Anesthetic Implications of Robotically Assisted Surgery with the Da Vinci Xi Surgical Robot

Surgeries performed with traditionally available robotic systems have many well-documented anesthetic implications. In this observational report, new and unique anesthetic considerations encountered with the introduction of the da Vinci Xi robot related to positioning operating room equipment, patient access and chance for unintended patient contact are described.

Robotic rectal cancer surgery:Results from a European multicentre case series of 240 resections and comparative analysis between cases performed with the da Vinci Si and Xi systems

Introduction:Robotic systems are designed to address the limitations of laparoscopic surgery,leading to a growing interest in robotic rectal surgery.However,certain technical limitations associated with the previous systems(da Vinci S&Si)have arguably slowed down its wholesale adoption.The latest robotic platform,the da Vinci Xi,addresses these limitations.This study aims to examine the short-term surgical outcomes of 240 single-docking fully-robotic rectal cancer resections and compare the outcomes of cases performed with the da Vinci Xi vs Si systems.Materials and methods:All consecutive patients receiving robotic rectal cancer resections from three centres between 2013 and 2018 were identified from prospectively collated databases.The baseline characteristics and short-term surgical outcomes are presented and the da Vinci Xi vs Si system outcomes are analysed.Results:A total of 240 patients were identified(124 Si,116 Xi).Median operation-time and length-of-stay were 260 minutes and 6 days respectively.Conversion and 30-day mortality rates were 0.The da Vinci Si vs Xi system analysis shows that operation-time was lower in the Si group(230 vs 300 min,p=0.000)but length-of-stay,lymph node yield and circumferential resection margin favoured the Xi group(7 vs 5 days,p=0.010;17 vs 21,p=0.000;92.7%vs 99.1%,p=0.020).Conclusion:Single-docking fully-robotic rectal cancer surgery is safe,feasible and can lead to good shortterm outcomes,making it a good alternative to laparoscopic rectal cancer surgery.The new systems technological advances may result in better short-term outcomes but further larger scale observational studies are required if we are to reach such a conclusion.

Managerial perspectives of scaling up robotic-assisted surgery in healthcare systems:A systematic literature review

Objectives Robotic-assisted surgery(RAS)is a minimally invasive technique practiced in multiple specialties.Standard training is essential for the acquisition of RAS skills.The cost of RAS is considered to be high,which makes it a burden for institutes and unaffordable for patients.This systematic literature review(SLR)focused on the various RAS training methods applied in different surgical specialties,as well as the cost elements of RAS,and was to summarize the opportunities and challenges associated with scaling up RAS.Methods An SLR was carried out based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses reporting guidelines.The PubMed,EBSCO,and Scopus databases were searched for reports from January 2018 through January 2024.Full-text reviews and research articles in the English language from Asia-Pacific countries were included.Articles that outlined training and costs associated with RAS were chosen.Results The most common training system is the da Vinci system.The simulation technique,which includes dry-lab,wet-lab,and virtual reality training,was found to be a common and important practice.The cost of RAS encompasses the installation and maintenance costs of the robotic system,the operation theatre rent,personnel cost,surgical instrument and material cost,and other miscellaneous charges.The synthesis of SLR revealed the challenges and opportunities regarding RAS training and cost.Conclusions The results of this SLR will help stakeholders such as decision-makers,influencers,and end users of RAS to understand the significance of training and cost in scaling up RAS from a managerial perspective.For any healthcare innovation to reach a vast population,cost-effectiveness and standard training are crucial.

Successful treatment of esophageal metastasis from hepatocellular carcinoma using the da Vinci robotic surgical system

A 59-year-old man with metastatic an esophageal tumor from hepatocellular carcinoma(HCC) presented with progressive dysphagia.He had undergone liver transplantation for HCC three and a half years prevously.At presentation,his radiological and endoscopic examinations suggested a submucosal tumor in the lower esophagus,causing a luminal stricture.We performed complete resection of the esophageal metastases and esophagogastrostomy reconstruction using the da Vinci robotic system.Recovery was uneventful and he was been doing well 2 mo after surgery.α-fetoprotein level decreased from 510 ng/mL to 30 ng/mL postoperatively.During the follow-up period,he developed a recurrent esophageal stricture at the anastomosis site and this was successfully treated by endoscopic esophageal dilatation.

