USA: video of a robotic hernia repair (digestive surgery) performed during a Prostatectomy case (urology)

Etats-Unis : Hernie digestive opérée en chirurgie mini invasive, en concomitance avec une prostatectomie (urologie) :

About multi-specialty minimally invasive surgery procedures:
Les procédures multidisciplinaires en chirurgie mini invasive :

Here is a video of a robotic hernia repair (digestive/general surgery), performed during a prostatectomy surgical procedure (urology).
La video que nous vous proposons montre une hernie digestive effectuée durant une prostatectomie (urologie).

Both surgical procedures were consecutively performed on the same patient, with a da Vinci™ surgical system.
Ces procédures ont toutes deux été effectuées en concomitance sur le même patient, l'opération en mini invasif a été effectuée avec un système de chirurgie assistée par ordinateur da Vinci™.

The video was shot by Domenico Savatta, MD
Associate in Urology, LLC

Newark Beth Israel Medical Center
New Jersey (NJ)
Cette vidéo a été mise en ligne par le Docteur Savatta, Centre Médical de Beth Israel, Newark, New Jersey, USA.

Why do prostate cancer patients often have to undergo a digestive procedure like hernia repair in succession of the radical prostatectomy case (urology) performed on them? Dr. Savatta about hernia repair procedure during a prostatectomy case:
Pourquoi les patients souffrant d'un cancer de la prostate doivent-ils subir, en même temps que la prostatectomie destinée à soigner leur cancer, une opération traitant la hernie hiatale ? Voici ce que dit le Dr. Savatta à ce sujet :

"Inguinal hernias often coexist in prostate cancer patients. They can sometimes be found on physical exam or during staging CT scans. At the time of transperitoneal robotic prostatectomy the inguinal areas are examined with the robotic scope. If hernias exist, they can be fixed at the time of prostatectomy."
"Les hernies inguinales coexistent souvent avec un cancer de la prostate. Elle peuvent être détectées lors de l'examen du patient ou lors d'une tomographie ou d'un scanner. Lors de la prostatectomie en chirurgie mini invasive par voie transpéritonéale, les régions inguinales sont examinées et apparaissent à l'écran 3D de la console du chirurgien. Si une hernie est détectée, elle peut être traitée chirurgicalement au cours de la même opération".

==> For dsl/cable modem feed of a robotic hernia repair, click here

Hernie hiatale opérée en chirurgie robotique, en même temps que l'ablation de la prostate (prostatectomie, urologie), sur patient atteint d'un cancer de la prostate :
==> Vidéo (nécessite une connection à internet en haut débit)

==> Access Dr. Savatta's Robotic surgery Blog: click here.

Blog de chirurgie robotique du Dr. Savatta (urologie): NB: ce Blog est en anglais.
==> cliquer ici.

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Urology: the Robotic cancer web site

Bloodless Prostate Cancer Surgery

"The last few years have been witness to significant advances in our ability to treat prostate cancer. Surgery has been the gold standard of treatment for cancer cure, but complications of impotence and incontinence, prolonged hospital stays and risks of blood loss have been cited as incentives for patients to seek out less invasive approaches, even if success rates were not quite as high. ROBOTIC PROSTATECTOMY represents a quantum leap forward in our ability to effectively treat prostate cancer, reduce hospital stays, and minimize the risk of complications. In addition, in my opinion, the long term sexual and urinary bother symptoms will be less than for current surgical techniques or any form of radiation therapy as well."

==> View Robotic Surgery Urology Procedures: click here.

What is Robotic Surgery?
Read more: click here.

"Robotic surgery is an extension of laparoscopic surgery. Most people are familiar with laparoscopy. Surgery is performed by manipulating straight instruments while viewing the instruments on a monitor. Robotic surgery is the evolution of laparoscopy that addresses the drawbacks of laparoscopy.

One obstacle of laparoscopy is the loss of 3-D spatial relationships since the 2-D monitor is used to operate. The da Vinci Surgical System® uses a laparoscope that is comprised of 2 cameras and lenses to provide the surgeon with a true minimally invasive 3-D view of the surgical field including depth of field, magnification and high resolution.

Laparoscopic instruments have the feel of "chop sticks". The da Vinci Surgical Cart® includes the EndoWrist ® Instruments. The EndoWrist® Instruments are designed to mimic the movement of the human hands, wrists and fingers. The extensive range of motion allows precision that is not available in standard minimally invasive procedures.

Laparoscopic surgery places the surgeon in an uncomfortable position that can lead to a higher rate of surgical errors. The Da Vinci Surgeon Console® contains the master controls that the surgeon uses to manipulate the EndoWrist® instruments. The handles or 'Masters' translate the surgeon's natural hand and wrist movements into corresponding, precise and scaled movements. The EndoWrist Instruments® are only able to move when commanded by the surgeon. There is a clutch that deactivates the instruments and allows the surgeon to maintain a comfortable position at all times."

How does the robot work?

"The da Vinci® Surgical System combines proprietary software and electronics that create surgical immersion. The Surgeon's Console gives doctors the control and ability to navigate inside the patient. The InSite® Vision System immerses surgeons in a true-to-life 3-D image. The Navigator™ Camera Control allows the surgeon to easily change, move, zoom and rotate his or her field of vision. The camera can be repositioned quickly and smoothly within the surgical opening without disrupting the procedure.

The EndoWrist®Instruments transform movement of the doctor's wrists, hands and fingers into movement of the tiny instruments.

The da Vinci® Surgical System is the only commercially available technology that can provide the surgeon with the intuitive control, range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through small ports of minimally invasive surgery.

Using the da Vinci® System, surgeons can operate with the look and feel of open surgery, performing complex surgical maneuvers through 1-cm ports."

What makes robotic surgery better?

"With its 3-D view, the da Vinci Surgical System aids the surgeon to more easily identify vital anatomy such as the delicate nerves and blood vessels surrounding specific anatomy. The EndoWrist® Instruments provide the surgeon with the dexterity not available using conventional laparoscopic instruments to perform a delicate and precise surgical dissection , reconstruction or removal of specific tissue. The da Vinci® Surgical System is groundbreaking technology that extends the surgeon's capabilities in the following ways:

=> Enhanced 3-D Visualization: Provides the surgeon with a true 3-dimensional view of the operating field. This direct and natural hand-eye instrument alignment is similar to open surgery with 'all-around' vision and the ability to zoom-in and zoom-out.

=> Improved Dexterity: Provides the surgeon with instinctive operative controls that make complex MIS (Minimally Invasive Surgery) procedures feel more like open surgery than laparoscopic surgery.

=> Greater Surgical Precision: Permits the surgeon to move instruments with such accuracy that the current definition of surgical precision is exceeded.

=> Improved Access: Surgeons perform complex surgical maneuvers through 1-cm ports, eliminating the need for large traumatic incisions.

=> Increased Range of Motion: EndoWrist® Instruments restore full range of motion and ability to rotate instruments more than 360 degrees through tiny incisions.

=> Reproducibility: Enhances the surgeon's ability to repetitively perform technically precise maneuvers such as endoscopic suturing and dissection."

=> The Robotic Operating Room:

1. What does an operating room need to house a da Vinci robot?
2. What staff are required?

"The only requirement for the operating room is the operating room size. The unit consists of a console that the surgeon sits at and the robot that needs to be wheeled in towards the patient. These pieces cant be too close while the patient is entering the OR suite as you need to have freedom for people to walk around.

The other components for the operation are components you would need for all surgery or laparoscopic surgery.

Laparoscopic equipment: TV monitors for the assistant and nurses, air insufflator, light source.

Standard equipment: cautery generators, suction canisters, anesthesia setup.

In our hospital there is only 1 room that is large enough for the robot to work in. The robot, although weighing in excess of 1000 pounds (I think) is relatively easy to move around. We move it to other parts of the operating room to practice with it and easily move it around the room between cases if we are doing 2 different operations that day.

Our hospital is building 3 state of the art laparoscopic suites which should have all the screens and lap equipment hanging from the ceiling. I am told there will be a 42 inch plasma on the wall for everyone in the OR to see. Teleconferencing will also be available and my expectation is to have surgeons from all over the country and world come learn how to do some of the advanced robotic procedures we are doing at NBI currently.

I am hoping that the next generation of robots will be integrated into the operating theaters and will need less space.

What staff are required?
The main difference between this surgery and previous surgeries is that the surgeon is not at the field. I am currently performing surgeries with another urologist, but plan on hiring and training a physician assistant or nurse first assist to help. 90% of the operations can be just as safely, quickly, and precisely performed with a qualified non-physician assisting after the learning curve has been passed.

The anesthesia requirements are the same as any surgery except a full general anesthetic is needed (not a spinal). The blood loss is much less, as are the fluid shifts as compared to open surgery, so I would consider most cases low stress for the anesthesiologist.

The scrub nurse is the same as any operation. She does much less work than open once there is an experienced robotic team since the amount of instrument changes, sutures, etc. is less as compared to open surgery.

The circulating nurse is also necessary, as we sometimes use different devices from special clips or staples depening on the anatomy.

The only time that additional people are nice to have in the room is the setup and docking of the robot and the removal of the robot. We have developed several ways to remove steps to make this process as streamlined as possible.

Compared to open or lap surgery, the staff requirements are similar. The room size is the only difference with a large room needed for robotics."

1.- Associates in Urology: da Vinci® Prostatectomy Robotic Surgery
==> Link to the web site: click here.

2.- Blog:
==> ROBOTIC SURGERY BLOG: click here.

"Haptics - A robotic limitation:"

"The most cited drawback of robotic surgery is the loss of fine feeling of the instruments on tissue.

The other drawbacks are the expense of the surgical system and the need for precise positioning of the robotic arms to provide for a full range of motion without repositioning the arms.

Haptics refers to the feedback of moving the robotic controls on the surgeon.

The current version of the da Vinci robotic surgical system does not have haptics Incorporated into the system. I admit it would be nice for the next version of the system to have haptics and enable the surgeon to feel the tension on sutures, as well as the tension of instruments on tissue.

