Zeus Robotic Surgical System Research Articles

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.

Commentary: Robotic Techniques in Cardiac and Thoracic Surgery (Innovations, May/June 2020).

This is a response to the papers in the May/June issue of Innovations focused on robotic techniques in cardiac and thoracic surgery. Successful robotic surgery relies on a high level of preparation and communication from each member of the operating room. The lack of a team approach can result in not only failure to establish and/or sustain a robotic program, but more importantly, in serious consequences at the detriment to patient care and safety. While these are salient points, the authors of this commentary wish to highlight that the first robot-assisted mitral valve surgery in North America was performed at NYU Langone Health using the Zeus robotic surgical system. Although that robotic platform had several disadvantages that limited its clinical advancement, an appreciation for this history in robotic cardiac surgery is important if we as cardiothoracic surgeons seek to move toward a future of expanding robotic surgery within the ever-changing landscape of cardiac surgery.

The Pransky interview: Dr Yulun Wang, Founder and CEO of InTouch Health

Purpose – The following paper is a “Q & A interview” conducted by Joanne Pransky of Industrial Robot Journal as a method to impart the combined technological, business and personal experience of a prominent, robotic industry engineer-turned entrepreneur regarding the evolution, commercialization and challenges of bringing a technological invention to market. Design/methodology/approach – The interviewee is Dr Yulun Wang, an inventor, self-taught entrepreneur, business leader and world-renowned authority on robotics and health care. Dr Wang shares his successful three-decade journey that began with researching the market needs and aligning himself with medical experts, followed by pioneering robotic solutions specifically for the health care industry. In the process, Dr Wang founded and spearheaded both a public and private robotics company. Findings – Dr Yulun Wang received a BSc and an MSc in Computer Science, and a PhD in Electrical Engineering, from the University of California, Santa Barbara (UCSB). After teaching at UCSB for a few years, with a grant he won from NASA, Dr Wang founded Computer Motion, Inc. in 1989 and conducted research on endoscopic robots. Computer Motion went public in 1997 and later merged with its competitor, Intuitive Surgical (NASDAQ:IRSG) in 2003 to forge the multi-billion dollar surgical robotics industry. Dr Wang founded InTouch Technologies (d.b.a. InTouch Health), in 2002, named one of the fastest-growing biomedical companies in the USA by INC Magazine. Originality/value – Dr Wang launched his career at the intersection of health care and technology with his invention of the voice-controlled robotic arm AESOP, the first US Food and Drug Administration (FDA)-cleared surgical robot. His next generation ZEUS robotic surgical system (ZRSS), was cleared by the FDA in 2001. Also in 2001, ZRSS was used in the world’s first telesurgery, as surgeons in New York controlled the arms of the Zeus to perform a cholecystectomy on a patient in Strasbourg, France, via a high-speed fiber optic supplied by France Telecom. This led Dr Wang to found InTouch Health, a company that pioneers remote presence robot systems that enable health care professionals to provide more effective and efficient health care. Dr Wang has received multiple other entrepreneurship and leadership awards, including being elected to the prestigious ranks of the National Academy of Engineering in 2011. He is the author of over 50 scientific publications, and holds over 100 patents registered in his name. Dr Wang serves on several boards, including the American Telemedicine Association (ATA) Board of Directors, where he also serves as an officer.

Comparison of robot-assisted laparoscopic adrenalectomy with traditional laparoscopic adrenalectomy - 1 year follow-up

Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy. From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality. Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 +/- 30.7 min vs. 131.4 +/- 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up. RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon's tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.

Teaching robotic surgery: a stepwise approach

After an initial institutional experience with 50 robot-assisted laparoscopic Roux-en-Y gastric bypass procedures, a curriculum was developed for fellowship training in robotic surgery. Thirty consecutive robotic gastric bypasses were performed using the Zeus robotic surgical system to fashion a two-layer gastrojejunostomy. For teaching purposes, performance of the anastomosis was divided into three discrete tasks. Robotic suturing tasks were assigned to the trainee in cumulative order in ten-case increments. Our patient population averaged 44 years of age and 47 kg/m(2) in BMI. Patients were predominantly female (87%). The robotic training experience of the fellow defines the increases in surgical responsibility over the series of cases. Statistical analysis revealed no significant differences in task times or total robotic operative time as participation of the trainee in performing the gastrojejunostomy increased. No adverse robotic events or surgical complications occurred throughout this series. The learning curve of the fellow compared favorably with the initial experience of the institution. Robotic surgery training may be safely implemented in a minimally invasive surgery training program. A gradual introduction of robotic technique appears to maximize the learning experience and minimize the potential for adverse outcomes.

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.

