Robot-assisted Group Research Articles

Percutaneous Sacroiliac Screw Placement: A Prospective Randomized Comparison of Robot-assisted Navigation Procedures with a Conventional Technique.

Background:Sacroiliac (SI) screw fixation is a demanding technique, with a high rate of screw malposition due to the complex pelvic anatomy. TiRobot™ is an orthopedic surgery robot which can be used for SI screw fixation. This study aimed to evaluate the accuracy of robot-assisted placement of SI screws compared with a freehand technique.Methods:Thirty patients requiring posterior pelvic ring stabilization were randomized to receive freehand or robot-assisted SI screw fixation, between January 2016 and June 2016 at Beijing Jishuitan Hospital. Forty-five screws were placed at levels S1 and S2. In both methods, the primary end point screw position was assessed and classified using postoperative computed tomography. Fisher's exact probability test was used to analyze the screws’ positions. Secondary end points, such as duration of trajectory planning, surgical time after reduction of the pelvis, insertion time for guide wire, number of guide wire attempts, and radiation exposure without pelvic reduction, were also assessed.Results:Twenty-three screws were placed in the robot-assisted group and 22 screws in the freehand group; no postoperative complications or revisions were reported. The excellent and good rate of screw placement was 100% in the robot-assisted group and 95% in the freehand group. The P value (0.009) showed the same superiority in screw distribution. The fluoroscopy time after pelvic reduction in the robot-assisted group was significantly shorter than that in the freehand group (median [Q1, Q3]: 6.0 [6.0, 9.0] s vs. median [Q1, Q3]: 36.0 [21.5, 48.0] s; χ2 = 13.590, respectively, P < 0.001); no difference in operation time after reduction of the pelvis was noted (χ2 = 1.990, P = 0.158). Time for guide wire insertion was significantly shorter for the robot-assisted group than that for the freehand group (median [Q1, Q3]: 2.0 [2.0, 2.7] min vs. median [Q1, Q3]: 19.0 [15.5, 45.0] min; χ2 = 20.952, respectively, P < 0.001). The number of guide wire attempts in the robot-assisted group was significantly less than that in the freehand group (median [Q1, Q3]: 1.0 [1.0,1.0] time vs. median [Q1, Q3]: 7.0 [1.0, 9.0] times; χ2 = 15.771, respectively, P < 0.001). The instrumented SI levels did not differ between both groups (from S1 to S2, χ2 = 4.760, P = 0.093).Conclusions:Accuracy of the robot-assisted technique was superior to that of the freehand technique. Robot-assisted navigation is safe for unstable posterior pelvic ring stabilization, especially in S1, but also in S2. SI screw insertion with robot-assisted navigation is clinically feasible.

Robot-assisted and conventional freehand pedicle screw placement: a systematic review and meta-analysis of randomized controlled trials.

Several studies have revealed that robot-assisted technique might improve the pedicle screw insertion accuracy, but owing to the limited sample sizes in the individual study reported up to now, whether or not robot-assisted technique is superior to conventional freehand technique is indefinite. Thus, we performed this systematic review and meta-analysis based on randomized controlled trials to assess which approach is better. Electronic databases including PubMed, EMBASE, CENTRAL, ISI Web of Science, CNKI and WanFang were systematically searched to identify potentially eligible articles. Main endpoints containing the accuracy of pedicle screw implantation and proximal facet joint violation were evaluated as risk ratio (RR) and the associated 95% confidence intervals (95% CIs), while radiation exposure and surgical duration were presented as mean difference (MD) or standard mean difference (SMD). Meta-analyses were performed using RevMan 5.3 software. Six studies involving 158 patients (688 pedicle screws) in robot-assisted group and 148 patients (672 pedicle screws) in freehand group were identified matching our study. The Grade A accuracy rate in robot-assisted group was superior to freehand group (RR 1.03, 95% CI 1.00, 1.06; P=0.04), but the Grade A+B accuracy rate did not differ between the two groups (RR 1.01, 95% CI 0.99, 1.02; P=0.29). With regard to proximal facet joint violation, the combined results suggested that robot-assisted group was associated with significantly fewer proximal facet joint violation than freehand group (RR 0.07, 95% CI 0.01, 0.55; P=0.01). As was the radiation exposure, our findings suggested that robot-assisted technique could significantly reduce the intraoperative radiation time (MD -12.38, 95% CI -17.95, -6.80; P<0.0001) and radiation dosage (SMD -0.64, 95% CI -0.85, -0.43; P<0.00001). But the overall surgical duration was longer in robot-assisted group than conventional freehand group (MD 20.53, 95% CI 5.17, 35.90; P=0.009). The robot-assisted technique was associated with equivalent accuracy rate of pedicle screw implantation, fewer proximal facet joint violation, less intraoperative radiation exposure but longer surgical duration than freehand technique. Powerful evidence relies on more randomized controlled trials with high quality and larger sample size in the future.

