Robotic General Surgery Research Articles

Rise of the robots: implementing robotic surgery into the acute care surgery practice.

Acute Care Surgery (ACS) admissions and procedures are substantially increasing. ACS disproportionally accounts for a majority of morbidity and mortality among surgical patients. Minimally invasive techniques are associated with improved outcomes and shorter hospital length of stay within the ACS population. While laparoscopy is widespread, ACS surgeons have been slower to adopt the use of robotics. We aimed to evaluate the feasibility of incorporating robotic surgery within ACS practice. Robotic General Surgery operations performed by 8 Acute Care Surgeons from 5 local facilities within a large integrated healthcare system were queried over a 15 month period. Patients who underwent emergent, urgent, sub-acute, and elective robotic operations by ACS staff were identified. Demographics collected included age, gender, BMI, and ASA score. Outcomes recorded included procedure classification, total supply and implant charges (TSI), conversion to open, hospital length of stay (LOS), 30 day readmission, and 30 day mortality. Of 200 operations, the most common were Cholecystectomy (43.5%), Inguinal hernia repair (26.0%), Ventral hernia repair (18.0%), Appendectomy (5.0%), and Sigmoid Colectomy (3.5%). The median (± std dev) age was 48 ± 16.66years and BMI was 29.9 ± 8.79kg/m2. 46% of cases were sub-acute (n = 92), 33.5% were elective (n = 67), 14% were emergent (n = 28), and 6.5% were urgent (n = 13). Most patients were ASA 2 (107, 46.1%) or ASA 3 (71, 45.9%). The median (IQR) TSI and LOS were $1,770 (889.50) USD and 0.1 (0.9) days. Forty-one inpatient procedures were performed. Median LOS was 3days and expected LOS was 3.1days (O:E = 0.96). Five patients were readmitted within 30days, and there were no deaths within 30days. Robotic techniques may be safely implemented by ACS surgeons, potentially benefitting both patient and surgeon. LOS was similar between laparoscopic and robotic cases and only two cases required conversion to an open procedure. Next steps include a multi-center prospective trial comparing robotic to laparoscopic cases.

SP8.1 - Emergency Robotic General Surgery in the UK: Operations, Staff, and Missed Opportunities

Abstract Aims The primary aim was to determine the volume of emergency robotic general surgery performed in the UK. Secondary aims were to determine compatible operations with opportunities for training and the availability of robotic-trained staff. Methods Freedom of Information (FOI) requests were sent to 122 UK Acute Trusts, asking for data on general surgery procedures (open, laparoscopic, robotic) from January 2019 to January 2023. Data on common emergency procedures, in-patient length of stay, robotic complications, and availability of robotically trained staff was requested. Results Of the 122 Acute Trusts, 22 did not respond (82% response rate), 32 had no general surgery robotic access, 16 could not comply due to cost (under section 12 of FOI Act), and 52 provided data. Fifteen Trusts performed emergency robotic surgeries: cholecystectomy (262 cases), hernia repair (140), and appendectomy (3). 86% of these Trusts utilized the DaVinci system, while the CMR Versius system was employed by the remaining 14%. There was a median of 12.5 (range 2-40) robotic-trained staff in-hours, versus a median of 0 (range 0-4) out-of-hours. Conclusions Emergency robotic general surgery in the UK is limited by financial constraints, staff availability, and selective procedural use. Compatible emergency operations that have been performed were cholecystectomies, hernias, and appendectomies. To expand its role, there's a need for training, infrastructure investment, and further research into the cost-effectiveness and outcomes of robotic surgery in emergency cases.

Public's Perception and Knowledge of Using Robotics in General Surgery in Eastern Region, Saudi Arabia.

