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Telemicrosurgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.


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Konnyaku shirataki model for training in robotic microsurgery anastomosis
The aim of this study was to test the feasibility of a type of Japanese noodle, named ‘shirataki konnyaku’, for microsurgery training in the operating room. Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: one in a model of a femoral artery of a rat (control) and one in a model of a konnyaku shirataki. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and tightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anastomosis was significantly higher in the control group. The number of stitches was similar in both groups. The patency of the anastomosis was significantly lower in the control group. The tightness (no leak) of the anastomosis was significantly higher in the control group. The ‘konnyaku shirataki’ model could improve the teaching of microsurgery due to its availability, low cost, and structural similarity to the animal model.
P Liverneaux, G Prunières
Surgical intervention
3 years ago
294 views
6 likes
0 comments
01:45
Konnyaku shirataki model for training in robotic microsurgery anastomosis
The aim of this study was to test the feasibility of a type of Japanese noodle, named ‘shirataki konnyaku’, for microsurgery training in the operating room. Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: one in a model of a femoral artery of a rat (control) and one in a model of a konnyaku shirataki. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and tightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anastomosis was significantly higher in the control group. The number of stitches was similar in both groups. The patency of the anastomosis was significantly lower in the control group. The tightness (no leak) of the anastomosis was significantly higher in the control group. The ‘konnyaku shirataki’ model could improve the teaching of microsurgery due to its availability, low cost, and structural similarity to the animal model.
Robotics and eye surgery
The introduction of surgical robots revolutionized a number of specialties and the list of appropriate indications is growing rapidly. The number of procedures performed each year with the da Vinci™ Robotic Surgical System is also increasing rapidly, but the number of ophthalmological papers published has curiously remained very low since the first publication in 1997. The question of the role of robotics in ophthalmic surgery - already minimally invasive microsurgery with very good results – is legitimate. We had the opportunity to use the new da Vinci™ system at the IRCAD training center in 2012-2013. The new da Vinci™ Si HD robot has been available since 2009. It is similar to the previous version but presents several new or improved features. We performed various ocular surface surgeries on porcine eyes and were able to confirm the feasibility of the different surgical steps. Advantages and drawbacks of robotics are discussed in the presentation. It is important that continuing R&D bring about the specific improvements necessary for broader robot implication in ophthalmological surgery.
T Bourcier
Lecture
3 years ago
257 views
15 likes
0 comments
08:19
Robotics and eye surgery
The introduction of surgical robots revolutionized a number of specialties and the list of appropriate indications is growing rapidly. The number of procedures performed each year with the da Vinci™ Robotic Surgical System is also increasing rapidly, but the number of ophthalmological papers published has curiously remained very low since the first publication in 1997. The question of the role of robotics in ophthalmic surgery - already minimally invasive microsurgery with very good results – is legitimate. We had the opportunity to use the new da Vinci™ system at the IRCAD training center in 2012-2013. The new da Vinci™ Si HD robot has been available since 2009. It is similar to the previous version but presents several new or improved features. We performed various ocular surface surgeries on porcine eyes and were able to confirm the feasibility of the different surgical steps. Advantages and drawbacks of robotics are discussed in the presentation. It is important that continuing R&D bring about the specific improvements necessary for broader robot implication in ophthalmological surgery.
Nancy Robotic & Simulation Training Center: evaluation of surgical learning curves
The teaching of surgery, as in other medical disciplines, is currently undergoing a dramatically (r)evolution. As a result, the development of minimally invasive techniques (laparoscopic, robotic assisted devices, etc.) requires constant re-assessment and certification of surgical skills. This involves new educational strategies based on surgical simulation in order to improve technical and gestural techniques and ultimately patient’s safety.
We have developed a multidisciplinary center of simulation in surgical training and especially in robotics. Surgical simulators are becoming a credible alternative to practical surgery training. They can be used to train in a stepwise fashion in extremely realistic interventions (virtual reality) with the added bonus of measurable spatial and temporal parameters to gauge a user's performance. The latest generation of simulators can even reproduce a particular intervention based on patient imaging data prior to surgery in the operating room. We propose various workshops, each concentrating on one surgical specialty (ENT, gynecology, ophthalmology, implantology, vascular surgery, interventional cardiology and cardiac surgery, digestive surgery, orthopedic surgery, and arthroscopy).
Sessions are practice-based, with groundbreaking industrial equipment. Our aim is to study and apply the most innovative approaches in order to improve the relationship between coherence in learning practice and constant improvement in the measurable and quantifiable skills throughout the process from classroom to patients via the simulator. The programs will provide practical answers to questions about:
- the role of simulators in surgery and how it relates to the acquisition of increasingly complex psychomotor skills (e.g., constant re-adaptation of 3D perception based on 2D imaging, coordination of surgical gestures, understanding and mastering the new environment "tool-patient", etc.);
- the evolution of surgical certification.
Authors: N. Tran, P. Maureira, C. Perrenot, D. Joseph, J. Hubert, L. Bresler
N Tran
Lecture
3 years ago
217 views
13 likes
0 comments
14:32
Nancy Robotic & Simulation Training Center: evaluation of surgical learning curves
The teaching of surgery, as in other medical disciplines, is currently undergoing a dramatically (r)evolution. As a result, the development of minimally invasive techniques (laparoscopic, robotic assisted devices, etc.) requires constant re-assessment and certification of surgical skills. This involves new educational strategies based on surgical simulation in order to improve technical and gestural techniques and ultimately patient’s safety.
We have developed a multidisciplinary center of simulation in surgical training and especially in robotics. Surgical simulators are becoming a credible alternative to practical surgery training. They can be used to train in a stepwise fashion in extremely realistic interventions (virtual reality) with the added bonus of measurable spatial and temporal parameters to gauge a user's performance. The latest generation of simulators can even reproduce a particular intervention based on patient imaging data prior to surgery in the operating room. We propose various workshops, each concentrating on one surgical specialty (ENT, gynecology, ophthalmology, implantology, vascular surgery, interventional cardiology and cardiac surgery, digestive surgery, orthopedic surgery, and arthroscopy).
Sessions are practice-based, with groundbreaking industrial equipment. Our aim is to study and apply the most innovative approaches in order to improve the relationship between coherence in learning practice and constant improvement in the measurable and quantifiable skills throughout the process from classroom to patients via the simulator. The programs will provide practical answers to questions about:
- the role of simulators in surgery and how it relates to the acquisition of increasingly complex psychomotor skills (e.g., constant re-adaptation of 3D perception based on 2D imaging, coordination of surgical gestures, understanding and mastering the new environment "tool-patient", etc.);
- the evolution of surgical certification.
Authors: N. Tran, P. Maureira, C. Perrenot, D. Joseph, J. Hubert, L. Bresler
Can robotic navigation simplify challenging revascularization and embolization procedures?
The Magellan™ robotic system is a peripheral interventional platform that has the potential to provide precise endovascular navigation and therapy delivery using 3D control of robotically steerable catheters and guidewires (1), fast and predictable procedures (1), vessel navigation with less trauma than manual approaches (2), catheter stability during delivery and placement of therapeutic devices, physician protection from radiation exposure and procedural fatigue. It is designed to easily integrate into the hybrid operating room and interventional lab.

Our department started the study with the Magellan™ robotic system in November 2012. Up until a hybrid room became available in our institution, the system was set up in a catheterization lab where we were not allowed to perform any cutdowns.

Our study included 35 patients, including treated iliac and femoral revascularizations in 19 and 2 cases respectively, internal iliac aneurysms in 4 cases, splenic aneurysms in 3 cases, renal angioplasties in 3 cases, EVAR for contralateral limb catheterization in 2 cases, subclavian artery recanalization in 1 case, and ovarian vein embolization in one case.
Regarding iliac revascularization, as for others (3), we found that the robotic system was valuable for long recanalizations of either the common or external iliac arteries, and for multiple stenting of the aorto-iliac tree (up to 4 stents in the same patient for reconstructions of both iliac bifurcations) with one femoral access.

Regarding iliac recanalization, the system allows to navigate inside the internal iliac artery aneurysmal sac, to perform embolizations of multiple branches, and also to close the proximal iliac neck of the internal iliac artery above an aneurysm, thereby avoiding coverage with an iliac covering stent.

In one case, we performed a distal gonadal vein embolization one day after renal vein transposition performed laparoscopically using the Da Vinci™ robot (4).