Improved joint-line restitution in unicompartmental knee arthroplasty using a robotic-assisted surgical technique.

Joint-line restitution is one objective of unicompartmental knee arthroplasty (UKA). However, the joint line is often lowered when resurfacing femoral implants are used. The aim of this study was to compare the joint-line height in UKA performed by robotic-assisted and conventional techniques. This retrospective case-control study compared two matched groups of patients receiving a resurfacing UKA between 2013 and 2016 by either a robotic-assisted (n=40) or conventional (n=40) technique. Each group comprised 27 women and 13 menm wuth a mean age of 69 and 68years, respectively. Indications for surgery were osteoarthritis (n=35) and condylar osteonecrosis (n=5). Two validated radiologic measurement methods were used to assess joint-line height. Forty UKA (23 medial and 17 lateral) were analysed in each group. Restitution of joint-line height was significantly improved in the robotic-assisted group compared than the control group: +1.4mm ±2.6 vs +4.7mm±2.4 (p<0.05) as assessed using method 1, and +1.5mm ±2.3 vs +4.6mm ±2.5 (p<0.05) as assessed using method 2. Restitution of joint-line height in resurfacing UKA can be improved with robotic-assisted surgery. Improvement in clinical outcome measures must be demonstrated with long-term studies.

Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial

BackgroundWhether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during prostate cancer surgery is debatable. ObjectiveTo report erectile function and early oncologic outcomes for both surgical modalities, stratified by prostate cancer risk grouping. Design, setting, and participantsIn a prospective nonrandomised trial, we recruited 2545 men with prostate cancer from seven open (n=753) and seven robot-assisted (n=1792) Swedish centres (2008–2011). Outcome measurements and statistical analysisClinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr prostate-specific antigen-relapse rates were measured. Results and limitationsAmong 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. ConclusionsEarlier recovery of erectile function in the robot-assisted surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted surgery also facilitates easier identification of nerve preservation planes during radical prostatectomy as well as wider dissection for pT3 cases. Patient summaryFor prostate cancer surgery, an open operation reduces erection problems in high-risk cancers but has higher relapse rates than robotic surgery. Relapse rates appear similar in low/intermediate-risk cancers and the robot appears better at preserving erections in these cases.

Efficacy analysis of Da Vinci robot-assisted esophagectmy and combined thoracoscopy- and laparoscopy-assisted esophagectomy

