Robotic4all project:Results of a hands-on robotic surgery training program

Objective Although robotic surgery adoption and its indications are growing worldwide,for multiple factors,including costs,there is a lack of training and experience.Our aim was to study the impact of a robotic introduction training program on gesture performance,such as suturing,in robot-naive individuals.Methods Using the DaVinci robot,a 2-hour program was based on virtual reality and anatomical model exercises.All participants performed 3 repetitions of virtual reality exercises on the virtual simulator,and then performed and were assessed on 2 tests,ie robot and laparoscopic training box.After the course,the participants were surveyed for this training program.Results Twenty-seven residents and surgeons were enrolled in the training program.With only 2 hours of training,all of the participants were able to complete the training program,thus learning generic and specific skills in robotic surgery.In virtual reality exercise,the scores of the 3 exercises increased significantly with every repetition(p<0.001)and the size of the increase was large.The completion time on the robot platform was 2.6 times faster(169.33±28.28 s vs.447.96±156.55 s,p<0.001)than that in the laparoscopic box,and the difference between both types of tests was large(pη2=0.797).The centralization and passage of the needle were significantly better on the robot platform(5 vs.3,p<0.001,r=0.47;5 vs.4,p<0.001,r=0.59)than in the laparoscopic box.For the intracorporeal stitch+knot test,every participant was able to perform the exercise on the robot but only 85.2%(23/27)in the laparoscopic box.Twenty-one participants answered the survey,and 13(61.9%)of them considered robotic performance independent of laparoscopic experience.Conclusions Surgeons are interested and seek training in robotic surgery.We implemented the first hands-on robotic surgery training program in Portugal and participants considered it was important and adequate for its purpose.All participants,even without robotic experience,learned quicker,performed better,faster and more precisely on the robot over laparoscopy.

Evolution of laparoscopy in colorectal surgery:An evidencebased review

Open surgery for colorectal disease has progressed significantly over the past century from humble beginnings to form the mainstay of treatment for colorectal cancer and a number of benign conditions.Following the introduction of laparoscopic abdominal surgery,the next stage in the evolution of the specialty began in the 1990s with the first laparoscopic colonic resection.Following some early concerns regarding its safety and oncological efficacy during the latter part of that decade,laparoscopic colorectal surgery rapidly came into mainstream use in the early part of the current century with evidence supporting its use being made available from large scale randomised controlled trials.This article provides an evidence-based summary of this evolutionary process as it relates to both benign and malignant colorectal disease,as well as discussion of the next phase of new technologies such as robotic surgery.

Comparing short-term outcomes of robot-assisted and conventional laparoscopic total mesorectal excision surgery for rectal cancer in elderly patients

BACKGROUND Da Vinci Robotics-assisted total mesorectal excision(TME)surgery for rectal cancer is becoming more widely used.There is no strong evidence that roboticassisted surgery and laparoscopic surgery have similar outcomes in elderly patients with TME for rectal cancer.AIM To determine the improved oncological outcomes and short-term efficacy of robot-assisted surgery in elderly patients undergoing TME surgery.METHODS A retrospective study of the clinical pathology and follow-up of elderly patients who underwent TME surgery at the Department of Gastrointestinal Oncology at the Affiliated Hospital of Nanjing University of Chinese Medicine was conducted from March 2020 through September 2023.The patients were divided into a robotassisted group(the R-TME group)and a laparoscopic group(the L-TME group),and the short-term efficacy of the two groups was compared.RESULTS There were 45 elderly patients(≥60 years)in the R-TME group and 50 elderly patients(≥60 years)in the L-TME group.There were no differences in demographics,conversion rates,or postoperative complication rates.The L-TME group had a longer surgical time than the R-TME group[145(125,187.5)vs 180(148.75,206.25)min,P=0.005),and the first postoperative meal time in the L-TME group was longer than that in the R-TME(4 vs 3 d,P=0.048).Among the sex and body mass index(BMI)subgroups,the R-TME group had better out-comes than did the L-TME group in terms of operation time(P=0.042)and intraoperative assessment of bleeding(P=0.042).In the high BMI group,catheter removal occurred earlier in the R-TME group than in the L-TME group(3 vs 4 d,P=0.001),and autonomous voiding function was restored.CONCLUSION The curative effect and short-term efficacy of robot-assisted TME surgery for elderly patients with rectal cancer are similar to those of laparoscopic TME surgery;however,robotic-assisted surgery has better short-term outcomes for individuals with risk factors such as obesity and pelvic stenosis.Optimizing the learning curve can shorten the operation time,reduce the recovery time of gastrointestinal function,and improve the prognosis.

