Vinci Surgical System Research Articles

Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report.

Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

First report of robotic-assisted total hysterectomy using the Hugo™ RAS system.

This study describes the first reported treatment of a benign gynecological disease with the Medtronic's Hugo™ RAS System, the first robot-assisted device used in the field of gynecology in Japan. Patients who underwent robot-assisted total laparoscopic hysterectomy with the Hugo™ RAS System at the Tottori University Hospital between March 2023 and June 2023 were included in this study. In the first case, the patient was in her 40s and had uterine fibroids. We describe our experience and compare the device with the conventional da Vinci surgical system. We discuss the key features of the Hugo system (including the independent arms, open console, and pistol-shaped handle), the convenience of robotic surgery, the potential to improve quality of life, and how this technology could revolutionize the field of surgery.

A Literature Review of Perioperative Outcomes of Robotic Radical Nephrectomy (RRN) Versus Laparoscopic Radical Nephrectomy (LRN) for Renal Cell Carcinoma (RCC).

Renal cell carcinoma (RCC) is an adenocarcinoma of the renal cortex. Radical nephrectomy remains the standard of care for managing massive renal tumours. Robotic-assisted radical nephrectomy is an increasing alternative technique to laparoscopic radical nephrectomy (LRN). The da Vinci Surgical System allows for improved dexterity, increased visualisation, tremor filtration and an ergonomic setting to enhance surgeon comfort. The aim was to compare the perioperative outcomes pertaining tooperative time, intraoperative complications, blood loss and length of hospital staybetween the robotic and LRN for RCC. Studies that compared the perioperative findings between robotic radical nephrectomy (RNN) and LRN for RCC were included. The literature review was carried out according to the Cochrane collaboration standards where applicable. Highly sensitive search strategies like MeSH terms and controlled vocabularies were used to identify relevant studies that compare the RNN outcomes to the LRN. Following the literature search, a total of 73 articles were collected, 60 articles were excluded at the stage of reviewing the titles, eight articles were excluded after reading the abstracts, and five articles were included in this paper. Five studies were included in this analysis, with a total sample size of 1770 patients, 735 were in the robotic arm, and 1035 were in the laparoscopic arm. Generally, there were no differences between both arms in terms of demographic data and age of patients. Closer analysis of the perioperative outcomes did not reveal significant differences between the two groups related to the estimated blood loss, length of hospital stay or post-operative complications. The laparoscopic techniques have less operative time than the robotic ones. RRNis an expanding approach for patients with RCCwith some potential technical benefits over laparoscopic ones. RRN is similar to LRN in the perioperative outcomes, with few potential drawbacks of RRN, including higher costs. However, a prospective comparison of RRN with LRN in many cases at multiple centres with long-term oncological results best illustrates the status of RRN versus LRN.

Transitioning from Da Vinci Si to Xi: assessing surgical outcomes at a high-volume robotic center.

In the emerging field of robotics, only few studies investigated the transition between different robotic platforms in terms of surgical outcomes. We aimed at assessing surgical outcomes of patients receiving robot-assisted radical prostatectomy (RARP) and robot-assisted partial nephrectomy (RAPN) at a high-volume robotic center during the transition from Si to Xi Da Vinci surgical systems. We analyzed data of 1884 patients undergoing RARP (n = 1437, 76%) and RAPN (n = 447, 24%) at OLV hospital (Aalst, Belgium) between 2011 and 2021. For both procedures, we assessed operative time, estimated blood loss, length of stay, and positive surgical margins. For RARP, we investigated length of catheterization and PSA persistence after surgery, whereas warm ischemia time, clampless surgery, and acute kidney injury (AKI) were assessed for RAPN. Multivariable analyses (MVA) investigated the association between robotic platform (Si vs. Xi) and surgical outcomes after adjustment for patient- and tumor-related factors. A total of 975 (68%) and 462 (32%) patients underwent RARP performed with the Si vs. Xi surgical system, respectively. Baseline characteristics did not differ between the groups. On MVA, we did not find evidence of a difference between the groups with respect to operative time (estimate: 1.07) or estimated blood loss (estimate: 32.39; both p > 0.05). Median (interquartile range [IQR]) length of stay was 6 (3, 6) and 4 (3, 5) days in the Si vs. Xi group, respectively (p < 0.0001). On MVA, men treated with the Xi vs. Si robot had lower odds of PSM (Odds ratio [OR]: 0.58; p = 0.014). A total of 184 (41%) and 263 (59%) patients received RAPN with the Si and Xi robotic system, respectively. Baseline characteristics, including demographics, functional data, and tumor-related features did not differ between the groups. On MVA, operative time was longer in the Xi vs. Si group (estimate: 30.54; p = 0.006). Patients treated with the Xi vs. Si system had higher probability of undergoing a clampless procedure (OR: 2.56; p = 0.001), whereas the risk of AKI did not differ between the groups (OR: 1.25; p = 0.4). On MVA, patients operated with the Xi robot had shorter length of stay as compared to the Si group (estimate: -0.86; p = 0.003), whereas we did not find evidence of an association between robotic system and PSM (OR: 1.55; p = 0.3). We found that the Xi robot allowed for improvements in peri-operative outcomes as compared to the Si platform, with lower rate of positive margins for RARP and higher rate of off-clamp procedures for RAPN. Hospital stay was also shorter for patients operated with the Xi vs. Si robot, especially after robot-assisted partial nephrectomy. Awaiting future investigations-in particular, cost analyses-these results have important implications for patients, surgeons, and healthcare policymakers.

