Use Of Robotic Surgery Research Articles

Robotic Surgery and Deep Infiltrating Endometriosis Treatment: The State of Art

Objective: Surgical treatment of endometriosis, when indicated, has demonstrated to be effective in reducing painful symptoms and improve quality of life of patients affected with endometriosis. The minimally invasive approach via laparoscopy is the preferred method when compared with laparotomy but in the last two decades another minimally invasive approach has become available, the robotically assisted laparoscopic surgery. Robotic technology is widely used in different surgical branches, such as general surgery and urology. Moreover, the use of robotic surgery is already accepted for different gynecological procedures either for benign and for oncological diseases. The advantages of robotic surgery such as improve dexterity of movements, avoided tremor, increased magnification of 3-dimensional vision seem strategic in the context of a complex surgery as is deep endometriosis eradication. However, to date there is no unanimous consensus on whether robotically assisted procedures are a valid and safe alternative to laparoscopy in the treatment of endometriosis. Mechanism: In this narrative review we analyze the available literature assessesing the robotic treatment of all types of endometriosis and specifically deep infiltrating endometriosis, compared to the outcomes of conventional laparoscopy. Findings in Brief: Indeed, the evidence of safety and effectiveness of robotically assisted laparoscopy in endometriosis treatment is strong and almost unanimous. There is no clear superiority of one approach to the other but robotic-related advantages and future prospective are promising to be able to improve operative outcomes, reduce surgeon’s fatigue and provide a technology easy to implement with a fast learning curve. Conclusions: Robotic technology applied to laparoscopy in the treatment of endometriosis could be seen as an effective and safe alternative to the conventional laparoscopic treatment.

The application of robotic surgery in gynecology in the age of artificial intelligence

In the field of gynecology, the selection of surgical approach should be carefully considered based on individual patient characteristics. The development of minimally invasive surgery has greatly impacted gynecological surgeries, and the number of robotic surgeries has been increasing yearly. Robotic surgery offers many benefits. The use of robotic surgery techniques in the multidisciplinary teamwork (MDT) surgery can make surgical operations more convenient, and has resulted in many successful cases, such as in advanced ovarian cancer and deep infiltrating endometriosis surgeries. Single-port robotic surgery has its operational limitations but shows potential for development. The use of remote robotic surgery is being explored. The support of national policies in China has contributed to the development of domestically produced surgical robots. The future of surgical robots lies in technological advancements, market dominance, and the integration of intelligence and miniaturization. Our goal is to disseminate high-quality medical resources and provide services to a larger number of patients.

Trends in the Characteristics, Treatment, and Outcomes of Rectal Adenocarcinoma in the US From 2004 to 2019

