Vinci System Research Articles

Robotic Surgery: Is There a Possibility of Increasing Its Application in Pediatric Settings? A Single-Center Experience.

Introduction: Robotic surgery has shown explicit benefits and advantages in adults, but it is not yet strongly established in the pediatric population, even though its popularity is increasing, especially in the urologic field. Materials and methods: In this article we present our experience with the Da Vinci System (SI first and XI nowadays) at our pediatric institution in order to analyze our progress over the years. We considered all patients from the start of the robotic surgery program in 2016 until the end of 2021, dividing them into general abdominal surgery and genitourinary surgery. Analyzed data were the patient’s demographic, details of surgery, and intra and post-operative complications. Results: The total number of patients (pts) included in this study was 76, of whom 40 (52%) were male and 36 (48%) were female. The mean age at surgery was 90.9 months (range 10–207 months), and the mean weight at surgery was 29.3 kg (range 9.5–68 kg). There were 18 general abdominal robotic surgeries and 58 genitourinary robotic surgeries performed. The most performed surgeries in these two categories were fundoplication for gastro-oesophageal reflux disease (11%) and Anderson–Hynes pyeloureteroplasty. The mean operative time was 224.2 min (range 72–530 min): the mean times in the two groups (general abdominal surgery and genitourinary surgery) were 165 min (range 84–204 min) and 194 min (range 95–360 min), respectively. A total of four (5%) minor complications were reported. The total conversions were two (2.6%) and the mortality rate was 0%. Conclusions: Pediatric robotic surgery is a field of considerable interest and it is rapidly expanding. In our experience, it is evident how the learning curve has increased gradually, but steadily, allowing us to advance from standardized surgery, such as fundoplication and pieloplasty, towards a more technically complex one, achieving the same good results. We believe that robotic surgery is very respectful of tissues and feasible, especially for reconstructive surgery. For these reasons, it could become of common use also in the pediatric population, overcoming impediments such as excessive cost and the lack of pediatric instruments, in order to be able to treat children with a progressively lower age and weight.

Initial Learning Curve and Stereotypical Use of Extra Arm During da Vinci Chest Procedures of McKeown Esophagectomy.

Objective: McKeown esophagectomy facilitates extensive lymphadenectomy for the optimal management of esophageal cancer. Robot-assisted esophagectomy (RAE) was introduced in an attempt to reduce the incidence of postoperative complications. The da Vinci System has 3 active robotic arms in addition to the camera scope, and an extra robotic arm (ERA) is generally used to maintain a fine and stable operative field. However, the optimal use of an ERA has not been documented. In addition, the learning curve of the RAE using the da Vinci System remains controversial. In this study, we aimed to determine the optimal use of an ERA in association with the initial learning curve of robotic McKeown esophagectomy with extremely extensive lymphadenectomy. Methods: We reviewed 81 consecutive patients who underwent RAE. To determine whether stereotypical use of an ERA after establishment of its optimal use accounted for the learning curve, we measured the duration of 14 steps and the duration when performed with optimal use of an ERA in the corresponding step by reviewing video-recorded procedures. We then calculated the ratio as the degree of stereotypical use of the ERA during the da Vinci chest procedures. Results: The cumulative sum method showed that the learning curve required 27 cases of RAE. In addition, stereotypical use of the ERA was significantly associated with the learning curve of RAE. Conclusions: Establishment of optimal use of an ERA could help to accelerate the learning curve in da Vinci chest procedures during McKeown esophagectomy with extensive lymphadenectomy.

EGFR-targeted fluorescent imaging using the da Vinci® Firefly™ camera for gallbladder cancer