Impact of preferred surgical modality on surgeon wellness: a survey of workload, physical pain/discomfort, and neuromusculoskeletal disorders

BackgroundWe compared surgeons’ workload, physical discomfort, and neuromusculoskeletal disorders (NMSDs) across four surgical modalities: endoscopic, laparoscopic, open, and robot-assisted (da Vinci Surgical Systems).MethodsAn electronic survey was sent to the surgeons across an academic hospital system. The survey consisted of 47 questions including: (I) Demographics and anthropometrics; (II) The percentage of the procedural time that the surgeon spent on performing each surgical modality; (III) Physical and mental demand and physical discomfort; (IV) Neuromusculoskeletal symptoms including body part pain and NMSDs.ResultsSeventy-nine out of 245 surgeons completed the survey (32.2%) and 65 surgeons (82.2%) had a dominant surgical modality: 10 endoscopic, 15 laparoscopic, 26 open, and 14 robotic surgeons. Physical demand was the highest for open surgery and the lowest for endoscopic and robotic surgeries, (all p < 0.05). Open and robotic surgeries required the highest levels of mental workload followed by laparoscopic and endoscopic surgeries, respectively (all p < 0.05 except for the difference between robotic and laparoscopic that was not significant). Body part discomfort or pain (immediately after surgery) were lower in the shoulder for robotic surgeons compared to laparoscopic and open surgeons and in left fingers for robotic surgeons compared to endoscopic surgeons (all p < 0.05). The prevalence of NMSD was significantly lower in robotic surgeons (7%) compared to the other surgical modalities (between 60 and 67%) (all p < 0.05).ConclusionsThe distribution of NMSDs, workload, and physical discomfort varied significantly based on preferred surgical approach. Although robotic surgeons had fewer overall complaints, improvement in ergonomics of surgery are still warranted.Graphical abstract

Use of targeted educational resources to improve robotic bariatric surgery training.

Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures. Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied. From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = -0.0019, p = 0.9; post r = -0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5). Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

Robotic Surgery in Pakistan: Precision, Progress, and Challenges

he Da Vinci Surgical (DVS) system, an example of surgery has made significant advancements since its introduction, in 2000. Thanks to state of the art technology surgeons are now able to perform procedures with exceptional precision and minimal invasiveness. These include urological, thoracic and cardiac surgeries, which have revolutionized the field of surgery.

Comparison of effectiveness and safety of Da Vinci robot's "3 + 1" and "4 + 1" modes of treatment for colorectal cancer.

To compare the effectiveness of the Da Vinci Surgical Robot System (DSRS) "3 + 1" and "4 + 1" models for colorectal cancer (CRC). A total of 107 patients with CRC admitted to our hospital from February 2021 to May 2022 were selected for the retrospective analysis. Of these, 57 patients underwent the DSRS "4 + 1" model (control group), while the rest 50 underwent the DSRS "3 + 1" model (research group). The operation time, intraoperative bleeding, number of lymph nodes detected, time of first postoperative urinary catheter removal, time of first feeding, time of first venting and hospitalization were compared between the two groups. The changes of white blood cell (WBC) and C-reactive protein (CRP) levels before and after surgery were detected, and patients' adverse effects and treatment costs between surgery and hospital discharge were counted. The Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) were used to assess the psychological state of the patients. There was no difference in operative time, intraoperative bleeding, and number of lymph nodes detected between both groups (P > 0.05), while time to first postoperative urinary catheter removal, time to first feeding, time to first venting, length of stay (LOS), postoperative inflammatory factor levels, incidence of adverse events, and treatment costs were all lower in the research group than in the control group (P < 0.05). SAS and SDS scores decreased after treatment in both groups, but the decrease was more obvious in the research group (P < 0.05). Both DSRS "4 + 1" and "3 + 1" modes have better treatment effects for CRC. However, the "3 + 1" mode has higher safety and lower treatment cost, which can significantly improve the postoperative recovery process of patients and is more worthy to be promoted in clinical practice.

