Robotic Microsurgery Research Articles

Re: Pros and Cons of Robotic Microsurgery as an Appropriate Approach to Male Reproductive Surgery for Vasectomy Reversal and Varicocele Repair.

Re: Pros and Cons of Robotic Microsurgery as an Appropriate Approach to Male Reproductive Surgery for Vasectomy Reversal and Varicocele Repair.

Robotic Microsurgery Training for Robot Assisted Reconstructive Surgery

Robotic Microsurgery Training for Robot Assisted Reconstructive Surgery

Robot-assisted microsurgical vasovasostomy: the learning curve for a pure microsurgeon

Vasovasostomy success rates improved with the application of the operative microscope in 1975. The robotic platform offers potential advantages including: a stable, ergonomic, scalable control system with three-dimensional visualization and magnification, the elimination of physiological tremor, and simultaneous control of three instruments and a camera. A previous publication revealed a fellowship-trained microsurgeon (PKK) could transition to robot-assisted microsurgical vasovasostomy (RAVV) with comparable outcomes. The objective of this current study was to evaluate the learning curve for the purely trained microsurgeon transitioning to RAVV. A retrospective chart review was performed of a microsurgeon’s first 100 RAVVs evaluating the learning curve for patency rates, anastomosis times, operative times, and sperm concentrations at the initial postoperative semen analyses. Cases were stratified into four groups by 25 case intervals. There were no statistically significant differences in patency rates or postoperative sperm concentrations between the groups over time. There were differences in anastomosis times between groups 1 and 2, as well as between groups 2 and 3, and there were differences in operative times between groups 2 and 3. High-percentage patency rates are achievable very early in the transition from pure microsurgical vasovasostomy to RAVV across wide ranges of obstructive intervals. Postoperative mean sperm concentrations in the initial semen analyses after RAVV are consistent over time. For a single microsurgeon not formally trained in robotic microsurgery, 75 RAVV cases were required to optimize and plateau in anastomosis times and 75 cases were required to optimize operative times.

Robotic (super) microsurgery: Feasibility of a new master-slave platform in an in vivo animal model and future directions.

Advanced microsurgical procedures are currently limited by human precision and manual dexterity. The potential of robotics in microsurgery is highlighted, including a general overview of applications of robotic assistance in microsurgery and its introduction in different surgical specialties. A new robotic platform especially designed for (super) microsurgery is presented. Results of an in vivo animal study underline its feasibility and encourage further development toward clinical studies. Future directions of robotic microsurgery are proposed.

Transoral Robotic Surgery versus Transoral Laser Microsurgery for Oropharyngeal Squamous Cell Carcinoma: A Systematic Review

Objective: Transoral robotic surgery (TORS) and transoral laser microsurgery (TLM), have undergone significant evolution for the treatment of oropharyngeal squamous cell (OPSCC). However, few have directly compared both methodologies. The objective of this work was to summarize and compare published data on surgical, functional, and oncological outcomes of TORS and TLM for the treatment of OPSCC. Methods: A literature search of MEDLINE, EMBASE, Web of Science, and The Cochrane Library databases was conducted to review studies that reported outcomes of TORS or TLM for primary OPSCC. Results: Studies that reported outcomes of TORS or TLM for primary OPSCC were included. 24 TORS studies including 801 patients and 14 TLM studies including 823 patients were identified. Only retrospective and non-randomized prospective studies were found. Despite significant heterogeneity and incomplete data, TORS and TLM resulted in similar hospital lengths of stay, operative times, positive margins, complication profiles, and tracheostomy and gastrostomy rates. Limited data suggests similar impacts on swallow function and quality of life; however, this assessment was confounded by adjuvant treatment. While TLM studies reported worse oncological outcomes, this is likely due to larger, more advanced tumors in the TLM group. Conclusions: Due to significant heterogeneity in study design, population characteristics, indications for adjuvant treatment, p16/ HPV status, and tumor stage, it was not possible to make any definitive conclusions about the superiority of one technique over the other. However, pooled analyses suggest that TORS and TLM result in similar surgical, functional, and oncological outcomes for the treatment of OPSCC. To accurately assess the impact of TORS versus TLM on outcomes, especially in combination with possible de-escalation adjuvant treatment protocols for HPV positive tumors, carefully constructed randomized controlled trials must be conducted.

Robot-assisted microsurgery for chronic orchialgia.