Minimally invasive surgery for gastric cancer: A comparison between robotic, laparoscopic and open surgery

AIM To investigate the role of minimally invasive surgery for gastric cancer and determine surgical, clinical, and oncological outcomes.METHODS This is a propensity score-matched case-control study, comparing three treatment arms: robotic gastrectomy(RG), laparoscopic gastrectomy(LG), open gastrectomy(OG). Data collection started after sharing a specific study protocol. Data were recorded through a tailored and protected web-based system. Primary outcomes: harvested lymph nodes, estimated blood loss, hospital stay, complications rate. Among the secondary outcomes, there are: operative time, R0 resections, POD of mobilization, POD of starting liquid diet and soft solid diet. The analysis includes the evaluation of type and grade of postoperative complications. Detailed information of anastomotic leakages is also provided.RESULTS The present analysis was carried out of 1026 gastrectomies. To guarantee homogenous distribution of cases, patients in the RG, LG and OG groups were 1:1:2 matched using a propensity score analysis with a caliper = 0.2. The successful matching resulted in a total sample of 604 patients(RG = 151; LG = 151; OG = 302). The three groups showed no differences in all baseline patients characteristics, type of surgery(P = 0.42) and stage of the disease(P = 0.16). Intraoperative blood loss was significantly lower in the LG(95.93 ± 119.22) and RG(117.91 ± 68.11) groups compared to the OG(127.26 ± 79.50, P = 0.002). The mean number of retrieved lymph nodes was similar between the RG(27.78 ± 11.45), LG(24.58 ± 13.56) and OG(25.82 ± 12.07) approach. A benefit in favor of the minimally invasive approaches was found in the length of hospital stay(P < 0.0001). A similar complications rate was found(P = 0.13). The leakage rate was not different(P = 0.78) between groups.CONCLUSION Laparoscopic and robotic surgery can be safely performed and proposed as possible alternative to open surgery. The main highlighted benefit is a faster postoperative functional recovery.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life.Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention.Traditionally surgery is reserved for patients who do not improve with other interventions.However,recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function.Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders,minimally invasive surgery for chronic pancreatitis is slow to evolve.Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis.With this background,the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis.A Pub Med search of all relevant articles was performed using the appropriate keywords,parentheses,and Boolean operators.Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy,considered an adequate procedure only in a small proportion of patients.The pancreatic head is the pacemaker of pain,so adequate decompression is critical for long-term pain relief.Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection.With improvements in laparoscopic instrumentation and technological advances,minimally invasive surgery for chronic pancreatitis is gaining momentum.However,more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Robotic Assisted Surgery for Endometriosis—“Is the Way Forward?”

Endometriosis is a chronic and progressive gynecologic disorder that affects 10% - 50% of women of reproductive age worldwide. Chronic pain and infertility are the most debilitating problems associated with it requiring both medical and surgical treatment. Laparoscopy is considered the gold standard for diagnosis and treatment. However, a 10% rate of conversion to laparotomy has been reported when performed by skilled laparoscopic surgeons and much higher in low volume less skilled surgeons. To improve surgical outcomes, robotic assistance is the logical next step in performing minimally invasive gynecological surgeries, especially in complex endometriosis cases. Enhanced 3D visualization and 10× magnification along with Endowrist instruments with seven degrees of freedom facilitates precise and careful dissection. Firefly technology using ICG green dye can improve detection of small and invisible lesions. Robotics is useful in deep infiltrating disease manifesting as lesions deeper than the superficial tissues of rectovaginal septum, vaginal fornix, pelvic sidewalls, parametrium, bowel or ureter and bladder. Trials show no increase in surgical time, blood loss, or intra- or postoperative complications and similar clinical outcome when robotics is compared with laparoscopy. At present, it is more appropriate to compare it with laparotomy rather than laparoscopy. Robotics can be used to manage recurrence of endometriosis after hysterectomy. Surgeons experienced in conventional laparoscopy can utilize robotic platform for deep infiltrating endometriosis for performing complex surgical dissection and achieving the surgical goals in mind and reduce conversions to open surgery. Robotic assistance can bridge the gap in performance of laparoscopic surgery in advanced endometriosis.