BackgroundFluorescent imaging may aid with the precise diagnosis and treatment of patients with gallbladder cancer. In this study, we sought to demonstrate whether the da Vinci® surgical system and Firefly™ camera could detect EGFR-targeted fluorescent images in orthotopic mouse models of gallbladder cancer.MethodsAn orthotopic mouse model of gallbladder cancer was created by injecting NOZ gallbladder cancer cells mixed with Matrigel into the gallbladder. In vivo imaging of subcutaneous and orthotopic gallbladder tumors was performed after the injection of DyLight 650- or 800-conjugated EGFR antibody.ResultsWestern blotting, flow cytometry, and confocal microscopy showed the presence of EGFR in NOZ cells, but not in HEK293 cells. Subcutaneous NOZ cell tumors fluoresced after injection with fluorescent EGFR antibody, but subcutaneous HEK293 tumors did not. Fluorescent EGFR antibody made orthotopic NOZ tumors fluoresce, with an intensity stronger than that in the surrounding normal tissues. Histochemical examination confirmed the location of the tumors inside the gallbladder and adjacent liver parenchyma. Fluorescent signal was also detected in orthotopic gallbladder tumors with Firefly™ camera.ConclusionOur study showed that fluorescent EGFR antibodies and the Firefly camera in the da Vinci system can detect fluorescing gallbladder tumors, which demonstrates their potential use for molecular imaging-based prevision surgery in the near future.

Comparison of right hemicolectomies with and without complete mesocolic excision (CME)

Abstract Objective Since the concept of complete mesocolic excision (CME) in right hemicolectomies was introduced, it is still under debate if all patients require this radical technique. Methods Patients with adenocarcinoma of the colon undergoing right hemicolectomies at our hospital were retrospectively analyzed and stratified in a non-CME group (08/2014-04/2018) and a CME group (05/2018-11/2021). Patients were compared in regard to clinical, histopathological and prognostic parameters. CME were classified according to Benz et al. Results A total of 130 right hemicolectomies were performed, 33 (25.4%) patients were excluded due to other pathologies or emergency patients. Finally, 97 patients were included (53 in the CME group, 39 in the non-CME group). No difference in patient's characteristics were found except more male patients in the CME group (20 vs. 6; p=0.02). Tumors in the CME group were mainly located in the colon ascendens (66.0%), in the non-CME group in the coecum (48.7%; n.s.). In the CME group, 26 of 53 (49.1%) patients were operated laparoscopically compared to 10 of 39 (25.6%) patients in the non-CME group. Da Vinci system were used exclusively in the CME group (5 of 53 (9.4%); p=0.003). TNM classification, histology and UICC stadium showed no significant difference. In total, 50 (94.3%) surgical specimen were classification either as CME 0 or 1. In average, 35.2 lymph nodes (8.2% positive) were found in the CME group compared to 32.7 (16.2% positive) lymph nodes in the non-CME group (p=0.9). No relevant intraoperative complications occurred in both groups. Distance of the mesocolon were available in 39 (73.6%) patients in the CME group and 34 (37.1%) in the non-CME group; the distance tended to be longer in the CME group (mean 116.0 mm in CME group vs. 96.6 mm in non-CME group; p=0.09). Follow-up were 336.4 days in CME-group and 1210.4 days in the non-CME group. In the follow-up, 2 (5.1%) patients in the non-CME group developed a local recurrence in the smaller pelvis. No local recurrence occurred in the CME group (p=0.18). Distant metastasis occurred in 5 of 53 (9.4%) patients in the CME group and in 2 of 39 (5.4%) patients in the non-CME group (p=0.7). Conclusion This study shows that the benefit for CME in all performed right hemicolectomies is marginal and that the surgical standards was already high in the pre-CME era.

Robot-assisted laparoscopic prostatectomy: a costs and break-even point analysis for decision-making in a university hospital and a regional healthcare system in Northern Italy


 
 BACKGROUND: Robotic Assisted Radical Prostatectomy (RALP) is one of the most expensive urological innovations. Prices of the “Da Vinci System” range from € 761.105 to € 1.902.762 for each unit, without taking into account the cost of maintenance and the use of additional devices. We evaluated outcomes, and costs retrospectively, comparing RALP to open retro-pubic radical prostatectomy (RRP) performed in our hospital between December 2009 and December 2010.
 METHODS: We compared 53 RALP, and 50 RRP in terms of costs, and clinical outcomes. We also implemented a Break Even Analysis in order to evaluate if the public reimbursement covered the total cost of RALP.
 RESULTS: According to our analysis, RALP showed lower hospitalization (p < 0,0001), higher early continence rate (p < 0,0001), better potency rate in nerve sparing procedures (p < 0,0142), and required no transfusions. Excluding the cost of purchasing and maintenance, single case costs were € 6.046,08 for RALP and € 4.834,11 for RRP, respectively. Considering the affordability of the technology, the point where the total revenue is sufficient to cover the total costs is an average of 60 cases performed per year, only in presence of additional reimbursement.
 CONCLUSIONS: Although our clinical analysis shows better results in favour of RALP, the economical analysis shows that RALP's costs are consistently higher than RRP. Considering also the purchasing costs, we demonstrate that the health gain of the technology does not necessarily offset the higher costs, even in a large, university hospital (1.000 beds).