Chronic orchialgia is one of the most common complaints seen in the urologists office and has traditionally been considered a very difficult diagnostic and therapeutic challenge for the clinician. First line management of chronic orchialgia is conservative treatment; however, in men who fail conservative therapy, surgical intervention may be indicated. Microsurgery has been the mainstay for surgical treatment of chronic orchialgia, but the implementation of robotics to microsurgery lends itself particularly to surgical treatment of chronic orchialgia. PubMed was used to perform a current literature search on chronic orchialgia with robotic microsurgery, robotic spermatic cord denervation, robotic varicocelectomy, and robotic vasectomy reversal. Although conservative therapy is considered the first line treatment for chronic orchialgia, reported outcomes are moderate to poor, with the need to proceed to surgical intervention in select cases. Current surgical therapies in which robot assistance have been applied to microsurgery include microsurgical denervation of the spermatic cord, varicocelectomy, and vasectomy reversal. As further studies have assisted in the understanding of surgical treatment of chronic orchialgia, the application of robot assistance to this level of microsurgery has been shown to be feasible and safe with comparable outcomes to traditional microsurgery and may provide potential advantages.

The landscape of surgical innovation in robotic microsurgery

The landscape of surgical innovation in robotic microsurgery

Calibration and Integration of B-Mode Optical Coherence Tomography for Assistive Control in Robotic Microsurgery

During retinal microsurgery, surgeons cannot adequately visualize subsurface anatomical structures. In our previous work, a customized B-mode optical coherence tomography (OCT) probe was integrated into an ophthalmic robotic system to provide depth perception. This paper presents new approaches for implementing and achieving real-time feedback and assistive robotic control based on B-mode OCT imaging. The robotic system was comprised of a parallel robot, a micro-injection tool, and a telemanipulation master interface. A method for calibrating the B-mode OCT image scaling and distortion was presented using thin plate splines. Determining the OCT scanning plane relative to the robot base frame is presented through experiments and analyzed for sensitivity. A dual-rate controller using low frequency OCT feedback and high frequency position servoing was presented and tested for accuracy and latency. Three-dimensional assistive telemanipulation virtual fixtures based on microscope and OCT feedback are presented. The experimental evaluation demonstrated following target anatomy and semi-automated micro-injection. These results present the key steps towards achieving an integrated system for OCT feedback control using a miniature intraocular B-mode probe.

Microsurgery robots: addressing the needs of high-precision surgical interventions.

Robotics has a significant potential to enhance the overall capacity and efficiency of healthcare systems. Robots can help surgeons perform better quality operations, leading to reductions in the hospitalisation time of patients and in the impact of surgery on their postoperative quality of life. In particular, robotics can have a significant impact on microsurgery, which presents stringent requirements for superhuman precision and control of the surgical tools. Microsurgery is, in fact, expected to gain importance in a growing range of surgical specialties as novel technologies progressively enable the detection, diagnosis and treatment of diseases at earlier stages. Within such scenarios, robotic microsurgery emerges as one of the key components of future surgical interventions, and will be a vital technology for addressing major surgical challenges. Nonetheless, several issues have yet to be overcome in terms of mechatronics, perception and surgeon-robot interfaces before microsurgical robots can achieve their full potential in operating rooms. Research in this direction is progressing quickly and microsurgery robot prototypes are gradually demonstrating significant clinical benefits in challenging applications such as reconstructive plastic surgery, ophthalmology, otology and laryngology. These are reassuring results offering confidence in a brighter future for high-precision surgical interventions.

Abstract: Trainee Selection and the Correlation between Cognitive and Technical Skill Evaluation