Robotics in general surgery is a field that involves the use of robotic systems to assist surgeons in performing various types of surgical procedures. The objective of this study was to evaluate the perception and knowledge of robotic surgery among the Eastern Region's population. This cross-sectional study used an electronic questionnaire that was developed using Google Docs. It included males and females aged above 18 years who lived in the Eastern Province. Participants who were below 18 or above 65 years of age, or non-Saudi, or people who lived in other than the Eastern Region of Saudi Arabia were excluded from the study. A total of 500 responses were received via the Google Form, and 81 subjects of them were excluded from the study. Approximately half of the participants were aware of the existence of general robotic surgery, while the other half had no prior knowledge about it. When assessing the participants' understanding of how robotic surgery works, a significant proportion provided incorrect responses. In terms of the advantages of general robotic surgery, the most commonly recognized benefit was that it makes the doctor's life easier, followed by more accurate surgical results. However, the participants' understanding of the disadvantages of robotic surgery was not as accurate. A substantial portion of participants were unsure about the disadvantages. The general public of the Eastern Region in Saudi Arabia showed a derated level of knowledge about the use of robotics in general surgery. Furthermore, a major portion of people were unaware of the availability of robotic surgery in Saudi Arabia. Educational programs are warranted to facilitate the implantation of robotic surgery in Saudi Arabia.

930 Single-Centre Experience in Establishing a Robotic General and Colorectal Surgery Programme in the UK

930 Single-Centre Experience in Establishing a Robotic General and Colorectal Surgery Programme in the UK

Residents underestimate their robotic performance: evaluating resident robotic console participation time

Lack of formal national robotic curriculum results in a void of knowledge regarding appropriate progression of autonomy in robotic general surgery training. One midwestern academic surgical training program has demonstrated that residents expect to independently operate more on the robotic console than they perceive themselves to do. As such, our study sought to evaluate expectations of residents and faculty regarding resident participation versus actual console participation time (CPT) at a community general surgery training program. We surveyed residents and faculty in two phases. Initially, participants were asked to reflect on their perceptions and expectations from the previous six months. The second phase included surveys (collected over six months) after individual cases with subjective estimation of participation versus CPT calculated by the Intuitive Surgical, Inc. MyIntuitive application. Using Mann–Whitney U-Test, we compared resident perceptions of CPT to actual CPT by case complexity and post-graduate year (PGY). Faculty (n = 7) estimated they allowed residents to complete a median of 26–50% of simple and 0–25% of complex cases in the six months prior to the study. They expected senior residents (PGY-4 and PGY-5) to complete more: 51–75% of simple and 26–50% of complex cases. Residents (n = 13), PGY-2–PGY-5, estimated they completed less than faculty perceived (0–25% of simple and 0–25% of complex cases). Sixty-six post-case (after partial colectomy, abdominoperoneal resection, low anterior resection, cholecystectomy, inguinal/ventral hernia repair, and others) surveys were completed. Residents estimated after any case that they had completed 26–50% of the case. However, once examining their MyIntuitive report, they actually completed 51–75% of the case (median). Residents, especially PGY-4 and 5, completed a higher percentage than estimated of robotic cases. Our study confirms that residents can and should complete more of (and increasingly complex) robotic cases throughout training, like the transition of autonomy in open and laparoscopic surgery.

Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy.

Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Active control time: an objective performance metric for trainee participation in robotic surgery.

Trainee participation and progression in robotic general surgery remain poorly defined. Computer-assisted technology offers the potential to provide and track objective performance metrics. In this study, we aimed to validate the use of a novel metric-active control time (ACT)-for assessing trainee participation in robotic-assisted cases. Performance data from da Vinci Surgical Systems was retrospectively analyzed for all robotic cases involving trainees with a single minimally invasive surgeon over 10months. The primary outcome metric was percent ACT-the amount of trainee console time spent in active system manipulations over total active time from both consoles. Kruskal-Wallis and Mann-Whitney U statistical tests were applied in analyses. A total of 123 robotic cases with 18 general surgery residents and 1 fellow were included. Of these, 56 were categorized as complex. Median %ACT was statistically different between trainee levels for all case types taken in aggregate (PGY1s 3.0% [IQR 2-14%], PGY3s 32% [IQR 27-66%], PGY4s 42% [IQR 26-52%], PGY5s 50% [IQR 28-70%], and fellow 61% [IQR 41-85%], p = < 0.0001). When stratified by complexity, median %ACT was higher in standard versus complex cases for PGY5 (60% vs. 36%, p = 0.0002) and fellow groups (74% vs. 47%, p = 0.0045). In this study, we demonstrated an increase in %ACT with trainee level and with standard versus complex robotic cases. These findings are consistent with hypotheses, providing validity evidence for ACT as an objective measurement of trainee participation in robotic-assisted cases. Future studies will aim to define task-specific ACT to guide further robotic training and performance assessments.

First worldwide report on Hugo RAS™ surgical platform in right and left colectomy.