113 Does Robotic Anterior Resection Improve the Outcomes for Patients with Rectal Cancer Over Standard Laparoscopic Surgery?

Abstract Background Currently, laparoscopic anterior resection (L-AR) is the standard approach for rectal cancer (RC) treatment. Increasingly, AR procedures have been conducted robotically using the Da Vinci Surgical System (DVSS). Its design has the potential to improve upon the operative outcomes of L-AR. However, the DVSS’s controversial price of $2,000,000 has slowed its clinical adoption. There has been speculation as to whether the clinical outcomes conferred by robotic-assisted AR (R-AR) merits the cost of the DVSS. Aim To review the literature on R-AR and L-AR surgery for RC, primarily comparing the clinical outcomes of each approach, with an auxiliary evaluation of cost-effectiveness. Method A literature search was performed using the databases OVID Embase, MedLine, and Web of Science. The keywords ‘anterior resection’, ‘rectal neoplasm’, ‘robotics’, ‘robotic surgical procedures’, and ‘laparoscopy’ were entered into each database. 141 records were initially retrieved and screened for relevance. The remaining texts that were fully available and adhered to the eligibility criteria were included in this review. Results Ten studies were identified. R-AR resulted in higher quality TME specimens in three studies, (p = 0.02, 0.03, 0.033). and in shorter hospital stays and longer operative times in four studies: (p = 0.03, 0.0001&amp;lt;, 0.001&amp;lt;, 0.001). Overall, R-AR had lower rates of intraoperative complications. Conclusions Generally, R-AR seemed to deliver better outcomes, but there is insufficient evidence to establish its superiority over L-AR. Longitudinal studies with extended research periods are required to evaluate the long-term oncological benefits of R-AR.

Robotic Systems and Navigation Techniques in Orthopedics: A Historical Review

Since the da Vinci surgical system was approved by the Food and Drug Administration (FDA) in 2000, the development and deployment of various robot-assisted minimally invasive surgery (MIS) systems have been largely expedited and boomed. With the rapid advancement of robotic techniques in recent decades, robot-assisted systems have been widely used in various surgeries including orthopedics. These robot-related techniques are transforming the conventional ways to conduct surgical procedures. Robot-assisted orthopedic surgeries have become more and more popular due to their potential benefits of increased accuracy and precision in surgical outcomes, enhanced reproducibility, reduced technical variability, decreased pain, and faster recovery time. In this paper, robotic systems and navigation techniques in typical orthopedic surgeries are reviewed, especially for arthroplasty. From the perspective of robotics and engineering, the systems and techniques are divided into two main categories, i.e., robotic systems (RSs), and computer-aided navigation systems (CANSs). The former is further divided into autonomous RS, hands-on RS, and teleoperated RS. For the latter, three key elements in CANS are introduced, including 3D modeling, registration, and navigation. Lastly, the potential advantages and disadvantages of the RS and CANS are summarized and discussed. Future perspectives on robotics in orthopedics, as well as the challenges, are presented.

Intraoperative laparoscopic photoacoustic image guidance system in the da Vinci surgical system.

This paper describes a framework allowing intraoperative photoacoustic (PA) imaging integrated into minimally invasive surgical systems. PA is an emerging imaging modality that combines the high penetration of ultrasound (US) imaging with high optical contrast. With PA imaging, a surgical robot can provide intraoperative neurovascular guidance to the operating physician, alerting them of the presence of vital substrate anatomy invisible to the naked eye, preventing complications such as hemorrhage and paralysis. Our proposed framework is designed to work with the da Vinci surgical system: real-time PA images produced by the framework are superimposed on the endoscopic video feed with an augmented reality overlay, thus enabling intuitive three-dimensional localization of critical anatomy. To evaluate the accuracy of the proposed framework, we first conducted experimental studies in a phantom with known geometry, which revealed a volumetric reconstruction error of 1.20 ± 0.71 mm. We also conducted an ex vivo study by embedding blood-filled tubes into chicken breast, demonstrating the successful real-time PA-augmented vessel visualization onto the endoscopic view. These results suggest that the proposed framework could provide anatomical and functional feedback to surgeons and it has the potential to be incorporated into robot-assisted minimally invasive surgical procedures.