Comparison of da Vinci 5 with previous versions of da Vinci and Sina:A review

Robotic systems have become popular in modern surgical procedures.The option of telesurgery has effectively addressed geographic limitations.These systems are offered by numerous companies worldwide.In this review article,we discuss four models of robotic systems to determine their advantages:the Sina flex system from Iran and the da Vinci Xi,SP,and 5 systems from the USA.We compared aspects such as architecture,instruments,visualizations,clinical use,and costs.Our findings suggest that the da Vinci robot,which was introduced earlier than the Sina system,utilizes proprietary and limited-use EndoWrist instruments with diameters ranging from 8 to 12 mm and features advanced imaging capabilities,including three-dimensional optical,tomographic,and fluorescence imaging.It is well established and widely utilized in various surgical procedures.Conversely,the Sina flex system employs single-use 5 mm instruments and is equipped with two-dimensional optical imaging as a standard,with optional three-dimensional and fluorescence imaging upgrades available.Despite its affordability,the Sina flex system is relatively new and has not yet been clinically tested.Additionally,the Sina flex system is more user-friendly.

Meta-analysis of robotic and laparoscopic surgery for treatment of rectal cancer

AIM: To conduct a meta-analysis to determine the relative merits of robotic surgery (RS) and laparoscopic surgery (LS) for rectal cancer. METHODS: A literature search was performed to identify comparative studies reporting perioperative outcomes for RS and LS for rectal cancer. Pooled odds ratios and weighted mean differences (WMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model. RESULTS: Eight studies matched the selection criteria and reported on 661 subjects, of whom 268 underwent RS and 393 underwent LS for rectal cancer. Compared the perioperative outcomes of RS with LS, reports of RS indicated favorable outcomes considering conversion(WMD: 0.25; 95% CI: 0.11-0.58; P = 0.001). Meanwhile, operative time (WMD: 27.92, 95% CI: -13.43 to 69.27; P = 0.19); blood loss (WMD: -32.35, 95% CI: -86.19 to 21.50; P = 0.24); days to passing flatus (WMD: -0.18, 95% CI: -0.96 to 0.60; P = 0.65); length of stay (WMD: -0.04; 95% CI: -2.28 to 2.20; P = 0.97); complications (WMD: 1.05; 95% CI: 0.71-1.55; P = 0.82) and pathological details, including lymph nodes harvested (WMD: 0.41, 95% CI: -0.67 to 1.50; P = 0.46), distal resection margin (WMD: -0.35, 95% CI: -1.27 to 0.58; P = 0.46), and positive circumferential resection margin (WMD: 0.54, 95% CI: 0.12-2.39; P = 0.42) were similar between RS and LS. CONCLUSION: RS for rectal cancer is superior to LS in terms of conversion. RS may be an alternative treatment for rectal cancer. Further studies are required.

Da Vinci robot-assisted pancreato-duodenectomy in a patient with situs inversus totalis:A case report and review of literature

BACKGROUND Situs inversus totalis(SIT)is an extremely rare congenital malformation characterized by mirror displacement of the thoracoabdominal organs such as the heart,liver,spleen,and stomach.Herein,we describe a patient with SIT complicated with cholangiocarcinoma who underwent successful pancreaticoduodenectomy with the assistance of a da Vinci robot.CASE SUMMARY A 58-year-old female presented to the hospital with paroxysmal pain in her left upper abdomen,accompanied by jaundice and staining of the sclera as chief complaints.Imaging examination detected a mass at the distal end of the common bile duct,with inverted thoracic and abdominal organs.Endoscopic retrograde cholangiopancreatography forceps biopsy revealed the presence of a well-differentiated adenocarcinoma.The patient successfully underwent robotic-assisted pancreaticoduodenectomy;the operation lasted 300 min,the intraoperative blood loss was 500 mL,and there were no intraoperative and postoperative complications.CONCLUSION SIT is not directly related to the formation of cholangiocarcinoma.Detailed preoperative imaging examination is conducive to disease diagnosis and also convenient for determining the feasibility of tumor resection.Robot-assisted pancreaticoduodenectomy for SIT complicated with cholangiocarcinoma provides a safe,feasible,minimally invasive,and complication-free alternative with adequate preoperative planning combined with meticulous intraoperative procedures.

