were analyzed. Result: Thirty patients (19 men and 11 women; mean age, 55.0 years) were included in the study. Twenty patients had a soft pancreas, and 15 patients had a small main pancreatic duct (MPD) (<3 mm). The mean operative time was 234.1 minutes, the mean duration of PJ was 14.9 min, and the median estimated blood loss was 100.0 mL (interquartile range, 50-150 mL). No patients required conversion to laparotomy or a blood transfusion. Postoperative major morbidities (Clavien ≥C) occurred in 3 patients (10%), and all recovered after conservative treatment. The overall incidence of postoperative pancreatic fistula was 30% and included 7 cases (23.2%) of Grade A, 2 cases (6.7%) of Grade B, and no case of Grade C pancreatic fistula. The mean postoperative hospital stay was 12.3 days. No 90-day readmission mortality or 90-day mortality was observed. Neither pancreatic texture nor MPD size affected the perioperative outcomes. Conclusion: SCS is a safe and feasible PJ technique for RPD. SCS is easy to perform and is associated with favorable clinical outcomes, regardless of the pancreatic duct size and texture.

Green indocyanine fluorescence in robotic abdominal surgery.

Fluorescent imaging with indocyanine green (ICG) is an emerging technology that is gaining acceptance for being a valid tool in surgeons' decision making. ICG binds to plasma lipoproteins if injected intravenously and, when excited by near-infrared light, provides anatomic information about organs vascularization and tissues perfusion. If injected in tissues, it migrates in the lymphatic system, therefore enabling the identification of lymphatic draining pathways of different organs. In this paper we address specific applications of ICG fluorescence in robotic general surgery.

Disturbance Rejection in Multi-DOF Local Magnetic Actuation for the Robotic Abdominal Surgery

The potential of multi-degrees-of-freedom (DOFs) local magnetic actuation (LMA) has been established in recent years for dexterous minimally invasive surgical manipulations. Nonetheless, having multiple magnetic based units, one for each DOF, within a close vicinity to each other leads to magnetic field interaction among the magnetic sources, hence, resulting in a disturbance to a given LMA unit. It is further realized that the disturbance is a result of actuation effort by the neighboring magnetic sources forming the LMA units, and that the actuation command to all LMA units is a known information to the controller. Therefore, partial information of the disturbance is known and can be exploited in a disturbance rejection strategy. In this letter, this disturbance is modeled and used to augment a simplified model of the systems dynamics of the LMA-based surgical manipulators. The internal model principle (IMP) strategy is selected in which an observer is designed to estimate the disturbance to be rejected. Numerical simulation as well as experimental validation were performed to validate the efficacy of the IMP. The results serve to remove a significant technical hurdle in bringing the new emerging technique of LMA into practical reality for abdominal surgeries.

Ultrasound-guided transversus abdominis plane block for control of postoperative pain after laparoscopy-assisted robotic abdominal cancer surgery

Background and objective Transversus abdominis plane (TAP) block is a recently developed method for analgesia that is now widely used in a variety of abdominal surgeries. Robotic laparoscopy is being increasingly adopted for surgical resection of abdominal cancers. We studied the efficacy and safety of TAP block to control pain after robot-assisted laparoscopic abdominal cancer surgery. Methods Totally, 30 patients scheduled for robot-assisted laparoscopic abdominal cancer surgery (hysterectomy, colorectal cancer resection, or cystectomy) received general anesthesia. Before extubation the patients were randomized into two equal groups: group T, in which TAP block was performed by means of an ultrasound-guided subcostal approach, and group C (control group), in which no TAP block was performed or other regional anesthesia was induced. We measured visual analog scale (VAS) both at rest and during episodes of coughing at 1, 2, 6, 12, and 24 h postoperatively. We measured total 24 h morphine consumption, in addition to complications and postoperative nausea and vomiting. Results VAS both at rest and during coughing was lower in the T group at all time intervals until 12 h (P Conclusion Ultrasound-guided TAP block by subcostal approach is an effective and safe method for providing analgesia that markedly reduces morphine consumption after robot-assisted laparoscopic abdominal cancer surgery

Magnetic Surgical Instruments for Robotic Abdominal Surgery.