Objective To compare the clinical efficacy of Da Vinci robot-assisted esophagectomy and combined thoracoscopy- and laparoscopy-assisted esophagectomy for esophageal cancer. Methods The retrospective cohort study was conducted. The clinicopathological data of 116 patients who underwent minimally invasive radical resection of esophageal cancer in the Shanghai Chest Hospital of Shanghai Jiaotong University between November 2015 and September 2016 were collected. Fifty-eight patients undergoing combined thoracoscopy- and laparoscopy-assisted esophagectomy and 58 undergoing Da Vinci robot-assisted esophagectomy were respectively allocated into the thoracoscopy- and laparoscopy-assisted and Da Vinci robot-assisted groups. Patients received esophagectomy by right thorax-left cervico-abdominal triple incisions, thorax-cervico 2-field lymph node dissection of esophageal cancer and digestive tract reconstruction via assisted incision. Observation indicators: (1) surgical and postoperative situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect the survival of patients and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were described as ±s. Measurement data with skewed distribution were described as M (range). Comparison between groups was analyzed by the nonparametric test, and comparisons of count data were done by the chi-square test and Fisher′s exact probability. Results (1) Surgical and postoperative situations: all patients received successful surgery, without conversion to open surgery. The number of lymph nodes dissected along the recurrent laryngeal nerve (RLN) and duration of postoperative hospital stay were 2.8±2.2, 13 days (range, 9-131 days) in the thoracoscopy- and laparoscopy-assisted group and 4.8±3.7, 11 days (range, 7-81 days) in the Da Vinci robot-assisted group, respectively, with statistically significant differences between the 2 groups (t=3.480, Z=2.361, P 0.05). Some of the patients had postoperative multiple complications. Patients with anastomotic leakage received local dressing changes, continuous gastrointestinal decompression and vacuum aspiration. The pronunciation and bucking response were observed in patients with injury of the RLN (unilateral injury). Patients with pleural effusion received pleural puncture fluid or closed thoracic drainage. Patients with pulmonary infection underwent antibiotic therapy and regular aerosol inhalation. Patients with respiratory failure underwent tracheotomy and assisted breathing with ventilator. Patients with chylothorax received fasting and closed thoracic drainage. Patients with arrhythmia were treated by drug. Patients with tracheo-esophageal fistula underwent conservative treatment. All the patients with complications were improved or cured. There were no wound infection, deep venous thrombosis of lower extremity, pulmonary embolism, reoperation and death within 30 days postoperatively in patients of 2 groups. (2) Follow-up and survival situations: all the 116 patients were followed up for 5-15 months, with a median time of 8 months. Numbers of patients with tumor-free survival, tumor recurrence and tumor metastasis were 50, 6, 4 (2 with simultaneous tumor recurrence and metastasis) in the thoracoscopy- and laparoscopy-assisted group and 51, 5, 4 (2 with simultaneous tumor recurrence and metastasis) in the Da Vinci robot-assisted group, respectively, showing no significant difference between the 2 groups (χ2=0.077, 1.000, P>0.05). Conclusions Da Vinci robot-assisted esophagectomy is safe and feasible in the treatment of esophageal cancer. Compared with combined thoracoscopy- and laparoscopy-assisted esophagectomy, Da Vinci robot-assisted esophagectomy has comparable operation time, and is associated with a greater yield of lymph nodes along the RLN. Key words: Esophageal neoplasms, squamous cell carcinoma; Radical section; Da Vinci robotic surgical system; Thoracoscopy; Laparoscopy

Robotic-assisted microvascular surgery: skill acquisition in a rat model.

Microsurgery is a technically demanding field with long learning curves. Robotic-assisted microsurgery has the ability to decrease these learning curves. We, therefore, sought to assess the feasibility of robotic-assisted microvascular surgery in a rat model, and whether this could be translated into a worthwhile skills acquisition exercise for residents. Twenty-eight rats underwent microvascular anastomosis. Procedures were performed by a trained microvascular surgeon with no robotic experience (n=14), or a trained robotic surgeon with no microvascular experience (n=14). Anesthetized rats were subjected to complete transection and end-to-end anastomosis of the abdominal aorta using 10-0 prolene. Manually (n=6) and robotic-assisted (n=8) procedures were performed by both surgeons. A successful procedure required a patent anastomosis and no bleeding. After approximately 35days, angiography and histopathological studies of the anastomoses were performed. Median times for robotic-assisted anastomoses were 37.5 (34.2-42.7)min for the microsurgeon and 38.5 (32.7-52)min for robotic surgeon. In the manual group, it took 17 (13.5-23)min for microsurgeon and 44 (34.5-60)min for robotic surgeon. Within the robotic-assisted group, there was a trend toward improvement in both surgeons, but greater in the microsurgeon. Robotic-assisted microvascular anastomosis in a rat model is a feasible skill acquisition exercise. By eliminating the need for a skilled microsurgical assistant, as well as, improved microsurgical technology, the robotic system may prove to be a crucial player in future microsurgical skill training.

Accuracy of robot-guided versus freehand fluoroscopy-assisted pedicle screw insertion in thoracolumbar spinal surgery.