To conclude, our initial experience with challenging revascularization and embolization procedures demonstrated that robotic technology is both effective and safe in the iliac arterial tree. Although robotics provides superior maneuverability as compared to current techniques, the endovascular experience is crucial to take full benefit of extra capabilities.
References:
1. Bismuth J, Stankovic M, Gerzak B, Lumsden AM. The role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries: a first in man study. 69th SVS Annual Meeting, June 2011. Chicago, USA.
2. Bismuth J, Kashef E, Cheshire N, Lumsden A. Feasibility and safety of remote endovascular catheter navigation in a porcine model. J Endovasc Ther 2011;18:243-9.
3. Bismuth J, Duran C, Stankovic M, Gersak B, Lumsden AB. A first-in-man study of the role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries. J Vasc Surg 2013;57:14S-9S.
4. Thaveau F, Nicolini P, Lucereau B, Georg Y, Lejay A, Chakfé N. Associated Da Vinci and Magellan robotic systems for successful treatment of Nutcracker syndrome. J Laparoendos Adv Surg Tech, in correction.
N Chakfé
Lecture
3 years ago
82 views
5 likes
0 comments
11:20
Can robotic navigation simplify challenging revascularization and embolization procedures?
The Magellan™ robotic system is a peripheral interventional platform that has the potential to provide precise endovascular navigation and therapy delivery using 3D control of robotically steerable catheters and guidewires (1), fast and predictable procedures (1), vessel navigation with less trauma than manual approaches (2), catheter stability during delivery and placement of therapeutic devices, physician protection from radiation exposure and procedural fatigue. It is designed to easily integrate into the hybrid operating room and interventional lab.

Our department started the study with the Magellan™ robotic system in November 2012. Up until a hybrid room became available in our institution, the system was set up in a catheterization lab where we were not allowed to perform any cutdowns.

Our study included 35 patients, including treated iliac and femoral revascularizations in 19 and 2 cases respectively, internal iliac aneurysms in 4 cases, splenic aneurysms in 3 cases, renal angioplasties in 3 cases, EVAR for contralateral limb catheterization in 2 cases, subclavian artery recanalization in 1 case, and ovarian vein embolization in one case.
Regarding iliac revascularization, as for others (3), we found that the robotic system was valuable for long recanalizations of either the common or external iliac arteries, and for multiple stenting of the aorto-iliac tree (up to 4 stents in the same patient for reconstructions of both iliac bifurcations) with one femoral access.

Regarding iliac recanalization, the system allows to navigate inside the internal iliac artery aneurysmal sac, to perform embolizations of multiple branches, and also to close the proximal iliac neck of the internal iliac artery above an aneurysm, thereby avoiding coverage with an iliac covering stent.

In one case, we performed a distal gonadal vein embolization one day after renal vein transposition performed laparoscopically using the Da Vinci™ robot (4).

To conclude, our initial experience with challenging revascularization and embolization procedures demonstrated that robotic technology is both effective and safe in the iliac arterial tree. Although robotics provides superior maneuverability as compared to current techniques, the endovascular experience is crucial to take full benefit of extra capabilities.
References:
1. Bismuth J, Stankovic M, Gerzak B, Lumsden AM. The role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries: a first in man study. 69th SVS Annual Meeting, June 2011. Chicago, USA.
2. Bismuth J, Kashef E, Cheshire N, Lumsden A. Feasibility and safety of remote endovascular catheter navigation in a porcine model. J Endovasc Ther 2011;18:243-9.
3. Bismuth J, Duran C, Stankovic M, Gersak B, Lumsden AB. A first-in-man study of the role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries. J Vasc Surg 2013;57:14S-9S.
4. Thaveau F, Nicolini P, Lucereau B, Georg Y, Lejay A, Chakfé N. Associated Da Vinci and Magellan robotic systems for successful treatment of Nutcracker syndrome. J Laparoendos Adv Surg Tech, in correction.
Microvascular robotic assisted anastomosis of the brain
Robotic microsurgery is a new medical field which finds its place amongst medical specialties, since it applies to any that benefits from precision, tremor filtration and minimally invasive approaches.
Microsurgical techniques applied to robotic surgery are well-known and described in the medical literature, especially in urology, orthopedics, and hand surgery, traditional medical specialties which have some microsurgical procedures.
The objective of the author was to investigate a new and exciting field, which is robotic microneurosurgery.
Neurosurgery uses microsurgical techniques in every single procedure, from brain to spine surgery, demands very precise movements, has a very small and straight working space and still cannot access some parts of the brain.
It seems very reasonable that robotics can help the specialty which demands all that it can offer. Besides that, places known before as no man’s land can finally be approached.
This presentation shows the current state-of-the-art research in robotic microneurosurgery, including microvascular cerebral anastomosis.
PM Porto de Melo
Lecture
3 years ago
221 views
11 likes
0 comments
12:14
Microvascular robotic assisted anastomosis of the brain
Robotic microsurgery is a new medical field which finds its place amongst medical specialties, since it applies to any that benefits from precision, tremor filtration and minimally invasive approaches.
Microsurgical techniques applied to robotic surgery are well-known and described in the medical literature, especially in urology, orthopedics, and hand surgery, traditional medical specialties which have some microsurgical procedures.
The objective of the author was to investigate a new and exciting field, which is robotic microneurosurgery.
Neurosurgery uses microsurgical techniques in every single procedure, from brain to spine surgery, demands very precise movements, has a very small and straight working space and still cannot access some parts of the brain.
It seems very reasonable that robotics can help the specialty which demands all that it can offer. Besides that, places known before as no man’s land can finally be approached.
This presentation shows the current state-of-the-art research in robotic microneurosurgery, including microvascular cerebral anastomosis.
Interactive robotics: challenges for assistance, healthcare & service applications
We have designed a new high-performance integrated electro-hydraulic actuator (IEHA). We propose a new solution robotics question which has remained unanswered, to provide an efficient and compliant actuation. The proposed actuator, which is dedicated to independently motorizing each joint of a robotic system, is designed to be fixed as close as possible to the joint itself, thus enhancing performance while reducing the usual drawbacks of conventional hydraulic actuation. The novel IEHA contains an integrated micro-pump with a floating barrel, allowing the inversion of the flow direction without inverting the rotation of the input electric motor. The integration of a micro-valve and a rotary hydraulic distributor ensure the compactness of the proposed solution. In this paper, the proposed hydraulic actuation principle is first outlined in detail. The designed prototype and the first experiments are then presented, demonstrating the novelty and the efficiency of our solution.
FB Ben Ouezdou
Lecture
3 years ago
42 views
1 like
0 comments
18:11
Interactive robotics: challenges for assistance, healthcare & service applications
We have designed a new high-performance integrated electro-hydraulic actuator (IEHA). We propose a new solution robotics question which has remained unanswered, to provide an efficient and compliant actuation. The proposed actuator, which is dedicated to independently motorizing each joint of a robotic system, is designed to be fixed as close as possible to the joint itself, thus enhancing performance while reducing the usual drawbacks of conventional hydraulic actuation. The novel IEHA contains an integrated micro-pump with a floating barrel, allowing the inversion of the flow direction without inverting the rotation of the input electric motor. The integration of a micro-valve and a rotary hydraulic distributor ensure the compactness of the proposed solution. In this paper, the proposed hydraulic actuation principle is first outlined in detail. The designed prototype and the first experiments are then presented, demonstrating the novelty and the efficiency of our solution.
Assessment of robotic assisted microsurgical skills: lessons learned from microsurgery simulation training
In recent years, training and education in surgery has evolved from a Halstedian apprenticeship model to a competency-based training model. This shift in training has sparked a myriad of research in education and simulation in surgery. The need for good training in microsurgery is evidenced by improved outcomes of microvascular procedures in patients by more experienced surgeons.
To develop a competency based training program, objective assessment tools have to be perfected, in order to understand learning curves in microsurgical skill acquisition. Once stage-specific learning curves in microsurgical skill acquisition have been developed, safe clinical thresholds can be identified to ensure that skills acquired in the simulation lab setting can be safely translated to the clinical setting. These same principles can be applied in developing a competency-based program for robotic microsurgery.
S Ramachandran
Lecture
3 years ago
98 views
2 likes
0 comments
10:14
Assessment of robotic assisted microsurgical skills: lessons learned from microsurgery simulation training
In recent years, training and education in surgery has evolved from a Halstedian apprenticeship model to a competency-based training model. This shift in training has sparked a myriad of research in education and simulation in surgery. The need for good training in microsurgery is evidenced by improved outcomes of microvascular procedures in patients by more experienced surgeons.
To develop a competency based training program, objective assessment tools have to be perfected, in order to understand learning curves in microsurgical skill acquisition. Once stage-specific learning curves in microsurgical skill acquisition have been developed, safe clinical thresholds can be identified to ensure that skills acquired in the simulation lab setting can be safely translated to the clinical setting. These same principles can be applied in developing a competency-based program for robotic microsurgery.
Robotic assistance to flexible endoscopy by physiological motion tracking
New techniques are currently under development for minimally invasive surgery with the objective to perform surgery without visible scars. Single port access surgery is one of the approaches, natural orifice endoluminal or transluminal surgery is the other one.