The robotic radical prostatectomy procedure is a delicate urologic procedures that is a good one to use in discussing haptics.

In my opinion, the loss of feedback is not a major or significant drawback. Although I think it will make the robot easier to use and possibly a little safer, the 10 times magnification more than makes up for this shortfall. We have different senses that are used to some extent in surgery. The sense of sight allows us to see tension in tissue and sutures. As long as the instruments are kept in the field of view, the loss of fine sense of feel is not a problem for me.

There is a limited sense of feel with the da Vinci. When instruments have tension, eventually it will be felt in the instruments. When I am retracting the prostate with my left hand, I feel the tension when it gets to a certain level, granted not as soon as I would with me hands. When I lift on the vas and seminal vesicles with my 4th arm, I can feel the tension in the instrument. If my instruments are colliding with each other, or with the bony side wall, or with a laparoscopic instrument the instruments don't move as smooth as usual.
To date I have performed 65 robotic operations and 49 prostate operations and have not had any complications related to lack of haptics. I haven't had any vessel or bowel injuries."

Continue reading: "Haptics - A robotic limitation":
==> click here.

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La valise diplomatique. Une fiction médicale

Je me suis décidée à écrire sur ce sujet aux frontières entre la vie et la mort, la mort et la vie, un no man’s land où nous, chirurgiens et chirurgiennes, procédons en passeurs anonymes à des échanges clandestins. Nous passons ces frontières en clandestins : «Non, je n’ai rien à déclarer» (ce territoire ne fait pas encore partie de l’espace Schengen). «Valise diplomatique !». Je brandis mon I.D. justifiant mon Immunité Diplomatique, et je franchis sans histoire les frontières successives, avec ma précieuse valise, que personne ne m’a demandé d’ouvrir. En général, à ce moment là, des images m’accompagnent : un ange aux ailes de sang. Pourquoi du sang ? J’ai dû essayer de faire rentrer mes ailes dans les gants chirurgicaux. Pas précisément adaptés. Je saigne, je sais, ça fait partie du métier. «Le sang coule, c’est le métier qui rentre». «Ce qui ne détruit pas rend plus fort». Ces phrases reviennent souvent dans la bouche de mes collègues. Des phrases pour cimenter les briques des épreuves.

Quand j’étais étudiante en première année de médecine, l’année du redoutable concours, l’amphi était bondé en début d’année. Un de nos profs procéda à un écrémage selon une recette maison, sans attendre le concours : «En faisant médecine, vous vous préparez à passer votre vie dans le sang, l’urine, la merde et le vomi. Ceux que ça gêne, il faut qu’ils partent à côté : ils apprendront à vendre des savonnettes». Trois cours plus tard, un bon quart des étudiants avait déserté l’amphi pour de bon. A la grande satisfaction du prof. En même temps que le sang et compagnie, il aurait dû mentionner le manque de sommeil. Parler du sommeil à un «chir.» (c’est comme ça qu’on nous appelle dans le métier) équivaut à parler du sucre à un diabétique. Orgie de douceur vengeresse qui me traverse, dans le sillage de l’ange aux ailes de sang.

Depuis 5 ans, je supervise les internes dans le service de chirurgie pédiatrique d’un grand hôpital parisien. Les usagers de la santé nous tiennent pour des scientifiques, des grands prêtres de la Science Exacte : chirurgie assistée par ordinateur pour opérer les organes mous en endoscopie, chirurgie au laser, robot pour opérer la cataracte, système high-tech de chirurgie assistée par ordinateur pour la pose de prothèses de genoux : la précision chirurgicale est devenue numérique. La chirurgie, c’est Matrix ; le chirurgien, c’est James Bond. Comme l’espion britannique de Sa Majesté, j’utilise la technologie de pointe en m’efforçant de ne pas faire de vagues. «Painless civilization». C’est le package que l’hôpital vend à l’usager de la santé. Un ami qui est comptable dans une clinique privée m'a repris l’autre jour : «Tu ne dois plus parler de malade ou de patient. Il faut parler de client». Je lui ai répondu : «Pour une fois que la compta et le marketing s’entendent !... D’habitude, le marketing dépense des sous et la compta râle».

«On va opérer votre petite Mélanie en chirurgie mini invasive, à cœur battant. Pas besoin de lui ouvrir la cage thoracique, il suffira de pratiquer quelques incisions minimes. Pas besoin de lui casser les côtes, pas besoin non plus d’utiliser le CEC (Système de Circulation Extracorporelle) qui gère l’arrêt temporaire du cœur et des poumons, la circulation du sang s’effectuant en 'itinéraire bis' pendant ce temps, grâce à une machine qui relaye les fonctions cardio-pulmonaires, tout ceci après ouverture de la cage thoracique et écartement des côtes. Lorsqu’on utilise cette méthode de chirurgie traditionnelle invasive, on opère ‘à ciel ouvert’, comme disent les chirurgiens. Pour Mélanie, plus besoin de tout ça. Par les toutes petites incisions qu’on pratiquera sur son thorax, on entrera les instruments destinés à opérer. Un chirurgien assis à une console équipée d’une image en 3D et d’un système infrarouge commandera, ou téléguidera, si vous voulez, les mouvements des instruments opérant à cœur battant. Vous voyez, ce n’est pas le robot qui opère, c’est le chirurgien, pour autant plus besoin d’ouvrir le thorax et d’utiliser la CEC. Rassurez-vous, c’est une opération pratiquée couramment aujourd’hui, votre petite fille sera sortie de l’hôpital et totalement rétablie en 3 jours». Tandis que je parle ainsi à la mère de ma petite patiente de 6 ans, l’ange aux ailes de sang me traverse à nouveau, cette fois-ci, il opère à ciel ouvert. Le fruit de vos entrailles est béni !

Chirurgie mini invasive, coelioscopie, etc. : je suis une chirurgienne informatisée, et je veille à avoir les derniers logiciels. Ils viennent de Californie. Silicon Valley, l’université de Stanford, l’UCLA (University of California, Los Angeles), etc. Le progrès est relégué au grenier. Nous sommes à l’ère des technologies, biotechnologies, bioéthique, éthique médicale. L’autre jour j’ai lu un article dans le NEJM, le très sérieux «New England Journal of Medicine», écrit par un «Medical Bioethicist PHD». J’ai mis un moment avant de déchiffrer ce que recouvrait exactement ce terme barbare. C’est dans la langue de Shakespeare, mais ce n’est pas du Shakespeare ! En salle de garde, un interne résume la situation : «La biotechnologie, c’est de la technologie bio. Et la bioéthique, c’est pour réfléchir là-dessus. Internet ; l’intranet et l’extranet, tout ça c’est bio, comme 'la Vie Claire'. Puisqu’on nous promet des écrans organiques pour nos ordinateurs de demain… Jamais entendu parler des écrans OLED ?»

Lire la suite (Format PDF) : cliquer ici.

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Blog sur la Transplantation d'Organes / Organ Transplantation Blog

Blog Bilingue d'informations destinées au Grand Public concernant les Transplantations d'Organes :
(Articles en français et en anglais)
==> Cliquer ici.
Date de création du Blog : mai 2005.

Bilingual Blog with Information intended for a Broad Public, regarding Organ Transplantation:
(with Articles in English and in French)
==> Click here.
Blog created in May 2005.

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La chirurgie robotique évolue à pas de géant !...
Expérimentée dès 1995, elle est en pleine évolution aujourd'hui.
Suivez l'actualité !

==> Accéder au Blog Bilingue des News (français et anglais).

Welcome in the high-paced world of Robotic Surgery!
The adventure started in 1995, and now a revolution is taking place:
Minimally Invasive Surgery (MIS) is replacing invasive surgery.
To keep up with this spectacular evolution, check the News Blog out!

==> Access the Bilingual News Blog (English and French).

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Le système de chirurgie assistée par ordinateur da Vinci™ à l'Institut Mutualiste Montsouris, Paris

L'Institut Mutualiste Montsouris (IMM), Paris 14ème, est un établissement privé et public à la fois. Ni clinique, ni hôpital publique (Assistance Publique des Hôpitaux de Paris, AP-HP), cet établissement a un statut particulier.

Le Professeur Guy Vallancien, à la tête du Département d'Urologie à l'Institut Mutualiste Montsouris :

**** Contribue à développer la robotique opératoire.

=> voir également le site :

**** Enseigne les nouvelles techniques chirurgicales à l'Ecole Européenne de Chirurgie, Paris, qui est équipée pour fournir une formation de haut niveau tant théorique que pratique.

==> Ecole Europeéenne de Chirurgie (

**** Contribue au développement de réseaux de collaboration ou partenariats avec l'IMM.

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Robotic surgery: Frequently Asked Questions (FAQ)

da Vinci™ robotic surgical system:

Frequently asked questions: click here or read below:

1. Will a surgeon using the da Vinci® robotic surgical system operate in “Virtual Reality?”

Although seated at a console a few feet away from the patient, the surgeon views an actual 3-D image of the surgical field while operating, real-time, with electro-mechanically enhanced instruments through tiny ports. At no time does the surgeon see a virtual image or program/command the system to perform any maneuver or operate outside of his/her direct, real-time, control.

2. Will the da Vinci® robotic surgical system make the surgeon unnecessary?

On the contrary, it will enable surgeons to be more precise, advancing their technique and enhancing their capability to perform complex minimally invasive surgery.

3. Is this telesurgery? Can you operate over long distances?

The da Vinci Surgical robotic surgical system theoretically be used to operate over long distances. This capability, however, is not the primary focus of the company and as such is not available with the current da Vinci system.

4. Is this “robotic surgery?”

“Robotic surgery” devices are designed to perform entirely autonomous movements after being programmed by a surgeon. The da Vinci system is a computer-enhanced surgical system, which interposes a computer between the surgeon’s hands and the tips of micro instruments. The system replicates the surgeon’s movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way or perform any type of surgical maneuver.