OBJECTIVE The quest to improve the safety and accuracy and decrease the invasiveness of pedicle screw placement in spine surgery has led to a markedly increased interest in robotic technology. The SpineAssist from Mazor is one of the most widely distributed robotic systems. The aim of this study was to compare the accuracy of robot-guided and conventional freehand fluoroscopy-guided pedicle screw placement in thoracolumbar surgery. METHODS This study is a retrospective series of 169 patients (83 women [49%]) who underwent placement of pedicle screw instrumentation from 2007 to 2015 in 2 reference centers. Pathological entities included degenerative disorders, tumors, and traumatic cases. In the robot-assisted cohort (98 patients, 439 screws), pedicle screws were inserted with robotic assistance. In the freehand fluoroscopy-guided cohort (71 patients, 441 screws), screws were inserted using anatomical landmarks and lateral fluoroscopic guidance. Patients treated before 2009 were included in the fluoroscopy cohort, whereas those treated since mid-2009 (when the robot was acquired) were included in the robot cohort. Since then, the decision to operate using robotic assistance or conventional freehand technique has been based on surgeon preference and logistics. The accuracy of screw placement was assessed based on the Gertzbein-Robbins scale by a neuroradiologist blinded to treatment group. The radiological slice with the largest visible deviation from the pedicle was chosen for grading. A pedicle breach of 2 mm or less was deemed acceptable (Grades A and B) while deviations greater than 2 mm (Grades C, D, and E) were classified as misplacements. RESULTS In the robot-assisted cohort, a perfect trajectory (Grade A) was observed for 366 screws (83.4%). The remaining screws were Grades B (n = 44 [10%]), C (n = 15 [3.4%]), D (n = 8 [1.8%]), and E (n = 6 [1.4%]). In the fluoroscopy-guided group, a completely intrapedicular course graded as A was found in 76% (n = 335). The remaining screws were Grades B (n = 57 [12.9%]), C (n = 29 [6.6%]), D (n = 12 [2.7%]), and E (n = 8 [1.8%]). The proportion of non-misplaced screws (corresponding to Gertzbein-Robbins Grades A and B) was higher in the robot-assisted group (93.4%) than the freehand fluoroscopy group (88.9%) (p = 0.005). CONCLUSIONS The authors' retrospective case review found that robot-guided pedicle screw placement is a safe, useful, and potentially more accurate alternative to the conventional freehand technique for the placement of thoracolumbar spinal instrumentation.

Functional Outcomes and Complications of Robot-Assisted Free Flap Oropharyngeal Reconstruction.

Robotic surgical systems provide a clear, magnified 3-dimensional visualization as well as precise, stable instrumental movement, thereby minimizing technical difficulties that may be encountered in the surgical treatment of oropharyngeal tumors. This study assessed the outcomes of robotic-assisted free flap oropharyngeal reconstruction compared with those of conventional free flap reconstruction. A retrospective review of 47 patients who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects was conducted over a 20-month period (May 2013-December 2014). Complications were evaluated for a robot-assisted reconstruction group and a conventional reconstruction group; postoperative complication rates and revision rates were further evaluated. The Functional Intraoral Glasgow Scale (FIGS) was adopted for functional outcome assessment. This study recruited 47 people who underwent reconstructive operations using a free radial forearm fasciocutaneous flap for oropharyngeal defects (14 robot-assisted and 33 conventional reconstructions). The mean postoperative FIGS score was 10.29 ± 2.02 in the robot-assisted group (P = 0.010) and 8.42 ± 2.29 in the conventional group at 1 month postoperatively. The mean postoperative FIGS score was 12.57 ± 1.91 in the robot-assisted group (P = 0.005) and 9.91 ± 3.09 in the conventional group at 3 months postoperatively. Complication rates between the robot-assisted and conventional groups were similar for flap failure (P = 0.531), partial necrosis, wound infection, hematoma or seroma formation (P = 0.893), wound dehiscence, and fistula formation (P = 0.515). The number of flap revision operations requiring additional surgery (P = 0.627) was comparable between the cohorts. There is no significant difference in complications or revision rates between the robot-assisted and conventional oropharyngeal reconstructions. The functional postoperative outcomes of robot-assisted reconstructions are superior to those of conventional reconstructions. Robotic surgical systems provide a safe option with optimal postoperative oral function for the free flap reconstruction of oropharyngeal defects without lip or mandible splitting.