Rectal cancer management has significantly evolved over the last 2 decades. This study aimed to evaluate trends in the characteristics, treatment, and outcomes of rectal adenocarcinoma across 16 years. This retrospective, observational case series study used data from the National Cancer Database (NCDB) to evaluate patients diagnosed with rectal adenocarcinoma from 2004 through 2019. Data analysis was performed from March to May 2022. Trends in the treatment and outcomes of rectal adenocarcinoma in the US between 2004 and 2019 were explored. This period was subdivided into 4 equal periods: 2004-2007, 2008-2011, 2012-2015, and 2016-2019. Patient and tumor characteristics, treatments, short-term outcomes, and overall survival. A total of 318 548 patients diagnosed with rectal adenocarcinoma were included in the analysis, 191 369 (60.1%) of whom were males and 127 179 (39.9%%) were females. The mean (SD) age of the patients was 63.5 (13.4) years, and 46 824 patients (14.8%) were younger than 50 years. Among the patients, 10 859 (3.4%) were of Asian race and ethnicity, 28 464 (8.9%) were Black, and 271 236 (85.1%) were White. The percentage of patients younger than 50 years who were diagnosed with rectal cancer increased by 1.5%, from 13.9% in period 1 to 15.4% in period 4. Patients in the last period (2016-2019) presented more often with stages III (36.2% vs 30.2% vs 25.0% vs 23.4%; P < .001) and IV (21.5% vs 19.3% vs 18.1% vs 18.6%; P < .001) disease compared with those in the remaining 3 periods. The use of chemotherapy (36.8% vs 48.1% vs 49.1% vs 47.0%; P < .001) and immunotherapy (0.4% vs 0.2% vs 3.5% vs 6.5%; P < .001) significantly increased across the 4 periods. Although neoadjuvant radiotherapy was used more often across the periods studied (28.6% in period 1 to 34.3% in period 4), the use of adjuvant radiotherapy was reduced by half (12.9% to 6.0%). The median (IQR) time from diagnosis to definitive surgery increased from 95 (15-126) days in period 1 to 128 (47-158) days in period 4. The rate of use of open surgery decreased by half (60.1% in period 2 to 30.1% in period 4), and the use of robotic surgery significantly increased (5.2% in period 2 to 28.4% in period 4). The conversion rate was significantly reduced (11.2% in period 2 to 7.3% in period 4) and the median (IQR) hospital stay decreased by 2 days, from 6 (3-9) days to 4 (2-7) days. The median (IQR) overall survival significantly increased across the periods (from 83.1 months [95% CI, 81.8-84.6 months] in period 1 to 92.1 months [95% CI, 90.2-93.6 months] in period 3; P < .001). The findings of this case series study suggest a treatment trend of increased use of chemotherapy, immunotherapy, sphincter-saving surgery, and minimally invasive surgery. In addition, the time between diagnosis and definitive surgery increased by a median of 33 days. This treatment trend was associated with a significant improvement in the overall survival, reduction in the conversion rate by 3.9%, and a 2-day shorter hospital stay. These findings have major clinical relevance to the management of rectal cancer. The improvements seen in short-term outcomes and survival of patients diagnosed with rectal cancer can probably be attributed to the treatment trends observed. Continued improvement in outcomes warrant further updates in treatments.

Current status of transanal total mesorectal excision for rectal cancer and the expanding indications of the transanal approach for extended pelvic surgeries.

Transanal total mesorectal excision (taTME) has been rapidly accepted as a promising surgical approach to the distal rectum. The benefits include ease of access to the bottom of the deep pelvis linearly over a short distance in order to easily visualize the important anatomy. Furthermore, the distal resection margins can be secured under direct vision. Additionally, a two-team approach combining taTME with a transabdominal approach could decrease the operative time and conversion rate. Although taTME was expected to become more rapidly popularized worldwide, enthusiasm for it has stalled due to unfamiliar intraoperative complications, a lack of oncologic evidence from randomized trials, and the widespread use of robotic surgery. While international registries have reported favorable short- and medium-term outcomes from taTME, a Norwegian national study reported a high local recurrence rate of 9.5%. The characteristics of the recurrences included rapid, multifocal growth in the pelvis, which was quite different from recurrences following traditional transabdominal TME; thus, the Norwegian Colorectal Cancer Group reached a consensus for a temporary moratorium on the performance of taTME. To ensure acceptable baseline quality and patient safety, taTME should be performed by well-trained colorectal surgeons. Although the appropriate indications for taTME remain controversial, the transanal approach is extremely important as a means of goal setting in difficult TME cases and as an aid to the transabdominal approach in various types of extended pelvic surgeries. The benefits in transanal lateral lymph node dissection and pelvic exenteration are presented herein.

Embracing robotic surgery in low- and middle-income countries: Potential benefits, challenges, and scope in the future

Robotic surgery has applications in many medical specialties, including urology, general surgery, and surgical oncology. In the context of a widespread resource and personnel shortage in Low- and Middle-Income Countries (LMICs), the use of robotics in surgery may help to reduce physician burnout, surgical site infections, and hospital stays. However, a lack of haptic feedback and potential socioeconomic factors such as high implementation costs and a lack of trained personnel may limit its accessibility and application. Specific improvements focused on improved financial and technical support to LMICs can help improve access and have the potential to transform the surgical experience for both surgeons and patients in LMICs. This review focuses on the evolution of robotic surgery, with an emphasis on challenges and recommendations to facilitate wider implementation and improved patient outcomes.