ThTP7.10 Does robotic anterior resection improve the outcomes for patients with rectal cancer over standard laparoscopic surgery?

Abstract Background Currently, laparoscopic anterior resection (L-AR) is the standard approach for rectal cancer (RC) treatment. Increasingly, AR procedures have been conducted robotically using the Da Vinci Surgical System (DVSS). Its design has the potential to improve upon the operative outcomes of L-AR. However, the DVSS’s controversial price of $2,000,000 has slowed its clinical adoption. There has been speculation as to whether the clinical outcomes conferred by robotic-assisted AR (R-AR) merits the cost of the DVSS. Aims To review the literature on R-AR and L-AR surgery for RC, primarily comparing the clinical outcomes of each approach, with an auxiliary evaluation of cost-effectiveness. Methods A literature search was performed using the databases OVID Embase, MedLine, and Web of Science. The keywords ‘anterior resection’, ‘rectal neoplasm’, ‘robotics’, ‘robotic surgical procedures’, and ‘laparoscopy’ were entered into each database. 141 records were initially retrieved and screened for relevance. The remaining texts that were fully available and adhered to the eligibility criteria were included in this review. Results Ten studies were identified. R-AR resulted in higher quality TME specimens in three studies, (p=0.02, 0.03, 0.033). and in shorter hospital stays and longer operative times in four studies: (p=0.03, 0.0001&amp;lt;, 0.001&amp;lt;, 0.001). Overall, R-AR had lower rates of intraoperative complications. Conclusions Generally, R-AR seemed to deliver better outcomes, but there is insufficient evidence to establish its superiority over L-AR. Longitudinal studies with extended research periods are required to evaluate the long-term oncological benefits of R-AR.

First-in-human Evaluation of a Prostate-specific Membrane Antigen–targeted Near-infrared Fluorescent Small Molecule for Fluorescence-based Identification of Prostate Cancer in Patients with High-risk Prostate Cancer Undergoing Robotic-assisted Prostatectomy

BackgroundMen with high-risk prostate cancer undergoing surgery likely recur due to failure to completely excise regional and/or local disease. ObjectiveThe first-in-human evaluation of safety, pharmacokinetics, and exploratory efficacy of IS-002, a novel near-infrared prostate-specific membrane antigen (PSMA)-targeted fluorescence imaging agent, designed for intraoperative prostate cancer visualization. Design, setting, and participantsA phase 1, single-center, dose-escalation study was conducted in 24 men with high-risk prostate cancer scheduled for robotic-assisted radical prostatectomy with (extended) pelvic lymph node dissection using the da Vinci surgical system. Outcome measurements and statistical analysisAdverse events (AEs), vital signs, complete blood count, complete metabolic panel, urinalysis, and electrocardiogram were assessed over a 14-d period and compared with baseline. The pharmacokinetic profile of IS-002 was determined. Diagnostic accuracy was assessed for exploratory efficacy. Results and limitationsAEs predominantly included discoloration of urine (n = 22/24; expected, related, grade 1). There were no grade ≥2 AEs. IS-002 Cmax and area under the curve increased with increasing dose. Plasma concentrations declined rapidly in a biphasic manner, with the median terminal half-lives ranging from 5.0 to 7.6 h, independent of dose and renal function. At 25 μg/kg, the exploratory efficacy readouts for the negative and positive predictive values were, 97% and 45% for lymph nodes, and 100% and 80% for residual/locoregional disease detection, respectively. ConclusionsIS-002 is safe and well tolerated, and has the potential to enable intraoperative tumor detection that could not be identified using standard imaging. Patient summaryIS-002 is a new imaging agent that specifically targets the prostate-specific membrane antigen receptor. In this study, we tested IS-002 for the first time in men with high-risk prostate cancer undergoing surgery and found that IS-002 is safe, is cleared from the body quickly, and potentially allows identification of prostate cancer in areas that would not be identified by conventional white light imaging.

Robotic Surgery: A Comprehensive Review of the Literature and Current Trends.

