Zeus Robotic Research Articles

Robotic pyeloplasty using internet protocol and satellite network‐based telesurgery

In North America, the urological community has embraced surgical robotic technology in the performance of complex laparoscopic surgery. The performance of complex long-distance telesurgery requires further investigation prior to clinical application. The feasibility of laparoscopic robot-assisted pyeloplasty in a porcine model was assessed using the Zeus robot and the internet protocol virtual private network (IP-VPNe) and satellite links. Eighteen pyeloplasty procedures were performed, using real-time, IP-VPNe and satellite network connection (six of each). Network and objective operative data were collected. Despite network delays and jitter, it was feasible to perform the pyeloplasty procedure without significant detriment in operative time or surgical results compared with real-time surgery. The completion of complex tasks such as robotic pyeloplasty is feasible using both land-line and satellite telesurgery. However, the clinical relevance of telesurgery requires further assessment.

Robot-assisted thoracoscopic brachytherapy for lung cancer: Comparison of the ZEUS robot, VATS, and manual seed implantation

Objective: Interstitial brachytherapy is becoming an accepted treatment option for lung cancer patients for whom surgery poses a high risk. Robotic surgery has the potential to deliver brachytherapy seeds into tumors while keeping surgeons at a safe distance from the radioactive source. Our aim was to compare the accuracy, number of attempts, and time needed to place seeds next to a target when using a manual technique, video-assisted thoracoscopic surgery (VATS), and the ZEUS robot for minimally invasive surgery (MIS).Methods: A brachytherapy seed injector was developed and attached to one of the ZEUS robotic arms. Four subjects each inserted inactive dummy brachytherapy seeds into clear agar-gelatin cubes containing a 1.6-mm stainless steel ball target. Two orthogonal radiographs were taken of each agar cube, and the corresponding distances were measured in triplicate using ImageJ processing software. The mean distance between the center of each seed and the corresponding target was calculated using the Pythagorean theorem. Comparisons were made using analysis of variance, t-tests, and Kruskal–Wallis tests, as appropriate.Results: A total of 384 tests (128 for each technique) were performed. The median accuracies for the manual technique, VATS, and ZEUS were 1.8 mm (range: 0.9–6.7 mm), 2.4 mm (range: 1.0–11.3 mm), and 3.6 mm (range: 1.3–16.7 mm), respectively (p < 0.01). The median numbers of attempts for the manual technique, VATS, and ZEUS were 1 (range: 1–5), 4 (range: 1–14), and 3 (range: 1–20), respectively (p < 0.01). The median times for the manual technique, VATS, and ZEUS were 3.0 s (range: 1–43 s), 86.5 s (range: 6–372 s), and 64.5 s (range: 5–356 s), respectively (p < 0.01).Conclusions: The manual technique is the most accurate, least traumatic, and fastest method of inserting seeds into tumors. The ZEUS robotic platform was able to place seeds beside a target within a clinically acceptable distance, with an acceptable amount of trauma and time required. It achieved results equal to or better than those obtained with VATS.

Robot-assisted thoracoscopic brachytherapy for lung cancer: Comparison of the ZEUS robot, VATS, and manual seed implantation

Objective: Interstitial brachytherapy is becoming an accepted treatment option for lung cancer patients for whom surgery poses a high risk. Robotic surgery has the potential to deliver brachytherapy seeds into tumors while keeping surgeons at a safe distance from the radioactive source. Our aim was to compare the accuracy, number of attempts, and time needed to place seeds next to a target when using a manual technique, video-assisted thoracoscopic surgery (VATS), and the ZEUS robot for minimally invasive surgery (MIS).Methods: A brachytherapy seed injector was developed and attached to one of the ZEUS robotic arms. Four subjects each inserted inactive dummy brachytherapy seeds into clear agar-gelatin cubes containing a 1.6-mm stainless steel ball target. Two orthogonal radiographs were taken of each agar cube, and the corresponding distances were measured in triplicate using ImageJ processing software. The mean distance between the center of each seed and the corresponding target was calculated using the Pythagorean theorem. Comparisons were made using analysis of variance, t-tests, and Kruskal–Wallis tests, as appropriate.Results: A total of 384 tests (128 for each technique) were performed. The median accuracies for the manual technique, VATS, and ZEUS were 1.8 mm (range: 0.9–6.7 mm), 2.4 mm (range: 1.0–11.3 mm), and 3.6 mm (range: 1.3–16.7 mm), respectively (p < 0.01). The median numbers of attempts for the manual technique, VATS, and ZEUS were 1 (range: 1–5), 4 (range: 1–14), and 3 (range: 1–20), respectively (p < 0.01). The median times for the manual technique, VATS, and ZEUS were 3.0 s (range: 1–43 s), 86.5 s (range: 6–372 s), and 64.5 s (range: 5–356 s), respectively (p < 0.01).Conclusions: The manual technique is the most accurate, least traumatic, and fastest method of inserting seeds into tumors. The ZEUS robotic platform was able to place seeds beside a target within a clinically acceptable distance, with an acceptable amount of trauma and time required. It achieved results equal to or better than those obtained with VATS.

