Robot-assisted Cases Research Articles

Committee opinion no. 628: robotic surgery in gynecology.

The field of robotic surgery has developed rapidly, and its use for gynecologic conditions has grown exponentially. Surgeons should be skilled at abdominal and laparoscopic approaches for a specific procedure before undertaking robotic approaches. Surgeon training, competency guidelines, and quality metrics should be developed at the institutional level. Robot-assisted cases should be appropriately selected based on the available data and expert opinion. As with any surgical procedure, repetition drives competency. Ongoing quality assurance is essential to ensure appropriate use of the technology and, most importantly, patient safety. Adoption of new surgical techniques should be driven by what is best for the patient, as determined by evidence-based medicine rather than external pressures. Well-designed randomized controlled trials or comparably rigorous nonrandomized prospective trials are needed to determine which patients are likely to benefit from robot-assisted surgery and to establish the potential risks.

Population Based Analysis of Incidence and Predictors of Open Conversion during Minimally Invasive Radical Prostatectomy

We used population based data to measure the rates and risk factors of open conversion during minimally invasive radical prostatectomy in the United States. We retrospectively analyzed the records of 87,415 patients in the NCDB who underwent minimally invasive radical prostatectomy between 2010 and 2011. We compared surgical outcomes and treatment facility characteristics between converted and nonconverted cases. Multivariable analysis was done to evaluate conversion risk factors. There were 82,338 robot-assisted (94%) and 5,077 laparoscopic (6%) radical prostatectomies, and 1,080 conversions (1.2%). Fewer robot-assisted cases were converted than laparoscopic cases (0.9% vs 6.5%, p <0.001). The median yearly treatment facility volume of minimally invasive radical prostatectomy was 32 (IQR 10-72). Patients who underwent conversion were more likely to be rehospitalized within 30 days (4.4% vs 2.7%, p = 0.002) and have a postoperative hospital stay of greater than 2 days (40.4% vs 15.1%, p <0.001) than those without conversion. Facilities in the lowest quartile of the yearly volume of the minimally invasive procedure represented 3.8% of minimally invasive radical prostatectomies but accounted for 22.9% of conversions. The second, third and fourth quartiles of yearly treatment facility minimally invasive volume predicted a lower likelihood of conversion compared to the first quartile (each p <0.001). Facility type (eg academic or community) did not predict conversion. Black race (vs white OR 1.52, 95% CI 1.24-1.86, p <0.001) and laparoscopic radical prostatectomy (OR 4.68, 95% CI 3.79-5.78, p <0.001) predicted higher odds of conversion. Open conversion during minimally invasive radical prostatectomy is a rare event. However, it is significantly more likely for pure laparoscopic surgery, in black men and at low volume facilities. Facility type did not affect conversion rates.

General Surgery Residents’ Perception of Robot-Assisted Procedures During Surgical Training

With the continued expansion of robotically assisted procedures, general surgery residents continue to receive more exposure to this new technology as part of their training. There are currently no guidelines or standardized training requirements for robot-assisted procedures during general surgical residency. The aim of this study was to assess the effect of this new technology on general surgery training from the residents' perspective. An anonymous, national, web-based survey was conducted on residents enrolled in general surgery training in 2013. The survey was sent to 240 Accreditation Council for Graduate Medical Education-approved general surgery training programs. Overall, 64% of the responding residents were men and had an average age of 29 years. Half of the responses were from postgraduate year 1 (PGY1) and PGY2 residents, and the remainder was from the PGY3 level and above. Overall, 50% of the responses were from university training programs, 32% from university-affiliated programs, and 18% from community-based programs. More than 96% of residents noted the availability of the surgical robot system at their training institution. Overall, 63% of residents indicated that they had participated in robotic surgical cases. Most responded that they had assisted in 10 or fewer robotic cases with the most frequent activities being assisting with robotic trocar placement and docking and undocking the robot. Only 18% reported experience with operating the robotic console. More senior residents (PGY3 and above) were involved in robotic cases compared with junior residents (78% vs 48%, p < 0.001). Overall, 60% of residents indicated that they received no prior education or training before their first robotic case. Approximately 64% of residents reported that formal training in robotic surgery was important in residency training and 46% of residents indicated that robotic-assisted cases interfered with resident learning. Only 11% felt that robotic-assisted cases would replace conventional laparoscopic surgery in the future. This study illustrates that although the most residents have a robot at their institution and have participated in robotic surgery cases, very few residents received formal training before participating in a robotic case.