The evolving use of robotic surgery: a population-based analysis.

Robotic surgery has integrated into the healthcare system despite limited evidence demonstrating its clinical benefit. Our objectives were (i) to describe secular trends and (ii) patient- and system-level determinants of the receipt of robotic as compared to open or laparoscopic surgery. This population-based retrospective cohort study included adult patients who, between 2009 and 2018 in Ontario, Canada, underwent one of four commonly performed robotic procedures: radical prostatectomy, total hysterectomy, thoracic lobectomy, partial nephrectomy. Patients were categorized based on the surgical approach as robotic, open, or laparoscopic for each procedure. Multivariable regression models were used to estimate the temporal trend in robotic surgery use and associations of patient and system characteristics with the surgical approach. The cohort included 24,741 radical prostatectomy, 75,473 total hysterectomy, 18,252 thoracic lobectomy, and 4608 partial nephrectomy patients, of which 6.21% were robotic. After adjusting for patient and system characteristics, the rate of robotic surgery increased by 24% annually (RR 1.24, 95%CI 1.13-1.35): 13% (RR 1.13, 95%CI 1.11-1.16) for robotic radical prostatectomy, 9% (RR 1.09, 95%CI 1.05-1.13) for robotic total hysterectomy, 26% (RR 1.26, 95%CI 1.06-1.50) for thoracic lobectomy and 26% (RR 1.26, 95%CI 1.13-1.40) for partial nephrectomy. Lower comorbidity burden, earlier disease stage (among cancer cases), and early career surgeons with high case volume at a teaching hospital were consistently associated withthe receipt of robotic surgery. The use of robotic surgery has increased. The study of the real-world clinical outcomes and associated costs is needed before further expanding use among additional providers and hospitals.

A Matched-Pair Analysis after Robotic and Retropubic Radical Prostatectomy: A New Definition of Continence and the Impact of Different Surgical Techniques.

Simple SummaryThe primary goal of radical prostatectomy is oncologic efficacy, but mitigation of the side effects related to prostatectomy is also important to preserve quality of life in these patients. In recent decades, robotic prostatectomy has become increasingly popular due to advantages related to better visualization of the anatomical structures, surgical precision, reduced blood loss, and shorter hospital stay. However, the available literature shows no difference in oncologic outcomes between robotic and open. Some authors suggest differences in its potential to improve functional outcomes, i.e., erectile function and urinary continence. The first is certainly more common but more accepted than urinary incontinence, considering that some patients already suffer from it before surgery and others are not particularly interested in recovering from it, unlike urinary incontinence, which causes psychophysical changes that are often difficult to resolve.Background: Radical prostatectomy is considered the gold-standard treatment for patients with localized prostate cancer. The literature suggests there is no difference in oncological and functional outcomes between robotic-assisted radical prostatectomy (RARP) and open (RRP). (2) Methods: The aim of this study was to compare continence recovery rates after RARP and RRP measured with 24 h pad weights and the International Consultation on Incontinence Questionnaire—Short Form (ICIQ-SF). After matching the population (1:1), 482 met the inclusion criteria, 241 patients per group. Continent patients with a 24 h pad test showing <20 g of urinary leakage were considered, despite severe incontinence, and categorized as having >200 g of urinary leakage. (3) Results: There was no difference between preoperative data. As for urinary continence (UC) and incontinence (UI) rates, RARP performed significantly better than RRP based on objective and subjective results at all evaluations. Univariable and multivariable Cox Regression Analysis pointed out that the only significant predictors of continence rates were the bilateral nerve sparing technique (1.25 (CI 1.02,1.54), p = 0.03) and the robotic surgical approach (1.42 (CI 1.18,1.69) p ≤ 0.001). (4) Conclusions: The literature reports different incidences of UC depending on assessment and definition of continence “without pads” or “social continence” based on number of used pads per day. In this, our first evaluation, the advantage of objective measurement through the weight of the 24 h and subjective measurement with the ICIQ-SF questionnaire best demonstrates the difference between the two surgical techniques by enhancing the use of robotic surgery over traditional surgery.