The latter is based on the use of flexible endoscopes and instruments which are introduced inside the patient through natural orifices such as the mouth or the anus. This type of surgery is quite complex. It relies on the use of flexible instruments which allow the surgeon or the endoscopist to control the orientation of the endoscope's head as well as the instruments inside the channels.

Two surgeons are often required to work simultaneously. The ICube laboratory and the IRCAD institute have developed a robotic platform for endoluminal and transluminal surgery with a flexible endoscope and two flexible instruments that can be efficiently telemanipulated by one surgeon.

Physiological motions of organs are difficult to compensate in manual procedures while controlling flexible instruments. By using automatic visual tracking of the anatomical target, the robotized flexible endoscope can follow the moving organ at a constant distance. This feature provides the surgeons the perception of a non-mobile surgical environment while the organ is moving. This feature has been tested and validated in vivo using porcine models.
M de Mathelin
Lecture
4 years ago
114 views
4 likes
0 comments
15:09
Robotic assistance to flexible endoscopy by physiological motion tracking
New techniques are currently under development for minimally invasive surgery with the objective to perform surgery without visible scars. Single port access surgery is one of the approaches, natural orifice endoluminal or transluminal surgery is the other one.

The latter is based on the use of flexible endoscopes and instruments which are introduced inside the patient through natural orifices such as the mouth or the anus. This type of surgery is quite complex. It relies on the use of flexible instruments which allow the surgeon or the endoscopist to control the orientation of the endoscope's head as well as the instruments inside the channels.

Two surgeons are often required to work simultaneously. The ICube laboratory and the IRCAD institute have developed a robotic platform for endoluminal and transluminal surgery with a flexible endoscope and two flexible instruments that can be efficiently telemanipulated by one surgeon.

Physiological motions of organs are difficult to compensate in manual procedures while controlling flexible instruments. By using automatic visual tracking of the anatomical target, the robotized flexible endoscope can follow the moving organ at a constant distance. This feature provides the surgeons the perception of a non-mobile surgical environment while the organ is moving. This feature has been tested and validated in vivo using porcine models.
State-of-the-art: anesthetic management for robotic surgery: the MD Anderson Cancer Center Experience
Background:
Robotic-assisted surgery has evolved over the past decade and has paved the way for the future surgical approach in multiple subspecialty disciplines. Technological advancements present potential advantages for our oncologic patients as well as new challenges for anesthesia and surgery teams. Robotic head and neck, plastic and thoracic surgery carry specific associated risks that require a precise anesthetic perioperative management plan in order to prevent catastrophic events such as airway fire, life-threatening hemodynamic instability and flap failure, from happening. The main goals are to estimate and minimize the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Description:
The three most important anesthetic considerations during TransOral Robotic Surgery (TORS) are: airway management, facial trauma prevention and fire prevention strategies. The surgical bed is usually rotated 180 degrees away from the anesthesiologist and securing the airway becomes pivotal in order to prevent accidental disconnection or extubation caused by the patient-robot conflict. Facial trauma, and specifically ocular trauma including retinal detachment, is prevented by the routine use of surgical goggles. The risk of fire is high during TORS and specific strategies must be put in place in order to prevent such a catastrophic event from occurring. Strategies include: a fire checklist including precise knowledge of oxygen shutoff location outside the OR and fire extinguisher location inside the OR, as well as decreasing oxygen concentration to less than 35% as tolerated by oxygen saturation.
During robotic reconstructive plastic surgery fluid management must be precise because very conservative fluid administration can lead to hypotension and hypoperfusion of the flap due to a decrease in oxygen delivery and potential ischemia. Over-administration of fluids can lead to interstitial edema putting flap integrity at risk, due to an increase in the distance oxygen molecules travel from the endothelium to the cells, to contribute with adequate tissue oxygenation and aerobic metabolism. Excessive fluid administration leads to dilution anemia increasing the need for blood transfusions, which negatively impact immunomodulation in cancer patients as demonstrated by several meta-analyses.
We currently have new minimally invasive hemodynamic monitoring technology such as Flo Trac, Vigileo and LiDCO at our fingertips, which allows to monitor beat-to-beat precise fluid administration to maintain a perfect state of euvolemia.
Minimally invasive thoracic surgery such as Da Vinci® assisted robotic surgery and Video-assisted thoracoscopic surgery (VATS) are routine procedures at our institution. Enhanced Recovery After Surgery (ERAS) and specifically Enhanced Recovery After Thoracic Surgery (ERATS) strategies are currently used as part of our thoracic surgical protocols in order to decrease morbidity, length of stay (LOS), opioid consumption and costs to the healthcare system and institution.

These strategies are the result of scientifically and evidence-based data from RCT’s and multiple meta-analyses. The role of multimodal analgesia for perioperative pain management with pharmacological opioid sparing strategies using Lyrica (Pregabalin), Tramadol ER (Ultram), Celebrex (Celecoxib), IV Acetaminophen (Ofirmev) and Ketorolac IV (Toradol) have clearly shown to decrease the use of opioids by more than 50%. Opioids are clearly known to lead to side effects such as ileus, urinary retention, respiratory depression and immunomodulation which are all associated with increased LOS, morbidity and costs.

Total Intravenous Anesthesia (TIVA) using continuous intraoperative infusions of propofol, dexmedetomidine (Precedex) and lidocaine are part of the ERATS strategies to decrease opioid use and to avoid the side effects of inhaled volatile agents.

Surgical strategies such as intercostal block with Exparel (Liposomal Encapsulated Bupivacaine) and incisional port injection with Exparel as well as early chest tube removal (24-48 hours) allow early patient mobilization and discharge while maintaining the same outcomes and increasing patient satisfaction.


Discussion:
Team work between surgeons and anesthesiologists as well as constant communication and a thorough understanding of the physiological, hemodynamic, oncologic and analgesic implications minimizes the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Anesthesiologists must have in-depth knowledge of specific anesthetic considerations and implications associated with TORS such as airway fire and fire prevention strategies. Precise fluid administration and Enhanced Recovery After Surgery (ERAS) strategies during plastic robotic surgery as well as thoracic robotic surgery are pivotal in the perioperative period and for accelerated recovery while maintaining same quality of care and patient satisfaction.
As surgical approaches change with robotic surgery, it is necessary to understand the impacts these changes have on perioperative care to optimize surgical success, safety, patient satisfaction, decreased LOS, opioid usage and Institutional costs.

References:
1. Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol 2010;23:1-6.
2. Steenwyk B, Lyerly R 3rd. Adavancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708.
3. Selber JC. Discussion: Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey. Plast Reconstr Surg 2013;131:188e-197e.
4. Hassanein AH, Mailey BA, Dobke MK. Robotic-assisted plastic surgery. Clin Plast Surg 2012 12;5:232-8.
5. Selber JC, Baumann DP, Holsinger CF. Robotic Harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg 2012;20:457-64.
6. Chi JJ, Mandel JE, Weinstein GS, O’Malley BW Jr. Anesthetic considerations for transoral robotic surgery. Anesthesiol Clin 2010;28:411-22.
7. Song JB, Vemana G, Mobley JM, Bhayani SB. The second “time-out”: a surgical safety checklist for lengthy robotic surgeries. Patient Saf Surg 2013;3:19.
8. Ahmed K, Khan N, Khan MS, Dasgupta P. Development and content validation of surgical safety checklist for operating theaters that use robotic technology. BJU Int 2013;111:1161-74.
GE Mena
Lecture
4 years ago
71 views
2 likes
0 comments
14:22
State-of-the-art: anesthetic management for robotic surgery: the MD Anderson Cancer Center Experience
Background:
Robotic-assisted surgery has evolved over the past decade and has paved the way for the future surgical approach in multiple subspecialty disciplines. Technological advancements present potential advantages for our oncologic patients as well as new challenges for anesthesia and surgery teams. Robotic head and neck, plastic and thoracic surgery carry specific associated risks that require a precise anesthetic perioperative management plan in order to prevent catastrophic events such as airway fire, life-threatening hemodynamic instability and flap failure, from happening. The main goals are to estimate and minimize the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Description:
The three most important anesthetic considerations during TransOral Robotic Surgery (TORS) are: airway management, facial trauma prevention and fire prevention strategies. The surgical bed is usually rotated 180 degrees away from the anesthesiologist and securing the airway becomes pivotal in order to prevent accidental disconnection or extubation caused by the patient-robot conflict. Facial trauma, and specifically ocular trauma including retinal detachment, is prevented by the routine use of surgical goggles. The risk of fire is high during TORS and specific strategies must be put in place in order to prevent such a catastrophic event from occurring. Strategies include: a fire checklist including precise knowledge of oxygen shutoff location outside the OR and fire extinguisher location inside the OR, as well as decreasing oxygen concentration to less than 35% as tolerated by oxygen saturation.
During robotic reconstructive plastic surgery fluid management must be precise because very conservative fluid administration can lead to hypotension and hypoperfusion of the flap due to a decrease in oxygen delivery and potential ischemia. Over-administration of fluids can lead to interstitial edema putting flap integrity at risk, due to an increase in the distance oxygen molecules travel from the endothelium to the cells, to contribute with adequate tissue oxygenation and aerobic metabolism. Excessive fluid administration leads to dilution anemia increasing the need for blood transfusions, which negatively impact immunomodulation in cancer patients as demonstrated by several meta-analyses.
We currently have new minimally invasive hemodynamic monitoring technology such as Flo Trac, Vigileo and LiDCO at our fingertips, which allows to monitor beat-to-beat precise fluid administration to maintain a perfect state of euvolemia.
Minimally invasive thoracic surgery such as Da Vinci® assisted robotic surgery and Video-assisted thoracoscopic surgery (VATS) are routine procedures at our institution. Enhanced Recovery After Surgery (ERAS) and specifically Enhanced Recovery After Thoracic Surgery (ERATS) strategies are currently used as part of our thoracic surgical protocols in order to decrease morbidity, length of stay (LOS), opioid consumption and costs to the healthcare system and institution.