PD30-11 ECONOMIC AND UTILIZATION ANALYSIS OF ROBOTIC-ASSISTED VS. LAPAROSCOPIC LIVE DONOR NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: In the past five years, there has been increased performance of robotic-assisted live-donor nephrectomy. Although it remains uncommon, it is important to understand the current utilization of robotic-assistance to determine if there is benefit over laparoscopic live-donor nephrectomy. METHODS: All adult cases of live-donor nephrectomy were identified from the 2009-2011 Nationwide Inpatient Sample (NIS) using ICD-9 medical and procedure codes (V59.4 and 55.51). Laparoscopic (54.21 and 54.51) and robotic cases (174.x) were identified for inclusion. Peri-operative complications were determined using ICD-9 CM codes (996-999) Population weighting using NIS discharge weights was used to estimate national rates. Descriptive analysis of categorical and continuous variables was performed using the Pearson chi-squared and the Mann Whitney tests, respectively. Cost data was missing on the majority of robotic-assisted patients, and thus only total charge was used in the final analysis. RESULTS: After population weighting 4,163 cases were identified for inclusion, 142 (3.4%) of which were performed with roboticassistance. There were no differences in age or sex between the populations. All robotic-assisted cases occurred in the Northwest region. The median (interquartile range (IQR)) length of stay for roboticassisted live-donor nephrectomy was 3 (3-4) days compared with 2 (2-3) days for laparoscopic (p<0.001). Median (IQR) total charges for robotic-assisted live-donor nephrectomy were $48,639 (42,380-53,050) vs. $37,019 (28,715-48,816) for laparoscopic (p<0.001). There was no statistical difference in the number of complications, although there were none in the robotic-assisted live-donor nephrectomy group (p1⁄40.206). CONCLUSIONS: Live-donor nephrectomy is infrequently performed with robotic-assistance. As the number of patients for study was small, it is difficult to make definitive conclusions; however, our findings indicate that robotic-assisted live-donor nephrectomy is associated with higher charges and longer hospitalization. Subsequent studies that examine post-operative complications will help define if there is a role for robotic-assistance in live-donor nephrectomy.

Is de novo stress incontinence after sacrocolpopexy related to anatomical changes and surgical approach?

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach. We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI. Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI. Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.

Gynaecological robotic surgery in an Irish setting—cost analysis

Robotic surgery is associated with reduced hospital stay compared with open surgery. While the initial outlay is expensive, the increased number of patients amenable to this minimal access approach compared with conventional ‘keyhole surgery’ has the potential for financial savings. Our aim was to show the cost per surgery and the potential for savings with increased caseload and reduced hospital bed stay. A cost analysis was performed incorporating an audit of robotic surgery over the initial 3 years. This was performed using prospectively acquired data completed after each robotically assisted case. Depreciation and maintenance on the robot accounted for an outlay of €260,000/annum. Due to the learning curves and hospital constraints, in year 1, an average of 1.5 cases were performed per week at a cost of €5,980/case, this cost reduced to €4,250 over the next 2 years with an increase to 2.4 cases/week. We projected that if maximum usage of nine cases/week was achieved the cost would reduce to €2,523/case. In 2010, 36 % of all hysterectomies were performed robotically. The average length of stay for robot-assisted cases was two nights compared to six to eight nights for open hysterectomy. The robotic approach is associated with savings of approximately €201,933/year compared with a similar tertiary referral hospital in Ireland with no robot. Purchasing a robot is costly but associated with greater cost savings when reduced length of stay is accounted for. Furthermore, maximisation of robotic use further decreases the cost per case.

Robot-assisted common bile duct exploration as an option for complex choledocholithiasis

This study aimed to describe the authors' early experience with robot-assisted common bile duct exploration (CBDE) for choledocholithiasis refractory to endoscopic therapy and to compare the outcomes with those of equivalent patients undergoing an open technique. At our institution, 55 CBDEs were performed between 2005 and 2010. All 19 robot-assisted cases were unselected elective referrals for stone disease. Of 36 open procedures, emergency cases and exploration not for stone disease were excluded, leaving 18 cases for analysis. Cases were analyzed on an intent-to-treat basis. A P value of 0.05 denoted statistical significance. The patients did not differ in terms of demography, comorbidity, or presenting symptoms. The reasons for endoscopic failure in both groups were similar. The mean operating time was longer for robot-assisted surgery (220 ± 41.26 min) than for open surgery (169 ± 65.81 min) (P = 0.01), but the median hospital stay was shorter (4 vs 11 days; P = 0.02). Four conversions to open surgery (21%) were performed due to severe adhesions. The two groups did not differ statistically in terms of T-tube usage (74 vs 61%; P = 0.414). One death occurred in the robotic group and two in the open cohort. Postoperative complications occurred in seven robotic and ten open cases (P = 0.402). They were mainly respiratory complications in the robot-assisted group, whereas they were cardiac and wound-related complications in the open group. Two of the converted cases had complications similar to those of the open group. Postoperative endoscopic retrograde cholangiopancreatography (ERCP) for retained stones was performed in one open case and three robotic cases. Robot-assisted CBDE offers some benefit when ERCP fails. Ideal case selection may enhance success.