Is robotic surgery equivalent to laparoscopy in the treatment of stage I endometrial cancers? (544)

Objectives: The LAP2 trial demonstrated that short-term outcomes for patients undergoing minimally invasive surgery (MIS) for endometrial cancer are similar to those undergoing laparotomy. However, recent reports in both cervical and uterine cancer suggest that route of surgery had an unanticipated impact on the long-term clinical outcomes of patients, including recurrence and death. Given an increasing use of robotic surgery since LAP2, we undertook to determine if outcomes following robotic surgery are similar to those of laparoscopy during intermediate and long-term follow-up. Methods: We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of stage I endometrial carcinoma and had at least five years of potential followup. Comparisons of recurrence-free (RFS) and overall survival (OS) by route of surgery were conducted using Cox regression models adjusting for stage, grade, use of adjuvant therapy, and age at surgery. Results: We identified 1,138 patients treated in the study window; 482 in the laparoscopy group and 656 in the RA-MIS group. The groups were similar in age, stage, grade, completeness of staging, and adjuvant therapy. There was a steady increase in the use of RA-MIS surgeries during the study window. Traditional risk factors, such as increasing age, stage, and grade, were associated with poorer outcomes. After controlling for these, RA-MIS was associated with poorer RFS (HR: 1.55, 95% CI: 1.12-2.16) and OS (HR: 1.57, 95% CI: 1.06-2.33). Disease-specific death risk was also higher in the RA-MIS group (competing risks analysis; HR: 3.48, 95% CI: 1.79-6.77). Among those who recurred, the median time to the first recurrence was shorter in the RA-MIS group than in the laparoscopy group (16.3 vs 29.3 months, p=0.046). Fifty-three percent of recurrences in the laparoscopy arm and 42% in the RA-MIS group occurred greater than 24 months after surgery, while 18% and 14% occurred after five years. Conclusions: RA-MIS was associated with poorer outcomes, even after adjusting for known risk factors. Our data in this lower-risk population suggest that relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS in this setting. Objectives: The LAP2 trial demonstrated that short-term outcomes for patients undergoing minimally invasive surgery (MIS) for endometrial cancer are similar to those undergoing laparotomy. However, recent reports in both cervical and uterine cancer suggest that route of surgery had an unanticipated impact on the long-term clinical outcomes of patients, including recurrence and death. Given an increasing use of robotic surgery since LAP2, we undertook to determine if outcomes following robotic surgery are similar to those of laparoscopy during intermediate and long-term follow-up. Methods: We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of stage I endometrial carcinoma and had at least five years of potential followup. Comparisons of recurrence-free (RFS) and overall survival (OS) by route of surgery were conducted using Cox regression models adjusting for stage, grade, use of adjuvant therapy, and age at surgery. Results: We identified 1,138 patients treated in the study window; 482 in the laparoscopy group and 656 in the RA-MIS group. The groups were similar in age, stage, grade, completeness of staging, and adjuvant therapy. There was a steady increase in the use of RA-MIS surgeries during the study window. Traditional risk factors, such as increasing age, stage, and grade, were associated with poorer outcomes. After controlling for these, RA-MIS was associated with poorer RFS (HR: 1.55, 95% CI: 1.12-2.16) and OS (HR: 1.57, 95% CI: 1.06-2.33). Disease-specific death risk was also higher in the RA-MIS group (competing risks analysis; HR: 3.48, 95% CI: 1.79-6.77). Among those who recurred, the median time to the first recurrence was shorter in the RA-MIS group than in the laparoscopy group (16.3 vs 29.3 months, p=0.046). Fifty-three percent of recurrences in the laparoscopy arm and 42% in the RA-MIS group occurred greater than 24 months after surgery, while 18% and 14% occurred after five years. Conclusions: RA-MIS was associated with poorer outcomes, even after adjusting for known risk factors. Our data in this lower-risk population suggest that relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS in this setting.