Comparison of Robotic and Other Minimally-Invasive Routes of Hysterectomy for Benign Indications

Background Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade. Objective We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications. Study Design A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data. Results In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3 ± 198.9 mL, P P P = .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P P = .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P = .01) and blood transfusion (0.8% [11] vs 1.9% [25], P = .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429). Conclusion Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Surgical treatment of retroperitoneal masses

To improve the results of treatment of patients with retroperitoneal tumors. The study included 83 patients with retroperitoneal tumors including 57 cases of benign tumors and 26 patients with malignancies. Laparotomy (Lt), robot-assisted (RA) and laparoscopic (Ls) techniques were used in 35, 34 and 14 patients respectively. Median tumor sizes in the largest dimension were 102 mm, 75 mm and 81.5 mm in Lt, RA and Ls groups respectively. Average time of surgery was 112.5 minutes in Lt-group, 140 min in RA group and 125 minutes in Ls group. Median blood loss was 125 ml, 50 ml and 50 ml in the same groups respectively. Conversion was performed in 1 patient during RA-surgery and in 7 patients during laparoscopy. Postoperative complications occurred in 6 patients after laparotomy and in 5 patients after RA-intervention. There were no deaths. Comprehensive evaluation of different surgical methods is necessary to achieve successful treatment of retroperitoneal tumors. Conventional approach is indicated for tumors over 10 cm while minimally invasive techniques are justified for tumors less than 10 cm. RA-interventions facilitates surgery for tumors located in difficult areas and small anatomical spaces as well as for neoplasms adjacent to great vessels.

Feasibility of rehabilitation using the single-joint hybrid assistive limb to facilitate early recovery following total knee arthroplasty: A pilot study

ABSTRACTWe aimed to evaluate the feasibility of robot-assisted rehabilitation in an early postoperative setting to improve knee mobility following total knee arthroplasty (TKA). A total of 20 patients were alternatively assigned to robotassisted rehabilitation (n = 10; all women) or a control group (n = 10; 2 men and 8 women). The use of a single-joint hybrid assistive limb (HAL-SJ) in active assistive knee exercise was performed for the robot-assisted rehabilitation group while the control patients underwent conventional active assistive knee exercise. We measured the extension lag (defined as the difference between active and passive range of knee extension). We also evaluated the visual analog scale score (VAS) during active movements and active assistive movement. Concerning the extension lag, the robot-assisted rehabilitation group showed 89.4% ± 15.7% improvement (p < 0.01) while the control group showed 34.8% ± 32.1% improvement (p = 0.016). As to the VAS, the robot-assisted rehabilitation group showed 40.7% ± 23.5% improvement while the control group showed 20.4% ± 25.8% improvement (p < 0.01). The use of HAL-SJ may facilitate early recovery from knee surgery and prevent long-term complications such as quadriceps arthrogenic muscle inhibition.

Change in quality of life in older people with dementia participating in Paro-activity: a cluster-randomized controlled trial.

The aim of this study was to investigate effects of robot-assisted group activity with Paro on quality of life in older people with dementia. Nursing home residents with severe dementia often experience social withdrawal and lower quality of life, which are suggested to be enhanced by non-pharmacological interventions. A cluster-randomized controlled trial. Ten nursing home units were randomized to robot-assisted intervention or control group (treatment as usual). Data were collected between March 2013-September 2014. 27 participants participated in group activity for 30minutes twice a week over 12weeks, 26 participated in the control group. Change in quality of life was assessed by local nurses through the Quality of Life in Late-Stage Dementia scale at baseline, after end of intervention and at 3months follow-up. The scale and regular psychotropic medication were analysed stratified by dementia severity. Analysis using mixed model, one-way anova and linear regression were performed. An effect was found among participants with severe dementia from baseline to follow-up showing stable quality of life in the intervention group compared with a decrease in the control group. The intervention explained most of the variance in change in the total scale and in the subscales describing Tension and Well-being for the group with severe dementia. The intervention group used significantly less psychotropic medication compared with the control group after end of intervention. Pleasant and engaging activities facilitated by nursing staff, such as group activity with Paro, could improve quality of life in people with severe dementia. The trial is in adherence with the CONSORT statement and is registered at www.clinicaltrials.gov (study ID number: NCT01998490) [corrected].