The diffusion of robotic surgery is rapidly and constantly growing in different surgical specialties. Recently, novel robotic platforms have entered into the market. To date, however, most of the reports on their clinical use have specifically focused on gynecological and urological surgery. In this study, we present the first three robotic-assisted colectomies performed with the new Hugo RAS system (Medtronic, Minneapolis, MN, USA). The surgical team had previous robotic experience and completed simulation training and an official 2-day cadaver laboratory session. Operating room setting and trocar layout were planned and two full cadaver procedures were carried out (right and left colectomy). Onsite dry-run sessions were performed before tackling clinical cases. Three patients underwent robotic-assisted colectomies: one left colectomy, two right colectomies with complete mesocolic excision (CME) and high vascular ligation (HVL) at our Institution. Preoperative diagnosis was colonic adenocarcinoma in all cases. A description of the operative room setup, robotic arm configuration and docking angles is provided. Mean docking time and console time were 8 and 259min, respectively. All the surgical steps were completed without critical surgical errors or high-priority alarms. Neither intraoperative complications nor conversions to open surgery were recorded. Postoperative courses were uneventful with a mean length of stay of 5days. Further clinical data and experience are required for procedural standardization and potential integration of the system into robotic general surgery and colorectal programs.

Robotic General Surgery Trends in the Veterans Health Administration, Community Practice, and Academic Centers From 2013 to 2021

This cross-sectional study compares trends in use of robotic surgery for general surgical procedures among the Veterans Health Administration (VHA), community practice, and academic health centers from 2013 to 2021.

Perception vs Reality: Examining Trainee Participation and Handoffs in Robotic General Surgery

INTRODUCTION: Despite expansion of robotic surgery, resident participation during robotic cases remains poorly characterized. The aim of this study was to compare perceptions of case participation and handoffs between trainees and faculty against objective robotic metrics. METHODS: Post-case assessments evaluating trainee participation and intra-operative handoffs were distributed to faculty and trainees following case conclusion. Metrics including percent active control time (%ACT)—defined as percent of trainee console time spent actively manipulating robotic instruments—and handoff counts between dual consoles were reviewed from the robotic platform. Wilcoxon and intra-class correlation tests were applied. RESULTS: From December 2021-January 2022, 20 robotic cases with matched trainee/faculty assessments were included (Table 1). On subset analysis, reliability between trainee-reported and objective %ACT ranged from “moderate” to “excellent” (ICC = 0.915, 95% CI 0.743-0.972). Reliability between faculty-reported and objective %ACT ranged from “good” to “excellent” (ICC = 0.954, 95% CI 0.868-0.985). Mean difference between trainee-reported and objective %ACT vs faculty-reported and objective %ACT was significant (mean -6.5 vs 2.2, p = 0.0078). There was no significant difference in reported handoff counts, however, the groups reported aligned handoff reasoning in only 53% of cases, most often due to pedagogical takeover or graded autonomy. There was no significant difference in reported case difficulty or educational effectiveness between groups. Table 1. - Robotic Case Series Demographic Information Case type Cases by trainee level Cholecystectomy 6 (30%) PGY2 1 (5%) Gastric bypass 6 (30%) PGY3 3 (15%) Inguinal hernia 4 (20%) PGY4 11 (55%) Hiatal hernia 4 (20%) PGY5 2 (10%) Fellow 3 (15%) Total 20 20 CONCLUSION: In this pilot case series, faculty more reliably and accurately estimated trainee robotic case participation. Trainees underestimated their case participation on average compared to objective metrics. Further studies must investigate the foundation of poor trainee case confidence and faculty-trainee handoff misalignment in robotic surgery.

Robotic Hernia Repair using a Barbed Suture.

Barbed sutures became available in the mid-1960's, when a popular bidirectional barbed suture was primarily used by plastic surgeons for skin closure. As laparoscopic surgery became more commonplace, so did the need for intracorporeal sewing, but the challenges of tying sutures under tension became apparent. While surgical devices such as the Endostich™ (Covidien, Dublin, Ireland) aided in overcoming the learning curve for laparoscopic sewing, over time, the introduction of a unidirectional barbed suture helped minimally invasive surgeons overcome the challenges of sewing laparoscopically. It is particularly difficult to secure knots under tension using commonly available monofilament and multifilament sutures. Barbed sutures allow for the distribution of tension along the suture closure without the need for securing knots. However, with the introduction of the daVinci™ robot by Intuitive (Sunnyvale, CA) in 2001, sewing has become easier and more popular with the availability of a 3-dimensional, high-definition view and wristed instruments. As robotic general surgery has become increasingly accepted, it is fitting that the use of a barbed suture in hernia surgery has become critical for primary fascia closure of the hernia defect and various layer closures.