Robotic surgery (RS) is an evolution of minimally invasive surgery that combines medical science, robotics, and engineering. The first robots approved by the Food and Drug Administration (FDA) were the Da Vinci Surgical System and the ZEUS Robotic Surgical System, which have been improving over time. Through the decades, the equipment applied to RS had undergone a wide transformation as a response to the development of new techniques and facilities for the assembly and implementation of the own. RS has revolutionized the field of urology, enabling surgeons to perform complex procedures with greater precision and accuracy, and many other surgical specialties such as gynecology, general surgery, otolaryngology, cardiothoracic surgery, and neurosurgery.Several benefits, such as a better approach to the surgical site, a three-dimensional image that improves depth perception, and smaller scars, enhance range of motion, allowing the surgeon to conduct more complicated surgical operations, and reduced postoperative complications have made robotic-assisted surgery an increasingly popular approach. However, some points like the cost of surgical procedures, equipment-instrument, and maintenance are important aspects to consider. Machine learning will likely have a role to play in surgical training shortly through "automated performance metrics," where algorithms observe and "learn" individual surgeons' techniques, assess performance, and anticipate surgical outcomes with the potential to individualize surgical training and aid decision-making in real time.

Indocyanine Green Tracer-Guided Radical Robotic Distal Gastrectomy Using the Firefly™ System Improves the Quality of Lymph Node Dissection in Patients with Gastric Cancer

BackgroundThis study investigated indocyanine green (ICG) as an intraoperative tool for improving lymph node dissection quality in radical robotic distal gastrectomy (RDG) for gastric cancer by comparing the rate of lymph node (LN) noncompliance with or without use of the Firefly™ system. MethodsPatients with potentially resectable gastric cancer including cT1-T4a, N0/ + , M0 were registered in a prospective nonrandomized cohort study at our institution between March 2019 and December 2022. Patients were assigned to the da Vinci surgical system with Firefly system (F group) or that without Firefly system (non-F group). F group patients received endoscopic peritumoral injection of ICG to the submucosa one day before surgery. Rate of LN noncompliance, number of harvested LNs, and short-term outcomes were compared. ResultsOf the 94 patients in this study, 55 underwent Firefly system-guided RDG and 39 underwent conventional RDG. The mean [SD] total number of harvested lymph nodes in F group, 31.2 [10.2], was significantly higher than that harvested in non-F group (25.6 [12.6]; p = 0.026). The LN noncompliance rate in F group was lower than that in non-F group (32.7% vs. 61.5%, p = 0.006). The mean number of LNs harvested in F group was significantly higher than that harvested in non-F group (31.2 [10.2] vs. 25.7 [12.6], p = 0.02). Significant differences were found between the F vs. non-F groups in blood loss and postoperative hospital stay (83.9 [75.1] vs. 301.9 [766.7] mL; p = 0.003 and 13.4 vs. 17.4 days, p = 0.049). ConclusionThe Firefly system-assisted ICG tracer improved LN dissection quality without compromising safety.

Feasibility and learning curve for robotic surgery in a small hospital: A retrospective cohort study.

Robotic surgery rates, typified by the use of the da Vinci Surgical System, have increased in recent years. However, robotic surgery is mostly performed in large hospitals and has not been fully implemented in small hospitals. Therefore, we aimed to verify the feasibility of robotic surgery in small hospitals and verify the number of cases in which perioperative preparation for robotic surgery is stable by creating a learning curve in small hospitals. Forty robot-assisted rectal cancer surgeries performed in large and small hospitals by a surgeon with extensive experience in robotic surgery were validated. Draping and docking times were recorded as perioperative preparation times. Unexpected surgical interruptions, intraoperative adverse events, conversion to laparoscopic or open surgery, and postoperative complications were recorded. Cumulative sum analysis was used to derive the learning curve for perioperative preparation time. Draping times were significantly longer in the small hospital group (7 vs 10 minutes, P = .0002), while docking times were not significantly different (12 vs 13 minutes, P = .098). Surgical interruptions, intraoperative adverse events, and conversions were not observed in either group. There were no significant differences in the incidence of severe complications (25% [5/20] vs 5% [1/20], P = .184). In the small hospital group, phase I of the draping learning curve was completed in 4 cases, while phase I of the docking learning curve was completed in 7 cases. Robotic surgery is feasible for small hospitals, and the preoperative preparation time required for robotic surgery stabilizes relatively early.

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.