5. Where is the da Vinci system being used now?

Currently, the da Vinci Surgical System is being used in major centers in the United States, Austria, Belgium, Denmark, France, Germany, Italy, Japan, the Netherlands, Sweden , Switzerland and the United Kingdom.

6. What procedures have been performed using the da Vinci? What additional procedures are possible?

The da Vinci system is a platform technology designed to enable complex procedures of all types to be performed through tiny ports. To date, hundreds of procedures including cardiac, general, urologic and gynecologic have been performed using the da Vinci. We believe, in the future, the technology will be used by surgeons specializing in vascular, orthopedic, spinal, neurologic and other surgical disciplines to offer their patients the option of minimally invasive surgery for the first time.

7. Why can’t surgeons perform complex procedures such as cardiac surgery through 1-centimeter ports today?

Cardiac surgery is complex and requires an excellent view of the operative field and the ability to maneuver instruments within the chest cavity with precision and control. Surgeons historically have used the “open sternotomy” approach, which requires a large 12-inch incision that provides visibility and allows room for the surgeon to get his hands and instruments very close to the operative site. More recently, smaller incisions have been used to perform a variety of cardiac procedures. Many surgeons, however, feel the smaller access restricts operative view and may impede access to the operative field.

8. What are the benefits of using the da Vinci system?

For the surgeon, the ability to perform complex minimally invasive procedures as if they were open surgery. For the patient, numerous benefits common in existing minimally invasive surgery procedures - such as reduced trauma, less pain, lower cost, shorter hospital stay and faster recovery are possible.

9. Has the da Vinci system been FDA approved?

On July 11, 2000, Intuitive Surgical received clearance from the FDA to begin commercializing the da Vinci Surgical System in the United States for use in laparoscopic surgical procedures. Additionally, on March 2, 2001, the manufacturer received its second FDA clearance for thorascopic procedures. And on May 30, 2001, the FDA cleared the da Vinci Surgical System for laparoscopic radical prostatectomy procedures. This makes the da Vinci Surgical System the only FDA-cleared, complete robotic surgical system commercially available in the United States for laparoscopic and thoracoscopic procedures.

University of Iowa Healthcare.

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Robotic Surgery and FDA Approvals

The da Vinci™ surgical system has been FDA approved to assist in urologic surgery, thoracoscopic (chest) surgery procedures, general surgery: general (digestive) laparoscopic procedures, gynecological laparoscopic procedures, coronary artery bypass surgery, mitral valve repair and cardiac revascularization.

In urologic procedures, the system is being used to perform radical prostatectomy, a minimally invasive radical prostate cancer surgery that profoundly reduces bleeding, pain, and recovery time. Intuitive Surgical noted that the da Vinci™ Surgical System has been successfully used in thousands of prostate cancer procedures world-wide.

In cardiac surgery, the system is being used to perform single or double vessel Beating Heart TECAB (Totally Endoscopic Coronary Artery Bypass), also called single or double vessel Beating Heart CABG (Coronary Artery Bypass Graft). This means surgeons currently perform single vessel or double vessel Coronary Artery Bypass Graft on patient's beating heart, with minimally invasive technique (closed-chest technique, keyhole surgery). In these cases, surgeons no longer need to crack patient's chest open (break patient's chestbones) and put patient's heart on the off-pump system to operate on an arrested heart (invasive, open-chest cardiac surgery).

On July 11, 2000, Intuitive Surgical received clearance from the FDA to begin commercializing the da Vinci™ Surgical System in the United States for use in laparoscopic surgical procedures.

Additionally, on March 2, 2001, the manufacturer received its second FDA clearance for thoracoscopic procedures. And on May 30, 2001, the FDA cleared the da Vinci™ Surgical System for laparoscopic radical prostatectomy procedures.

On November 13, 2002, Intuitive Surgical's da Vinci™ surgical system received first FDA Cardiac Clearance for Mitral Valve Repair Cardiac Surgery.

On January 30, 2003, the FDA Clearance for Intracardiac Surgery now encompasses "ASD" Closure (Atrial Septal Defect Closure surgical procedure).

On July 8, 2004, Intuitive Surgical received clearance from the FDA for Cardiac Revascularization with the da Vinci™ surgical system.

On April 26, 2005, Intuitive Surgical received clearance from the FDA for Gynecological Laparoscopic procedures with the da Vinci™ Surgical System.

This makes the da Vinci™ Surgical System the only FDA-cleared, complete robotic surgical system commercially available in the United States for laparoscopic and thoracoscopic procedures.

*** Intuitive Surgical receives FDA Clearance for Gynecological Laparoscopic procedures:
=> read.

*** Intuitive Surgical receives FDA Clearance for Cardiac Revascularization:
=> read.

More about laparoscopic and thoracoscopic surgical procedures with the da Vinci™ surgical system:



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Scientific press on urological robotic surgery

Read the latest da Vinci™ white papers in urology:

Robot-Assisted Versus Open Radical Prostatectomy: A Comparison of One Surgeon's Outcomes
Robotic Revelation: Laparoscopic Radical Prostatectomy by a Nonlaparoscopic Surgeon
Robot-Assisted, Retropubic Radical Prostatectomy Shows Similar Outcomes
Robotic Radical Prostatectomy and the Vattikuti Urology Institute Technique: An Interim Analysis of Results and Technical Points

==> See Video clips cited in this article: click here.
Source: Elsevier Urology.

Robotic Prostatectomy Chapter in Atlas of the Prostate
(to be published soon).

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da Vinci™ surgical system: multi-specialty scientific press (white paper abstracts)

You'll find below a selection of white paper abstracts related to thoracoscopic and laparoscopic minimally invasive procedures with the da Vinci™ surgical system.

==> For an update on scientific press articles published between August and October 2005, click here.

1.- Totally endoscopic robot-assisted transmyocardial revascularization.

In: J Thorac Cardiovasc Surg. 2005 Jul;130(1):120-4.Yuh DD, Simon BA, Fernandez-Bustamante A, Ramey N, Baumgartner WA.

Division of Cardiac Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD 21827-4618, USA.

OBJECTIVE: Laser transmyocardial revascularization is an emerging therapy for intractable angina stemming from diffuse, small-vessel coronary disease not amenable to percutaneous coronary intervention or coronary bypass grafting. Presently, this therapy is delivered through a median sternotomy or left thoracotomy. In this pilot study, we sought to combine the advantages of a dexterous robotic surgical platform with a flexible fiberoptic laser to develop a minimally invasive approach toward transmyocardial revascularization. METHODS: A flexible fiberoptic holmium:yttrium-aluminum-garnet laser probe (CardioGenesis Corporation, Foothill Ranch, Calif), deployed with the da Vinci™ surgical robotic system (Intuitive Surgical, Sunnyvale, California), was used to create transmyocardial channels through all left ventricular wall regions in 5 canine subjects. The channels were localized, quantified, and histologically analyzed to assess distribution, dimensions, and transmurality.

RESULTS: Transmyocardial channels were successfully created in all 6 defined left ventricular wall segments by using this minimally invasive approach without port repositioning, instrument exchange, or probe modifications. Gross pathologic and histologic analyses confirmed the uniform distribution of 1.0-mm transmural channels in all left ventricular regions. No direct pressure, topical hemostatic agents, or suture repairs were required for hemostasis. No significant hemodynamic instability or sustained arrhythmias were encountered at any time during the procedures.

CONCLUSIONS: We report the first use of a prototype flexible fiberoptic laser probe deployed by the da Vinci surgical robotic system to successfully perform totally endoscopic off-pump transmyocardial revascularization in a canine model, demonstrating the feasibility, precision, and safety of this approach. Refinement of this minimally invasive technique may reduce the morbidity of open-chest transmyocardial revascularization and facilitate its use as sole therapy or as an adjunct to percutaneous coronary interventions.

2.- A new era in laparoscopic surgery. Evaluation of robot-assisted laparoscopic procedures.

In: Saudi Med J. 2005 May;26(5):777-80. Khairy GA, Fouda M, Abdulkarim A, Al-Saigh A, Al-Kattan K.

Department of Surgery, College of Medicine and King Khalid University Hospital, PO Box 7805, Riyadh 11472, Kingdom of Saudi Arabia.

OBJECTIVE: To present the experience with the advanced technology of robot-assisted laparoscopic surgery at our institute.

METHODS: We reviewed and present patients who had robot-assisted laparoscopic surgical procedures, between April 2003 and March 2004, at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. All procedures were carried out using the da Vinci™ system (Intuitive Surgical, Mountain View, Ca, USA). We recorded the time for system setup, operating time, morbidity and postoperative hospital stay.

RESULTS: We performed 42 robot-assisted laparoscopic operations. The most frequently performed operations were robot-assisted cardiac procedures (n=25), laparoscopic cholecystectomy (n=9) other operations were: thymectomy (4), apical bullectomy (2), and one for each adrenalectomy, and lung volume reduction. The median time to install and drape the robotic system was 15 minutes. In 2 patients (4.7%) we converted the procedures to conventional laparoscopy or open. There was postoperative wound infection at the site of the port in one patient. The average postoperative hospital stay was similar to conventional laparoscopic procedures.

CONCLUSION: Robot-assisted minimally invasive surgery is feasible, safe and may become the surgical procedure of the future.

3.- Long-term follow-up after robotic cholecystectomy.

In: Am Surg. 2005 Apr;71(4):281-5. Bodner J, Hoeller E, Wykypiel H, Klingler P, Schmid T.

Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria.

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci™ surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30-35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.

4.- Robotic mitral valve surgery: a United States multicenter trial.

In: J Thorac Cardiovasc Surg. 2005 Jun;129(6):1395-404. Nifong LW, Chitwood WR, Pappas PS, Smith CR, Argenziano M, Starnes VA, Shah PM.

Brody School of Medicine at East Carolina University, Pitt County Memorial Hospital, Greenville, NC, USA.