Robotic laparoendoscopic single-site surgery(R-LESS) ：current status in urology

Laparoendoscopic single-site surgery(LESS)is technically challenging;it can reduces instrument triangulation and robust retraction and is associated with a steep learning curve.The instruments of the daVinci  surgical system(Intuitive Surgical)are designed with seven degrees of motion mimicing the dexterity of the human hand and wrist.This inherent feature of the robotic arm provides superior ergonomics when performing LESS,especially for complex reconstructive surgery.This review analyzes the evidence supporting current and future application of robotic technology in the field of urologic LESS.

Robotic liver surgery is the optimal approach as bridge to transplantation

The role of minimally invasive liver surgery as a bridge to transplantation is very promising but still underestimated. However, it should be noted that surgical approach for hepatocellular carcinomas(HCC) is not merely a technical or technological issue. Nowadays, the epidemiology of HCC is evolving due to the increasing role of non-alcoholic fatty-liver-disease, and the emerging concerns on direct-acting antivirals against hepatitis C virus in terms of HCC incidence. Therefore, a fully multidisciplinary study of the cirrhotic patient is currently more important than ever before, and the management of those patients should be reserved to tertiary referral hepatobiliary centers. In particular, minimally invasive approach to the liver showed several advantages compared to the classical open procedure, in terms of:(1) the small impact on abdominal wall;(2) the gentle manipulation on the liver;(3) the limited surgical trauma; and(4) the respect of venous shunts. Therefore, more direct indications should be outlined also in the Barcelona Clinic Liver Cancer model. We believe that treatment of HCC in cirrhotic patients should be reserved to tertiary referral hepatobiliary centers, that should offer patient-tailored approaches to the liver disease, in order to provide the best care for each case, according to the individual comorbidities, risk factors, and personal quality of life expectations.

Single-Incision Robotic Surgery

Introduction: Single Incision Laparoscopic Surgery (SILSTM) has been developed as a less invasive laparoscopic surgery. On the other hand, robotically assisted surgical technology has offered new options for minimally invasive surgery. In this study, we report a new surgical technology to perform SILS using the da Vinci S surgical system (Intuitive Surgical Inc., Sunnyvale, CA). Materials and Surgical Technique: A porcine liver with gallbladder was placed on an endoscopic surgery trainer, and a 25 mm incision was made for one robotic camera and two instruments at the umbilicus position. Both instruments were crossed while preventing them from colliding with each other, and Robot-assisted single-incision cholecyctectomy was perfumed. Discussion: This technique is expected to contribute to the development of a number of procedures in the future.

第三代da Vinci Si手术机器人系统在妇科单孔腹腔镜手术中的初步应用

目的探讨da Vinci Si手术机器人系统在妇科单孔腹腔镜手术中的初步应用效果。方法选择2018年5月27日至6月20日在海军军医大学(第二军医大学)长征医院妇产科住院、拟行妇科手术的患者5例,应用第三代da Vinci Si手术机器人系统和LagiportTM多通道单孔腹腔镜手术穿刺器实施单孔机器人腹腔镜手术。其中宫颈高级别上皮内瘤变(宫颈锥切术后提示微浸润不除外)患者1例,行全子宫切除术+前哨淋巴结切除术;宫颈浸润癌Ⅰa1期患者1例,行全子宫切除术+双附件切除术+前哨淋巴结切除术;子宫内膜癌Ⅰa1期患者1例,行全子宫切除术+双附件切除术+前哨淋巴结切除术;子宫内膜异位症Ⅳ期患者1例,行广泛肠粘连松解术+单侧附件切除术;宫颈浸润癌Ⅱa1期患者1例,行广泛子宫切除术+双附件切除术+盆腔淋巴结清扫术。结果5例患者手术均顺利完成,未增加辅助孔操作。5例患者的手术时间分别为174、110、90、125、300 min,术中出血量分别约为110、80、100、210、150 mL。5例患者均未出现围手术期并发症。结论利用第三代da Vinci Si机器人手术系统进行妇科单孔腹腔镜手术具备一定的可行性。