This review looks at the implementation of magnetic-based approaches in surgical instruments for abdominal surgeries. As abdominal surgical techniques advance toward minimizing surgical trauma, surgical instruments are enhanced to support such an objective through the exploration of magnetic-based systems. With this design approach, surgical devices are given the capabilities to be fully inserted intraabdominally to achieve access to all abdominal quadrants, without the conventional rigid link connection with the external unit. The variety of intraabdominal surgical devices are anchored, guided, and actuated by external units, with power and torque transmitted across the abdominal wall through magnetic linkage. This addresses many constraints encountered by conventional laparoscopic tools, such as loss of triangulation, fulcrum effect, and loss/lack of dexterity for surgical tasks. Design requirements of clinical considerations to aid the successful development of magnetic surgical instruments, are also discussed.

Dense soft tissue 3D reconstruction refined with super-pixel segmentation for robotic abdominal surgery.

Single-incision laparoscopic surgery decreases postoperative infections, but introduces limitations in the surgeon's maneuverability and in the surgical field of view. This work aims at enhancing intra-operative surgical visualization by exploiting the 3D information about the surgical site. An interactive guidance system is proposed wherein the pose of preoperative tissue models is updated online. A critical process involves the intra-operative acquisition of tissue surfaces. It can be achieved using stereoscopic imaging and 3D reconstruction techniques. This work contributes to this process by proposing new methods for improved dense 3D reconstruction of soft tissues, which allows a more accurate deformation identification and facilitates the registration process. Two methods for soft tissue 3D reconstruction are proposed: Method 1 follows the traditional approach of the block matching algorithm. Method 2 performs a nonparametric modified census transform to be more robust to illumination variation. The simple linear iterative clustering (SLIC) super-pixel algorithm is exploited for disparity refinement by filling holes in the disparity images. The methods were validated using two video datasets from the Hamlyn Centre, achieving an accuracy of 2.95 and 1.66mm, respectively. A comparison with ground-truth data demonstrated the disparity refinement procedure: (1) increases the number of reconstructed points by up to 43% and (2) does not affect the accuracy of the 3D reconstructions significantly. Both methods give results that compare favorably with the state-of-the-art methods. The computational time constraints their applicability in real time, but can be greatly improved by using a GPU implementation.

Crimped braided sleeves for soft, actuating arm in robotic abdominal surgery

Background: This paper investigates different types of crimped, braided sleeve used for a soft arm for robotic abdominal surgery, with the sleeve required to contain balloon expansion in the pneumatically actuating arm while it follows the required bending, elongation and diameter reduction of the arm. Material and methods: Three types of crimped, braided sleeves from PET (BraidPET) or nylon (BraidGreyNylon and BraidNylon, with different monofilament diameters) were fabricated and tested including geometrical and microstructural characterisation of the crimp and braid, mechanical tests and medical scratching tests for organ damage of domestic pigs. Results: BraidPET caused some organ damage, sliding under normal force of 2-5 N; this was attributed to the high roughness of the braid pattern, the higher friction coefficient of polyethylene terephthalate (PET) compared to nylon, and the high frequency of the crimp peaks for this sleeve. No organ damage was observed for the BraidNylon, attributed to both the lower roughness of the braid pattern and the low friction coefficient of nylon. BraidNylon also required the lowest tensile force during its elongation to similar maximum strain as that of BraidPET, translating to low power requirements. Conclusion: BraidNylon is recommended for the crimped sleeve of the arm designed for robotic abdominal surgery.

Robotic versus laparoscopic resection for sigmoid diverticulitis with fistula.

Robotic abdominal surgery is growing despite a paucity of clinical reports to evaluate its impact on patient outcomes. In this retrospective case series, we aim to analyze our early experience with robotic resection in 11 consecutive patients with chronic colonic diverticulitis complicated by fistula to bladder, vagina, or skin and to compare the results of the robotic approach to 20 patients undergoing laparoscopic resection for the same indication. Our main outcome measures include operative time, blood loss, conversion rate, transfusion rate, hospital length of stay, complications, readmission, and fistula healing rate. In our study, we found robotic resection for colonic diverticulitis with fistula was technically feasible and yielded 100% fistula healing rate. The operative time, complication and readmission rates were similar to laparoscopy. A higher conversion rate, diverting stoma need, and longer hospital length of stay were noted in the robotic group; however, these findings could have been attributed to a higher number of cases involving rectal excision in the robotic group. Larger studies are needed to further examine the impact of robotic surgery on the outcome of patients with complicated chronic sigmoid diverticulitis.