OBJECTIVE: In a prospective phase II Food and Drug Administration trial, robotic mitral valve repairs were performed in 112 patients at 10 centers by using the da Vinci™ surgical system. The safety of performing valve repairs with computerized telemanipulation was studied.

METHODS: After institutional review board approval, informed consent was obtained. Patients had moderate to severe mitral regurgitation. Operative technique included peripheral cardiopulmonary bypass, a 4- to 5-cm right minithoracotomy, a transthoracic aortic crossclamp, and antegrade cardioplegia. The successful study end point was grade 0 or 1 mitral regurgitation by transthoracic echocardiography at 1 month after surgery.

RESULTS: Valve repairs included quadrangular resections, sliding plasties, edge-to-edge approximations, and both chordal transfers and replacements. The average age was 56.4 +/- 0.09 years (mean +/- SEM). There were 77 (68.8%) men and 35 (31.2%) women. Valve pathology was myxomatous degeneration in 105 (91.1%), and 103 (92.0%) had type II leaflet prolapse. Leaflet repair times averaged 36.7 +/- 0.2 minutes, with annuloplasty times of 39.6 +/- 0.1 minutes. Total robot, aortic crossclamp, and cardiopulmonary bypass times were 77.9 +/- 0.3 minutes, 2.1 +/- 0.1 hours, and 2.8 +/- 0.1 hours, respectively. On 1-month transthoracic echocardiography, 9 (8.0%) had grade 2 mitral regurgitation, and 6 (5.4%) of these had reoperations (5 replacements and 1 repair). There were no deaths, strokes, or device-related complications.

CONCLUSIONS: Multiple surgical teams performed robotic mitral valve repairs safely early in development of this procedure, with a reoperation rate of 5.4%. Advancements in robotic design and adjunctive technologies may help in the evolution of this minimally invasive technique by decreasing operative times.

5.- Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system.

In: Surg Endosc. 2004 Oct 13. Dogan S, Aybek T, Risteski P, Mierdl S, Stein H, Herzog C, Khan MF, Dzemali O, Moritz A, Wimmer-Greinecker G.

Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany,

BACKGROUND: Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or countertraction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci™ surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature.

METHODS: The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci™ surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon.

RESULTS: The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195 +/- 58, 25 +/- 10, and 18 +/- 5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique.

CONCLUSIONS: The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci™ surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community.

6.- Feasibility of robotic radical nephrectomy--initial results of single-institution pilot study.

In: Urology. 2005 Jun;65(6):1086-9. Klingler DW, Hemstreet GP, Balaji KC.

Division of Urological Surgery, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198-2360, USA.

OBJECTIVES: To report our initial experience and the utility of the da Vinci ™ surgical robotic system (DSRS) for performing robotic radical nephrectomy (RRN). The DSRS has been increasingly evaluated to determine its feasibility for assisting surgeons in major urologic procedures.

METHODS: The perioperative outcomes of the first five RRNs performed at our institution were analyzed to establish the safety and utility of the DSRS in performing RRN.

RESULTS: Five male patients with a median age of 72 years (range 45 to 78) underwent RRN. The median body mass index, operative time, intraoperative blood loss, postoperative decrease in hemoglobin, postoperative rise in serum creatinine, postoperative morphine use, hospital stay, kidney size, and tumor size was 28 (range 20.9 to 32.9), 321 minutes (range 246 to 437), 150 mL (range 25 to 1500), 1.4 g/dL (range 0.2 to 3.5), 0.6 mg/dL (range 0.5 to 0.7), 28 mg (range 10 to 212), 3 days (range 1 to 5), 430 cm3 (range 158 to 1387), and 66 cm3 (range 29 to 120), respectively. One RRN was converted to hand-assisted laparoscopy because of bleeding from the left renal vein. No perioperative morbidities or mortalities occurred. The final pathologic examination revealed conventional clear cell carcinoma in 4 patients (1 with pT1a, 2 with pT1b, and 1 with T3a) and a benign cyst in 1 patient.

CONCLUSIONS: The results of our study have confirmed that RRN is a feasible and viable alternative for performing radical nephrectomy. A larger randomized study incorporating cost and outcome comparisons with laparoscopic and open radical nephrectomy is needed before wider application of RRN.

7.- Robotic transperitoneal detrusor myotomy: description of a novel technique.

In: J Endourol. 2005 May;19(4):476-9. Mammen T, Balaji KC.

Section of Urologic Surgery, University of Nebraska Medical Center, Omaha, Nebraska 68198, USA.

The da Vinci™ Surgical Robotic System has recently been added to the armamentarium of minimally invasive surgeon and has been shown to be useful to urologists in performing complex operations. We report the first case of detrusor myotomy performed using the da Vinci™, describe the novel technique, and review the indications and published outcomes of detrusor myotomy to identify potential applications of this novel technique in patients with neurogenic bladder.

8.- Da Vinci robot-assisted excision of a vallecular cyst: a case report.

In: Ear Nose Throat J. 2005 Mar;84(3):170-2. McLeod IK, Melder PC.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Walter Reed Army Medical Center, 6900 Georgia Ave., Washington, DC 20307-5001, USA.

The da Vinci™ Surgical System is a new and exciting entrant into the field of robotic technology. This system is undergoing considerable research and is being practically applied in general surgery, cardiothoracic surgery, urology, and gynecology. We have previously described our experience with the da Vinci™ system in the laboratory setting, and we have reviewed its potential applications in otolaryngology. Here we present a case report of the first da Vinci™-assisted excision of a vallecular cyst in a human. Although we initially encountered some difficulties in the setup, we were able to perform the procedure with moderate ease and without complication. The potential of the da Vinci™ system in otolaryngology is promising. Further research is needed to explore all of its possible uses in our field.

9.- Experience on the way to totally endoscopic atrial septal defect repair.

In: Heart Surg Forum. 2004;7(5):E440-5. Bonaros N, Schachner T, Oehlinger A, Jonetzko P, Mueller S, Moes N, Kolbitsch C, Mair P, Putz G, Laufer G, Bonatti J.

Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria.

BACKGROUND: Remote-access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect (ASD) and patent foramen ovale (PFO). We report on a stepwise approach to a totally endoscopic procedure.

METHODS: Seventeen patients (median age, 39 years; range, 21-55 years) underwent limited-access ASD or PFO closure. As a preparative step, the operation was carried out through minithoracotomy in 11 patients. In parallel, experience with robotic surgery was gained with totally endoscopic coronary artery bypass grafting procedures. After performance of ASD closures in dry-laboratory models using the da Vinci™ telemanipulation system, 6 patients were operated on in a totally endoscopic fashion.

RESULTS: With the endoscopic approach, significant learning curves were noted for cardiopulmonary bypass time y(min) = 226 - 41 * ln(x) (P = .03) and aortic cross-clamp time y(min) = 134 - 42 * ln(x) (P = .01) (x = number of procedures). There was no hospital mortality, and no residual shunts were detected at postoperative echocardiography. Median ventilation time was 9 hours (range, 0-18 hours) for the minithoracotomy group and 6 hours (range, 4-19 hours) for the totally endoscopic group. Median intensive care unit stay was 20 hours (range, 18-24 hours) and 18 hours (range, 18- 120 hours), respectively.

CONCLUSIONS: The implementation of robotic totally endoscopic closure of ASD or PFO in a heart surgery program seems to be safe. An intermediate step of performing the operations through minithoracotomy, adapting to remote access perfusion systems, and gaining experience in other robotic cardiac surgical procedures seems worthwhile. Learning curves are apparent, and adequate defect closure does not seem to be compromised by the totally endoscopic approach.

10.- Robotic mitral valve annuloplasty with double-arm nitinol U-clips.

In: Ann Thorac Surg. 2005 Apr;79(4):1372-6; discussion 1376-7. Reade CC, Bower CE, Bailey BM, Maziarz DM, Masroor S, Kypson AP, Nifong LW, Chitwood WR Jr.

Division of Cardiothoracic Surgery, The Brody School of Medicine at East Carolina University, Greenville, North Carolina 27858, USA.

PURPOSE: Robotic mitral valve repair increases precision however operative times are longer. Prior studies have indicated that robotic knot tying is time consuming and it is without potential room for improvement. We therefore investigated tissue approximation devices that may shorten operative times.

DESCRIPTION: A 67-year-old female was approached through a right mini-thoracotomy with the da Vinci™ Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Using 12 nitinol U-clips (Coalescent Surgical, Sunnyvale, CA) an annuloplasty band was placed under robotic guidance. Clip placement and deployment times were recorded and statistical comparisons were assessed to prior suture annuloplasties.

EVALUATION: Clip placement time was 1.3 +/- 0.9 (minutes +/- standard deviation), statistical comparison with first, most recent, and all prior suture annuloplasties proving no significance. Clip deployment time was 0.5 +/- 0.2, whereas knot-tying times and respective statistical comparison for first, most recent, and all prior suture annuloplasties were 2.0 +/- 0.7 (p = 0.003), 1.2 +/- 0.4 (p = 0.0004), and 1.6 +/- 0.6 (p < 0.00001). Follow-up echocardiography performed postoperatively, at 3 months, and at 9 months revealed valvular structural integrity with only minimal mitral regurgitation.

CONCLUSIONS: U-clips considerably reduce time for annuloplasty over conventional suture and may help reduce operative times as well.

11.- Total laparoscopic hysterectomy utilizing a robotic surgical system.

In: JSLS. 2005 Jan-Mar;9(1):13-5. Beste TM, Nelson KH, Daucher JA.

Department of Obstetrics and Gynecology, East Carolina University Brody School of Medicine, Greenville, North Carolina 27858, USA.

OBJECTIVES: To describe the use of a robotic surgical system for total laparoscopic hysterectomy.

METHODS: We report a series of laparoscopic hysterectomies performed using the da Vinci™ Robotic Surgical System. Participants were women eligible for hysterectomy by standard laparoscopy. Operative times and complications are reported.