Robotic surgery: financial impact of surgical trays optimization in bariatric and thoracic surgery.

The incorporation of new technologies in the surgical field, such as the robotic da Vinci System, has made it possible to offer a series of advantages to the patient and the surgeon, with important benefits for both. However, cost continues to be a limiting factor to the adoption of this technology. The development of strategies to maximize the measures that can lead to reduced expenses is a key factor to improve cost-benefit ratio. According to some studies, more than 50% of the costs of a surgical procedure are related to materials and medical supplies, which is why any measure aimed at optimizing their use is pertinent. Our institution, the Orlando Regional Medical Center (ORMC), created a working group whose main purpose is to optimize the Robotic OR process. Their first step was to optimize the surgical trays, and this was carried out in four stages: observation, modification, trial period, and cost analysis. The specialties involved in this initiative were Bariatric and Thoracic Surgeries. Once the optimization process ended, the number of laparoscopic/thoracoscopy instruments in the trays decreased by 63 and 87% for bariatric and thoracic surgery, respectively; and the number of conventional surgery instruments was also reduced by 47 and 64%, for the same specialties, respectively. The financial analysis concluded that implementing this measure will lead to an estimated six-figure savings per year.

A survey on robotic-assisted laparoscopic myomectomy technique among high-volume gynecologic robotic surgeons in Korea

Objective: This study aimed to investigate the of robotic-assisted laparoscopic myomectomy (RALM) techniques among Korean gynecologic robotic surgeons with heavy robotic gynecologic caseloads.Methods: We conducted this online survey consisting of 11 questions regarding various aspects of RALM, such as the type of da Vinci system, number of skin incisions, trocar ports, robotic instruments, and suture materials, with a focus on multiport RALM. Twenty-one board-certified robotic gynecologic surgeons from 16 university-based tertiary medical centers responded.Results: The da Vinci Xi was the most commonly installed system at the respondents’ affiliated hospitals. In terms of instruments, monopolar curved scissors, fenestrated bipolar forceps, and mega suture needle driver were the most used. The most commonly used suture materials for serosal and myometrial layer closure were barbed suture materials, and the endometrial layer was most commonly closed with multifilament delayed absorbable suture material. Continuous running and baseball suture techniques were most frequently used for serosal layer closure.Conclusion: This is the first study investigating RALM surgical methods among Korean gynecologic robotic surgeon with heavy caseloads, and the findings can be of a great benefit to beginners as well as experts in the field of robotic surgery.

11 Robotic Left Lower Sleeve Lobectomy with Bronchoplasty for the Removal of a Carcinoid Tumour

Abstract Lung carcinoid tumours constitute approximately 1–2% of all pulmonary tumours. They are derived from enterochromaffin cells, which are also known as ‘Kulchitsky cells' and generally have indolent growth and development patterns. Carcinoid tumours are categorized as typical or atypical, depending on the number of mitoses per high power field and the presence of necrosis. In terms of management, surgical resection has been recognized to be the standard treatment for pulmonary carcinoid tumours. To our knowledge, the da Vinci system and robotic surgery have not been applied in sleeve lobectomies and bronchoplasty for the removal of carcinoid tumours in the United Kingdom. Therefore, we present a case of a sleeve lobectomy with bronchoplasty procedure for the removal of a carcinoid tumour located in the left lower lobe of the patient. The bronchus was repaired using a V-lock suture & Prolene sutures with the surgery performed using the da Vinci robotic surgical system.