Comparison of robotic and other minimally invasive routes of hysterectomy for benign indications

Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade. We sought to compare clinical outcomes and estimated cost of robotic-assisted vs other routes of minimally invasive hysterectomy for benign indications. A statewide database was used to analyze utilization and outcomes of minimally invasive hysterectomy performed for benign indications from Jan. 1, 2013, through July 1, 2014. A 1-to-1 propensity score-match analysis was performed between women who had a hysterectomy with robotic assistance vs other minimally invasive routes (laparoscopic and vaginal, with or without laparoscopy). Perioperative outcomes, intraoperative bowel and bladder injury, 30-day postoperative complications, readmissions, and reoperations were compared. Cost estimates of hysterectomy routes, surgical site infection, and postoperative blood transfusion were derived from published data. In all, 8313 hysterectomy cases were identified: 4527 performed using robotic assistance and 3786 performed using other minimally invasive routes. A total of 1338 women from each group were successfully matched using propensity score matching. Robotic-assisted hysterectomies had lower estimated blood loss (94.2 ± 124.3 vs 175.3± 198.9 mL, P < .001), longer surgical time (2.3 ± 1.0 vs 2.0± 1.0 hours, P < .001), larger specimen weights (178.9 ± 186.3 vs 160.5 ± 190 g, P= .007), and shorter length of stay (14.1% [189] vs 21.9% [293] ≥2 days, P < .001). Overall, the rate of any postoperative complication was lower with the robotic-assisted route (3.5% [47] vs 5.6% [75], P= .01) and driven by lower rates of superficial surgical site infection (0.07% [1] vs 0.7% [9], P= .01) and blood transfusion (0.8% [11] vs 1.9% [25], P= .02). Major postoperative complications, intraoperative bowel and bladder injury, readmissions, and reoperations were similar between groups. Using hospital cost estimates of hysterectomy routes and considering the incremental costs associated with surgical site infections and blood transfusions, nonrobotic minimally invasive routes had an average net savings of $3269 per case, or 24% lower cost, compared to robotic-assisted hysterectomy ($10,160 vs $13,429). Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.

Cystectomie totale avec remplacement vésical orthotopique : comparaison des résultats des patients opérés par voie ouverte et par voie cœlioscopique robot-assistée

Radical cystectomy remains the referent treatment of non-metastatic muscle-invasive bladder cancer (MIBC). The fast development of robotic surgery has led some teams to use it for the surgical treatment of the MIBC, in the hope of reducing postoperative morbidity. Urinary diversion by bladder substitution is a bypass option. The aim of our study was to compare the robot-assisted cystectomy with open cystectomy, with urinary diversion by bladder substitution. Over a two-year period, all the patients who underwent a robot-assisted laparoscopic or open cystectomy with urinary diversion by bladder substitution have been included. The urinary diversion performed was extra-corporeal. The study concerned were 26 men, 15 of them underwent robot-assisted cystectomy, and 11 open cystectomy. There was no significant difference in the median operating time or duration of stay (300 vs 314min and 14 vs 18 days). However, there were less blood loss and more lymph nodes collected in the cystectomies robot-assisted group (median: 400 vs 800mL, P=0.016; 15 vs 10, P=0.01). Three grade III complications of the Clavien-Dindo classification have been described in the robot-assisted group, and none in the open group. No robot-assisted procedure required a conversion to laparotomy. Within 90 postoperative days, complications are basically low grades and results are consistent with the literature. In our series, robot-assisted cystectomies with extracorporeal bladder substitution is technically feasible, with best results on blood loss and the number of lymph nodes removed, without impact on the length of stay. 4.

Robotic-assisted total knee arthroplasty may lead to improvement in quality-of-life measures: a 2-year follow-up of a prospective randomized trial.