Robotic laparoscopic distal gastrectomy: a comparison of the da Vinci and Zeus systems

The robotic surgical systems working on a master-slave principle have been developed and used in the worldwide in cardiac, urologic, and general surgery. The two robotic systems, the da Vinci and the Zeus Robotic Surgical System (Intuitive Surgical, Calif., USA), were compared with the aim of evaluating operative feasibility and technical efficacy in distal gastrectomy. During laparoscopic gastrectomy, the da Vinci System (n = 2) had a shorter total operative time (445 versus 656 minutes; p = 0.09) and less blood loss (65 versus 277 mL; p = 0.08) compared with the Zeus System (n = 3). The articulated instruments of both systems were useful in lymph node dissection, isolation of vessels in fat tissue, ligation of vessels, and intraabdominal anastomosis of the gastrointestinal tract. Robotic laparoscopic procedures can be performed effectively using either the da Vinci or Zeus System. In this limited study, the robotic instruments, especially those of da Vinci system, made it easier to complete tissue dissection including lymph nodes, complicated endoscopic anastomoses, and ligatures in a closed cavity.

Totally minimally invasive robot-assisted unstented pyeloplasty using the Zeus Microwrist Surgical System: an animal study

Background Minimally invasive pyeloplasty is a difficult procedure even for an expert laparoscopic surgeon. The major difficulty is associated with the limitations of intracorporeal suturing and knot tying. Surgical robots, which hold minimally invasive surgical instruments, have wrists and provide tremor filtration and motion scaling that might be expected to facilitate complex procedures in newborns. Methods Seven survival piglets (4.0-7.5 kg) underwent a totally minimally invasive robot-assisted unstented pyeloplasty employing the Zeus Robotic Microwrist System. The ureter was transected at the level of the ureteropelvic junction and 8 mm was resected. The unstented anastomosis was fashioned with running suture and intracorporeal knot tying. The animals were recovered and intravenous urography was performed at 1 month. After sacrifice, the anastomosis and the kidney were evaluated grossly and histologically for leak, caliber, and healing. Results All animals survived the procedure without postoperative complications. The mean robotic setup time was 19 minutes (range, 10-30 min), mean anastomosis time 51 minutes (range, 39-63 min), and mean total operation time 76 minutes (range, 57-87 min). The urography showed hydronephrosis in the first animal. The other 6 animals had no abnormalities. Histopathology demonstrated severe hydronephrosis in the first pig and moderate hydronephrosis in the sixth and seventh. All other animals had no sign of hydronephrosis. All anastomoses were well healed and intact. Conclusions Robot-assisted laparoscopic pyeloplasty is a technically feasible procedure with acceptable morbidity in an animal model. The robotic technology enhances surgical dexterity and precision. Robotic assistance can increase the applicability of minimally invasive surgery to complex procedures in children.

Robot-enhanced fetoscopic surgery

Background Fetoscopic surgery carries with it less maternal morbidity than open fetal surgery. Robotic surgery facilitates endoscopic surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. The goal of the authors was to explore using a robotic surgery platform in a fetal animal model. Methods Using the Zeus Robotic Surgery System (Computer Motion, Santa Barbara, CA), fetoscopic surgery in pregnant sheep was performed using a variety of techniques: uterus exteriorized or totally percutaneous and with liquid or gas insufflation. Using the percutaneous technique and gas insufflation, the authors created and sutured fetal skin and fascial defects. The ewes were recovered and killed 2 weeks postoperatively, and autopsies were performed on them and their fetuses. Results In the exteriorized uterus model, instrument movement was unpredictable and fluid leaked. In the fluid environment, clouding of the visual field and difficulty in immobilizing the fetus were major difficulties. In the survival model, 4 of the 6 fetuses survived to autopsy at 2 weeks and showed good healing grossly and histologically. Conclusions The Zeus Robotic Surgery System can be used for fetoscopic surgery in a sheep model. The percutaneous approach with a nitrous oxide environment is the most effective. Advantages of robotic surgery may be applicable in fetoscopic surgery, but further work in a primate model is required.