Comparison of Skill Training with Robotic Systems and Traditional Endoscopy: Implications on Training and Adoption

Robotic systems are being used by an increasing number of surgeons. This environment is markedly different from that of traditional surgery and involves videoscopic guidance, remote surgical control, and the loss of haptic feedback. Defining how surgeons learn with these systems is necessary to establish training protocols for this technology. This study compared the learning curve for a robotic surgical system with that of traditional endoscopy in the performance of two standardized skill drills. Twenty participants (average age 27 +/- 4 years, six females) repeated two standardized endoscopic dexterity and depth perception drills for 15 repetitions with the ZEUS robotic surgical system and manual endoscopic instruments (MAN). A score combining time and precision was given for each repetition. The learning curves and overall performance with and without robotic assistance were compared. For both MAN and ZEUS, improvements in performance were significantly greatest during the first five repetitions (P < 0.01, for both). Participants reached the training curve plateau faster with ZEUS than with conventional instruments (8th versus 10th for both drills). Using robotic assistance, dominant and non-dominant hand performance were statistically similar. The number of errors committed with ZEUS were significantly fewer for drill two (0.09 errors/repetition versus 0.24 errors/repetition, P = 0.002) compared to manual technique. This study demonstrated that training curves for conventional and robotic-assisted systems are remarkably similar. This should prove useful in the training and education of this new technology. This study further suggested that robotics may increase ambidexterity by improving non-dominant hand performance.

Robot-assisted laparoscopic Roux-en-Y gastric bypass

Robotic surgery promises to extend the capabilities of the minimally invasive surgeon. The aim of this study was to examine the feasibility of robotic surgery in the setting of laparoscopic gastric bypass. The Zeus robotic surgical system was used in 50 laparoscopic gastric bypass procedures. The learning curve was staged to add complexity to the robotic tasks as experience grew. Robotic setup time, robotic operative time, total operative time, and operative outcomes were tracked prospectively. We observed a significant decrease in the robotic setup time. Our robotic learning curve demonstrated decreased operative time, even as more complex tasks were accomplished. Total operative time also decreased significantly over the series. There were no complications in our series that could be attributed to the robotic technique. Robot-assisted laparoscopic Roux-en-Y gastric bypass is safe. The steadiness and extra degrees of freedom of surgical robotic systems may improve the accuracy of laparoscopic tasks. The learning curve for robot-assisted laparoscopic Roux-en-Y gastric bypass is significant but manageable.

Minimally Invasive Radical Prostatectomy

Minimally Invasive Radical Prostatectomy

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.

Robot-assisted general surgery.

With the initiation of laparoscopic techniques in general surgery, we have seen a significant expansion of minimally invasive techniques in the last 16 years. More recently, robotic-assisted laparoscopy has moved into the general surgeon's armamentarium to address some of the shortcomings of laparoscopic surgery. AESOP (Computer Motion, Goleta, CA) addressed the issue of visualization as a robotic camera holder. With the introduction of the ZEUS robotic surgical system (Computer Motion), the ability to remotely operate laparoscopic instruments became a reality. US Food and Drug Administration approval in July 2000 of the da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) further defined the ability of a robotic-assist device to address limitations in laparoscopy. This includes a significant improvement in instrument dexterity, dampening of natural hand tremors, three-dimensional visualization, ergonomics, and camera stability. As experience with robotic technology increased and its applications to advanced laparoscopic procedures have become more understood, more procedures have been performed with robotic assistance. Numerous studies have shown equivalent or improved patient outcomes when robotic-assist devices are used. Initially, robotic-assisted laparoscopic cholecystectomy was deemed safe, and now robotics has been shown to be safe in foregut procedures, including Nissen fundoplication, Heller myotomy, gastric banding procedures, and Roux-en-Y gastric bypass. These techniques have been extrapolated to solid-organ procedures (splenectomy, adrenalectomy, and pancreatic surgery) as well as robotic-assisted laparoscopic colectomy. In this chapter, we review the evolution of robotic technology and its applications in general surgical procedures.

Computer-enhanced thoracoscopic thymectomy with the Zeus telemanipulation surgical system

Recent years have witnessed important progress in the use of minimally invasive robotic-enhanced surgical systems in cardiac and general thoracic interventions. We report the first-ever successful use of the Zeus robotic surgical system (Computer Motion, Inc, Goleta, CA) for the excision of an anterior mediastinal mass. Proper positioning of the thoracic ports for the robotic arms to permit a wide range of movement, is the key to the application of the system for intrathoracic cage operations. Other advantages of the system include three-dimensional voice controlled imaging, low-heat surgical field, and good exposure of the structures.