Современные минимально инвазивные технологии в гинекологической практике

Abstract. A comparison of surgical techniques (SILS, NOTES, Da Vinci robotic system, 3D modeling, Radius Surgical System) showed that they will provide endovideosurgery with new ways of performing surgical interventions in the near future. The aim of the research. Conducting a comparative analysis of minimally invasive surgical methods of treatment used in modern gynecological practice, as well as identifying their advantages and disadvantages, indications and contraindications for use, possible complications. Material and methods. A review of the data in PubMed, eLibrary, Cyberleninka, Scopus and WoS on the keywords “minimally invasive surgery”, “NOTESsurgery”, “SILS-surgery”, “Da Vinci system”, “3D modeling”, “gynecology” for 2016-2021 was performed. In addition, a manual search for articles in journals was carried out. Exclusion criteria from the analysis: description of individual clinical cases, books and documents. The final analysis included 60 sources out of 127 initially identified. Results. Minimally invasive surgical technologies have become the method of choice in the diagnosis and treatment of many gynecological pathologies

Technical Feasibility of Single-Port Robotic Left Lateral Sectionectomy Using the da Vinci SP

The recent introduction of robot surgery system is bringing new innovation to the field of minimal invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. Well-known advantages of the robotic surgery such as improved vision of surgical field via three-dimentional vision, visual magnification , tremor suppression , and the flexibility and dexterity of the instruments have allowed precise and meticulous operation techniques. The da Vinci system has recently released a true single-port platform, the da Vinci SP system with 3 instrument which has the multi-joint (elbow and wrist) and flexible camera entering into one single port. We now present the first case of robotic liver resection using the da Vinci SP system, showing surgical technical feasibility. A 63-years old female presented with elevated liver function test(LFT) and abdominal pain. CT scan and MRCP shows that multiple intrahepatic duct stone at left lateral section and distal CBD stone near ampullar of vater. Thus, we removed distal CBD stone via ERCP. After performing ERCP, there were no biliary obstructive symptoms, so we doing operation after that. Docking time took 8 minites. The patient underwent successful da Vinci SP with a total operation time of 135 minutes. There was no significant intraoperative event. The patient was discharged post-operative 5 days after checking the CT scan without any surgical complication. We report a technique of left lateral sectionectomy without additional port. For active application of da Vinci SP in hepatobiliary surgery, more device development and further research are needed.

Managerial aspect of missionary activity of A. Scriabin

The purpose of the article is to identify the historical and cultural specifics of A. Scriabin's missionary activity in dealing with the features of music management as a value, creative phenomenon of spiritual culture, which has a practical implementation in the conditions of socio-cultural interaction. The methodology includes analytical, comparative-historical, and genre-nominative musicological approaches determined by aesthetic-cultural and philosophical positions, as we have in the works of P. Valeri, O. Losev, L. Sabaneev, in the dissertations of D. Androsova, V. Batanov, Liu Binqian, etc. The methodological foundations of the research are the theory of knowledge, philosophical principles of dialectics of unity and interaction of object and subject, general and individual, spiritual and material, cultural and historical. The scientific novelty lies in the distinctive historical and cultural features of Music Management in the missionary efforts of Fr. Scriabin, directed by the Christian-Hesychast incentives of his ideological attitudes, which fueled both the creative and practical activities of both a brilliant artist and organizational and peacekeeping efforts to protect the "intellectual rebirth" of people during the bloody realities of the first World War. Conclusions. The Christian-Hesychast, including the genesis of the ideological foundations of Fr. Scriabin, who gave the features of music management, organizational and managerial principles determined by the national mentality of the need to "save humanity" through religious unity in an ecumenical-expanding interpretation of planetary-significant actions ("Religare"-communication). Scriabin saw the value-semantic load of organizational and managerial means in the dispatch of the mystery as a planetary-unifying factor-despite the socio-political discord of the first World War. Extra-artistic indicators of missionary activity by their nature are indicated. Scriabins demonstrate the paradigmatic component of combinations of creative-practical and organizational-educational, theoretical-cultural-creative, etc. in the person of outstanding personalities of the last century, the phenomenon of which is indicated in the "Leonardo da Vinci system" by P. Valerie as a marking index of the psychological attitude of a creative person in the last century.

Feasible techniques in robotic thoracoscopic repair of congenital esophageal atresia: case report and literature review

BackgroundRobotic repair for esophageal atresia (EA) using da Vinci system is challenging. Specific surgical techniques need to be explored to overcome the current hurdles.Case presentationTwo cases with EA (type I and type III by Gross classification, respectively) were repaired using da Vinci robotic system. Step trocar insertion and asymmetric ports distribution techniques were used. The mean weight was 3.2 kg. Operative times were 95 min totally, with the anastomotic time of 27.5 min. Follow-up duration was 12 months. Esophageal fistula reoccurred in one case. None was confirmed anastomotic stricture.ConclusionStep trocar insertion procedure and asymmetric ports distribution technique are effective in robotic esophageal atresia.