Robotics and self-closing U-clips for microsurgical nerve repair

Abstract Introduction: Robotic surgery provides tremor filtration allowing fine precision at high magnification, which should be a significant advantage for microsurgeons. We aimed to demonstrate feasibility and compare robotic nerve repair with standard microsurgical techniques, also comparing suture with self-closing U-clips, which do not require knot-tying. Methods: We divided and reanastomosed 36 sciatic nerves in 18 rats, half with the Zeus robot and half by traditional microsurgery, all using an operating microscope. Nine anastomoses in each group were created with interrupted 8-0 sutures; the other half employed nitinol U-clips. We recorded time for each anastomosis and calculated average time per stitch or clip. Results: The time required to place each stitch or clip was not significantly different, except when sutures were placed with the robot, which took more time (see Table 1). Clipped repairs, whether by hand or robot, did not take significantly longer than traditional hand-sutured anastomoses. ∗Robotic time (min)Hand-sewn time (min)Per clip5.4 ± 1.33.5 ± 1.2Per stitch6.5 ± 2.13.5 ± 1.1∗Clipped anastomosis16.4 ± 3.510.6 ± 3.7Sutured anastomosis28.1 ± 7.8 † 14.7 ± 4.8∗∗Indicates statistically significant difference between columns (p ≤ 0.001).†Indicates statistically significant difference between rows (p ≤ 0.001). Conclusions: U-clips can be used to create a peripheral nerve anastomosis. Robotic microsurgical nerve repair is feasible with U-clips or suture. Both stitches and U-clips take about the same amount of time to place. With present technology and currently available instruments, robotic microsurgery with sutures takes longer than by hand. Further studies are in progress to demonstrate and compare functional healing in a survival model.

Use of a robotic system as surgical first assistant in advanced laparoscopic surgery.

To date, the use of robotic systems has concentrated on enhancing the dexterity of the individual surgeon performing advanced laparoscopic surgery. Surgical assistants must still be present. We present a clinical experience using a robotic system as a surgical first assistant, enabling the performance of solo surgery in increasingly complex procedures. Laparoscopic fundoplication was selected as an advanced laparoscopic procedure that has routinely required a human assistant. Between January and April 2001, 10 patients with gastroesophageal reflux disease underwent laparoscopic antireflux surgery. The Zeus Robotic Surgical System (Computer Motion) was used to perform all functions typically handled by surgical assistants. The system was manipulated solely by the surgeon at all times with controls draped within the sterile field. This control console remained at the surgeon's side and at no time did the surgeon leave the sterile field. The presence of the robotic system did not interfere with access to the patient. Among 10 operations, 8 were performed completely without the need or use of any human assistance. Set-up of the robotic system averaged 28 minutes per patient, including sterile draping. Operative times ranged from 68 to 155 minutes. There were no adverse events noted in the perioperative period. All patients were discharged the day after the procedure without any complications. Robotic assistance to facilitate solo surgery in advanced laparoscopic procedures appears to be a feasible and safe technique. More importantly, this experience seems to demonstrate a potential for the Zeus robotic system for telementoring applications. Given a real-time communication system, a distant mentor could manipulate the robotic arms and guide a local, novice laparoscopic surgeon through an advanced procedure. Additional instrumentation must be available and more study is needed to quantify the clinical usefulness, safety, and efficacy of this new tool.