Clinical Outcomes in Endometrial Cancer Care When the Standard of Care Shifts From Open Surgery to Robotics

In Singapore, the standard of care for endometrial cancer staging remains laparotomy. Since the introduction of gynecologic robotic surgery, there have been more data comparing robotic surgery to laparoscopy in the management of endometrial cancer. This study reviewed clinical outcomes in endometrial cancer in a program that moved from laparotomy to robotic surgery. A retrospective review was performed on 124 consecutive endometrial cancer patients. Preoperative data and postoperative outcomes of 34 patients undergoing robotic surgical staging were compared with 90 patients who underwent open endometrial cancer staging during the same period and in the year before the introduction of robotics. There were no significant differences in the mean age, body mass index, rates of diabetes, hypertension, previous surgery, parity, medical conditions, size of specimens, histologic type, or stage of cancer between the robotic and the open surgery groups. The first 20 robotic-assisted cases had a mean (SD) operative time of 196 (60) minutes, and the next 14 cases had a mean time of 124 (64) minutes comparable to that for open surgery. The mean number of lymph nodes retrieved during robot-assisted staging was smaller than open laparotomy in the first 20 cases but not significantly different for the subsequent 14 cases. Robot-assisted surgery was associated with lower intraoperative blood loss (110 [24] vs 250 [83] mL, P < 0.05), a lower rate of postoperative complications (8.8% vs 26.8%, P = 0.032), a lower wound complication rate (0% vs 9.9%, P = 0.044), a decreased requirement for postoperative parenteral analgesia (5.9% vs 51.1, P < 0.001), and shorter length of hospitalization (2.0 [1.1] vs 6.0 [4.5] days, P < 0.001) compared to patients in the open laparotomy group. Our series shows that outcomes traditionally associated with laparoscopic endometrial cancer staging are achievable by laparoscopy-naive gynecologic cancer surgeons moving from laparotomy to robot-assisted endometrial cancer staging after a relatively small number of cases.

Age, Obesity, Medical Comorbidities and Surgical Technique are Predictive of Symptomatic Anastomotic Strictures After Contemporary Radical Prostatectomy

Anastomotic strictures are relatively common after radical prostatectomy and are associated with significant morbidity, often requiring multiple surgical interventions. There is controversy in the literature regarding which factors predict the development of anastomotic strictures. In this study we determined predictors of symptomatic anastomotic strictures following contemporary radical prostatectomy. Between 1999 and 2007, 4,592 consecutive patients underwent radical prostatectomy without prior radiotherapy at our institution. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from inpatient and outpatient medical and billing records. Cases were assigned a Charlson score to account for comorbidities. Complications were graded according to the modified Clavien classification. Open radical prostatectomy was performed in 3,458 men (75%) and laparoscopic radical prostatectomy was performed in 1,134 (25%). The laparoscopic radical prostatectomy group included 97 robotic-assisted cases. Median patient age was 59.5 years (IQR 54.7, 64.2). Symptomatic anastomotic strictures developed in 198 patients (4%) after a median postoperative followup of 3.5 months (IQR 2.1, 6.1). On multivariate analysis significant predictors included patient age, body mass index, Charlson score, renal insufficiency, individual surgeon, surgical approach and the presence of postoperative urine leak or hematoma. Patient factors as well as technical factors influence the development of symptomatic anastomotic strictures following contemporary radical prostatectomy. The impact of these factors is influenced by the individual surgeon and the approach used.