INTRODUCTION: The selection process for surgical trainees aims to identify those who will perform best during training and have the greatest potential as future surgeons. Better understanding the predictive relationship between interview performance, level of technical skill, and performance during training will allow optimization of the interview and evaluation process to identify the best candidates.1–3 MATERIALS AND METHODS: Three annual cohorts of Reconstructive Microsurgery fellows at the Department of Plastic Surgery at the University of Texas MD Anderson Cancer Center, comprising 20 trainees, were included in the study. At interview, subjects were rated using seven criteria, as well as given a score for overall impression. At the start and end of the fellowship, microsurgical technical skill was assessed both in the OR and laboratory using a validated tool. At the end of the fellowship there was a final evaluation of performance using criteria adapted from the six Accreditation Council for Graduate Medical Education (ACGME) core competencies. Scores at interview, technical skill assessment, and final evaluation scores were all compared in multiple ways to determine associations and predictive factors. RESULTS: Microsurgical skill assessment in the OR at the start of training correlated with all domains evaluated at interview, most closely with Plastic Surgery Training Experience. Microsurgical skill assessment in the OR at the end of training also correlated with scores on the majority of final assessment criteria based on ACGME core competencies, with the highest correlations with Patient Care and Medical Knowledge. Assessment of microsurgical skill in the laboratory at the start of the fellowship did not improve the predictive relationship between interview scores and ACGME core competency evaluations. CONCLUSION: Microsurgical technical skill in the OR tracked with all domains evaluated at interview, and also with the majority of ACGME core competency evaluations. These results validate the use of the current selection process in choosing candidates with the highest level of both cognitive and technical skill, and also support the effectiveness of the one-year microsurgical fellowship at improving microsurgical skill in all trainees. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Selber JC, Chang EI, Liu J, Suami H, Adelman DM, Garvey P, Hanasono MM, Butler CE. Tracking the learning curve in microsurgical skill acquisition. Plast Reconstr Surg. 2012;130:550. 2. Selber JC, Tong W, Koshy J, Ibrahim A, Liu J, Butler C. Correlation between Trainee Candidate Selection Criteria and Subsequent Performance. J Am Coll Surg. 2014; 219:951–7. 3. Alrasheed T, Liu J, Hanasono MM, Butler CE, Selber JC. Robotic microsurgery: validating an assessment tool and plotting the learning curve. Plast Reconstr Surg. 2014;134:794–803.

Robotic intercostal nerve harvest: a feasibility study in a pig model.

The aim of this study was to report the feasibility of robotic intercostal nerve harvest in a pig model. A surgical robot, the da Vinci Model S system, was installed after the creation of 3 ports in the pig's left chest. The posterior edges of the fourth, fifth, and sixth intercostal nerves were isolated at the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvesting procedures, requiring an average of 33 minutes, were successfully performed in 3 pigs without major complications. The advantages of robotic microsurgery for intercostal nerve harvest include elimination of physiological tremor, free movement of joint-equipped robotic arms, and amplification of the surgeon's hand motion by as much as 5 times. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvest for brachial plexus reconstruction.

Quantifying workspace and forces of surgical dissection during robot-assisted neurosurgery.

A prerequisite for successful robot-assisted neurosurgery is to use a hand-controller matched with characteristics of real robotic microsurgery. This study reports quantified data pertaining to the required workspace and exerted forces of surgical tools during robot-assisted microsurgery. A surgeon conducted four operations in which the neuroArm surgical system, an image-guided computer-assisted manipulator specifically designed to perform robot-assisted neurosurgery, was employed to surgically remove brain tumors. The position, orientation, and exerted force of surgical tools were measured during operations. Workspace of the neuroArm manipulators, for the cases studied, was 60×60×60 mm(3) while it offered orientation ranges of 103°, 62° and 112°. The surgical tools exerted a maximum force of 1.86 N with frequency band of less than 20 Hz. This data provides important information specific to neurosurgery that can be used to select among commercially available, or further design a customized, haptic hand-controller for robot-assisted neurosurgical systems. Copyright © 2015 John Wiley & Sons, Ltd.

Robotic microsurgery

Robotic microsurgery

Primary Surgical Management of Oropharyngeal Squamous Cell Carcinoma

Surgical treatment of oropharyngeal squamous cell carcinoma (OPSCC) has been advanced by the development of transoral surgical approaches. Transoral robotic surgery and transoral laser microsurgery are two approaches that allow minimally invasive surgical treatment of OPSCC. In this article, we review the most recent literature regarding the use of TORS and TLM in the surgical management of OPSCC, with a focus on indications, oncologic, and functional outcomes.

Smart surgical tool.

A laser-induced breakdown spectroscopy (LIBS) guided smart surgical tool using a femtosecond fiber laser is developed. This system provides real-time material identification by processing and analyzing the peak intensity and ratio of atomic emissions of LIBS signals. Algorithms to identify emissions of different tissues and metals are developed and implemented into the real-time control system. This system provides a powerful smart surgical tool for precise robotic microsurgery applications with real-time feedback and control.

Robot-Assisted Pterygium Surgery: Feasibility Study in a Nonliving Porcine Model.

