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. dyuh@csurg.jhmi.jhu.edu

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. gkhairy@ksu.edu.sa

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. nifongL@mail.ecu.edu

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, S.Dogan@em.uni-frankfurt.de.

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. readec@mail.ecu.edu

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. bestet@mail.ecu.edu

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. Nicola.di.lorenzo@uniroma2.it

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. chitwoodw@mail.ecu.edu

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. johannes.bodner@uibk.ac.at

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. dryugal@yahoo.com

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. slorin@wanadoo.fr

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. msavitt@starrwood.com

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. guy.hubens@uza.be

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. adannibale@tin.it

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. reinhard.peschel@uibk.ac.at

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, adannibale@ulss15.pd.it

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.

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