Despite reduction in radiological outliers in previous randomized trials comparing robotic-assisted versus conventional total knee arthroplasty (TKA), no differences in short-term functional outcomes were observed. The aim of this study was to determine whether there was improvement in functional outcomes and quality-of-life (QoL) measures between robotic-assisted and conventional TKA. All 60 knees (31 robotic-assisted; 29 conventional) from a previous randomized trial were available for analysis. Differences in range of motion, Knee Society (KSS) knee and function scores, Oxford Knee scores (OKS), SF-36 subscale and summative (physical PCS/mental component scores MCS) were analysed. In addition, patient satisfaction, fulfilment of expectations and the proportion attaining a minimum clinically important difference (MCID) in KSS, OKS and SF-36 were studied. Both robotic-assisted and conventional TKA displayed significant improvements in majority of the functional outcome scores at 2years. Despite having a higher rate of complications, the robotic-assisted group displayed a trend towards higher scores in SF-36 QoL measures, with significant differences in SF-36 vitality (p=0.03), role emotional (p=0.02) and a larger proportion of patients achieving SF-36 vitality MCID (48.4 vs 13.8%, p=0.009). No significant differences in KSS, OKS or satisfaction/expectation rates were noted. Subtle improvements in patient QoL measures were observed in robotic-assisted TKA when compared to conventional TKA. This finding suggests that QoL measures may be more sensitive and clinically important than surgeon-driven objective scores in detecting subtle functional improvements in robotic-assisted TKA patients. II.

Robotic surgery rapidly and successfully implemented in a high volume laparoscopic center on living kidney donation.

It is important to minimize risks associated with live donor nephrectomy. In this study we evaluated the results of left-sided robot-assisted donor nephrectomies in comparison with standard techniques. Data on perioperative results, kidney function, and recipient and graft survival were collected. All left-sided laparoscopic and hand-assisted procedures were selected as control groups. Fifty-nine robot-assisted procedures were performed by two surgeons. Operative time was significantly longer in the robot-assisted group compared with both control groups. However, it decreased significantly during procedures 40-59 compared with procedures 20-39 (P = 0.014) to median 172.5 (114.0-242.0) min. One conversion to the open approach occurred in the robot group due to a bleeding of the renal artery stump. No difference was found between all techniques at 3 months post-donation. Left-sided robot-assisted donor nephrectomy is feasible with over time a significant decrease in operative time with good outcomes for donor and recipient. Copyright © 2016 John Wiley & Sons, Ltd.

Minimally Invasive Versus Open Pancreatic Surgery in Patients with Multiple Endocrine Neoplasia Type 1.

The role of minimally invasive pancreatic surgery for pancreatic neuroendocrine neoplasms (pNENs) in patients with multiple endocrine neoplasia type 1 (MEN1) is not well defined. The aim of this study was to compare the outcome of minimally invasive versus open pancreatic resections in patients with MEN1. Prospectively collected data of MEN1 patients who underwent a primary distal pancreatic resection and/or enucleation for non-functioning pNENs or insulinoma were retrospectively analyzed regarding the outcome of minimally invasive or open pancreatic resections. Thirty-three patients underwent primary pancreatic resection for either organic hyperinsulinism (n=9, 27%) or non-functioning pNENs >1cm in size (n=24, 73%) between 1987 and 2015. 21 (64%) patients underwent an open surgical (group 1) and 12 patients (36%) a minimally invasive approach, either laparoscopic (n=8) or robotic assisted (n=4) (group 2). Both groups were comparable regarding age, gender, number, and size of pancreatic tumors. In both groups, the hyperinsulinism of all patients (9/9,100%) could be cured and all NF-pNENs >1cm could be resected. Group 2 had a significant shorter operative time (200 vs. 260min; p=0.036), less intraoperative blood loss (120 vs. 280ml; p<0.001), and a shorter hospital stay (11 vs. 15.5days; p=0.034). The rate of patients with postoperative complications, especially postoperative pancreatic fistulas, was not different between groups (62% group 1 vs. 67% group 2, p=0.74). Minimally invasive distal pancreatic resections and enucleations are feasible and safe in MEN1 patients with insulinoma or non-functioning pNENs.

Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study.