Current Practice in Robotic Surgery Among Pediatric Urologists: A Survey Study.

Introduction: Since its introduction, robotic surgery has gained most traction among urologists. Pediatric urologists have been slower to adopt the technology than their adult counterparts. Our objectives were to understand current practice patterns for robotic surgery among pediatric urologists, to identify perceived barriers, and to identify factors associated with the use of robotic surgery. Methods: An anonymous online survey was administered using Research Electronic Data Capture (REDCap) to members of the Societies for Pediatric Urology (SPU) including questions about provider demographics and personal practice patterns. Comparisons were made using Pearson's chi-squared analysis. Results: Of 351 SPU members surveyed, 95 completed the survey (27%): 55 (58%) reported performing robotic surgery and 40 (42%) reported not performing robotic surgery. Twenty-seven (28%) reported receiving robotic training in residency, 26 (27%) in fellowship, 34 (36%) in a robotics course, and 30 (32%) with proctored surgery. Cited reasons for not performing robotic surgery were lack of training, referring to practice partners, and lack of benefit. Of those performing robotic surgery, most reported performing 0-1 or 2-4 per month. Thirty-one (56%) reported having selection criteria for use of the robot: 26 (47%) cited an age cutoff, 12 (22%) cited a weight cutoff, and 14 (26%) cited an abdominal size cutoff. Eighteen (33%) reported using hidden incisions endoscopic surgery (HIdES) approach and 40 (42%) reported using an assistant port. Factors associated with using the robot included surgeon age, years in practice, practice setting, having robotic training, and having practice partners who perform robotic surgery. Conclusions: Practice variation exists in the use and application of robotic surgery among pediatric urologists. The main self-reported barriers to performing robotic surgery are lack of training, referring to practice partners, and no perceived benefit to robotic surgery. Factors associated with performing robotic surgery were surgeon age, years in practice, practice setting, and having practice partners perform robotic surgery. There is no Clinical Trial Registration number associated with this study.

Operative Time and 30-Day Outcomes in Bariatric Surgery: Comparison between Robotic and Laparoscopic Approach: 4-Year MBSAQIP Database Analysis.

The main criticism of robotic surgery is longer operative time (OT). The aim of this study was to examine the variables that determine OT, the association between OT and 30-day outcomes, and the effect of the robotic approach in bariatric surgery. MBSAQIP data for 2016 to 2019 were queried. Logistic regression was performed to examine the association between OT and outcomes for each surgical approach while adjusting for patients' characteristics. The results of each fitted logistic regression model were reported as odds ratio and the associated 95% CI. A total of 666,182 patients underwent robotic sleeve gastrectomy (R-SG), laparoscopic sleeve gastrectomy, robotic Roux-en-Y gastric bypass (R-RYGB), laparoscopic Roux-en-Y gastric bypass, robotic duodenal switch (R-DS), and laparoscopic duodenal switch). More patients underwent laparoscopic surgery (89.7%) than robotic surgery (10.3%). OT for robotic cases was longer than for laparoscopic cases (p < 0.0001). Longer OT was associated with increased odds of adverse 30-day outcomes irrespective of the surgical approach. The association between OT and adverse outcomes was stronger in the laparoscopic cohort. There was no significant difference in postoperative outcomes when comparing the laparoscopic and robotic approaches after adjusting for OT, except a lower reoperation rate for R-SG (p = 0.03) and readmission rates in R-RYGB and R-DS (p < 0.01). The variability of OT was higher in the laparoscopic group and was more affected by the first assistant. The outcomes in robotic bariatric surgery were comparable with the laparoscopic approach despite longer OT. Use of robotic surgery decreased the variability in OT.