Short-term outcomes of robotic liver resection: An initial singleinstitution experience

BACKGROUND Liver surgery has traditionally been characterized by the complexity of its procedures and potentially high rates of morbidity and mortality in inexperienced hands.The robotic approach has gradually been introduced in liver surgery and has increased notably in recent years.However,few centers currently perform robotic liver surgery and experiences in robot-assisted surgical procedures continue to be limited compared to the laparoscopic approach.AIM To analyze the outcomes and feasibility of an initial robotic liver program implemented in an experienced laparoscopic hepatobiliary center.METHODS A total of forty consecutive patients underwent robotic liver resection(da Vinci Xi,intuitive.com,United States)between June 2019 and January 2021.Patients were prospectively followed and retrospectively reviewed.Clinicopathological characteristics and perioperative and short-term outcomes were analyzed.Data are expressed as mean and standard deviation.The study was approved by the Institutional Review Board.RESULTS The mean age of patients was 59.55 years,of which 18(45%)were female.The mean body mass index was 29.41 kg/m^(2).Nine patients(22.5%)were cirrhotic.Patients were divided by type of resection as follows:Ten segmentectomies,three wedge resections,ten left lateral sectionectomies,six bisegmentectomies(two VVI bisegmentectomies and four IVb-V bisegmentectomies),two right anterior sectionectomies,five left hepatectomies and two right hepatectomies.Malignant lesions occurred in twenty-nine(72.5%)of the patients.The mean operative time was 258.11 min and two patients were transfused intraoperatively(5%).Inflow occlusion was used in thirty cases(75%)and the mean total clamping time was 32.62 min.There was a single conversion due to uncontrollable hemorrhage.Major postoperative complications(Clavien–Dindo>Ⅲb)occurred in three patients(7.5%)and mortality in one(2.5%).No patient required readmission to the hospital.The mean hospital stay was 5.6 d.CONCLUSION Although robotic hepatectomy is a safe and feasible procedure with favorable short-term outcomes,it involves a demanding learning curve that requires a high level of training,skill and dexterity.

Robots in Cancer Surgery: A Boon or Bane

It is an ongoing task to keep exploring and applying the best available technology to alleviate the pain and sufferings of the cancer patients. Since the discovery of robotic surgery, da Vinci surgical systems have played a special and significant role in cancer surgeries worldwide, however, surgeons are still skeptical with the clinical and oncological outcomes which are almost comparable to the laparoscopic approach in several cancers. Many meta-analyses using mostly retrospective studies indicated significant advantage of robotic surgery over laparoscopic or open surgery approaches for various cancers, however, scarcity of technically sound robot savvy surgeons and quality multicentered, multinational, coordinated, random clinical trials had not done justice to the positives of robotic surgery which were quite often suppressed by the negative factors like operative cost and oncological outcomes. Nevertheless, robotic surgery approach has been clinically accepted for hysterectomy and prostatectomy. This overview briefly discusses the comparative approaches (open, laparoscopic, robotic assisted) and their clinical outcomes in the surgery of various cancers.

da Vinci外科手术系统在胰腺肿瘤外科应用的优势及现状

由于胰腺的解剖复杂,比邻重要的大血管,腹腔镜胰腺手术发展缓慢。da Vinci外科手术系统（da Vinci surgical system,DVSS）的3D视野,使术者视野恢复到开放手术,放大10~15倍使术者进入显微手术,7个自由度的Endo-wrist使术者分离、解剖、缝合、吻合极为精准,因而在以复杂著称的胰腺手术中迅速开展。国内外的临床研究显示：DVSS可安全地应用于所有胰腺手术,技术上可行,临床效果与腹腔镜和开腹手术相似。本文对DVSS在胰腺肿瘤外科应用的优势及其现状进行文献总结,相信机器人辅助胰腺手术治疗胰腺肿瘤会有广阔的发展前景。