Computer-assisted robot-enhanced laparoscopic fundoplication in children

Background/purpose Robotic surgery improves laparoscopic surgery through a more natural interface, tremor filtration, motion scaling, and additional degrees of freedom of the instruments. Here, the authors report that experience with robot-assisted fundoplication in children. Methods The authors have performed 15 laparoscopic fundoplications with the Zeus Robotic Surgery System and retrospectively reviewed prospectively collected data on set-up time, operating time, and outcome. Results All cases were completed successfully: one Heller myotomy with Dor fundoplication and 14 Nissen fundoplications. Patients ranged from 2 months to 18 years old (mean, 4.3 years) and from 3.4 kg to 37.7 kg (mean, 13.0 kg). There were no technical errors, equipment errors, or conversions. There were no complications in the first 30 days after surgery. The operating time declined from 323 minutes for the first case to 180 minutes for the last (mean, 195 minutes). The 14th case was the shortest at 123 minutes. Setting up the robotic surgery system took an average of 11 minutes. The surgeons perceived benefits of greater ease and confidence in suture placement and knot tying. Conclusions The authors have successfully used surgical robots for gastric fundoplication at a pediatric teaching hospital. Our experience with this operation has shown the additional dexterity that the robot provides and will pave the way to more complex procedures.

Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation

Background Laparoscopically assisted aortic aneurysm resection requiring a minilaparotomy can be performed as a routine procedure. It was the purpose of our study to evaluate whether a total laparoscopic operation can be offered to aneurysm patients as a minimally invasive alternative. We also wanted to test whether a master-slave robot could facilitate the total laparoscopic procedure. Methods A prospective, consecutive number of 50 patients was evaluated. A transperitoneal left retrocolic access was used to expose the aorta. If possible, a tube graft repair was performed. The aortic anastomosis was sutured totally laparoscopically, with the surgeon standing on the right side of the operating table. In 10 consecutive patients, the anastomosis was sutured with the help of the Zeus robot. Results After excluding 3 cases that required suprarenal cross-clamping, 47 patients were operated using a total laparoscopic approach. A totally laparoscopic operation could be performed successfully in 39 patients with aneurysms. In 8 patients (17%), conversion to a laparoscopic hand-assisted operation with a 7-cm minilaparotomy was required. The robot was used to perform the aortic anastomosis in 10 patients. In 8 patients, a tube graft repair could successfully be performed totally laparoscopically. In the remaining patients, a bifurcated graft was implanted laparoscopically. The mean operating time was 227 minutes in the laparoscopy group and was 242 minutes in those patients in whom the anastomosis was sutured with the help of the Zeus Robot. Mean cross-clamping time, ± SD, was 81.4 + 31 minutes. None of the patients died perioperatively. Major complications occurred in three patients (6.3%). The overall morbidity was 14.8%, including one patient who required temporary hemodialysis postoperatively. The time to suture the aortic anastomosis was significantly shorter in the robotic-assistance group (40.8 ± 4 minutes), yet total operating time was longer in this group because of the technical complexity of the robotic device. Patients with a total laparoscopic procedure asked for significantly fewer analgesics and could regain full mobility earlier compared with those patients for whom a minilaparotomy after conversion to the laparoscopic hand-assist procedure was required. Conclusions Total laparoscopic aneurysm resection can be offered to the majority of patients in our institution. The robot still requires further refinements to reduce operating times and the aortic cross-clamping period. We now have the technique and the instrumentation to offer laparoscopic aneurysm surgery as a minimally invasive alternative for patients whose conditions are unsuitable for endovascular aneurysm repair.

Implementation of robotic laparoscopic cholecystectomy in a university hospital.

Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed.

Implementation of robotic laparoscopic cholecystectomy in a university hospital.

Robot surgery is a further step towards new potential developments in minimally invasive surgery. Surgeons must keep abreast of these new technologies and learn their limits and possibilities. Robot-assisted laparoscopic cholecystectomy has not yet been performed in our institution. The purpose of this report is to present the pathway of implementation of robotic laparoscopic cholecystectomy in a university hospital. The Zeus(R) robot system was used. Experimental training was performed on animals. The results of our experimental training allowed us to perform our first two clinical cases. Robot arm set-up and trocar placement required 53 and 35 minutes. Operative time were 59 and 45 minutes respectively. The overall operative time was 112 and 80 minutes, respectively. There were no intraoperative complications. Patients were discharged from the hospital after an overnight stay. Robotic laparoscopic cholecystectomy is safe and patient recovery similar to those of standard laparoscopy. At present, there are no advantages of robotic over conventional surgery. Nevertheless, robots have the potential to revolutionise the way surgery is performed. Robot surgery is not reserved for a happy few. This technology deserves more attention because it has the potential to change the way surgery is performed.