These strategies are the result of scientifically and evidence-based data from RCT’s and multiple meta-analyses. The role of multimodal analgesia for perioperative pain management with pharmacological opioid sparing strategies using Lyrica (Pregabalin), Tramadol ER (Ultram), Celebrex (Celecoxib), IV Acetaminophen (Ofirmev) and Ketorolac IV (Toradol) have clearly shown to decrease the use of opioids by more than 50%. Opioids are clearly known to lead to side effects such as ileus, urinary retention, respiratory depression and immunomodulation which are all associated with increased LOS, morbidity and costs.

Total Intravenous Anesthesia (TIVA) using continuous intraoperative infusions of propofol, dexmedetomidine (Precedex) and lidocaine are part of the ERATS strategies to decrease opioid use and to avoid the side effects of inhaled volatile agents.

Surgical strategies such as intercostal block with Exparel (Liposomal Encapsulated Bupivacaine) and incisional port injection with Exparel as well as early chest tube removal (24-48 hours) allow early patient mobilization and discharge while maintaining the same outcomes and increasing patient satisfaction.


Discussion:
Team work between surgeons and anesthesiologists as well as constant communication and a thorough understanding of the physiological, hemodynamic, oncologic and analgesic implications minimizes the risk of morbidity and mortality associated with robotic surgery and anesthesia.

Anesthesiologists must have in-depth knowledge of specific anesthetic considerations and implications associated with TORS such as airway fire and fire prevention strategies. Precise fluid administration and Enhanced Recovery After Surgery (ERAS) strategies during plastic robotic surgery as well as thoracic robotic surgery are pivotal in the perioperative period and for accelerated recovery while maintaining same quality of care and patient satisfaction.
As surgical approaches change with robotic surgery, it is necessary to understand the impacts these changes have on perioperative care to optimize surgical success, safety, patient satisfaction, decreased LOS, opioid usage and Institutional costs.

References:
1. Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol 2010;23:1-6.
2. Steenwyk B, Lyerly R 3rd. Adavancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708.
3. Selber JC. Discussion: Reconstructive techniques in transoral robotic surgery for head and neck cancer: A North American survey. Plast Reconstr Surg 2013;131:188e-197e.
4. Hassanein AH, Mailey BA, Dobke MK. Robotic-assisted plastic surgery. Clin Plast Surg 2012 12;5:232-8.
5. Selber JC, Baumann DP, Holsinger CF. Robotic Harvest of the latissimus dorsi muscle: laboratory and clinical experience. J Reconstr Microsurg 2012;20:457-64.
6. Chi JJ, Mandel JE, Weinstein GS, O’Malley BW Jr. Anesthetic considerations for transoral robotic surgery. Anesthesiol Clin 2010;28:411-22.
7. Song JB, Vemana G, Mobley JM, Bhayani SB. The second “time-out”: a surgical safety checklist for lengthy robotic surgeries. Patient Saf Surg 2013;3:19.
8. Ahmed K, Khan N, Khan MS, Dasgupta P. Development and content validation of surgical safety checklist for operating theaters that use robotic technology. BJU Int 2013;111:1161-74.
Health in space: surgery in the context of manned space exploration
The European Space Agency (ESA) foresees the exploration of the solar system, which implies as a long-term objective the prospect of Mars’s exploration by human beings. Ensuring the crew’s well-being and operational performance will not only depend on the ability to prevent health issues, but also to make a fast and accurate diagnosis and therefore to quickly provide reliable and adequate treatment. Building the required knowledge and understanding the aspects specifically related to crewed exploration will be performed on a long timescale. It is therefore of high interest to also develop short-term and medium-term technologies, especially by resorting to the use of analog environments such as the Concordia station to validate these technological concepts for future space activities.
While the ESA has carried out several activities in the field of prevention and countermeasures, monitoring, and diagnosis, only a very limited number of projects have been dealing with treatment techniques. Consequently, the ESA recently decided to explore this rather untapped field and has started working on assisted surgery as a potential treatment possibility for future space exploration missions. During a manned Lunar or Martian mission, emergency surgical care for life-threatening pathologies (e.g. major trauma) may have to be carried out inside the spacecraft or habitat since an evacuation to a specialized surgical facility may not be immediately possible. The crew would therefore need some support, in order 1) to overcome the lack of surgical expertise and sufficiently skilled staff on the site where the patient is located (e.g. spacecraft, geographically isolated place), 2) to overcome the lack of training (no daily practice) and preserve medical skills (including surgical procedures) of the crew’s medical officer, if any.
The presentation given in November 2013 at the 3rd RAMSES symposium aims at providing a first overview about surgery-related activities at the European Space Agency, including achievements and future perspectives.
A Runge
Lecture
4 years ago
162 views
6 likes
0 comments
13:11
Health in space: surgery in the context of manned space exploration
The European Space Agency (ESA) foresees the exploration of the solar system, which implies as a long-term objective the prospect of Mars’s exploration by human beings. Ensuring the crew’s well-being and operational performance will not only depend on the ability to prevent health issues, but also to make a fast and accurate diagnosis and therefore to quickly provide reliable and adequate treatment. Building the required knowledge and understanding the aspects specifically related to crewed exploration will be performed on a long timescale. It is therefore of high interest to also develop short-term and medium-term technologies, especially by resorting to the use of analog environments such as the Concordia station to validate these technological concepts for future space activities.
While the ESA has carried out several activities in the field of prevention and countermeasures, monitoring, and diagnosis, only a very limited number of projects have been dealing with treatment techniques. Consequently, the ESA recently decided to explore this rather untapped field and has started working on assisted surgery as a potential treatment possibility for future space exploration missions. During a manned Lunar or Martian mission, emergency surgical care for life-threatening pathologies (e.g. major trauma) may have to be carried out inside the spacecraft or habitat since an evacuation to a specialized surgical facility may not be immediately possible. The crew would therefore need some support, in order 1) to overcome the lack of surgical expertise and sufficiently skilled staff on the site where the patient is located (e.g. spacecraft, geographically isolated place), 2) to overcome the lack of training (no daily practice) and preserve medical skills (including surgical procedures) of the crew’s medical officer, if any.
The presentation given in November 2013 at the 3rd RAMSES symposium aims at providing a first overview about surgery-related activities at the European Space Agency, including achievements and future perspectives.
Robot-assisted vasectomy reversal
Robot-assisted surgery developed faster and earlier in urology as compared to other fields of surgery. As some microsurgical procedures are applicable to this field, the evolution towards robot-assisted microsurgery was a logical extension. We started our vasectomy reversal program as early as 2003 and completely left the traditional microscope aside.
Microsurgical techniques must be mastered first. The lack of haptic feedback must then be compensated with the robot by means of optical vision of the tension applied on the thread. In addition, the force applied on the manipulators must be controlled with gentle pressure in order to prevent mashing and cutting of the threads or bending of the needles. The pressure of the jaws of the forceps is less intense at the tip, and only that part of the instrument should be used.
Our results on 19 robot-assisted vasectomy reversal (RAVV) procedures demonstrate a 92% patency rate.
We present two videos. The first video describes a two-plane vasectomy reversal with 11/0 and 10/0 sutures. The second one presents a modified two-plane vasectomy reversal with 10/0 and 9/0 sutures. We use two black diamond micro-forceps and Potts scissors. The use of the fourth arm shortens the procedure, precluding the need to change instruments or the help of an assistant.
Robotic microsurgery offers a better outcome with a more stable operative field, more precise movements without tremor and better ergonomics for the surgeon, hence reducing the operative time.
GA de Boccard
Lecture
4 years ago
168 views
6 likes
0 comments
16:26
Robot-assisted vasectomy reversal
Robot-assisted surgery developed faster and earlier in urology as compared to other fields of surgery. As some microsurgical procedures are applicable to this field, the evolution towards robot-assisted microsurgery was a logical extension. We started our vasectomy reversal program as early as 2003 and completely left the traditional microscope aside.
Microsurgical techniques must be mastered first. The lack of haptic feedback must then be compensated with the robot by means of optical vision of the tension applied on the thread. In addition, the force applied on the manipulators must be controlled with gentle pressure in order to prevent mashing and cutting of the threads or bending of the needles. The pressure of the jaws of the forceps is less intense at the tip, and only that part of the instrument should be used.
Our results on 19 robot-assisted vasectomy reversal (RAVV) procedures demonstrate a 92% patency rate.
We present two videos. The first video describes a two-plane vasectomy reversal with 11/0 and 10/0 sutures. The second one presents a modified two-plane vasectomy reversal with 10/0 and 9/0 sutures. We use two black diamond micro-forceps and Potts scissors. The use of the fourth arm shortens the procedure, precluding the need to change instruments or the help of an assistant.
Robotic microsurgery offers a better outcome with a more stable operative field, more precise movements without tremor and better ergonomics for the surgeon, hence reducing the operative time.
Transoral supraglottic and tongue base surgery: da Vinci® robot versus CO2 laser surgery
Introduction
To date, the gold standard for transoral tongue base and supraglottic surgery is the CO2 laser. The Da Vinci robot has been tested for transoral surgery since 2006. Is the Da Vinci robot an alternative or will it replace the CO2 laser for these surgical procedures?