Performing robot-assisted pylorus and vagus nerve-preserving gastrectomy for early gastric cancer:A case series of initial experience

BACKGROUND Pylorus and vagus nerve-preserving gastrectomy(PPG)is a function-preserving surgery for early gastric cancer(GC)that has gained considerable interest in the recent years.The operative technique performed using the Da Vinci Xi robot system is considered ideal for open and laparoscopic surgery.AIM To introduce Da Vinci Xi robot-assisted PPG(RAPPG)-based operative procedure and technical points as well as report the initial experience based on the clinical pathology data of eight cases of early GC.METHODS Da Vinci Xi robot-assisted pylorus and vagus nerve-preserving gastrectomy(RAPPG)was performed for 11 consecutive patients with middle GC from December 2020 to July 2021.Outcome measures were postoperative morbidity,operative time,blood loss,number of lymph nodes harvested,postoperative hospital stay,time to first flatus,time to diet,and resection margins.RESULTS Eight of the 11 patients who were pathologically diagnosed with early GC were enrolled in a retrospective study to assess the feasibility and safety of RAPPG.The mean operative time,mean blood loss,mean number of lymph nodes harvested,length of preserved pylorus canal,distal margin,and proximal margin were 330.63±47.24 min,57.50±37.70 mL,18.63±10.57,3.63±0.88 cm,3.50±1.31 cm,and 3.63±1.19 cm,respectively.None of the cases required conversion to laparotomy.Postoperative complications occurred in two(25.0%)patients.Postoperative complications were hyperamylasemia and gastric stasis in one case and incision infection in the other.Time to first flatus was 3.75±2.49 d after the operation,andpostoperative hospital stay was 10.13±4.55 d.CONCLUSIONThe core technique in the Da Vinci Xi RAPPG is lymph node dissection and the anatomic methodof the nerve.Robotic surgical procedures are feasible and safe.With the progress of surgicaltechnology,optimization of medical insurance structure,and emergence of evidence-basedmedicine,automated surgery systems will have a broad application in clinical treatment.

达芬奇-S外科手术辅助系统在普胸外科的应用

目的评价使用达芬奇-S外科手术辅助系统(机器人)行不开胸普胸手术,观察其实用性及手术效果。方法利用达芬奇-S外科手术辅助系统对46例患者行普胸手术,其中胸腺切除术18例、食管癌根治术4例、双侧广泛肺大泡切除缝扎术1例、肺叶切除术18例、肺楔形切除术4例、食道-左主支气管瘘修补术1例。结果 46例患者的手术均为全机器人完成,无中转开胸手术,患者术后均恢复平稳,平均住院时间为4.6 d(2～9 d)。结论几乎所有类型的胸科手术辅助系统都可以做到不开胸,手术安全可靠,效果确实,与传统开胸手术方式相比优势明显,损伤小、恢复快。但要注意医师及其他操作人员需具备胸科开放性手术经验,注意患者的选择,并做好紧急开胸的准备,以保证患者的安全。