Surgery for refractory gastroesophageal reflux disease (GERD) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients. Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality. This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery, with the objective to detect possible advantages for the robot-assisted approach. A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study. Baseline characteristics, symptoms, medical history, procedural data, hospital stay, complications and outcome were prospectively gathered. The main indications for redo surgery were dysphagia, pyrosis or a combination of both in combination with a proven anatomic abnormality. The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups, respectively. The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy (1/45 vs. 5/30, p = 0.035) despite a higher proportion of patients with previous surgery by laparotomy (9/45 vs. 1/30, p = 0.038). Median hospital stay was reduced by 1 day (3 vs. 4, p = 0.042). There were no differences in mortality, complications or outcome. Robotic support, when available, can be regarded beneficial in redo surgery for GERD and hiatal hernia. Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery, a reduced number of conversions and shorter hospital stay.

Oral Presentation I

ABSTRACT BACKGROUND AND AIMS Minimally invasive surgery of the adrenal gland is widespread. Although reports demonstrate the safety and feasibility of robot-assisted adrenalectomy, the objective benefits are still unclear, compared to those of conventional laparoscopy. Recently, robot-assisted approach has also become possible for pheochromocytoma resection. Since cardiopulmonary changes during robot-assisted dissection of the pheochromocytoma patient has not been studied in detail, we aimed to assess these concerns, compared to the routine laparoscopic technique. METHODS In this case-control study, 19 consecutive robot-assisted adrenal resections were compared with a control group consisting of 14 conventional laparoscopic adrenalectomy. Patient characteristics and intraoperative hemodynamic and respiratory parameters were assessed. Groups were compared using the χ2 test for categorical variables and Student's t-test for continuous variables. Significance was considered p &lt; 0.05. RESULTS The robot-assisted procedure was performed successfully in all patients, except one. The duration of the robot-assisted procedure, compared to the conventional laparoscopy group, was significantly longer (p &lt; 0.05). Intraoperative blood loss was significantly less in the robot-assisted group (p &lt; 0.05). Dissection of pheochromocytoma showed a significant difference between the groups, according to the incidence of intraoperative blood pressure fluctuations (p &lt; 0.05). The robot-assisted approach resulted in less incidents. Other hemodynamic and respiratory parameters did not differ between groups significantly. There were no perioperative deaths. Complication rates and postoperative hospital stays were not significantly different. CONCLUSION Robot-assisted adrenalectomy is a safe and technically feasible procedure for a pheochromocytoma patient. Robot-assisted resection of pheochromocytoma minimized the occurrence of intraoperative blood pressure fluctuations and blood loss.

Laparoscopic versus robotic-assisted colectomy and rectal resection: a systematic review and meta-analysis.

Lately, the main technical innovations in the field of colorectal surgery have been the introduction of laparoscopic and robotic techniques; the aim of this study is to investigate the results and the advantages of these two surgical approaches. Twenty-two studies including 1652 laparoscopic and 1120 robotic-assisted resections were analyzed and categorized into right, left, and pelvic resections of the middle/low rectum, aiming to the following outcomes: operating time, blood loss, bowel function recovery, return to oral intake, morbidity, hospital stay, and costs. The vast majority of the studies were non-randomized investigations (19/22 studies) enrolling small cohorts of patients (median 55.0 laparoscopic and 34.5 robotic-assisted group) with a mean age of 62.2-61.0 years. Funnel plot analysis documented heterogeneity in studies which combined cancers and benign diseases. Our meta-analysis demonstrated a significant difference in favor of laparoscopic procedures regarding costs and operating time (standardized mean difference (SMD) 0.686 and 0.493) and in favor of robotic surgery concerning morbidity rate (odds ratio (OR) 0.763), although no benefits were documented when analyzing exclusively randomized trials. When we differentiated approaches by side of resections, a significant difference was found in favor of the laparoscopic group when analyzing operating time in left-sided and pelvic procedures (SMD 0.609 and 0.529) and blood loss in pelvic resections (SMD 0.339). Laparoscopic techniques were documented as the shorter procedures, which provided lower blood loss in pelvic resections, while morbidity rate was more favorable in robotic surgery. However, these results could not be confirmed when we focused the analysis on randomized trials only.