Methods
The advantages and drawbacks of all approaches (i.e. external approach, transoral approach) with the CO2 laser and the Da Vinci robot are reviewed.

Results
The external approach still has an interest for massive pre-epiglottic space invasion. For small tumors, the CO2 laser presents an advantage as compared to the Da Vinci robot as it causes less thermal damage. For large tumors, the quality of exposure provided by the Da Vinci robot as compared to the scope of the CO2 laser improves quality and makes tumor resection easier.

Conclusion
The Da Vinci robot has been largely developed over these last years and therefore will replace the CO2 laser for some surgical procedures.
P Schultz
Lecture
4 years ago
121 views
5 likes
0 comments
14:18
Transoral supraglottic and tongue base surgery: da Vinci® robot versus CO2 laser surgery
Introduction
To date, the gold standard for transoral tongue base and supraglottic surgery is the CO2 laser. The Da Vinci robot has been tested for transoral surgery since 2006. Is the Da Vinci robot an alternative or will it replace the CO2 laser for these surgical procedures?

Methods
The advantages and drawbacks of all approaches (i.e. external approach, transoral approach) with the CO2 laser and the Da Vinci robot are reviewed.

Results
The external approach still has an interest for massive pre-epiglottic space invasion. For small tumors, the CO2 laser presents an advantage as compared to the Da Vinci robot as it causes less thermal damage. For large tumors, the quality of exposure provided by the Da Vinci robot as compared to the scope of the CO2 laser improves quality and makes tumor resection easier.