This study aims to investigate the feasibility of pterygium surgery using the DaVinci Si HD robotic surgical system, and to describe a porcine model for pterygium surgery and evaluate its usefulness. The pterygium models were constructed using enucleated pig eyes and cold cuts. Robotically-assisted pterygium surgeries in nonliving biological pterygium models were performed using the DaVinci Si HD robotic surgical system. Twelve models were prepared, and 12 pterygium excision and conjunctival autografts were performed. The DaVinci system provided the necessary dexterity to perform delicate ocular surface surgery and robotic tools were safe for the tissues. The mean duration of the surgical procedures was 36 minutes. There were no intraoperative complications and no unexpected events. Robotic-assisted pterygium surgery is technically feasible for porcine eyes using the DaVinci Si HD robotic surgical system. The pterygium model that we describe could be of interest for surgical training. Little research has been done in robotic microsurgery. Animal experimentation will allow the advantages of robotic-assisted microsurgery to be identified, while underlining the improvements and innovations necessary for clinical use.

1P1-D02 顕微鏡下微細手術支援システムにおけるタスク認識手法の開発

In this paper, we describe an algorithm for recognizing the surgical tasks conducted during robotic microsurgery, especially for suturing a micro-blood vessel. In the proposed method, the surgical tasks are recognized using a hybrid HMM/RF model. The motion of the robotic system during each surgical task is modeled using a random forest, and the transition between the surgical tasks is modeled using a hidden Markov model, which considers the minimum duration of each surgical task in the hybrid HMM/RF model. The proposed method was evaluated by recognizing 12 tasks during the suturing of an artificial blood vessel using the microsurgical robotic system, and the tasks were successfully recognized to have a 78.5% accuracy.

Robotic microsurgery: validating an assessment tool and plotting the learning curve.

The surgical robot has emerged as a potentially useful tool in microsurgery. The purpose of this study was to develop a validated assessment instrument and assess the learning curve for robotic microsurgery. The authors hypothesized that subjects would demonstrate improvement across multiple domains of performance with repetition of robotic microsurgical tasks. In part 1, a novel assessment instrument called the Structured Assessment of Robotic Microsurgical Skills was tested. Four blinded expert evaluators graded six robotic microsurgery videos and interrater reliability was determined. In part 2, a cohort of 10 participants at various skill levels performed five robotic microvascular anastomoses. All 50 sessions were subjected to blind evaluation using the assessment instrument. Primary outcome measures included changes in operative time over the five sessions, and changes in assessment scores for all skill areas. Interrater reliability for the Structured Assessment of Robotic Microsurgical Skills instrument was excellent for each skill area, demonstrated by Cronbach alpha scores greater than 0.9 in each category across evaluators. All skill areas improved significantly for all participants, and operative time decreased for all participants over the course of the study. The results showed an initial steep ascent in technical skill acquisition followed by more gradual improvement, and a steady decrease in operative time to as short as 9 minutes. The Structured Assessment of Robotic Microsurgery Skills is a valid instrument for assessing microsurgical skill. Subjects at all levels of training, ranging from minimal microsurgical experience to expert microsurgeons, gained proficiency over the course of five robotic sessions.

Robotic phrenic nerve harvest: A feasibility study in a pig model

The aim of this study was to report on the feasibility of robotic phrenic nerve harvest in a pig model. A surgical robot (Da Vinci S™ system, Intuitive Surgical®, Sunnyvale, CA) was installed with three ports on the pig's left chest. The phrenic nerve was transected distally where it enters the diaphragm. The phrenic nerve harvest was successfully performed in 45 minutes without major complications. The advantages of robotic microsurgery for phrenic nerve harvest are the motion scaling up to 5 times, elimination of physiological tremor, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for harvesting the phrenic nerve for brachial plexus reconstruction.

Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps with the da Vinci robot: six cases.

Nerve transfer to the deltoid muscle using the nerve to the long head of the triceps is a reliable method for restoration of deltoid function. The aim of this retrospective study was to report the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps procedure using a robot. Our series included six patients (mean age 36.3 years) with total deltoid muscle paralysis. A da Vinci-S robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, and then robotically sutured with two 10-0 nylon stiches. In two cases, an endoscopic procedure was tried under carbon dioxide (CO2) insufflation. In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No weakness of elbow extension was observed. In two cases with the endoscopic technique, vision was blurred and conversion to open technique was performed. The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremor. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without the sensory feedback. The robot-assisted nerve transfer to deltoid muscle using the nerve to the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury. Therapeutic Study. Level of Evidence IV.