Value of robotic surgery simulation for training surgical residents and attendings: a systematic review protocol

IntroductionRobotic surgery is a method of minimally invasive surgery performed through small incisions using a remote robotic console. Surgical residents and attendings participate in simulation training to be able to...

Expertise in perception during robotic surgery (ExPeRtS): What we see and what we say

BackgroundGiven the challenges of teaching in robotic operating rooms, we sought to investigate the language of perceptual expertise used by robotic surgeons, in an effort to improve current approaches to robotic training. MethodsExpert robotic surgeons reviewed 8 anonymous video clips portraying key portions of two robotic general surgery procedures and their comments were recorded and transcribed. Using content analysis, each transcript was double-coded and reconciled using a consensus developed codebook. ResultsSeventeen expert robotic surgeons participated and comments formed two primary themes: visual comprehension and surgical technique. Surgeons minimally used tactile language. Risk avoidance was a second-order theme dominating language used. ConclusionsExperts occasionally used tactile language and emphasized risk avoidance as they observed robotic surgery. Despite the need to communicate perceptual expertise to trainees in robotic surgery, tactile language was not exhibited by expert surgeons, revealing an important future area of focus for intraoperative teaching skills.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study.

Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery. Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook. Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility. This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Robotic surgery training curricula: prevalence, perceptions, and educational experiences in general surgery residency programs.

Utilization of robotics in general surgery has increased exponentially in the past decade. The purpose of this study was to provide an updated analysis of the prevalence of robotic training curricula among general surgery residency programs across the United States. A 19-item survey was distributed to program directors of the Association of Program Directors in Surgery email list. The survey focused on the programs' demographics, program directors' opinions of robotic surgery, and status of robotic surgery curricula. Data was compiled and analyzed using Qualtrics Survey Software, Microsoft Excel and IBM SPSS. Chi-Squared statistical significance was defined as a p value of < 0.05. Of the 280 program directors, 107 (38.2%) responded. Overall, 75 (70%) residency programs provided a formal robotic surgery curriculum. Regarding the importance of robotics to general surgery training, 67 (89%) programs that provided a formal robotic surgery curriculum stated it was either 'Very important' or 'Probably important' as opposed to 23 (72%) programs that did not offer a formal robotic surgery curriculum (p = 0.017). 73 of the 75 residency programs with a formal robotic surgery training curriculum answered the curriculum specific questions. 58 (79%) had been present for 3years or less. Bedside assisting began in 62 (85%) programs as a post-graduate year (PGY) 1 or PGY2 and residents began operating on the console as a PGY2 or PGY3 in 53 (72%) programs. However, there was variability regarding the percentage of the case a senior resident actually operated on the robotic console. A majority of general surgery residency programs offer formal robotic surgery curricula and have been present for 3years or less. Most residencies begin their curricula in PGY1 or PGY2 year, with an opportunity to bedside assist and operate on the robotic console in the first 3 years of residency. Operative barriers and defined milestones for general surgery trainees need to be identified.

Defining the Learning Curve for Robotic Pancreaticoduodenectomy at a Single Center with an Established Laparoscopic Pancreaticoduodenectomy Program

Introduction: Robotic pancreaticoduodenectomy (RPD) has a learning curve (LC) of approximately 30-250 cases to reach proficiency. The LC for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study compares the LC for LPD and subsequently RPD at a single institution. Methods: LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and LCs were defined with respect to operative time using CUSUM analysis. Results: Thirty-nine LPD and 69 RPD were analyzed. Introduction of LPD was completed first as a hybrid technique (excluded), followed by total LPD. LPD had a bimodal or inverted LC possibly accounting for proficiency attained from hybrid LPD and introduction of additional surgeons later in the experience. The LC for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 406 minutes, p<0.03), improved LN harvest (15 vs 19, p<0.02), and similar estimated blood loss and R0 resection. RPD also had improved LOS (7 vs 9 days, p<0.002), and lower rates of surgical site infection (10% vs 38%, p<0.001), abscess (7% vs 23%, p<0.04), and readmission (13% vs 33%, p<0.03). Conclusion: Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.