RESULTS: We completed 10 total laparoscopic hysterectomies between November 2001 and December 2002 with the use of the da Vinci™ Robotic Surgical System. Operative results were similar to those of standard laparoscopic hysterectomy. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes. Blood loss varied from 25 mL to 350 mL. Uterine weights varied from 49 g to 227 g. A cystotomy occurred in a patient with a history of a prior cystotomy unrelated to the robotic system.

CONCLUSION: Total laparoscopic hysterectomy is a complex surgical procedure requiring advanced laparoscopic skills. Tasks like lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system, thus providing unique advantages over existing standard laparoscopy. Total laparoscopic hysterectomy can be performed using robotic surgical systems.

12.- Robotic systems and surgical education.

In: JSLS. 2005 Jan-Mar;9(1):3-12. Di Lorenzo N, Coscarella G, Faraci L, Konopacki D, Pietrantuono M, Gaspari AL.

Department of General Surgery, University of Rome, Tor Vergata, Italy.

This experimental study aimed at evaluating the efficiency of robots in the learning of surgical techniques. We recruited 40 surgeons, divided them into 2 groups of 20, each of which used the robotic system. The first group consisted of experienced physicians, and the second group comprised physicians in training. Each surgeon was allowed to use the da Vinci™ robotic system for 30 minutes twice in the span of 24 hours. The practice time period was divided into 15 minutes for tying and placement of sutures and 15 minutes for incisions and vascular suturing. We recorded the times required for the performances, and a statistically significant outcome was obtained. With variance analysis (ANOVA), it has been shown that the time needed to perform the exercises depends in a statistically significant way on the kind of test to be performed (P<0.01), the experience of the surgeon (P<0.001), and the kind of operation (P<0.025). Robotic systems can be an optimal tool both for residents and experienced surgeons, for learning of basic surgical tasks and for perfection of clinical skills. The use of the system has great potential in surgical training, offering a reduction in the learning period, enabling checking for errors, and allowing an evaluation of the capabilities obtained. Final goals are a drastic reduction in the learning curve, a better technique, with a significant reduction in surgical errors and complications, with greater safety for the patient.

13.- Robotic mitral valve surgery: a technologic and economic revolution for heart centers.

In: Am Heart Hosp J. 2003 Winter;1(1):30-9. Chitwood WR Jr, Kypson AP, Nifong LW.

Department of Surgery, Brody School of Medicine at East Carolina University, Greenville, NC 27858, USA.

A renaissance in cardiac surgery is occurring. Cardiac operations are being performed through smaller incisions with enhanced technologic assistance. Specifically, minimally invasive mitral valve surgery has become standard for many surgeons. At our institution, we have developed a robotic mitral surgery program with the da Vinci™ telemanipulation system, which has recently gained Food and Drug Administration approval. This system allows the surgeon to perform complex mitral valve operations through small port sites rather than a traditional median sternotomy. Our techniques and initial results are reported. Despite procedural success, these devices are not inexpensive and hospitals will have to justify their purchase. The implementation of robotic surgery has forced us to compare costs and benefits compared with conventional cardiac surgery. Nevertheless, our desire for improved and less traumatic patient care will drive this new technology, which will serve as a good model for us to study over the next several years.

14.- Laparoscopic splenectomy with the da Vinci™ robot.

In: J Laparoendosc Adv Surg Tech A. 2005 Feb;15(1):1-5. Bodner J, Lucciarini P, Fish J, Kafka-Ritsch R, Schmid T.

Department of General and Transplant Surgery, Innsbruck University Hospital, Anichstrasse 35, A-6020 Innsbruck, Austria.

BACKGROUND: We report our first series of minimally invasive splenectomies with a robotic surgical system.

METHODS: From August 2001 to October 2003, laparoscopic splenectomies with the da Vinci™ operating robot were performed in 7 patients (five females and two males, ages 20 to 74 years).

RESULTS: Indications for splenectomy were hematologic disorders in four patients and hypersplenism in three patients. Median dimensions of the resected spleens were 140 +/- 34 mm x 80 +/- 11 mm x 50 +/- 17 mm and median weight was 307 +/- 193 g. Median total operative time was 147 +/- 58 minutes including 107 +/- 49 minutes for the robotic act. There were no intraoperative complications and no conversions to open surgery. The median postoperative hospital stay was 7 days.

CONCLUSION: This first series suggests that robotic splenectomy with the da Vinci™ surgical system is technically feasible and safe. It provides an alternative to the conventional laparoscopic procedure. Nevertheless, justification for this new technique will require a larger prospective series and longer follow-up.

15.- Robotically enhanced coronary artery bypass surgery.

In: Indian Heart J. 2004 Nov-Dec;56(6):622-7. Mishra YK, Wasir H, Sharma M, Sharma KK, Mehta Y, Trehan N.

Department of Cardiovascular Surgery, Escorts Heart Institute and Research Centre, New Delhi.

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart.

METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci ™ telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting.

CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.

16.- Design of a prototype operating seat with SESAM (Ergonomic System of Mobile Forearm Rests) mobile armrests designed to optimize the surgeon's ergonomy during pelvic laparoscopy

In: Prog Urol. 2004 Dec;14(6):1181-7. Lorin S, Poumarat G, Memeteau Y, Wattiez A, Tostain J.

Service d'Urologie, CHU de Saint-Etienne, France.

INTRODUCTION: Pelvic laparoscopic surgery offers multiple advantages for patients, but requires uncomfortable, non-ergonomic positions for the surgeon. Only a remote operator (Robot "slave" reproducing the surgeon's movements performed on a "master" console situated away from the patient), like Da-Vinci™ or Zeus™ (Intuitive Surgical) can improve the laparoscopic surgeon's working conditions. The objective of this study, based on an ergonomic analysis and recording of a laparoscopic surgeon's movements, was to define the specifications for the manufacture of an operating seat with armrests, based on the surgeon's position using a remote operator.

MATERIAL AND METHODS: Movements of the centre of pressure and upper limbs of 12 urologists and gynaecologists with various levels of experience, were recorded using a force platform and a SAGA 3 RT movement analysis system (Biogesta), during 4 exercises performed on a pelvi-trainer, with the surgeon positioned to the left (introduction of a needle, unravelling of a cord, dissection, suture). Ergonomic analysis of the laparoscopic surgeon's movements was based on video recordings of a surgeon under real operating conditions. The specifications were defined from all of these data.

RESULTS AND DISCUSSION: The small amplitude of movements of the surgeon's centre of pressure (< 45 cm2) confirmed that surgeons can be seated during laparoscopy. Recordings of the upper defined the elbow working zones and the need for 3D mobile armrests. Ergonomic analysis of posture defined the characteristics of the prototype. On the basis of these specifications, a prototype operating seat was developed. This prototype now needs to be validated or invalidated clinically.

17.- Tele-surgical simulation system for training in the use of da Vinci surgery.

In: Stud Health Technol Inform. 2005;111:543-8. Suzuki S, Suzuki N, Hayashibe M, Hattori A, Konishi K, Kakeji Y, Hashizume M.

Institute for High Dimensional Medical Imaging, The Jikei University School of Medicine, 4-11-1 Izumihoncho, Komae-shi, Tokyo 201-8601, Japan.

Laparoscopic surgery including robotic surgery allows the surgeon to be able to conduct minimally invasive surgery. A surgeon is required to master difficult skills for this surgery to compensate for the narrow field of view, limitation of work space, and the lack of depth sensation. To counteract these drawbacks, we have been developing a training simulation system that can allow surgeons to practice and master surgical procedures. In addition, our system aims to distribute a simulation program, to provide a means of collaboration between remote hospitals, and to be able to provide a means for guidance from an expert surgeon. In this paper, we would like to show the surgery simulation for da Vinci™ surgery, in particular a cholecystectomy. The integral parts of this system are a soft tissue model which is created by the sphere-filled method enabling real-time deformations based on a patient's data, force feedback devices known as a PHANTOM and the Internet connection. By using this system a surgeon can perform surgical maneuvers such as pushing, grasping, and detachment in real-time manipulation. Moreover, using the broadband communication, we can perform the tele-surgical simulation for training.

18.- Early experience in robot-assisted laparoscopic Heller myotomy.

In: Scand J Gastroenterol Suppl. 2004;(241):4-8. Ruurda JP, Gooszen HG, Broeders IA.

Dept. of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.

Heller myotomy for achalasia is routinely performed laparoscopically. This offers patients significant benefits compared to open surgery. Surgeons, however, are limited in their manipulation and visualization during laparoscopic interventions. Robotic telemanipulation systems were introduced with the objective of alleviating these limitations. The purpose of this study was to demonstrate the efficacy and safety of performing a Heller myotomy with the use of a robotic telemanipulation system. Fourteen patients were operated on with the da Vinci™ robot system. Robotic system set-up time, per- and postoperative complications, blood loss, operating time and hospital stay were recorded. Follow-up included manometry and symptom score. The robotic system set-up time was 15 min (10-15). Thirteen procedures (13/14: 93%) were completed by laparoscopic surgery. One procedure was converted because of inadequate exposure. One peroperative mucosal perforation was closed laparoscopically. The median blood loss was 10 mL (10-200). Median operating time was 90 min (75-150). Hospitalization ranged from 2 to 8 days (median 3). No complications occurred during a 30-day postoperative period. Dysphagia was relieved in 12/14 patients (86%). Heartburn was present postoperatively in 2/14 patients (14%). Manometry showed a significant decrease in median lower oesophageal sphincter (LOS) pressure from 2.9 preoperatively to 1 kPa postoperatively (P = 0.008). Robot-assisted laparoscopic Heller myotomy was demonstrated to be safe and effective in reducing basal LOS pressure and dysphagia. The results of this study clearly support the feasibility of the use of this system in performing a delicate laparoscopic surgical procedure. The use of a robotic system was experienced as being highly supportive in manipulation and visualization by the surgical team involved.

19.- Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediastinum.