Robotic surgery in colon cancer: current evidence and future perspectives – narrative review

In the last 10 years,surgery has been developing towards minimal invasiveness;therefore,robotic surgery represents the consequent evolution of laparoscopic surgery.Worldwide,surgeons’performances have been upgraded by the ergonomic developments of robotic systems,leading to several benefits for patients.The introduction into the market of the new Da Vinci Xi system has made it possible to perform all types of surgery on the colon,an in selected cases,to combine interventions in other organs or viscera at the same time.Optimization of the suprapubic surgical approach may shorten the length of hospital stay for patients who undergo robotic colonic resection.From this perspective,single-port robotic colectomy,has reduced the number of robotic ports needed,allowing a better anesthetic outcome and faster recovery.The introduction on the market of new surgical robotic systems from multiple manufacturers is bound to change the landscape of robotic surgery and yield high-quality surgical outcomes.

Minimally invasive surgery for post cholecystectomy biliary stricture:current evidence and future perspectives

Postcholecystectomy bile duct injury(BDI)remains a devastating iatrogenic complication that adversely impacts the quality of life with high healthcare costs.Despite a decrease in the incidence of laparoscopic cholecystectomy-related BDI,the absolute number remains high as cholecystectomy is a commonly performed surgical procedure.Open Roux-en-Y hepaticojejunostomy with meticulous surgical technique remains the gold standard surgical procedure with excellent longterm results in most patients.As with many hepatobiliary disorders,a minimally invasive approach has been recently explored to minimize access-related complications and improve postoperative recovery.Since patients with gallstone disease are often admitted for a minimally invasive cholecystectomy,laparoscopic and robotic approaches for repairing postcholecystectomy biliary stricture are attractive.While recent series have shown the feasibility and safety of minimally invasive post-cholecystectomy biliary stricture management,most are retrospective analyses with small sample sizes.Also,long-term follow-up is avail-able only in a limited number of studies.The principles and technique of minimally invasive repair resemble open repair except for the extent of adhesiolysis and the suturing technique with continuous sutures commonly used in minimally invasive approaches.The robotic approach overcomes key limitations of laparoscopic surgery and has the potential to become the preferred minimally invasive approach for the repair of postcholecystectomy biliary stricture.Despite increasing use,lack of prospective studies and selection bias with available evidence precludes definitive conclusions regarding minimally invasive surgery for managing postcholecystectomy biliary stricture.High-volume prospective studies are required to confirm the initial promising outcomes with minimally invasive surgery.

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life.Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture.Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit.Colon is the commonly used esophageal substitute,particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures.Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area,with adverse cosmetic outcomes and long-term complications like an incisional hernia.As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition.However,minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure.With advancements in laparoscopic skills and instrumentation,the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented.Initial series have mainly used a laparoscopic-assisted approach,whereas more recent studies have shown the safety of a total laparoscopic approach.The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse longterm outcomes.Also,well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture.The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.

扶镜机器人在急腹症手术中的研究与应用

目的:探讨扶镜机器人在急腹症手术临床应用中的可行性与安全性。方法:选取住院急诊行阑尾切除术、胆囊切除术、嵌顿性疝(部分伴有肠梗阻)和消化道穿孔手术的病人临床资料,根据不同的扶镜方式分为机器人辅助扶镜组和人工扶镜组,收集病人性别、年龄、体质量指数(BMI)、手术时间、术中出血、住院时间、参与手术外科医生人数、并发症发病率相关临床资料。结果:共纳入病人203例,其中急性阑尾炎90例,急性胆囊炎60例,嵌顿性腹股沟疝23例,消化道穿孔30例。机器人辅助扶镜组和人工扶镜组在年龄、性别、BMI、术中出血、住院时间以及并发症发生率等方面并无差异,但机器人辅助扶镜组的外科医生数明显少于人工组(P<0.01)。结论:机器人辅助扶镜在急腹症手术中是安全、可行的,机器人辅助扶镜可以提供更加稳定而准确的手术视野,更有利于主刀医生操作,提高手术效率;同时,机器人辅助扶镜,可以减少一位扶镜助手,减少人力成本的同时,可以让更多的医生投身到其他急诊工作中。