(533) Penile Venous Stripping for Treating Patients with Erectile Dysfunction Secondary to a Minimally Invasive Prostatectomy

Abstract Introduction A minimally invasive prostatectomy becomes a treatment of choice in patients with operable prostate cancer. However, it is not uncommon to encounter patients with erectile dysfunction (ED) secondary to this procedure. Objective Although there are many ED treatment strategies, we want to report a physiological penile venous stripping surgery to those patients whose ED was secondary to prostatectomy and refractory to all medical treatments in the recent decade. Methods From 2012 to 2021, 15 consecutive patients, aged 62 to 79, sustained erectile dysfunction (ED) following a minimally invasive prostatectomy for treating prostate cancer. Meanwhile, their ED was refractory to contemporary varied treatment strategies, including one 70-year-old patient non-responsive to 800 mg sildenafil. All patients received dual cavernosography in which the penile venous anatomy was shown by a pilot cavernosograpy, PGE-1 test in-between, and a veno-occlusive dysfunction (VOD) was documented by pharmaco-cavernosography. Eventually, they underwent a physiologically penile venous stripping surgery (PVSS) for erection restoration from VOD. The ambulatory basis was unexceptionally conducted under acupuncture-assisted local anesthesia. PVSS begins with a circumferential approach, followed by degloving those tissues superficial to the Colles' fascia until the penile base. Next, it entailed stripping a deep dorsal vein and two cavernosal veins while fixing every emissary's vein with 6-0 nylon closest to the outer tunica. In contrast, the two pairs of para-arterial veins were only segmentally ligated. The abridged 5-item version of the International Index of Erectile Function (IIEF-5) score system and corporeal radio-opacity assessed erection restoration. Additionally, the erection hardness scale (EHS) confirmed improvement. Results The prostatectomy was performed in laparoscopic (n=7) and Da Vinci surgical system (n=8) elsewhere. The average follow-up period was 5.3±0.4 years. It was unexceptionally pronounced on the radiopacity of the corpora cavernosa to the femoral cortex, denoting the intracorporeal retention established in the corpora cavernosa after PVSS. It was statistically significant between the preoperative and postoperative IIEF-5 scores (5.9±1.8 vs. 11.8±2.6, P&amp;lt;0.01). The EHS improved at least one scale. Surprisingly, two patients reported gratifying outcomes although they were committed to Parkinsonism. Overall, just 42.9% (9/21) of patients reported unaided sex. The remaining patients required medication aid every five men depending on 20 mg sildenafil and 5 mg vardenafil, respectively. Eventually, four resorted to malleable penile implants, which firmly declined preoperatively. Conclusions PVSS is beneficial in managing some groups of males whose ED is secondary to a minimally invasive prostatectomy, although the sample size is limited. Disclosure No

O134 Does robotic anterior resection improve the outcomes for patients with rectal cancer over standard laparoscopic surgery?

Abstract Introduction Currently, laparoscopic anterior resection (L-AR) is the standard approach for rectal cancer (RC) treatment. Increasingly, AR procedures have been conducted robotically using the Da Vinci Surgical System (DVSS). Its design has the potential to improve upon the operative outcomes of L-AR. However, the DVSS's controversial price of $2,000,000 has slowed its clinical adoption. There has been speculation as to whether the clinical outcomes conferred by robotic-assisted AR (R-AR) merits the cost of the DVSS. Aims To review the literature on R-AR and L-AR surgery for RC, primarily comparing the clinical outcomes of each approach, with an auxiliary evaluation of cost-effectiveness. Methods A literature search was performed using the databases OVID Embase, MedLine, and Web of Science. The keywords ‘anterior resection’, ‘rectal neoplasm’, ‘robotics’, ‘robotic surgical procedures’, and ‘laparoscopy’ were entered into each database. 141 records were initially retrieved and screened for relevance. The remaining texts that were fully available and adhered to the eligibility criteria were included in this review. Results Ten studies were identified. R-AR resulted in higher quality TME specimens in three studies, (p=0.02, 0.03, 0.033). and in shorter hospital stays and longer operative times in four studies: (p=0.03, 0.0001&amp;lt;, 0.001&amp;lt;, 0.001). Overall, R-AR had lower rates of intraoperative complications. Conclusion Generally, R-AR seemed to deliver better outcomes, but there is insufficient evidence to establish its superiority over L-AR. Longitudinal studies with extended research periods are required to evaluate the long-term oncological benefits of R-AR.

AB004. SOH23ABS_084. Robot-assisted retroperitoneal right hemi nephrectomy with partial ureterectomy for non-functioning obstructed upper-pole moiety: operative technique with a dual-console Xi da Vinci surgical system

AB004. SOH23ABS_084. Robot-assisted retroperitoneal right hemi nephrectomy with partial ureterectomy for non-functioning obstructed upper-pole moiety: operative technique with a dual-console Xi da Vinci surgical system