In: Ann Thorac Surg. 2005 Feb;79(2):450-5; discussion 455. Savitt MA, Gao G, Furnary AP, Swanson J, Gately HL, Handy JR.

Providence St. Vincent Heart and Vascular Institute, Portland, Oregon 97225, USA.

BACKGROUND: We report our initial experience with the application of robotic-assisted technologies to the treatment of diseases of the anterior mediastinum.

METHODS: Between October 2001 and December 2003, 18 consecutive patients with anterior mediastinal masses were referred for diagnosis and treatment. Fifteen patients underwent robotic-assisted surgery with the da Vinci™ robotic system. A single surgical team performed all operations. Resection was accomplished by either median sternotomy or robotic-assisted techniques.

RESULTS: Fourteen patients underwent successful robotic-assisted thymectomy. One patient underwent robotic-assisted biopsy of a mass that was later determined to be a poorly differentiated carcinoma, 3 patients underwent complete thymectomy by median sternotomy for biopsy-proven extracapsular thymoma, 7 patients had thymoma, and 3 had myasthenia gravis. There were 2 patients each with benign thymic cysts and thymic hyperplasia. Primary thymic carcinoid, thymolipoma, papillary thyroid cancer, and poorly differentiated carcinoma were present in 1 patient each. No conversions, intraoperative complications, or deaths occurred in the 15 patients who underwent robotic-assisted resection. The mean operative time was 96 minutes (range 62 to 132 minutes). The mean robotic time was 48 minutes (range 22 to 76). The median hospital stay was 2 days. All patients are doing well, with a median follow-up of 1 year.

CONCLUSIONS: Robotic-assisted surgery of the anterior mediastinum, and particularly thymectomy, can be performed safely and efficiently. The increased visualization and instrument dexterity afforded by this technology provides an optimal minimally invasive approach to the anterior mediastinum. From this experience we have formulated a comprehensive treatment algorithm for the surgical evaluation and treatment of patients with anterior mediastinal diseases.

20.- What have we learnt after two years working with the da Vinci robot system in digestive surgery?

In: Acta Chir Belg. 2004 Nov-Dec;104(6):609-14. Hubens G, Ruppert M, Balliu L, Vaneerdeweg W.

Dept of Abdominal Surgery, University Hospital Antwerp.

Robotic- assisted surgery has been introduced recently in order to overcome some of the difficulties surgeons encounter during advanced laparoscopic surgery. Due to the 3D vision equipment, higher number of degrees of freedom in manipulating instruments and better ergonomics it is hoped that by using robot techniques the indications of minimally invasive surgery in the field of digestive surgery can be broadened or that difficult procedures will be easier to perform. Since the introduction of the system in our hospital now almost two years ago 70 procedures have been performed with the aid of the da Vinci™ system covering the whole spectrum of GI (Gastro Intestinal) surgery. Conversion took place in 2.5% and peroperative morbidity related to the use of robotic techniques was 10%. Although we had the subjective feeling that the procedures were indeed easier to perform and more relaxing for the surgeon, some major problems still exist as the complete lack of tactile feedback and the cost effectiveness of these procedures. Before robotics can be introduced in the every day clinical practice of the surgeon, its true benefit still needs to be established. This can only be done by well randomised prospective studies comparing one technique with the other.

21.- Robotic and laparoscopic surgery for treatment of colorectal diseases.

In: Dis Colon Rectum. 2004 Dec;47(12):2162-8. D'Annibale A, Morpurgo E, Fiscon V, Trevisan P, Sovernigo G, Orsini C, Guidolin D.

Divisione di Chirurgia Generale, Ospedale di Camposampiero, Padova, Italy.

PURPOSE: In the last ten years, several robotic systems have been developed to overcome the loss of the three-dimensional view and dexterity characteristic of laparoscopic surgery. The aim of this study was to compare the traditional laparoscopic approach and robotic techniques in the treatment of colorectal diseases.

METHODS: The study compares a consecutive series of patients treated surgically for colorectal disease from June 2001 to May 2003 with the da Vinci™ robotic system (Intuitive Surgical) and a matched number of patients who underwent conventional laparoscopy during the same time interval. The factors analyzed were the time required to prepare the patient and the room, total time of surgery, length of specimens, number of lymph nodes retrieved, blood loss, complications, and postoperative results.

RESULTS: The study included 106 patients (53 in each group). No differences were observed in total time of surgery (laparoscopic group, 222 +/- 77 minutes vs. robotic group, 240 +/- 61 minutes), specimen length (laparoscopic group, 29 +/- 11 cm vs. robotic group, 27 +/- 13 cm), or number of lymph nodes retrieved (laparoscopic group, 16 +/- 9 vs. robotic group, 17 +/- 10). It took significantly longer to prepare the operating room and patient in the robotic group (24 +/- 12 minutes) than in the laparoscopic group (18 +/- 7 minutes). There were three conversions to laparotomy in the laparoscopic group; in the robotic group, two cases were converted to laparoscopy and three to hand-assisted laparoscopy. No significant differences were observed between the two groups in terms of recovery of bowel function and postoperative hospital stay.

CONCLUSIONS: Robot-assisted surgery proved to be as safe and effective as laparoscopic techniques in the treatment of colorectal diseases. Because of its dexterity and three-dimensional view, the da Vinci™ system was particularly useful in specific stages of the procedure, e.g., takedown of the splenic flexure, dissection of a narrow pelvis, identification of nervous plexus, and handsewn anastomosis. The cost-effectiveness of the procedure still needs to be evaluated.

22.- Effect of sensory substitution on suture-manipulation forces for robotic surgical systems.

In: J Thorac Cardiovasc Surg. 2005 Jan;129(1):151-8. Kitagawa M, Dokko D, Okamura AM, Yuh DD.

Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA.

OBJECTIVES: Direct haptic (force or tactile) feedback is not yet available in commercial robotic surgical systems. Previous work by our group and others suggests that haptic feedback might significantly enhance the execution of surgical tasks requiring fine suture manipulation, specifically those encountered in cardiothoracic surgery. We studied the effects of substituting direct haptic feedback with visual and auditory cues to provide the operating surgeon with a representation of the forces he or she is applying with robotic telemanipulators.

METHODS: Using the robotic da Vinci™ surgical system (Intuitive Surgical, Inc, Sunnyvale, Calif), we compared applied forces during a standardized surgical knot-tying task under 4 different sensory-substitution scenarios: no feedback, auditory feedback, visual feedback, and combined auditory-visual feedback.

RESULTS: The forces applied with these sensory-substitution modes more closely approximate suture tensions achieved under ideal haptic conditions (ie, hand ties) than forces applied without such sensory feedback. The consistency of applied forces during robot-assisted suture tying aided by visual feedback or combined auditory-visual feedback sensory substitution is superior to that achieved with hand ties. Robot-assisted ties aided with auditory feedback revealed levels of consistency that were generally equivalent or superior to those attained with hand ties. Visual feedback and auditory feedback improve the consistency of robotically applied forces.

CONCLUSIONS: Sensory substitution, in the form of visual feedback, auditory feedback, or both, confers quantifiable advantages in applied force accuracy and consistency during the performance of a simple surgical task.

23.- Robotic radical prostatectomy: a technique to reduce pT2 positive margins.

In: Urology. 2004 Dec;64(6):1224-8. Ahlering TE, Eichel L, Edwards RA, Lee DI, Skarecky DW.

Department of Urology, University of California, Irvine, Medical Center, Orange, California 92868-3298, USA.

OBJECTIVES: To describe a technique using the da Vinci™ robotic system that enhances one's ability to visualize and dissect the apex and reduce surgical margins. An important outcome of radical prostatectomy is the reduction of iatrogenic positive margins in organ-confined prostate cancer.

TECHNICAL CONSIDERATIONS: The clinical data of our first 140 consecutive robot-assisted radical prostatectomies were divided into two groups: group 1, cases 1 to 50; and group 2, cases 51 to 140. After reviewing the surgical margin data and appropriate video clips of our initial 50 patients, we altered our technique. Initially, we had used two sutures to control the dorsal venous complex (DVC), one proximally and distally. The prostate was freed, and, finally, the DVC and urethra were divided. However, a bundle of fat obscured the apex, leading to positive apical margins. We developed the following method. First, we removed all of the fat overlying the DVC and prostate. Second, we divided the puboprostatic ligaments and dissected the levator fibers to expose and increase the DVC length fully. Finally, we stapled and divided the DVC using a vascular stapler.

RESULTS: The two groups were clinically comparable. Overall, the pathologic margin rate improved from 36% in group 1 to 16.7% in group 2. In group 1, 9 (27.3%) of 33 pT2 tumors had positive margins versus 3 (4.7%) of 64 pT2 tumors in group 2 (P = 0.003).

CONCLUSIONS: The data demonstrate that this change in technique for robotic prostatectomy resulted in a more defined apical dissection and a statistically significant reduction in positive margins in patients with organ-confined disease.

24.- Advantages and limits of robot-assisted laparoscopic surgery: preliminary experience.

In: Surg Endosc. 2005 Jan;19(1):117-9. Epub 2004 Nov 18. Corcione F, Esposito C, Cuccurullo D, Settembre A, Miranda N, Amato F, Pirozzi F, Caiazzo P.

Department of Surgery and Laparoscopy, AORN Monadi Hospital, Via Monaldi 234, Naples, 80100, Italy.

BACKGROUND: In the last few years, robotics has been applied in clinical practice for a variety of laparoscopic procedures. This study reports our preliminary experience using robotics in the field of general surgery to evaluate the advantages and limitations of robot-assisted laparoscopy.

METHODS: Thirty-two consecutive patients were scheduled to undergo robot-assisted laparoscopic surgery in our units from March 2002 to July 2003. The indications were cholecystectomy, 20 patients; right adrenalectomy, two points; bilateral varicocelectomy, two points; Heller's cardiomyotomy, two points; Nissen's fundoplication, two points; total splenectomy, one point; right colectomy, one point; left colectomy, 1 point; and bilateral inguinal hernia repair, one point. In all cases, we used the da Vinci™ surgical system, with the surgeon at the robotic work station and an assistant by the operating table.