Conclusion
The Da Vinci robot has been largely developed over these last years and therefore will replace the CO2 laser for some surgical procedures.
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
J Selber
Lecture
4 years ago
375 views
10 likes
0 comments
14:26
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
J Selber
Lecture
4 years ago
152 views
4 likes
0 comments
17:18
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.
J Selber
Lecture
4 years ago
213 views
9 likes
0 comments
17:18
Transoral robotic surgery
Access to oropharyngeal tumors has traditionally been using a transmandibular, translabial approach. Unfortunately, mandibulotomies and large pharyngotomies can result in significant postoperative morbidity and functional compromise. Because of the morbidity involved in some of these more aggressive resections, and the proven efficacy of chemoradiation in the treatment of some oropharyngeal cancers, there has been a paradigm shift away from ablative surgery. As long-term follow-up on these “organ-sparing” protocols have begun to take shape, however, significant morbidity and mortality has emerged with these therapies as well. Trans-oral robotic resections and reconstructions can provide the benefits of locoregional control without the morbidity of wide pharyngeal access or high-dose radiation. It can also prevent the use of external facial incisions and morbidity related to division of the mandible including hardware complications such as fistula. In addition, it can reduce and occasionally eliminate the need for radiation and its associated problems such as osteoradionecrosis and a functionless larynx. Transoral robotic tumor resection provides a challenge to the plastic surgeon because the cylinder of the oropharynx remains closed, making access to the oropharyngeal anatomy very difficult, particularly between the uvula and the epiglottis. The surgical robot, when positioned transorally, can allow the reconstructive surgeon to inset a variety of free and local flaps to perform complex reconstructions in challenging areas and meet the reconstructive demands of transoral resections.
Robotics in hand and peripheral nerve surgery: Brazilian experience (3 years)
Our Brazilian experience using the da Vinci® robot in hand surgery and peripheral nerve starts in 2010. The first case was that of a male patient with brachial plexus upper roots injury in a motorcycle accident. The classical supraclavicular open approach was performed and the da Vinci® robot was used as a substitute of the microscope. Repair was performed by means of a sural nerve graft.
Another brachial plexus injury was treated with the same method. Two ulnar nerves transposition at elbow level was performed with endoscopic approach and using the da Vinci® robot. One digital nerve lesion was repaired with neural conduit using the da Vinci® robot as a substitute of the microscope. The main reasons for the few number of cases in Brazil are as follows:
- few numbers of hand and peripheral nerve surgeons with valid Intuitive Certificate of da Vinci® training;
- high costs and Brazilian economy problems;
- lack of evidence of better results with robotic surgery;
- only 6 da Vinci® robots in Brazil.
L Alves de Mendonça Jr.
Lecture
4 years ago
94 views
6 likes
0 comments
06:42
Robotics in hand and peripheral nerve surgery: Brazilian experience (3 years)
Our Brazilian experience using the da Vinci® robot in hand surgery and peripheral nerve starts in 2010. The first case was that of a male patient with brachial plexus upper roots injury in a motorcycle accident. The classical supraclavicular open approach was performed and the da Vinci® robot was used as a substitute of the microscope. Repair was performed by means of a sural nerve graft.
Another brachial plexus injury was treated with the same method. Two ulnar nerves transposition at elbow level was performed with endoscopic approach and using the da Vinci® robot. One digital nerve lesion was repaired with neural conduit using the da Vinci® robot as a substitute of the microscope. The main reasons for the few number of cases in Brazil are as follows:
- few numbers of hand and peripheral nerve surgeons with valid Intuitive Certificate of da Vinci® training;
- high costs and Brazilian economy problems;
- lack of evidence of better results with robotic surgery;
- only 6 da Vinci® robots in Brazil.
Optimization and new adjunctive tools
There is an increasing migration from standard microsurgical approach to robotic assistance. This evolution creates a demand for technological advances and novel adjunctive tools. The VITOM camera system (Karl Storz, Tuttlingen, Germany) is one such development for enhanced magnification. Micro-Doppler probe (VTI Vascular Technology, Inc., Nashua, NH) and micro-ultrasound probe (Hitachi-Aloka, Tokyo, Japan) allow for intraoperative real-time identification of the surrounding vasculature. The Vein Viewer (Christie Digital Systems, Cypress, CA) is also another adjunctive tool that allows intra-operative detection of small diameter veins. Flexible fiber optic carbon dioxide laser (Omni-Guide, Cambridge, MA) offers a novel ablation technique with precise and decreased thermal damage for robotic micro-surgical dissection. Single port orifice robot technology (SPORT, Titan Medical, Inc., Toronto, Ontario, Canada), the surgeons operating force-feedback interface Eindhoven (SOFIE, Eindhoven University of Technology, Eindhoven Netherland), Raven (University of California, Berkeley, CA) and Amadeus (Titan Medical, Inc., Toronto, Ontario, Canada) are upcoming novel robotic platforms that are still in their development process. In addition to such new adjunctive tools and robotic platforms, there is also a new framework called IDEAL recommendations in an effort to optimize surgical innovations.
A Gudeloglu
Lecture
4 years ago
72 views
2 likes
0 comments
12:25
Optimization and new adjunctive tools
There is an increasing migration from standard microsurgical approach to robotic assistance. This evolution creates a demand for technological advances and novel adjunctive tools. The VITOM camera system (Karl Storz, Tuttlingen, Germany) is one such development for enhanced magnification. Micro-Doppler probe (VTI Vascular Technology, Inc., Nashua, NH) and micro-ultrasound probe (Hitachi-Aloka, Tokyo, Japan) allow for intraoperative real-time identification of the surrounding vasculature. The Vein Viewer (Christie Digital Systems, Cypress, CA) is also another adjunctive tool that allows intra-operative detection of small diameter veins. Flexible fiber optic carbon dioxide laser (Omni-Guide, Cambridge, MA) offers a novel ablation technique with precise and decreased thermal damage for robotic micro-surgical dissection. Single port orifice robot technology (SPORT, Titan Medical, Inc., Toronto, Ontario, Canada), the surgeons operating force-feedback interface Eindhoven (SOFIE, Eindhoven University of Technology, Eindhoven Netherland), Raven (University of California, Berkeley, CA) and Amadeus (Titan Medical, Inc., Toronto, Ontario, Canada) are upcoming novel robotic platforms that are still in their development process. In addition to such new adjunctive tools and robotic platforms, there is also a new framework called IDEAL recommendations in an effort to optimize surgical innovations.
Robotic microsurgery and the future
Vasectomy is one of the most common urological procedures in the United States. Each year approximately five hundred thousand men undergo vasectomy. However, up to 6% of these patients desire a vasectomy reversal at some point in their lives in order to regain fertility. Vasectomy reversal is a challenging microsurgical procedure that requires re-anastomosis of the transected vas deferens using 9/0 and 10/0 sutures. Chronic groin or scrotal content pain is another entity that affects up to 100,000 patients annually. Targeted microsurgical denervation of the spermatic cord is a viable option for this condition. This presentation covers our work on the use of a robotic assisted microsurgical platform in over 1,000 such procedures. The use of robotics for microsurgery may provide advantages in terms of multi-view magnification, motion scaling, elimination of tremor, and additional surgical arms in a stable ergonomic platform. The additional fourth arm can improve surgeon efficiency (provides an extra microsurgical instrument handled simultaneously with less reliance on a skilled microsurgical assistant). Previously, we could perform only two standard microsurgical procedures a day due to surgeon fatigue limitations using the standard microscope. With the aid of the robotic system, the same microsurgeon has been able to routinely perform up to 4-5 microsurgical procedures a day due to the ergonomic advantages of the robot. Robotics may also help to inspire our youth and operating room staff and help to motivate their interest in our field. We also present collaborative programs to achieve these goals: a collegiate high-school program developed with Polk State College to engage our youth to pursue science and engineering careers, and a robotic nurse training credentialing program.
SJ Parekattil
Lecture
4 years ago
182 views
4 likes
0 comments
19:21
Robotic microsurgery and the future
Vasectomy is one of the most common urological procedures in the United States. Each year approximately five hundred thousand men undergo vasectomy. However, up to 6% of these patients desire a vasectomy reversal at some point in their lives in order to regain fertility. Vasectomy reversal is a challenging microsurgical procedure that requires re-anastomosis of the transected vas deferens using 9/0 and 10/0 sutures. Chronic groin or scrotal content pain is another entity that affects up to 100,000 patients annually. Targeted microsurgical denervation of the spermatic cord is a viable option for this condition. This presentation covers our work on the use of a robotic assisted microsurgical platform in over 1,000 such procedures. The use of robotics for microsurgery may provide advantages in terms of multi-view magnification, motion scaling, elimination of tremor, and additional surgical arms in a stable ergonomic platform. The additional fourth arm can improve surgeon efficiency (provides an extra microsurgical instrument handled simultaneously with less reliance on a skilled microsurgical assistant). Previously, we could perform only two standard microsurgical procedures a day due to surgeon fatigue limitations using the standard microscope. With the aid of the robotic system, the same microsurgeon has been able to routinely perform up to 4-5 microsurgical procedures a day due to the ergonomic advantages of the robot. Robotics may also help to inspire our youth and operating room staff and help to motivate their interest in our field. We also present collaborative programs to achieve these goals: a collegiate high-school program developed with Polk State College to engage our youth to pursue science and engineering careers, and a robotic nurse training credentialing program.
A structured assessment for robotic microsurgical training
Robotic surgery as a field has expanded rapidly over the past two decades and is being used widely among surgical subspecialties. Its applications in plastic surgery have emerged gradually over the last few years. One of those promising applications is robotic assisted microvascular anastomosis. The purpose of this study was to develop a validated assessment instrument, and then assess the learning curve for robotic assisted microvascular anastomoses. The authors hypothesized that the subjects would demonstrate measurable improvement across multiple domains of performance as a result of robotic practice.
Methods:
In part 1, an assessment instrument called SARMS (structured assessment of robotic microsurgical skills), which combines the previously validated SAMS (Structured Assessment of Microsurgical Skills) with validated skill domains in robotic surgery was tested. Four blinded expert evaluators graded 6 recorded videos and inter-rater reliability was determined. In part 2, a cohort of 5 microsurgery fellows and 5 Faculty members: each participant performed five robotic assisted micro-anastomotic sessions. All 50 sessions were subjected to blind evaluation using SARMS. Primary outcomes were changes in time required to complete an anastomosis for each participant over the 5 sessions, and trends in SARMS scores for each skill area for each participant over the 5 sessions.
Result:
Inter-rater reliability for the SARMS instrument was excellent for all skill areas rated among the 4 expert, blinded evaluators, demonstrated by Cronback alpha scores greater than 0.9 in each category. All skill areas and overall performance improved significantly for each participant over the 5 robotic assisted micro-anastomosis sessions, and operative time decreased over the study for all participants. The results showed an initial steep technical skill acquisition followed by more gradual improvement, and a steady decrease in operative times that ranged between 1.2 hours and 9 minutes.

Conclusion:
The Structured Assessment of Robotic Microsurgery Skills (SARMS) is a valid instrument for assessing microsurgical skills, with good inter-rater reliability. Subjects at all levels of training from very little microvascular experience to microsurgery experts gained proficiency over the course of 5 sessions.
T Alrasheed
Lecture
4 years ago
115 views
4 likes
0 comments
05:48
A structured assessment for robotic microsurgical training
Robotic surgery as a field has expanded rapidly over the past two decades and is being used widely among surgical subspecialties. Its applications in plastic surgery have emerged gradually over the last few years. One of those promising applications is robotic assisted microvascular anastomosis. The purpose of this study was to develop a validated assessment instrument, and then assess the learning curve for robotic assisted microvascular anastomoses. The authors hypothesized that the subjects would demonstrate measurable improvement across multiple domains of performance as a result of robotic practice.
Methods:
In part 1, an assessment instrument called SARMS (structured assessment of robotic microsurgical skills), which combines the previously validated SAMS (Structured Assessment of Microsurgical Skills) with validated skill domains in robotic surgery was tested. Four blinded expert evaluators graded 6 recorded videos and inter-rater reliability was determined. In part 2, a cohort of 5 microsurgery fellows and 5 Faculty members: each participant performed five robotic assisted micro-anastomotic sessions. All 50 sessions were subjected to blind evaluation using SARMS. Primary outcomes were changes in time required to complete an anastomosis for each participant over the 5 sessions, and trends in SARMS scores for each skill area for each participant over the 5 sessions.
Result:
Inter-rater reliability for the SARMS instrument was excellent for all skill areas rated among the 4 expert, blinded evaluators, demonstrated by Cronback alpha scores greater than 0.9 in each category. All skill areas and overall performance improved significantly for each participant over the 5 robotic assisted micro-anastomosis sessions, and operative time decreased over the study for all participants. The results showed an initial steep technical skill acquisition followed by more gradual improvement, and a steady decrease in operative times that ranged between 1.2 hours and 9 minutes.