Robotic-assisted esophagoesophagostomy

Background/Purpose: Minimally invasive repair of esophageal atresia has been described but remains technically challenging. Robotic surgical systems address many of these technical challenges. The purpose of this study was to develop the procedure for and evaluate the technical feasibility of performing a robotic-assisted esophagoesophagostomy using the Zeus Robotic Surgical System. Methods: Esophagoesophagostomy was performed in 10 piglets using thoracoscopic (control, n = 5) and robotic-assisted (Zeus, experimental, n = 5) approaches. An interrupted esophageal anastomosis using intracorporeal knot tying techniques was performed and evaluated for leak, narrowing, caliber, and mucosal approximation. Anesthesia, operative, anastomotic, and robotic set-up times were recorded as was the number of stitches used. Results: All 10 anastomoses were patent with no narrowing and with excellent mucosal approximation. One anastomosis in the control group had a small leak. There was no statistically significant difference between the groups for the parameters measured. Weight (kg): control (C), 6.4 ± 0.8; experimental (E), 6.3 ± 1.0, P =.08. Times (min): anesthesia, C-124 ± 25, E-151 ± 20, P =.09; operative, C-97 ± 21, E-131 ± 27, P =.06; anastomotic, C-89 ± 20, E-125 ± 34, P =.08; robotic set-up, C-6.4 ± 9.3, E-15.6 ± 20, P = 0.13. Stitches (No.): C-11.8 ± 0.8, E-12.0 ± 1.2, P =.7. Caliber (French):C-18F-5; E-18F-4, 14F-1. Conclusion: Robotic-assisted esophagoesophagostomy is technically feasible and offers an alternative approach to thoracoscopic repair of esophageal atresia. J Pediatr Surg 37:983-985. Copyright 2002, Elsevier Science (USA). All rights reserved.

Applications of robotic surgery in pediatric patients.

Minimally invasive surgery is increasingly becoming the standard approach to treatment for pediatric patients. Infants present a technical challenge due to the small size of structures and the small workspace available. Master-slave robotic surgical telemanipulators help overcome this challenge by facilitating microsurgery in a confined workspace. The Zeus Robotic Surgical System (Computer Motion, Inc., Goleta, CA, U.S.A.) was used to develop the robotic approach and to evaluate the technical feasibility of performing four technically challenging procedures that are typically performed in infants. Robotic enteroenterostomy, hepaticojejunostomy, portoenterostomy, and esophagoesophagostomy were performed in piglets and compared with the same procedures performed by standard minimally invasive techniques. Enteroenterostomy, hepaticojejunostomy, and esophagoesophagostomy procedures were successfully developed and are technically feasible. The portoenterostomy procedure needs further study to validate data from the second set of experiments, showing a lower complication rate in the robotic group. Survivor studies are needed to fully elucidate the advantages that may be provided by the robotic approach.

Robotic laparoscopic surgery: a comparison of the da Vinci and Zeus systems

Objectives. To evaluate two currently available robotic surgical systems in performing various urologic laparoscopic procedures in an acute porcine model. Methods. Robotic laparoscopic surgery was performed in 14 swine. Data were compared between the da Vinci Robotic System and the Zeus Robotic System. Results. During laparoscopic nephrectomy, the da Vinci System (n = 6) had a significantly shorter total operating room time (51.3 versus 71.6 minutes; P = 0.02) and actual surgical time (42.1 versus 61.4 minutes; P = 0.03) compared with the Zeus System (n = 5). However, the blood loss and adequacy of surgical dissection were comparable between the two groups. For laparoscopic adrenalectomy, the da Vinci System (n = 5) had a shorter actual surgical time (12.2 versus 26.0 minutes; P = 0.006) than did the Zeus System (n = 5). For laparoscopic pyeloplasty, the da Vinci System had a shorter total operating room time (61.4 versus 83.4 minutes; P = 0.10) and anastomotic time (44.7 versus 66.4 minutes; P = 0.11). During pyeloplasty anastomosis, the total number of suture bites per ureter was 13.0 for the da Vinci System (n = 6) and 10.8 for the Zeus System (n = 6). The complications included an adrenal parenchymal tear each during a da Vinci System-based left adrenalectomy and a Zeus System-based right adrenalectomy. An inferior vena caval tear during a Zeus System-based right adrenalectomy occurred in 1 case, which was suture-repaired telerobotically. Conclusions. Robotic laparoscopic procedures can be performed effectively using either the da Vinci or Zeus System. In this limited study, the learning curve and operative times were shorter and the intraoperative technical movements appeared inherently more intuitive with the da Vinci System. Additional clinical experience is necessary.