The Atlantic divide: contrasting surgical robotics training in the USA, UK and Ireland

The uptake of robotic surgery is rapidly increasing worldwide across surgical specialties. However, there is currently a much higher use of robotic surgery in the United States of America (USA) compared to the United Kingdom (UK) and Ireland. Reduced exposure to robotic surgery in training may lead to longer learning curves and worse patient outcomes. We aimed to identify whether any difference exists in exposure to robotic surgery during general surgical training between trainees in the USA, UK and Ireland. Over a 15-week period from September 2021, a survey was distributed through the professional networks of the research team. Participants were USA, UK or Irish trainees who were part of a formal general surgical training curriculum. 116 survey responses were received. US trainees (n = 34) had all had robotic simulator experience, compared to only 37.93% of UK (n = 58) and 75.00% of Irish (n = 24) trainees (p < 0.00001). 91.18% of US trainees had performed 15 or more cases as the console surgeon, compared to only 3.44% of UK and 16.67% of Irish trainees (p < 0.00001). Fifty UK trainees (86.21%) and 22 Irish trainees (91.67%) compared to 12 US trainees (35.29%) do not think they have had adequate robotics training (p < 0.00001). Surgical trainees in the USA have had significantly more exposure to training in robotic surgery than their UK and Irish counterparts.

Short-term outcomes of robotic-assisted surgery following neoadjuvant chemotherapy for lower rectal cancer.

There have been reports about robotic surgery for rectal cancer with chemoradiotherapy (CRT), but only a few studies have compared the use of robotic surgery with and without neoadjuvant chemotherapy (NAC). The aim of our study was to compare the perioperative outcomes of robotic surgery with and without NAC for lower rectal cancer and to examine the effects of NAC on robotic surgery. From January 2016 to July 2021, we compared the short-term outcomes of 45 patients who did not undergo NAC and 55 patients who underwent NAC. The rate of sphincter-preserving surgeries was higher in the NAC group than in the non-NAC group (P=.024). The total operative time was significantly longer in the NAC group than in the non-NAC group (P < .001). The rate of lateral lymph node dissection was significantly higher in the NAC group than in the non-NAC group (P < .001). No significant differences were identified in the rate of incisional surgical site infections (SSI), organ/space SSI postoperative bleeding, small bowel obstruction, anastomotic leakage, urinary dysfunction, or urinary infections between the groups. There were eight incidences of lateral lymph node metastasis (15%) and two cases with positive resection margins (4.0%) in the NAC group. Robotic surgery after NAC has few complications and a higher sphincter-preserving rate that without NAC.

Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer

ObjectiveRecent reports in both cervical and endometrial cancer suggest that minimally invasive surgery (MIS) had an unanticipated negative impact on long-term clinical outcomes, including recurrence and death. Given increasing use of robotic surgery since the LAP2 trial, we sought to compare the intermediate and long-term outcomes between those who underwent robotic surgery or laparoscopy for Stage I endometrial cancer. MethodsWe performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of endometrial carcinoma between 2006 and 2016, ensuring at least 5 years of potential follow-up. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. Overall and recurrence-free survival were compared using Cox proportional hazards regression models adjusting for confounding weights. Results1027 patients were included; 461 received laparoscopy and 566 received RA-MIS. RA-MIS use increased steadily during the study window, which resulted in longer mean surveillance in laparoscopy group (median 8.7 years versus 6.3 years, p < 0.001). RA-MIS was associated poorer recurrence-free (HR: 1.41, 95% CI: 1.12, 1.77) and overall survival (HR: 1.39, 95% CI: 1.06, 1.83). Disease-specific survival was also poorer in the RA-MIS group (HR: 3.51, 95% CI: 2.19, 5.63). Among those who recurred, median time to first recurrence was shorter in the RA-MIS group than the laparoscopy group (16.3 vs. 28.7 months, p = 0.07). ConclusionRA-MIS was associated with poorer long-term patient outcomes. Our data in this lower-risk population indicate relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS.