Conclusion:
The Structured Assessment of Robotic Microsurgery Skills (SARMS) is a valid instrument for assessing microsurgical skills, with good inter-rater reliability. Subjects at all levels of training from very little microvascular experience to microsurgery experts gained proficiency over the course of 5 sessions.
da Vinci® Si™ Surgical System: current and future technologies
Since the first robotic case in 1999 with the da Vinci® system, Intuitive Surgical has created three different surgical platforms: the da Vinci Standard, the S and the Si. This presentation first reviews the latest da Vinci® system and instrumentation: the simulator, firefly, suction-irrigation, and the vessel-sealer. It then moves on to show upcoming instruments (the linear stapler) and introduces the possible future application of medical imaging agents (non-specific to the robot). As this presentation was made within the context of the RAMSES congress, a few slides show ongoing work specific to “shallow procedures” as well as ongoing research in that field.
R Bastier
Lecture
4 years ago
303 views
12 likes
0 comments
23:10
da Vinci® Si™ Surgical System: current and future technologies
Since the first robotic case in 1999 with the da Vinci® system, Intuitive Surgical has created three different surgical platforms: the da Vinci Standard, the S and the Si. This presentation first reviews the latest da Vinci® system and instrumentation: the simulator, firefly, suction-irrigation, and the vessel-sealer. It then moves on to show upcoming instruments (the linear stapler) and introduces the possible future application of medical imaging agents (non-specific to the robot). As this presentation was made within the context of the RAMSES congress, a few slides show ongoing work specific to “shallow procedures” as well as ongoing research in that field.
Robotic-assisted latissimus dorsi in delayed immediate breast reconstruction
Background: For two-stage delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a secondary option for patients who wish to avoid a donor site incision. The purpose of this study was to compare outcomes of RALDH versus a traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy.
Methods: A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications and outcomes were assessed.
Results: 146 pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed with robotic assistance during the study period (average follow-up 14.6 ±7.3 months). Latissimus dorsi breast reconstruction following radiation was performed in 64 TOT patients and 12 RALDH patients. Surgical complication rates were 37.5% TOT versus 16.7% RALDH (p=0.31), which included seroma (8.9% vs. 8.3%), infection (14.1 vs. 8.3%), wound healing (7.8% vs. 0), and capsular contracture (4.7% vs. 0).
Conclusion: RALDH is associated with a low complication rate and reliable results for reconstruction of the irradiated breast while obviating the need for a donor site incision.
MW Clemens
Lecture
4 years ago
275 views
9 likes
0 comments
15:39
Robotic-assisted latissimus dorsi in delayed immediate breast reconstruction
Background: For two-stage delayed-immediate reconstruction of the radiated breast, robotic-assisted latissimus dorsi harvest (RALDH) is a secondary option for patients who wish to avoid a donor site incision. The purpose of this study was to compare outcomes of RALDH versus a traditional open technique (TOT) for patients undergoing delayed-immediate breast reconstruction following radiation therapy.
Methods: A retrospective analysis of a prospective database of all consecutive patients undergoing latissimus dorsi harvest for radiated breast reconstruction between 2009 and 2013 was performed. Indications, surgical technique, complications and outcomes were assessed.
Results: 146 pedicled latissimus dorsi muscle flaps were performed for breast reconstruction and 17 were performed with robotic assistance during the study period (average follow-up 14.6 ±7.3 months). Latissimus dorsi breast reconstruction following radiation was performed in 64 TOT patients and 12 RALDH patients. Surgical complication rates were 37.5% TOT versus 16.7% RALDH (p=0.31), which included seroma (8.9% vs. 8.3%), infection (14.1 vs. 8.3%), wound healing (7.8% vs. 0), and capsular contracture (4.7% vs. 0).
Conclusion: RALDH is associated with a low complication rate and reliable results for reconstruction of the irradiated breast while obviating the need for a donor site incision.
Intercostal nerves harvesting through thoracoscopy without da Vinci™ robot
Intercostal nerve transfer is useful in brachial plexus surgery, especially for the restoration of elbow flexion. Freeing of intercostal nerves for nerve transfer, however, requires a long skin incision and can result in damage to the muscles and ribs. Video-assisted thoracoscopic surgery (VATS) has been developed recently as a diagnostic and therapeutic technique for intrathoracic organ diseases. Intercostal nerve transfer to the musculocutaneous nerve (MCN) using the VATS system has been performed in eight patients with brachial plexus injuries.

Eight patients (seven males, one female, 17-32 y.o.) underwent intercostal nerve transfer to the MCN using the VATS system between 2005 and 2012. Two patients were converted from thoracoscopic surgery to open surgery. Power of the biceps was recovered to M3 or more in five out of seven patients, who were followed for more than two years postoperatively. No respiratory complications occurred.
Although this technique is challenging, the da Vinci® system will make the procedure easier and improve its accuracy and safety.
Y Mikami
Lecture
4 years ago
68 views
2 likes
0 comments
09:50
Intercostal nerves harvesting through thoracoscopy without da Vinci™ robot
Intercostal nerve transfer is useful in brachial plexus surgery, especially for the restoration of elbow flexion. Freeing of intercostal nerves for nerve transfer, however, requires a long skin incision and can result in damage to the muscles and ribs. Video-assisted thoracoscopic surgery (VATS) has been developed recently as a diagnostic and therapeutic technique for intrathoracic organ diseases. Intercostal nerve transfer to the musculocutaneous nerve (MCN) using the VATS system has been performed in eight patients with brachial plexus injuries.

Eight patients (seven males, one female, 17-32 y.o.) underwent intercostal nerve transfer to the MCN using the VATS system between 2005 and 2012. Two patients were converted from thoracoscopic surgery to open surgery. Power of the biceps was recovered to M3 or more in five out of seven patients, who were followed for more than two years postoperatively. No respiratory complications occurred.
Although this technique is challenging, the da Vinci® system will make the procedure easier and improve its accuracy and safety.
Robotic subinguinal varicocelectomy
Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.
T Shu
Lecture
4 years ago
641 views
29 likes
0 comments
08:03
Robotic subinguinal varicocelectomy
Purpose: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy.
Material and Methods: Ten patients with an average age of 28.4 years underwent 11 microscopic subinguinal varicocelectomies. Ten patients with an average age of 23.1 years underwent 11 robot-assisted varicocelectomies.
Results: The average operative time for microscopic inguinal varicocelectomy was 69.2 minutes, whereas the robot-assisted technique took 70.3 minutes. There were no difficulties in identifying and isolating vessels and the vas deferens with robotic-assisted subinguinal varicocelectomy. Hand tremor was eliminated with the robotic procedure. Robotic patients were able to resume daily activities on the day of surgery and full activities within two weeks. There were no complications or recurrences of varicocele.
Conclusions: From our experience, we believe that robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic surgery, with the added benefit of reducing hand tremor.
International Microsurgical Simulation Society- a new networking society of microsurgeons that can promote training in microsurgery and robotics
Training in specific skills such a microsurgery including robotic microsurgery has become an essential part of surgical training in many institutions around the world. IMSS is a great proof of that with a pronounced group of instructors and practicing microsurgeons who will be working towards standardization of the microsurgery training around the globe and the right skill assessments tools.
There is a vast wealth of expertise and experience that could and needs to be shared between masters and new upcoming instructors in microsurgery. Creating a golden standard for teaching basic microsurgery would help the new courses and centers to adopt the right structure and algorithm to teaching everyone at the very similar methods. Utilizing non-living and living models can be systematized too.
There is also an intense indication towards generating the assessments tools for the microsurgical skills that would allow to significantly improve the quality not only of the surgical training but of patients’ care as well.
One of the goals of IMSS is to stimulate this process and help with network between leading institutions and surgeons. Training in robotic microsurgery is one the aspects of collaboration between IMSS and RAMSES that can lead to successful creation of an assessment tool that can work both in conventional and robotic microsurgery.
Y Akelina
Lecture
4 years ago
90 views
2 likes
0 comments
13:54
International Microsurgical Simulation Society- a new networking society of microsurgeons that can promote training in microsurgery and robotics
Training in specific skills such a microsurgery including robotic microsurgery has become an essential part of surgical training in many institutions around the world. IMSS is a great proof of that with a pronounced group of instructors and practicing microsurgeons who will be working towards standardization of the microsurgery training around the globe and the right skill assessments tools.
There is a vast wealth of expertise and experience that could and needs to be shared between masters and new upcoming instructors in microsurgery. Creating a golden standard for teaching basic microsurgery would help the new courses and centers to adopt the right structure and algorithm to teaching everyone at the very similar methods. Utilizing non-living and living models can be systematized too.
There is also an intense indication towards generating the assessments tools for the microsurgical skills that would allow to significantly improve the quality not only of the surgical training but of patients’ care as well.
One of the goals of IMSS is to stimulate this process and help with network between leading institutions and surgeons. Training in robotic microsurgery is one the aspects of collaboration between IMSS and RAMSES that can lead to successful creation of an assessment tool that can work both in conventional and robotic microsurgery.
Transitioning from microsurgery to robotic microsurgery in reproductive urology
For years, people have been dreaming of robots. Whether for science fiction or for practical use, the idea of a robotic system to mechanically assist us with tasks has been sought after. We used to hear people say “someday robots will perform surgery for us”. It is not necessarily the case, but robots are certainly finding more utility in assisting us with different types of surgery.