Two cases report of brachial plexus injury in laparoscopic colorectal surgery

The brachial plexus is structurally vulnerable to damage because it is fixed at the cervical vertebra, pre-cervical fascia, and axillary fascia while it extends longitudinally on the surface layer [1]. Causative factors for brachial plexus injury (BPI) during surgery are patients' comorbidity, anatomical malformation, operative factors such as intra-operative postures, operation time, and median sternotomy, and physiological factors such as hypotension and hypothermia. In particular, the Trendelenburg position, which is necessary for laparoscopic and robotic abdominal surgery, may act as a risk factor. We experienced two cases of BPI following colorectal surgery in the Trendelenburg position.

Robotic abdominal surgery: initial experiences of a single center

Robotic abdominal surgery: initial experiences of a single center

Computer-Assisted Laparoscopic Repair of “Upside-Down” Stomach With the Da Vinci System

Recently introduced telerobotic surgical systems attempt to elude the inherent limitations of traditional laparoscopic surgery. Four patients (3 male, 1 female) with mixed hiatal and paraesophageal hernias with fixed intrathoracic partial or complete displacement of the stomach were operatively treated using the Da Vinci robotic system. Tissue dissection, hiatoplasty, and anterior hemifundoplication (Dor) were performed with the telerobotic system. There were no surgical complications. The system broke down in the fourth patient due to a software defect. Advantages were seen in terms of the intrathoracic dissection of displaced stomach through a narrow hiatus, intracorporeal suturing due to 6 degrees of freedom plus grasping. At the moment, lack of the appropriate robotic instruments for abdominal surgery as well as the enormous functional cost of the robotic system are considered to be the most significant current impediment to the adoption of robotic abdominal surgery. The continuous evolution and upgrade of the system is quite promising so far. Telerobotic-assisted hiatal hernia operation is feasible with many advantages compared with the traditional laparoscopic approach, especially during the dissection in the mediastinum in patients with intrathoracic stomach. A prospective, randomized trial will be performed later to evaluate the advantages and limitations of robotic compared with traditional laparoscopy. Technological evolution will perhaps diminish the current problems and the cost associated with robotic surgery.

Robotic abdominal surgery

As a whole, abdominal surgeons possess excellent videoendoscopic surgical skills. However, the limitations of laparoscopy—such as reduced range of motion and instrument dexterity and 2-dimensional view of the operative field—have inspired even the most accomplished laparoscopists to investigate the potential of surgical robotics to broaden their application of the minimally invasive surgery paradigm. This review discusses data obtained from articles indexed in the MEDLINE database written in English and mapped to the following key words: “surgical robotics,” “robotic surgery,” “robotics,” “computer-assisted surgery,” “da Vinci,” “Zeus,” “fundoplication,” “morbid obesity,” “hepatectomy,” “pancreatectomy,” “small intestine,” “splenectomy,” “colectomy,” “adrenalectomy,” and “pediatric surgery.” A limited subset of 387 publications was reviewed to determine article relevance to abdominal robotic surgery. Particular emphasis was placed on reports that limited their discussion to human applications and surgical outcomes. Included are comments about the initial 202 robotic abdominal surgery cases performed at Johns Hopkins University Hospital (Baltimore, MD) from August 2000 to January 2004. Surgical robotic systems are being used to apply laparoscopy to the surgical treatment of diseases in virtually every abdominal organ. Procedures demanding superior visualization or requiring complex reconstruction necessitating extensive suturing obtain the greatest benefit from robotics over conventional laparoscopy. Whereas advanced surgical robotic systems offer the promise of a unique combination of advantages over open and conventional laparoscopic approaches, clinical data demonstrating improved outcomes are lacking for robotic surgical applications within the abdomen. Outcomes data for surgical robotics are essential given the exorbitant costs associated with the use of these tools.