Sutureless thoracic aorta to femoral artery bypass with robotic videoendoscopic approach: a fast track procedure

This study was undertaken to determine the feasibility of robotic videoendoscopic thoracic aorta to femoral artery bypass. In six pigs, three ports were inserted in the fourth, eighth and tenth left intercostal spaces. Lung retraction was obtained by insufflating CO2. The ZEUS robotic surgical system and the AESOP system were used to perform aortic dissection and to position the camera via voice control. A length of 5 cm of descending thoracic aorta was exposed. A 4mm polytetrafluoroethylene (PTFE) graft was used as conduit. The proximal anastomosis was constructed using a prototype of sutureless aortic connector. Left femoral artery was exposed and an endograsp was passed to create a retroperitoneal tunnel. The prosthesis was then anastomosed to the left femoral artery. CO2 insufflating pressure was 9+/-1 mmHg. The operation was completed in three animals while the other three died. In two animals, the death was due to aortic injury during aortic exposure and in one complications of anesthesia. Total operative time was 48+/-15 min. Robotic videoendoscopic descending thoracic aorta to femoral artery bypass is a technically feasible operation in a pig model. The use of the sutureless device to perform the proximal anastomosis dramatically reduces the technical demand of this procedure.

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.

Robotically assisted minimally invasive biliary surgery in a porcine model.

A robotic surgery system has the potential both to reduce the effects of tremor and fatigue and to enhance dexterity in the performance of complex, fine endosurgical tasks. We report a prospective study of robotically assisted minimally invasive biliary surgery in a porcine model using the Zeus robotic surgical system (Computer Motion, Goleta, Ca, USA). For this study, 50-kg domestic swine were used. Minimally invasive robotically assisted cholecystectomy was performed in 16 animals, either longitudinal or transverse common bile duct incision, T-tube placement, and suture repair of the common bile duct. Retrieval of 12 simulated bile duct calculi was attempted. Eight animals were monitored for 6 weeks postoperatively. Liver function tests and cholangiography were performed 2 and 6 weeks after surgery. The median setup time for the robotic system was 45 min (range, 10-120 min). The median operative time was 40 min (range, 25-60 min) for cholecystectomy and 80 min (range, 40-165 min) for bile duct dissection, exploration, and repair. Of 12 bile duct calculi, 11 were retrieved successfully. Cholangiography demonstrated no leaks, and the anastomotic stenotic index (diameter of the proximal bile duct divided by the diameter of distal bile duct) at 6 weeks was 0.98. The results of the liver function tests remained normal in all animals. One postoperative death unrelated to operative technique occurred. Complications included one minor splenic laceration and two intraoperative gallbladder perforations. Robotically assisted minimally invasive biliary surgery in this animal model is both feasible and safe. The Zeus system provides enhanced dexterity, which facilitates precise laparoscopic suture repair of small bile ducts.

Robotically assisted endoscopic coronary artery bypass procedures without cardiopulmonary bypass

Minimally invasive coronary artery surgical procedures still require a minithoracotomy or partial sternotomy for the coronary artery anastomosis. The clinical performance of manual endoscopic coronary artery grafting is extremely difficult and has not been published yet. For this reason, computer-assisted systems have been developed to facilitate endoscopic microsurgery. 1 This is the description of the first clinical use of the voice-controlled and computer-assisted system ZEUS (Computer Motion Inc, Goleta, Calif) for endoscopic coronary artery surgical procedures on the beating heart without cardiopulmonary bypass. Four patients (3 men and 1 woman, aged 44 to 64 years) with an isolated proximal stenosis of the left anterior descending (LAD) coronary artery were evaluated for the procedure. After approval by the local ethics committee, written informed consent was given by the patients. At surgery, 3 thoracoscopic ports (10 mm and 5 mm) were inserted in the left side of the chest. First, the left internal thoracic artery (LITA) was dissected endoscopically. After this, a small parasternal incision (4 cm) was made above the 5th intercostal space. The pericardium was incised through the minithoracotomy. The LAD was visualized and the Octopus system (Medtronic GmbH, Dusseldorf, Germany) was used for coronary artery stabilization. One stabilization pod was inserted through the incision and the second one through one of the thoracoscopic ports. The ZEUS Robotic Surgical System was used to perform an endoscopic graft anastomosis. This system consists of 3 interactive robotic arms placed at the operating table, a computer controller, and an ergonomically enhanced surgeon console. One robotic arm was used to position the endoscope by means of voice control, and the other 2 robotic arms manipulated the surgical instruments under the surgeon’s direct control. A 3-dimensional camera (Vista Cardiothoracic Systems Inc, Westborough, Mass) was inserted through the minithoracotomy. The 2 instrument controllers were inserted through 2 of the thoracoscopic ports

Use of the voice-controlled and computer-assisted surgical system zeus for endoscopic coronary artery bypass grafting

Objective: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. Methods: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. Phase I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. Phase II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. Phase III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. Results: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. Conclusions: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits. (J Thorac Cardiovasc Surg 1999;118:11-6)