Robotic transaxillary lateral neck dissection for thyroid cancer: learning experience from 500 cases.

Differentiated thyroid carcinoma with lateral neck lymph node metastasis requires aggressive operative intervention, including lateral neck dissection. Although several robotic approaches have made precise surgery for thyroid cancer possible, few centers have expanded the technique for application to lateral neck dissections. This study aimed to demonstrate the technical feasibility, cosmetic effectiveness, and safety of robotic transaxillary lateral neck dissection (RTLND) using the da Vinci system. From January 2008 to July 2019, 500 patients diagnosed with thyroid cancer with lateral neck node metastasis underwent RTLND. The clinicopathologic characteristics and surgical outcomes were retrospectively reviewed. All operations were performed successfully without open conversion. As the primary operation for thyroid cancer, 476 (95.2%) patients underwent unilateral or bilateral RTLND, including robotic total thyroidectomy. The remaining 24 patients (4.8%), all of whom had a recurrence, also underwent RTLND with additional procedures, if needed. The mean operation time for the 500 operations was 293.71 ± 67.22min. Only five cases had recurrence and required further treatment. RTLND is technically feasible and safe through the precise manipulation of robotic instruments. While this method is thorough and provides safe and effective surgical outcomes, it also offers the additional advantage of being minimally invasive.

Exposure and perception of general surgery residents' toward robotic-assisted surgeries in Riyadh, Saudi Arabia

Introduction: Robotic surgery is one of the rapidly expanding technologies in the field of medicine. It has been implemented since 2000; and its use has expanded over the past years. Da Vinci system was first introduced to the Middle East in 2003 by Saudi Arabia; then over the following 15 years it was utilized by other gulf countries. With the expanding knowledge of this technology and the effectiveness of its utilization; formal training programs were introduced by many hospitals. However; there are no established credentialing standards or well-structured curriculum to provide this training in the gulf region. Method: This we aim to understand the perception of general surgery residents toward robotic surgery training in tertiary care centers in Riyadh; Saudi Arabia. An anonymous web based survey was conducted on general surgery residents enrolled in Saudi Commission for health specialties approved residency training hospitals in Riyadh. Results: 50% of GS residents were involved in robotic assisted surgery which was significantly associated with the presence of robotic machines in their training centers (P0.025). Sixty Percent of residents who were involved in RAS did not receive a formal training prior to their participation, barely even a brief introduction. Conclusion: exposure and education about RAS at early training years showed that residents have better technical performance during their fellowship training. However, it should not the main focus of the training.

Robotic Right Hepatectomy with Portal Vein Thrombectomy for Colorectal Liver Metastasis (with Video)

BackgroundHepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. MethodWe present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. ResultsThe Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retrohepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a suprapubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 min with no transfusion. Pathology conformed the diagnosis with free surgical margins. ConclusionRobotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.

Adverse event reporting in head and neck transoral robotic surgery: a MAUDE database study.

Transoral robotic surgery (TORS) using the da Vinci Surgical system was approved by the US Food and Drug Administration in 2009. Currently, most available safety information on TORS procedures describes adverse events occurring in the context of clinical trials or series at high-volume academic centers. The goal of this study was to catalog reported adverse events associated with the da Vinci device in head and neck procedures by querying an FDA database. A search was performed on the MAUDE database inspecting for TORS safety incident reports generated from January 2009 through May 2020 using key words "da Vinci" and "Intuitive Surgical". A total of 3312 medical device records were produced. Of these 36 head and neck adverse events, reports were identified through manual screening of the data by the authors. Death was found to be the most common adverse event reported overall, manifesting in 44% of all reported incidents. The most frequent source of mortality was found to be hemorrhaging in the perioperative period rather than incidents of device malfunction or structural damage from surgery. This was found to be similar to the results of other published series for transoral ablative surgery. This study suggests that the small number of reported adverse events related to TORS with the da Vinci system seems to mirror what would be expected from the same procedures using other methods for transoral surgery.