A Cross-Sectional Study of Resident Training in Robotic Surgery in India.

BackgroundThe widespread implementation of robotic surgery in the Indian subcontinent has received mixed reactions from residents and mentors alike. To date, however, no study has documented the perception of Indian surgical trainees on the effect of robotic surgery on surgical training. Therefore, we conducted a questionnaire-based study on Indian surgical residents to assess their views about robotic surgery and the effect, they believe, it might have on resident training.Materials and methodsQuestionnaires were distributed to 300 surgical residents from programs that do not have surgical robots. All other residents, faculty, medical students, and interns were excluded from the study. The responses were collected and analyzed using appropriate statistical methods.ResultsOverall, 210 surgical residents responded to the survey. A majority of them (57.72%) reported low levels of knowledge regarding robotic surgery. While 88.10% of the study participants reported that the use of robotic surgery will continue to rise in India, an equal proportion (88%) believed that procuring a robot in their program will impair their training in open and laparoscopic surgeries.ConclusionsThe introduction of robotic surgery into surgical residency programs is seen, by most residents, as a threat to training in traditional surgical methods. This calls for the effective incorporation of robotic training into residency training with equal distribution of resident training cases in programs across the country.

Disparities in utilization of robotic surgery for colon cancer: an evaluation of the U.S. National Cancer Database.

Despite the benefits of minimally invasive surgery for colorectal procedures, significant disparities in access to these techniques remain. While these gaps have been well-documented for laparoscopy, few studies have evaluated inequalities in access to robotic surgery. We analyze whether disparities exist in the use of robotic surgery in the management of colon cancer. The U.S. National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma who underwent resection with the robotic platform (2010-2016). Demographic, clinicopathologic, and treatment facility-related variables were analyzed with respect to preferential utilization of robotic surgery with multivariable logistic regression. Patients with metastatic disease, missing or incomplete surgical information, and those who underwent local tumor excision were excluded. 74,984 patients were identified, 3001 (4%) of whom underwent robotic surgery. In multivariable analysis, patients who were older, Black, or were living in an urban area had decreased odds of receiving robotic surgery compared with open or laparoscopic surgery. Patients who were privately insured or living in areas with higher education had increased odds of receiving robotic surgery. Robotic surgery was also preferentially associated with lower clinical stage, more recent year of diagnosis, and hospitals with higher procedural volume. As advantages of the robotic platform are becoming better understood, use of this approach is increasing in popularity for treatment of non-metastatic colon cancer. Despite this, significant disparities exist with respect to patient demographics and socioeconomic factors, and access may only be limited to certain types of hospitals. Further studies are needed to define why these inequalities exist.

Saudi Urological Association consensus guidelines on the use of robotic surgery in urology.

Over the past three decades, minimally invasive robotic technology has evolved substantially in urological practice, replacing many open procedures and becoming part of routine clinical practice. The Health Sector Transformation Program for the Kingdom’s Vision 2030 aims to restructure the health sector and optimize its status and prospects as an effective and integrated ecosystem centered on the patient’s health. Therefore, this consensus seeks to endorse the clinical practice guidelines for robotic surgery (RS) in the KSA, highlighting its effectiveness, safety, and favorable outcomes compared to open and laparoscopic surgeries in certain procedures when used by trained surgeons in well-structured RS programs.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

P146 ROBOTIC REPAIR OF COMPLICATED INGUINAL HERNIAS

Abstract Aim In this video, the authors provide an educational demonstration on the use of robotic surgery in management of two patients with complicated and recurrent inguinal hernias. The two patients demonstrated in these videos show the benefits of use of robotics in the approach to a patient with a recurrent hernia after previous open repair with plug and patch method as well as repair in a very obese patient with large hernias causing obstruction of the left ureter. Material and Methods N/a Results N/a Conclusions Robotic surgery is an emerging technology in surgery and can be a useful modality in treating patients with complex and recurrent inguinal hernias. Furthermore, the visualization in these complex cases can be helpful in identifying the important structures during dissection. Regardless of technique, the two videos presented demonstrate a complex dissection which may be needed when repairing recurrent or very large inguinal hernias.