RESULTS: Twenty-nine of 32 procedures (90.6%) were completed robotically, whereas three were converted to laparoscopic surgery. Conversion to laparoscopy was due in two patients to minor bleeding that could not be managed robotically and to robot malfunction in the third patient. There were no deaths. Median hospital stay was 2.2 days (range, 2-8).

CONCLUSIONS: The main advantages of robot-assisted laparoscopic surgery are the availability of three-dimensional vision and easier instrument manipulation than can be obtain with standard laparoscopy. The learning curve to master the robot was >or= 10 robotic procedures. The main limitations are the large diameter of the instruments (8 mm) and the limited number of robotic arms (maximum, three). We consider these technical shortcomings to be the cause for our conversions, because it is difficult to manage bleeding episodes with only two operating instruments. The benefit to the patient must be evaluated carefully and proven before this technology can become widely accepted in general surgery.

25.- Robotic pyeloplasty: technique and results

In: Urol Clin North Am. 2004 Nov;31(4):737-41. Peschel R, Neururer R, Bartsch G, Gettman MT.

Department of Urology, University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria.

The da Vinci™ robotic system can be used to perform dismembered and nondismembered pyeloplasty techniques effectively. Robotics not only seems to improve dexterity and surgical precision but also provides an ergonomic surgical environment for a surgeon performing complex reconstructive procedures such as pyeloplasty. Although performance-enhancing features of the da Vinci™ robot seem to decrease the difficulty of intracorporeal suturing, a learning curve also exists for telerobotic procedures. This learning curve may decrease as experience with telerobotics increases and as advances in technology are introduced. Presently, the interaction between the primary and assistant surgeon seems crucial to the success of the procedure. Although the early clinical experience with robotic pyeloplasty is favorable, continuing clinical evaluation and careful follow-up are required to determine if the procedure is as efficacious in the long run as open pyeloplasty and laparoscopic pyeloplasty.

26.- The da Vinci robot in right adrenalectomy: considerations on technique.

In: Surg Laparosc Endosc Percutan Tech. 2004 Feb;14(1):38-41. D'Annibale A, Fiscon V, Trevisan P, Pozzobon M, Gianfreda V, Sovernigo G, Morpurgo E, Orsini C, Del Monte D.

Department of General Surgery, Camposampiero Hospital, Padua, Italy,

The da Vinci™ Robotic System (Intuitive Surgical, Mountain View, CA) became available at the General Surgery Department of Camposampiero Hospital in May 2001. From May 2001 to October 2002, 139 robotic operations were performed, one of which was a right adrenalectomy for a right adrenal mass. The progressive growth of the mass was the indication for surgical excision. Surgical adrenalectomy was successfully completed with da Vinci™ Robotic System using 5 ports (3 for the robotic system, 2 as service trocars). The wrist-like movements of the instrument's tip easily enabled the detachment of the right hepatic lobe from the gland and vessel isolation, while the 3-dimensional vision facilitated dissection of the veins from the vena cava.


==> PubMed
==> National Center for Biotechnology Information (NCBI)

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Information on Minimally Invasive Surgery (USA)

Benefits of Minimally Invasive Procedures (MIP) :

"MIP is changing the way many people think about surgery. Patients who choose MIP over conventional surgery may no longer face lengthy recoveries and hospital stays. Instead, they are able to get back to the things that are important to them much sooner.

MIP, which includes laparoscopic surgery, uses state-of-the-art technology. When performing MIP, the surgeon creates small, dime-sized incisions that allow the use of a miniature camera, or videoscope, and specialized instruments to perform the procedure—so there’s no need for a large, conventional incision."

For more information on the following MIP in the USA:
Colon surgery ; Appendectomy ; Ventral Hernia Repair ; Hemorrhoid surgery ; Hysterectomy :click here.

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La chirurgie mini invasive en urologie : procédés et vidéos (French and English)


=> cliquer ici (1.-).


=> click here to view the video (2.-).


=> click here (3.-).

=> Prostatectomie radicale par laparoscopie extrapéritonéale:

"La prostatectomie radicale par voie laparoscopique est un traitement curatif du cancer prostatique. Les résultats oncologiques et fonctionels sont maintenant confirmés.
Au début de notre expérience, comme la plupart des équipes, nous considérions, que la dissection première transpéritonéale des vésicules séminales est la clef de cette intervention.
Cependant, la voie transpéritonéale comporte des risques potentiels:
- fuites urinaires dans l'espace péritonéale
- douleurs de l'épaule liés à la présence du pneumopéritoine
- ileus postopératoire
- péritonite
- adhérences péritonéales postopératoires
Pour toutes ces raisons, nous avons développé une technique purement extrapéritonéale, plus proche de la technique classique par voie ouverte. Cette modification a permis de diminuer les durées opératoires et la morbidité postopératoire."

=> Néphrectomie élargie par laparoscopie extrapéritonéale :

"L'avantage de cette voie d'abord est l'abord premier du pédicule rénal, sans la nécessité de disséquer le colon.

Les temps opératoires sont ainsi réduits, et les suites simplifiées."

=> Création d'accès pour la prostatectomie laparoscopique extrapéritonéale :

"Nous présentons notre technique originale de création d'accès pour la prostatectomie par voie laparoscopique extrapéritonéale. Le principe est simple: nous réalisons une incision sous-ombilicale, puis le feuillet antérieur de la gaine des muslces droits est incisé. Une dissection au doigt est alors réalisé entre le muscle grand droit et le feuillet postérieur. Nous arrivons ainsi dans l'espace de Retzius. Nous évitons ainsi toute déchirure du péritoine. Cette technique est entièrement standardisée et reproductible."

=> Plastie de jonction pyélourétérale par laparoscopie extrapéritonéale :

Ce film montre deux interventions: la première est une plastie de jonction selon la technique de Hynes-Anderson, la deuxième illustre en plus notre technique de décroisement d'artère polaire.

=> Surrénalectomie laparoscopique: Un nouveau standard :

"La surrénalectomie est probablement l'une des meilleurs indications de la chirurgie laparoscopique. En effet, il s'agit d'un organe de petit volume, en une situation anatomique profonde. En chirurgie ouverte, une incision de grande taille est nécessaire pour l'aborder. La laparoscopie diminue la morbidité postopératoire de façon spectaculaire."

=> L'apprentissage de la laparoscopie en Urologie :

"La chirurgie laparoscopique est une innovation majeure en urologie, mais son apprentissage est difficile. Compte tenu des bénéfices majeurs qu'offre cette technique aux patients, l'enseignement de cette nouvelle technologie aux chirurgiens doit faire parti des objectifs essentiels de toute école de chirurgie laparoscopique. Dans ce film, nous présentons notre programme d'enseignement pas à pas.
1. Entrainement sur modèles inanimés: L'avantage de cette méthode (pelvi-trainer) est la possibilité de reproduire les gestes élémentaires autant de fois que nécessaire. Les coûts sont limités.
2. Apprentissage sur animaux:
Cet étape permet d'acquérir les techniques de dissection et d'hémostase.
3. Dissections sur cadavres.
Dernier étape inconturnable dont l'objectif est l'apprentissage de l'anatomie humaine tel que vue en laparoscopie."

=> Prostatectomie radicale extrapéritonéale assistée par robot :

"Afin de diminuer la courbe d'apprentissage, les robots chirurgicaux ont été proposés pour la prostatectomie radicale laparoscopique. Néanmoins, la proximité des trocarts par voie transpéritonéale est peu ergonomique. Nous présentons ici la variante extrapéritonéale qui permet d'espacer les instruments et simplifie les suites de l'intervention du fait de l'absence d'ouverture péritonéale."

=> Description comparative de la néphrectomie élargie laparoscopique par voie transpéritonéale, rétropéritonéale et assistée manuellement :

Ce film a été réalisé en collaboration avec l'équipe de l'hôpital Saint-Louis (Paris, Professeur Desgrandchamps) et de la clinique Saint-Augustin (Bordeaux, Docteur Piéchaud)

=> Transplantation rénale assistée par robot :

"Les robots permettent de réaliser des actes chirurgicaux à distance grâce à des télémanipulateurs. L'une des applications possible de ces robots est la prévention des transmissions virales du personnel soignant au patient ou du patient au personnel soignant. En urologie, un tel risque existe chez les patients dialysés, candidats à la transplantation. Outre ces avantages, le robot permet de réaliser des gestes ultra-précises grâce à la miniaturisation des gestes lors de la transmission et l'agrandissement de l'image par le système vidéo-endoscopique."

=> Prelèvement d'un rein chez le donneur vivant :

"La transplantation rénale à partir d'un donneur vivant a beaucoup d'avantages.
Pour le receveur, ce sont ces greffons qui donnent les meilleurs résultats, pour des raisons de compatibilité. Cette technique a aussi l'avantage d'être programmable, l'équipe soignant ne travaille pas dans des conditions d'urgence. Cette transplantation s'adapte aussi aux impératifs d'emploi du temps du donneur et du receveur. Pour le donneur, les techniques laparoscopiques diminuent les inconvéniants: durée d'hospitalisation et de convalescence réduites, meilleurs résultats esthétiques, moins de douleurs

(1.-) Hopital Henri-Mondor, Créteil (94).
Service d'urologie.
Chef de service: M. le Professeur Clément-Claude Abbou.

(2.-) University Physicians Hospital (UPH Hospital) at Kino Campus, Southern Arizona, USA.

(3.-) Robotic (da Vinci Robotic Prostatectomy).

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Chirurgie robotique : prélèvement sur patient vivant en vue d'une transplantation rénale

Grâce au blog, j'ai trouvé un article du Telegraph qui raconte un cas effectué en chirurgie robotique avec le système da Vinci TM.
Il s'agit d'un prélèvement de rein sur donneur vivant en vue d'une transplantation. Le donneur a été opéré avec le système de chirurgie robotique, donc en mini-invasif.