达芬奇机器人联合西门子Artis Zeego“一站式”Hybrid手术在肺磨玻璃样病变术前定位中临床应用及效果

目的总结达芬奇机器人联合西门子Artis Zeego"一站式"复合手术在肺磨玻璃样病变术前定位中应用的方法和疗效。方法将沈阳军区总医院胸外科自2012年1月至2014年6月先经放射诊断科术前局麻下定位磨玻璃样病变、再转送手术室实施机器人辅助病灶切除手术的30例患者设为A组,将自2014年7至2017年6月在"一站式"复合手术室行全麻下先经西门子Artis Zeego系统引导、亚甲蓝精准定位后实施达芬奇机器人辅助下肺病灶楔形切除的30例患者设为B组。两组患者均根据术中快速冰冻结果回报,决定下一步手术方式。记录并比较两组患者麻醉诱导前生命体征变化、焦虑情况及手术时间。结果麻醉诱导前B组患者的血压为(127.43±6.80)/(97.40±3.94)mm Hg、心率(95.53±5.21)次/min、平均Zung焦虑自评量表(SAS)评分(51.53±2.61)分,A组患者的血压为(131.33±3.25)/(101.83±5.71)mm Hg、心率(104.17±3.77)次/min、平均SAS评分(57.03±2.54)分,两组间比较,差异均有统计学意义(P<0.05)。B组患者各时间点焦虑值及焦虑时间明显低于A组,差异有统计学意义(P<0.05)。B组手术时间明显短于A组,差异有统计学意义(P<0.05)。结论 "一站式"复合手术室结合CT及数字减影血管造影引导亚甲蓝定位、联合达芬奇手术系统可以安全、高效、微创、准确地完成手术治疗,对于切除肺小结节及磨玻璃样病变有一定的价值。

FTS应用于达芬奇机器人辅助下宫颈癌根治术后患者的疗效观察

目的观察快速康复理念(FTS)应用于达芬奇机器人辅助下宫颈癌根治术后患者的临床应用效果。方法选取医院2020年1月—2021年1月收治的50名行达芬奇机器人辅助下宫颈癌根治术患者为研究对象,其中2020年1—6月入院的27例患者作为对照组,2020年7月—2021年1月入院的23例患者为观察组。对照组患者接受常规护理,而观察组在对照组的基础上接受FTS护理,对两组护理效果进行比较。结果观察组患者术后FS-FI量表性唤起、阴道润滑度、性高潮、性欲望、性满足评分高于对照组,性交疼痛低于对照组;观察组患者康复预后效果、对护理满意率均优于对照组;观察组患者并发症发生率低于对照组;各项指标组间比较差异均有统计学意义(P<0.05)。结论在接受达芬奇机器人辅助下宫颈癌根治术患者的术后护理中,应用FTS护理可以改善患者术后性生活质量,提高术后康复效果,并且有效降低并发症的同时也能提高患者对护理工作的满意程度。

达芬奇机器人NOSES与传统腹腔镜手术治疗直肠癌的临床对比

目的:探讨达芬奇机器人经自然腔道取标本手术(natural orifice specimen extraction endoscopic surgery,NOSES)与传统腹腔镜手术治疗直肠癌的临床对比。方法:选取2020年11月-2021年11月于九江市第一人民医院与南昌大学第一附属医院进行就诊的120例直肠癌患者为研究对象,采用随机数字表法将其分为观察组和对照组,各60例。对照组行传统腹腔镜手术治疗,观察组行达芬奇机器人NOSES治疗。对比两组相关临床指标与并发症发生情况。结果:观察组手术时间长于对照组,住院费用低于对照组,术中出血量少于对照组,且低位直肠癌保肛率高于对照组,差异均有统计学意义(P<0.05);两组术中尿量、淋巴结清扫数目对比,差异均无统计学意义(P>0.05)。观察组排气时间、进流质时间、拔尿管时间均短于对照组(P<0.05),两组住院时间对比,差异无统计学意义(P>0.05)。两组并发症发生率对比,差异无统计学意义(P>0.05)。结论:对于直肠癌患者可以考虑采用达芬奇机器人NOSES进行治疗,具有出血量少与康复速度快等优势。

基于FDA MAUDE数据库的手术机器人不良事件数据的智能化分析

检索了美国食品药品监督管理局(Food and Drug Administration,FDA)制造商和用户设施设备体验(Manufa-cturer and User Facility Device Experience,MAUDE)数据库中2000—2021年的达芬奇机器人手术系统不良事件数据,利用Python对所有不良事件进行了智能化处理与分析,重点阐述了达芬奇机器人手术系统的不良事件变化趋势、应用科室分布和各类不良事件占比、主要设备故障类型、2013—2019年的手术量及分布科室,为达芬奇机器人手术系统安全性评价提供了临床证据。