机器人辅助腹腔镜与传统腹腔镜治疗肾上腺肿瘤的疗效对比分析

目的对比分析机器人辅助腹腔镜手术与传统腹腔镜手术治疗肾上腺肿瘤的手术效果,评估二者之间的优缺点。方法回顾性分析作者医院泌尿外科2020-08/2021-08月由同一术者行肾上腺肿瘤切除术49例患者的病历资料。其中,机器人组27例,传统腹腔镜组22例。比较两组患者的术中出血量、手术时间、术后引流时间、术后住院时间。结果机器人组与传统腹腔镜组均手术成功,无术中转开放手术患者,术后无并发症发生。两组患者在手术时间上比较差异无统计学意义(P>0.05)。机器人组患者较传统腹腔镜组患者术中出血量少、术后引流时间和术后住院时间短,且差异具有统计学意义(P均<0.05)。结论对于手术切除肾上腺肿瘤,机器人辅助腹腔镜手术相比于传统腹腔镜手术在手术时间上并无明显差异,但在控制术中出血量及术后恢复方面有一定的优势。

达芬奇机器人手术治疗小儿环状胰腺的初步经验

目的 总结我院使用达芬奇机器人手术治疗小儿环状胰腺的近期疗效和初步经验。方法 回顾性分析我院2020年10月~2022年12月应用达芬奇机器人手术治疗3例小儿环状胰腺的临床资料。结果 3例均在机器人辅助下顺利完成十二指肠侧侧吻合术,无术中并发症。手术时间分别为240分钟、212分钟、135分钟,术后开始进食时间分别为12天、7天、6天,术后住院时间分别为33天、18天、13天,第一例患儿术后并发新生儿坏死性小肠结肠炎,予以保守治疗后治愈出院,其余2例痊愈出院。随访时间分别为2年、3个月、5个月,随访期间未出现相关并发症,3例患儿预后良好。结论 达芬奇机器人手术治疗小儿环状胰腺是一个安全可行的选择,但尚需大样本研究支持。

布比卡因脂质体注射与腹横肌平面阻滞治疗机器人辅助腹腔镜下妇科肿瘤手术后疼痛比较

目的:探讨布比卡因脂质体注射与腹横肌平面阻滞(TAPB)治疗机器人辅助腹腔镜下妇科肿瘤手术后疼痛。方法:选取2022年1月—2023年6月咸阳市第一人民医院行机器人辅助腹腔镜下妇科肿瘤手术的80例患者,按随机数表法分为对照组(40例,TAPB)和研究组(40例,布比卡因脂质体注射),比较两组患者围手术期相关指标、术后疼痛及舒芬太尼用量。结果:与对照组比较,研究组下床活动时间、住院时间更短,差异具有统计学意义(P<0.05),研究组额外镇痛率和恶心呕吐率更低,差异具有统计学意义(P<0.05)。与对照组比较,研究组术后4 h、8 h、12 h、24 h静息和咳嗽状态VAS评分更低,差异具有统计学意义(P<0.05)。比较两组术后4 h、8 h舒芬太尼用量,差异无统计学意义(P>0.05),研究组术后12 h、24 h舒芬太尼用量更少,差异具有统计学意义(P<0.05)。结论:相较于TAPB,布比卡因脂质体应用于机器人辅助腹腔镜下妇科肿瘤手术可有效减轻术后疼痛,减少舒芬太尼用量,降低额外镇痛率和恶心、呕吐率,有利于患者快速康复。

Laparoscopic and robot-assisted laparoscopic digestivesurgery:Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Laparoscopic colorectal surgery:current status andimplementation of the latest technological innovations

The introduction of laparoscopy is an example of surgical innovation with a rapid implementation in many areas of surgery. A large number of controlled studiesand meta-analyses have shown that laparoscopic colorectal surgery is associated with the same benefits than other minimally invasive procedures, including lesser pain, earlier recovery of bowel transit and shorter hospital stay. On the other hand, despite initial concerns about oncological safety, well-designed prospective randomized multicentre trials have demonstrated that oncological outcomes of laparoscopy and open surgery are similar. Although the use of laparoscopy in colorectal surgery has increased in recent years, the percentages of patients treated with surgery using minimally invasive techniques are still reduced and there are also substantial differences among centres. It has been argued that the limiting factor for the use of laparoscopic procedures is the number of surgeons with adequate skills to perform a laparoscopic colectomy rather than the tumour of patients' characteristics. In this regard, future efforts to increase the use of laparoscopic techniques in colorectal surgery will necessarily require more efforts in teaching surgeons. We here present a review of recent controversies of the use of laparoscopy in colorectal surgery, such as in rectal cancer operations, the possibility of reproducing complete mesocolon excision, and the benefits of intracorporeal anastomosis after right hemicolectomy. We also describe the results of latest innovations such as single incision laparoscopic surgery, robotic surgery and natural orifice transluminal endoscopic surgery for colon and rectal diseases.