Content validation of a novel robotic surgical simulator

• To assess the content validity of an early prototype robotic simulator. Minimally invasive surgery poses challenges for training future surgeons. The Robotic Surgical Simulator (RoSS) is a novel virtual reality simulator for the da Vinci Surgical System. • Participants attending the 2010 International Robotic Urology Symposium were invited to experience RoSS. Afterwards, participants completed a survey regarding the appropriateness of the simulator as a teaching tool. • Forty-two subjects including surgeons experienced with robotics (n= 31) and novices (n= 11) participated in this study. • Eighty per cent of the entire cohort had an average of 4 years of experience with robot-assisted surgery. • Eleven (26%) novices lacked independent robot-assisted experience. The expert group comprised 17 (41%) surgeons averaging 881 (160-2200) robot-assisted cases. Experts rated the 'clutch control' virtual simulation task as a good (71%) or excellent (29%) teaching tool. • Seventy-eight per cent rated the 'ball place' task as good or excellent but 22% rated it as poor. • Twenty-seven per cent rated the 'needle removal' task as an excellent teaching tool, 60% rated it good and 13% rated it poor. • Ninety-one per cent rated the 'fourth arm tissue removal' task as good or excellent. • Ninety-four per cent responded that RoSS would be useful for training purposes. • Eighty-eight per cent felt that RoSS would be an appropriate training and testing format before operating room experience for residents. • Seventy-nine per cent indicated that RoSS could be used for privileging or certifying in robotic surgery. • Results based on expert evaluation of RoSS as a teaching modality illustrate that RoSS has appropriate content validity.

The First 100 Da Vinci Gynecologic Robotic–Assisted Cases at a Metropolitan Community Hospital

Study Objective: This study reports the first 100 robotic-assisted cases done by two board certified Gynecologic Oncologists, and includes cases of hysterectomy with or without bilateral salpingo-oophorectomy (BSO), salpingo-oophorectomy (S-O), hysterectomy for endometrial cancer, supra-cervical hysterectomy, adnexectomy, myomectomy, and staging.

Policy guidelines suggested for robot-assisted prostatectomy.

Policy guidelines suggested for robot-assisted prostatectomy.

Robotic technology in surgery: Past, present, and future

It has been nearly 20 years since the first appearance of robotics in the operating room. In that time, much progress has been made in integrating robotic technologies with surgical instrumentation, as evidenced by the many thousands of successful robot-assisted cases. However, to build on past success and to fully leverage the potential of surgical robotics in the future, it is essential to maximize a shared understanding and communication among surgeons, engineers, entrepreneurs, and healthcare administrators. This article provides an introduction to medical robotic technologies, develops a possible taxonomy, reviews the evolution of a surgical robot, and discusses future prospects for innovation. Robotic surgery has demonstrated some clear benefits. It remains to be seen where these benefits will outweigh the associated costs over the long term. In the future, surgical robots should be smaller, less expensive, easier to operate, and should seamlessly integrate emerging technologies from a number of different fields. Such advances will enable continued progress in surgical instrumentation and, ultimately, surgical care.

Analysis of Procedure Time in Robot-Assisted Surgery: Comparative Study in Laparoscopic Cholecystectomy

Introduction: Robotic surgery systems have been introduced to deal with the basic disadvantages of laparoscopic surgery. However, working with these systems may lead to time loss due to additional robot-specific tasks, such as set-up of equipment and sterile draping of the system. To evaluate loss of time in robot-assisted surgery, we compared 10 robot-assisted cholecystectomies to 10 standard laparoscopic cholecystectomies.Materials and Methods: The robot-assisted procedures were performed with the da Vinci telemanipulation system. The total time in the operating room (OR) was scored and divided into preoperative, operative, and postoperative phases. These phases were further divided into smaller timeframes to precisely define moments of time loss.Results: The most significant difference between the two groups was found in the preoperative phase. Robot-related tasks led to time loss in all time-frames of this phase. In the operative phase, the trocar entry time-frame was longer in robot-assisted cases than in standard procedures. Additionally, postoperative OR clearing was longer in the robot-assisted cases. Total operating time did not differ significantly between the two procedures.Conclusion: Robot-assisted surgery leads to time loss during preparation of routine laparoscopic procedures.

Feasibility of robot-assisted laparoscopic cholecystectomy

To enhance the surgeon's dexterity in laparoscopic surgery, robotic telemanipulation systems have recently been introduced into the operating theatre. Feasibility of robot-assisted surgery was evaluated in this study during 20 laparoscopic cholecystectomies. The procedures were performed with the Da Vinci® robotic telemanipulation system (Intuitive Surgical). System set-up time, complications, technical problems and OR-time were recorded. The surgeon succeeded in completing the cholecystectomy laparoscopically in 19 out of 20 cases. Robot-related technical problems did occur in a low number of cases. This did not result in complications or harmful situations to the patient. OR time in robot-assisted cases exceeded the time needed for conventional laparoscopic cholecystectomy, mainly caused by time-loss during set-up.