Robotic right hepatectomy with portal vein thrombectomy for colorectal liver metastasis

Presenter: Marcel Autran Machado MD | Nove de Julho Hospital Background: Hepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable survival. Repeat hepatectomy is also technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. Methods: We present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019 she underwent non-anatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. Results: The Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluorescence imaging after indocyanine green injection. A future line of transection was marked along ischemic area. The liver was divided using bipolar forceps under saline irrigation until it was detached from the retro-hepatic vena cava. A right hepatic vein was divided with a stapler to complete the right hepatectomy. The surgical specimen was removed through a supra-pubic incision, and the abdominal cavity was drained with a closed-suction drain. The total operative time was 270 minutes with no transfusion. Pathology conformed the diagnosis with free surgical margins. Conclusion: Robotic right hepatectomy with tumor thrombectomy is feasible and safe even in the presence of lobar portal vein invasion. This video may help HPB surgeons perform this complex procedure.

Silent operating theatre optimisation system for positive impact on surgical staff-members' stress, exhaustion, activity and concentration in urological da Vinci surgeries

BackgroundNoise in the operating room (OR) is a stressor with far-reaching negative consequences. The Silent Operating Theatre Optimisation System (SOTOS) suppresses the noise level in the OR and improves the...

Robot-assisted adrenalectomy: state of the art

Currently, laparoscopic adrenalectomy is worldwide considered the gold standard technique. Both transperitoneal and retroperitoneal approaches have proved their efficacy with excellent outcomes. Since the introduction of da Vinci System (Intuitive Surgical, Sunnyvale, CA), robotic surgery has made many steps forward gaining progressively more diffusion in the field of general and endocrine surgery. The robotic technique offers advantages to overcome some laparoscopic shortcomings (rigid instruments, loss of 3D vision, unstable camera). Indeed, the robotic system is provided of stereoscopic 3D-magnified vision, additional degree of freedom, tremor-filtering technology and a stable camera. Recently, several case series have demonstrated the feasibility and the safety of robot-assisted adrenalectomy in high-volume centers with outcomes comparable to laparoscopic adrenalectomy. Notwithstanding, the technical advantages of the robotic system have not yet demonstrated significant improvements in terms of outcomes to undermine laparoscopic adrenalectomy. Moreover, robotic adrenalectomy harbor inherits drawbacks, such as longer operative time and elevated costs, that limit its use. In particular, the high cost associated with the use of the robotic system is primarily related to the purchase and the maintenance of the unit, the high instruments cost and the longer operative time. Notably, these aspects make robotic adrenalectomy up to 2.3 times more costly than laparoscopic adrenalectomy. This literature review summarizes the current available studies and provides an overview about the robotic scenario including applicability, technical details and surgical outcomes.

Romanian customers’ satisfactions regarding private health services

Abstract Nowadays customers become more concerned about private health services, as performance, innovation and creativity overspread into our lives. Digital health services development in Romania has grown gradually through the acquisition of state-of-the-art equipment as RMN Siemens Magnetom Essenza machine, CT Optima 520 available in Romanian health private clinics. Is the e-health the future of health services in Romania? The answer will be a strong yes. Immunotherapy has revolutionized cancer treatment by leveraging the immune system to fight tumors. The hope is that someday immunotherapy options will exist for all types of tumors. On the other hand, 3-D printing allows the user to create health products specific to the patient, including prosthetics, implants, and airway stents. More than that, Virtual reality/mixed reality applications have become popular in Romanian medical education. Robotic approaches to surgery are less invasive and faster, and are often associated with improved clinical outcomes, such as decreased recovery time and reduced pain. For example, the da Vinci Surgical System translates the surgeon’s hand movements to smaller movements made by the robot inside the body, all visualized via laparoscopy. The da Vinci System has been used on more than 3 million patients globally. The present paper researched the Romanian customers’ satisfactions regarding private health services. The sample size was 400 people, of which 168 males and 232 females, with an average age of 40 years old, all from the urban area, developed standard of living with an average income of 1,500 euro per month. The results have shown that Romanian customers are willing to pay for private health services more than 500 euro per year. Romanian customers had declared in proportion of 68% that are satisfied with the prices of private healthcare networks, in proportion of 79% that are satisfied with the medical services offered by the private healthcare networks. In what it concerns the surgery performed by robots instead of doctors, only 45% customers had declared in the robots favor. Further insights will be discussed in the research paper and concussions will be drawn reflecting the assessment of the Romanian customers’ satisfaction regarding private health services.