Impact of laparoscopic surgery training laboratory on surgeon's performance

Minimally invasive surgery has been replacing the open standard technique in several procedures. Similar or even better postoperative outcomes have been described in laparoscopic or robot-assisted procedures when compared to open surgery. Moreover, minimally invasive surgery has been providing less postoperative pain, shorter hospitalization, and thus a faster return to daily activities. However, the learning curve required to obtain laparoscopic expertise has been a barrier in laparoscopic spreading. Laparoscopic surgery training laboratory has been developed to aid surgeons to overcome the challenging learning curve. It may include tutorials, inanimate model skills training(box models and virtual reality simulators), animal laboratory, and operating room observation. Several different laparoscopic courses are available with specific characteristics and goals. Herein, we aim to describe the activities performed in a dry and animal-model training laboratory and to evaluate the impact of different kinds of laparoscopic surgery training courses on surgeon's performance. Several tasks are performed in dry and animal laboratory to reproduce a real surgery. A short period of training can improve laparoscopic surgical skills, although most of times it is not enough to confer laparoscopic expertise for participants. Nevertheless, this short period of training is able to increase the laparoscopic practice of surgeons in their communities. Full laparoscopic training in medical residence or fellowship programs is the best way of stimulating laparoscopic dissemination.

Minimally invasive surgery for inflammatory bowel disease: Review of current developments and future perspectives

Patients with inflammatory bowel disease(IBD)com-prise a population of patients that have a high likelihood of both surgical treatment at a young age and repetitive operative interventions.Therefore surgical procedures need to aim at minimizing operative trauma with bestpostoperative recovery.Minimally invasive techniques have been one of the major advancements in surgery in the last decades and are nowadays almost routinely performed in colorectal resections irrespective of underlying disease.However due to special disease related characteristics such as bowel stenosis,interen-teric fistula,abscesses,malnutrition,repetitive sur-geries,or immunosuppressive medications,patients with IBD represent a special cohort with specific needs for surgery.This review summarizes current evidence of minimally invasive surgery for patients with Crohn’s disease or ulcerative colitis and gives an outlook on the future perspective of technical advances in this highly moving field with its latest developments in single port surgery,robotics and trans-anal techniques.

Evolution and future of laparoscopic colorectal surgery

The advances of laparoscopic surgery since the early 1990 s have caused one of the largest technical revolutions in medicine since the detection of antibiotics(1922,Flemming),the discovery of DNA structure(1953,Watson and Crick),and solid organ transplantation(1954,Murray).Perseverance through a rocky start and increased familiarity with the chop-stick surgery in conjunction with technical refinements has resulted in a rapid expansion of the indications for minimally invasive surgery.Procedure-related factors initially contributed to this success and included the improved postoperative recovery and cosmesis,fewer wound complications,lower risk for incisional hernias and for subsequent adhesionrelated small bowel obstructions; the major breakthrough however came with favorable long-term outcomes data on oncological parameters.The future will have to determine the specific role of various technical approaches,define prognostic factors of success and true progress,and consider directing further innovation while potentially limiting approaches that do not add to patient outcomes.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Minimally invasive surgery for inflammatory bowel disease: Current perspectives

The surgical management of complicated and recurrent inflammatory bowel disease(IBD),has remained a challenge.Minimally invasive surgery(MIS),in the form of laparoscopic resections,single port approach and robotic-assisted dissections in the management of IBD,have been examined in several prospective studies.All of them have shown advantages over open surgeryin terms of reduction of physical trauma of surgery,recovery time,better cosmetic outcomes and shorter hospitalization.However,it is important to appreciate that not all patients with IBD are suitable for MIS,so a combination of both open and MIS should be adopted to achieve optimum outcomes.A review on this subject performed by Neumann et al in this issue of World Journal of Gastrointestinal Pharmacology and Therapeutics have provided evidence in support of the contemporary practice of MIS in the management of IBD and the accompanying commentary further critically evaluates their application in clinical practice.