Robotic General Surgery Resident Training Curriculum: A Pilot Experience.

The purpose of this study was to report the impact of a pilot robotic general surgery resident training curriculum. A single institution pilot robotic general surgery training curriculum was instituted in 2016. Accreditation Council for Graduate Medical Education operative case log trends, resident simulation performance, and surveys were analyzed. Forty-three general surgery residents participated in the robotic surgery training curriculum, 2016 to 2019. In total, 161 robotic cases were logged, increasing each academic year. Residents acted as bedside assistant in 42.9% (n=69) and as console surgeon in 57.1% (n=92). Fifteen first-year residents were surveyed on the training curriculum. On the postcurriculum survey, 100% found the curriculum to be very helpful, notably the hands-on in-service and skills simulator. Since the curriculum onset, residents participated in an increasing number of robotic operative cases and were actively engaged in simulation exercises. The establishment of this curriculum has facilitated the integration of resident education into the utilization of robotic technology. This study highlights the value of a formal robotic surgery curriculum for general surgery residency training.

Robotics in general surgery: a promising evolution.

Robotics in general surgery: a promising evolution.

Robotic colorectal surgery in Australia: evolution over a decade.

Despite reports of increasing adoption of robotics in colorectal surgery worldwide, data regarding its uptake in Australasia are lacking. This study examines the trends of robotic colorectal surgery in Australia during the last 10 years. Data from patients undergoing robotic colorectal surgery with the da Vinci robotic platform between 2010 and 2019 were obtained. Overall, numbers of specific colorectal procedures across Australia were obtained from the Medicare Benefit Schedule data over the same period. Pearson's correlation analysis was used to determine the statistical trends of overall and specific robotic colorectal procedures over time. A total of 6110 robotic general surgery procedures were performed across Australia during the study period. Of these, 3522 (57.6%) were robotic colorectal procedures. An increasing trend of overall robotic colorectal procedures was seen over 10 years (Pearson's coefficient of 0.875; P= 0.001). While this applied to both the public and private sectors, 90.7% of the procedures were undertaken in the private sector. Restorative rectal resections, rectopexies, and right hemicolectomies accounted for 82.6% of the robotic colorectal procedures performed during this period with an increasing trend seen over time for each intervention. Moreover, a robotic approach was utilized in 12.5%, 41.0% and 9.0% of all restorative rectal resections, rectopexies and right hemicolectomies undertaken in Australia during 2019, respectively. Robotic colorectal surgery has increased dramatically in Australia over the last 10 years, especially in the private sector. Penetration of robotic colorectal surgery in the public healthcare system will require focussed cost-benefit evaluations and governmental investment.

Residents’ Views on the Impact of Robotic Surgery on General Surgery Education

The use of the da Vinci Robot has been fast growing in general surgery in the United States over the past decade. While the financial cost of robot-assisted procedures has been studied, there has been limited research on the educational cost of the robotic approach on general surgery trainees, and their surgical skills. Analysis of anonymous educational survey responses collected from residents, in addition to case logs which were used as a retrospective review for the 5 years preceding the survey. One thousand bed, tertiary care hospital general surgery residency program. Twenty-four enrolled general surgery residents in 2018. There has been a rapid expansion in the use of robotics in general surgery. In 2017 the total number of general surgery cases using the da Vinci robot increased 6 fold over that in 2013 (23 cases in 2013, 136 in 2017), while both open and laparoscopic procedures have witnessed about a 33% drop in the case volume during those years. Almost all residents would prefer a residency program which offers the da Vinci robot for care and training (95%), however, 38% of general surgery residents reported that the presence of robotic-assisted surgery had a "detrimental" effect on their surgical training. Senior residents were more likely to report a "detrimental" effect (56% vs 27%). A third of the residents believe that robotic surgery is impeding their ability to learn open and laparoscopic surgical techniques, and only 25% denied a negative impact. Senior residents are more likely to report this negative impact (67% vs 13%). Reforms in residency curricula need to be in place to accommodate the expansion of the use of the robotic platform in general surgery. A subjective survey of the residents suggests that robotic surgery can potentially impede the development of residents' open and laparoscopic surgical skills.