Clinical application of robotic orthopedic surgery: a bibliometric study

ObjectivesThe present study aimed to evaluate the status and trends of robotic orthopedic surgery in a clinical setting using bibliometrics.MethodsAll relevant publications on the clinical use of robotic surgery in orthopedics were searched from the Web of Science database. Subsequently, data were analyzed using bibliometrics. Visualizing data of bibliographic coupling, co-citation, and co-occurrence analysis were performed using VOSviewer.ResultsIn total, 224 clinical studies met the included standards between 2000 to 2019. Global publications presented an increasing annual trend, with the United States found to have the largest number of publications and robotic companies active in the field (n = 99), followed by China (n = 38), and the United Kingdom (n = 27). The institution with the most contributions was the Beijing Jishuitan Hospital in China (n = 15). The most productive scholars were Tian Wei and Mont Michael A, with 14 publications each. The top 30 most cited papers list showed 29 publications to be cited on more than 40 occassions. The journal with the most related and influential publications on robotic orthopedic surgery was the Journal of Arthroplasty. Fourteen types of robots were used, with the majority applied in knee and spinal surgery. MAKO was the most widely used robot in hip and knee surgery and Mazor in spinal surgery. Most studies were small sample populations of low-quality in this field. The top 20 most frequently used keywords were identified from 950 author keywords. Research on orthopedic robots were classified into two clusters by co-occurrence networks: spinal-related robotic surgery and joint-related robotic surgery.ConclusionsThe present bibliometric study summarizes the clinical research of orthopedic robots on study type, sample size, type of surgery, robot information, surgical site, most popular keywords, most cited papers, journals, authors, institutions, and countries. These findings may assist the scholars better understand the current status and research trends to guide future practice and directions.

Credentialing and Patient Safety in Robotic Gynecologic Surgery: Changes over the Last Nine Years

<h3>Study Objective</h3> To assess how credentialing standards and perceptions of safe use of robotic surgery in gynecology have changed over time. <h3>Design</h3> Two anonymous online surveys conducted in 2012 and 2021. <h3>Setting</h3> ACGME approved residency programs. <h3>Patients or Participants</h3> Trainees (residents and fellows) and attending physicians. <h3>Interventions</h3> Survey. <h3>Measurements and Main Results</h3> A total of 367 physicians responded to the survey; 265 in 2012 and 102 in 2021. Distributions of responses were compared using the Fisher exact test and percentage-based statistics. 89% of 2021 respondents compared to 30% of 2012 respondents reported having the robot at their institution for >5 years. The average number of robotic cases performed increased over time, with only 19% performing >5 cases monthly in 2012 compared to 35% in 2021. 100% of attending respondents in 2021 reported having formalized credentialing processes for robotic surgery compared to 70% in 2012. The percentage of attendings performing bedside assisting prior to console work increased from 46% to 79%. Attendings report of institutional minimum case number requirements to maintain robotic credentials increased from 27% to 90%, with the majority (76%) reporting 10-20 cases needed annually. When asked about beliefs about the number of cases needed for surgical independence, trainees and attendings reported higher numbers in 2021; the percentage reporting >20 cases were required for independence increased from 58% to 93% and 29% to 70%, respectively. Trainees and attendings increased their rate of reporting that attendings are always fully independent and competent (52% to 69% and 51% to 68%, respectively) and decreased their rate of reporting that those doing robotic cases lacked the skills to do so safely (54% to 6% and 30% to 21%, respectively). Notably, nearly a quarter of attending surgeons still reported they had colleagues who lacked skills to consistently perform safe robotic surgery in 2021. <h3>Conclusion</h3> Expansion of credentialing processes over time correlated with improved confidence in surgeon skills.