Au sujet du prélèvement de rein sur donneur vivant, en vue d'une transplantation rénale : vous pourrez lire ci-après l'interview du Professeur Hubert, chirurgien urologue au CHU de Nancy !

Petite précision : la greffe ne concerne que la personne "greffée" avec un "greffon". La transplantation concerne une double opération : à partir d'un donneur vers un receveur. En fait, l'usage en français ne fait pas trop la distinction entre les deux termes : greffe et transplantation...

Tout d'abord il faut savoir que l'être humain peut parfaitement vivre avec un seul rein, même si la nature l'a pourvu de deux reins. Les reins font partie de ce que le corps médical appelle les organes divisibles.

Les organes divisibles, comme les reins, le foie et les poumons, peuvent être prélevés sur donneur vivant :

En 2002, il y a eu 2255 greffes de rein, c'est donc la greffe d'organe la plus effectuée ! Un don d'une partie du foie peut être envisagé, car cet organe se régénère. Quant aux poumons, ils ont 5 lobes : 3 à droite et 2 à gauche. Le prélèvement d'un lobe en vue d'une greffe reste possible mais c'est un cas rare en France : seulement 2 greffes en 2002.
(source : Agence de Biomédecine, juin 2005)

Toujours en France, plus de 2.000.000 de personnes sont atteintes de maladie rénale chronique, dont 31.000 sont dialysées et 21.000 greffées. Ces chiffres sont en perpétuelle augmentation.
(source : Fédération Nationale d'Aide aux Insuffisants Rénaux ).

Actuellement, le nombre de patients greffés d'un rein est estimé à plus de 200.000 de par le monde. Si l'on compte que ceux-ci forment près des deux tiers de l'ensemble des personnes greffées, celles-ci devraient représenter une population d'environ 300.000 individus.
(source : "Ethique et transplantation d'organes", sous la direction de Jean-François Collange, Ellipses Edition Marketing SA, 2000)

Testez vos connaissances sur les prélèvements d'organes sur donneur vivant et sur donneur décédé, ou faites le point en quelques minutes sur le sujet pour parfaire vos connaissances avec le Quizz de l'Agence de Biomédecine !

Il est désormais possible d'effectuer le prélèvement d'un rein sur donneur vivant en utilisant les procédés de la chirurgie mini invasive, c'est-à-dire la chirurgie laparoscopique :

Elle offre les avantages de la chirurgie traditionnelle mini-invasive (appelée coelioscopie), tout en en dépassant les inconvénients : les instruments qu'elle utilise ont plus de souplesse et offrent d'avantage de degrés de liberté, donc la qualité du geste chirurgical se trouve significativement améliorée.

C'est la chirurgie assistée par ordinateur qui permet ces progrès. Elle est également appelée chirurgie robotique par les chirurgiens usagers.

Ah oui, un détail : il arrive que ces chirurgiens usagers parlent de "robot" pour désigner le système de chirurgie assistée par ordinateur da Vinci TM.
Ainsi, le Professeur Hubert, chirurgien urologue au CHU de Nancy, va vous parler des prélèvements de rein sur donneur vivant, qu'il a effectués au moyen du "robot" !...Soyez rassurés : c'est là un raccourci pour désigner le système de chirurgie assistée par ordinateur, mais c'est bel et bien le chirurgien qui fait tout à la console du système ! Car ce système n'ayant aucune autonomie, il est impropre de le qualifier de robot stricto sensu. On n'appuie pas sur des boutons du "robot" pour effectuer ou programmer une opération !

Voici le point de vue du Docteur Adrian Lobontiu, chirurgien, service de Développement Clinique Chirurgie Robotique et Téléchirurgie, Intuitive Surgical Europe :

"Bien que l'idée de prélever un rein sur donneur vivant en vue d'une transplantation soit assez largement acceptée, l'attitude des médecins et chirurgiens sur ce sujet est très variable. Le prélèvement d'un rein sur donneur vivant ne peut être envisagé qu'en respectant deux règles fondamentales de l'éthique médicale: le bénéfice potentiel et le consentement libre et éclairé. Un bénéfice potentiel est attendu pour le receveur mais il s'agit ici du donneur dont le bénéfice n'est pas évident, sauf au plan psychologique.

Ce que je peux affirmer avec certitude, ayant participé avec
le Pr. Jacques Hubert aux nombreux prélèvements de rein sur donneur vivant à l'aide du système de chirurgie assistée par ordinateur da Vinci TM : pas de douleur ressentie, car tous ces malades ont été bien endormis et ont eu un excellent réveil sans problèmes particuliers. La technique robotique est maintenant très au point."

Voici maintenant le point de vue du Professeur Jacques Hubert, chirurgien urologue au CHU de Nancy :

[Question]: Quelles sont les indications pour ce cas pratiqué avec le
da Vinci TM ?

[Réponse]: le prélèvement de rein sur donneur vivant se développe :
il permet de répondre à une demande croissante de greffons rénaux (le nombre de patients dialysés augmente d’année en année et plus vite que le nombre de greffes).

Le prélèvement (c’est à dire l’ablation d’un rein), fait avec le robot, permet de faire bénéficier le donneur (qui est quelqu’un en bonne santé, qui fait un cadeau extraordinaire à quelqu’un de sa famille) du caractère mini-invasif de la coeliochirurgie : moins de douleur post-opératoire, durée d’hospitalisation et convalescence plus courtes.

Le robot apporte, avec ses perfectionnements techniques que vous connaissez, l’avantage d’un geste chirurgical plus précis et plus sûr.
[Question]: Combien de prélèvement de rein en mini-invasif (sur donneur vivant) ont déjà été faits au CHU de Nancy ?

[Réponse]: Une trentaine.

Pour télécharger le compte-rendu de l'HAS (Haute Autorité de Santé): "laparoscopic live donor nephrectomy VS live donor nephrectomy with open surgery" (2003), cliquer ici.
Il s'agit d'évaluer les bénéfices du prélèvement du rein sur donneur vivant avec la chirurgie mini-invasive en comparaison du prélèvement du rein sur donneur vivant avec la chirurgie invasive traditionnelle.

Presse scientifique en anglais :

==> "Laparoscopic Radical Prostatectomy: Description of the Extraperitoneal Approach Using the da Vinci Robotic System." In: Journal of Urology. 170(2, Part 1): p.416-419, August 2003. By: GETTMAN, MATTHEW T. *; HOZNEK, ANDRAS; SALOMON, LAURENT; KATZ, RAN; BORKOWSKI, TOMASZ; ANTIPHON, PATRICK; LOBONTIU, ADRIAN; ABBOU, CLEMENT-CLAUDE. Abstract.

==> "Robotic Assisted Kidney Transplantation: An Initial Experience." In: Journal of Urology. 167(4): p.1604-1606, April 2002. By: HOZNEK, ANDRAS; ZAKI, SAFWAT K.; SAMADI, DAVID B.; SALOMON, LAURENT; LOBONTIU, ADRIAN; LANG, PHILIPPE; ABBOU, CLEMENT-CLAUDE. Abstract.

==> "LAPAROSCOPIC RADICAL PROSTATECTOMY WITH A REMOTE CONTROLLED ROBOT." In: Journal of Urology. 165(6, Part 1 of 2): p.1964-1966, June 2001. By:

(source: The Journal of Urology)

En conclusion : la chirurgie robotique pour le prélèvement de rein sur donneur vivant en vue d'une greffe de rein, ça marche !!

Transplantation rénale à partir de donneur vivant : où en sommes nous ?
Article de M.O. BITKER, B. BARROU, E. VAN GLABEKE, Ch. CHATELAIN, F. RICHARD, Service d’Urologie et de Transplantation Réno-pancréatique Groupe Hospitalier Pitié-Salpêtrière – Paris, 2005 :

Lire l'article de presse scientifique [version française PDF] :
==> cliquer ici

Read the scientific press article [Abstract in English; text in French, PDF extension]:
==> click here

"Kidney transplantation from living donors: where do westand ? In 2002, in France 4.8 per cent of kidney transplants were harvested from living donors. Despite the penury of organs from brain death donorsand the steady growth of the average age of donors, this percentage has remained stable since 1975. Only 50 per cent of the 36 French kidney transplantation teams perform that kind of surgery, considering that 5 teams performed 55 per cent of the 108 kidney transplantations from living donors performed in 2002. However, the benefit of such a surgery is now generally acknowledged for the recipient. Indeed, the estimation of graft half-lifetime is 12 years in case of organs from brain death donors, 20 years incase of organs from a semi-identical HLA relative, and 36 years incase of organs from an HLA identical sibling. In our country, transplantation performed from living donors has been limited mostly because of a very constraining legal procedure limiting transplantations to direct relatives, and because of the fear that donors may later develop medical or surgical pathologies with a risk of threatening their future health. However, all research papers and studies over the past fifteen years have demonstrated that apart from peri-operative mortality (0,03 per cent), there is neither mid-term nor long-term negative effect to donate a kidney. As far as kidney transplantation from living donors is concerned, the debates currently focus on the surgical issue of comparing the benefits and drawbacks of both incisional and coelioscopical surgery. The ethical debate focuses on the propositions made to the legal system to extend the pool of potential donors. The review of the research studies examining the future of donors emphasizes the global insufficiency of their follow-up, only 50 per cent of them having a regular check-up on their single kidney."

Le saviez-vous ?
En France, le prélèvement de rein sur donneur vivant se développe mais il ne représente que 5% de la totalité des prélèvements. Dans d'autres pays, comme les pays Scandinaves, la Grèce, les USA et le Canada, la pratique du prélèvement du rein sur donneur vivant est nettement plus développée.

==> La chirurgie robotique télémanipulée. Conférence par le Professeur Jacques HUBERT et le Docteur Bruno SCHJOTH, du CHU de Nancy : pour visionner cette conférence ainsi que les interviews du Professeur Hubert et du Docteur Schjoth, cliquer ici.

Source :

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