The da Vinci® system began with uses for gross surgical procedures and has expanded its utility to microsurgery. In urology, this particularly lends itself to fertility surgery. This technology is primarily useful for vasectomy reversal and varicocelectomy in the realm of reproductive urology. Surgery that we initially tried with the naked eye, advanced through multiple technologies including optical loupes, operative microscopes, and now the operative robot.

The advantages of using robotics to assist with microsurgery in reproductive urology include the robotic endowrists allowing for seven degrees of freedom, which allow for movements that the human hand and wrist cannot make, an ergonomic design for the surgeon which is less fatiguing than an operative microscope which may enhance performance, and high definition 3D optimal visualization of a microsurgical field. The ability to stop operating for a few seconds and to take a breath during challenging microsurgical cases also allows for an unchanged operative field once the surgeon resumes work unlike the operative microscope.

Once the learning curve for robotic microsurgery has been mastered by microsurgeons it should improve operative times as well. My data on robotic vasectomy reversal shows comparable outcomes with robotic microsurgery, even in my very early case series, proving the feasibility of transitioning from pure microsurgery to robotic microsurgery for a formally trained microsurgeon.
P Kavoussi
Lecture
4 years ago
208 views
11 likes
0 comments
13:52
Transitioning from microsurgery to robotic microsurgery in reproductive urology
For years, people have been dreaming of robots. Whether for science fiction or for practical use, the idea of a robotic system to mechanically assist us with tasks has been sought after. We used to hear people say “someday robots will perform surgery for us”. It is not necessarily the case, but robots are certainly finding more utility in assisting us with different types of surgery.

The da Vinci® system began with uses for gross surgical procedures and has expanded its utility to microsurgery. In urology, this particularly lends itself to fertility surgery. This technology is primarily useful for vasectomy reversal and varicocelectomy in the realm of reproductive urology. Surgery that we initially tried with the naked eye, advanced through multiple technologies including optical loupes, operative microscopes, and now the operative robot.

The advantages of using robotics to assist with microsurgery in reproductive urology include the robotic endowrists allowing for seven degrees of freedom, which allow for movements that the human hand and wrist cannot make, an ergonomic design for the surgeon which is less fatiguing than an operative microscope which may enhance performance, and high definition 3D optimal visualization of a microsurgical field. The ability to stop operating for a few seconds and to take a breath during challenging microsurgical cases also allows for an unchanged operative field once the surgeon resumes work unlike the operative microscope.

Once the learning curve for robotic microsurgery has been mastered by microsurgeons it should improve operative times as well. My data on robotic vasectomy reversal shows comparable outcomes with robotic microsurgery, even in my very early case series, proving the feasibility of transitioning from pure microsurgery to robotic microsurgery for a formally trained microsurgeon.
New inside out harvest of flaps
Background:
The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvesting damages the anterior rectus sheath and requires an abdominal incision. Robotic harvesting can be reliably and efficiently performed using three ports, and no additional incisions. This method, better known as the “inside out” harvest has shown to remarkably reduce the morbidity and facilitate a more accurate dissection of the rectus muscle.
Methods:
Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. In half of the free flap cases, a small pubic hairline incision was used to remove the muscle. In the other half, the muscle was removed using a laparoscopic “gallbladder bag.” Basic demographic information, operative variables, and outcomes were recorded.
Results
All cases were completed robotically by three different surgeons at three institutions. Four muscles were harvested for free flaps for lower extremity and 6 muscles were used as pedicled flaps, three for APR reconstruction and two for protection of visceral repair following radical cystoprostatectomy. Average robotic set-up time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8mm ports and one 12mm port were in each case. One patient developed a grade I decubitus ulcer during surgery. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique. No hernias noted.
Conclusions
Robotic rectus muscle harvesting is safe, efficient and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity, and the cumulative incisional length can be less than two inches for extensive, multi-service pelvic procedures, thus minimizing morbidity and perhaps shortening length of stay compared to open techniques.
JC Pedersen
Lecture
4 years ago
184 views
6 likes
0 comments
13:35
New inside out harvest of flaps
Background:
The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvesting damages the anterior rectus sheath and requires an abdominal incision. Robotic harvesting can be reliably and efficiently performed using three ports, and no additional incisions. This method, better known as the “inside out” harvest has shown to remarkably reduce the morbidity and facilitate a more accurate dissection of the rectus muscle.
Methods:
Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. In half of the free flap cases, a small pubic hairline incision was used to remove the muscle. In the other half, the muscle was removed using a laparoscopic “gallbladder bag.” Basic demographic information, operative variables, and outcomes were recorded.
Results
All cases were completed robotically by three different surgeons at three institutions. Four muscles were harvested for free flaps for lower extremity and 6 muscles were used as pedicled flaps, three for APR reconstruction and two for protection of visceral repair following radical cystoprostatectomy. Average robotic set-up time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8mm ports and one 12mm port were in each case. One patient developed a grade I decubitus ulcer during surgery. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique. No hernias noted.
Conclusions
Robotic rectus muscle harvesting is safe, efficient and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity, and the cumulative incisional length can be less than two inches for extensive, multi-service pelvic procedures, thus minimizing morbidity and perhaps shortening length of stay compared to open techniques.
Large vessels: what is the robot's place in vascular surgery?
Since 2006, our vascular surgery team has developed an original program in the field of minimally invasive aortic surgery; for all cases of aortic disease unsuitable for endovascular treatment, we propose an alternative way to open surgery: using the da Vinci® surgical robotic system to perform aorto-aortic, aortobi-iliac and aorto-bifemoral bypasses, in more than 95 patients to date.

Contrarily to laparoscopy, the robot provides operating conditions, namely more comfort with a 3D vision, and operative steps very similar to open surgery. These key points account for a learning curve that is shorter than laparoscopy for aortic procedures.

For the first time in the literature, the robot was used by our team to perform the entire procedure including the retroperitoneal approach, aortic exposure, and the prosthetic suture.

We respect TASC recommendations for revascularizations by aorto-bifemoral bypasses, and surgery is always decided upon after failure of endovascular treatment.

For aneurysms, robotic surgery is proposed if the case is not suitable for endograft, and after informed patient consent.

The new design of the operating room with the robot, the training of the surgical team, the original design of the technique with placement of robotic ports, explain a mean operative time exceeding 6 hours, and a conversion rate with mini-lumbotomy of 30% of our learning curve in the first 30 cases. Currently, we treat more than 20 patients per year, with an average operative time of less than 5 hours, and with only 5% of surgical conversions by mini-lumbotomies. The progression of technology now allows us to clamp the suprarenal aorta and to perform cases of aneurysms with tubes or bifurcated grafts if we need to go on the primitive iliac arteries.

Our clinical results show a primary patency rate of 96% at the first year, 94% at the third year, and 86% at the fifth year. No postoperative death was related to the aortic pathology, the mortality rate was 96% at the first year, 83% at the third year, and 76% at the fifth year.

In addition, new surgical indications provide the opportunity to use the da Vinci® robot to deal with complex arterial disease: our team was able to treat cases of splenic aneurysms, with direct arterial reconstructions, arterial sutures performed entirely with the robot.

Our experience shows that arterial surgery for large vessels is entirely feasible with the da Vinci® robot. This opens valuable future perspectives, which will depend on the improvement of surgical robotic systems available.
F Thaveau
Lecture
4 years ago
164 views
1 like
0 comments
09:41
Large vessels: what is the robot's place in vascular surgery?
Since 2006, our vascular surgery team has developed an original program in the field of minimally invasive aortic surgery; for all cases of aortic disease unsuitable for endovascular treatment, we propose an alternative way to open surgery: using the da Vinci® surgical robotic system to perform aorto-aortic, aortobi-iliac and aorto-bifemoral bypasses, in more than 95 patients to date.

Contrarily to laparoscopy, the robot provides operating conditions, namely more comfort with a 3D vision, and operative steps very similar to open surgery. These key points account for a learning curve that is shorter than laparoscopy for aortic procedures.

For the first time in the literature, the robot was used by our team to perform the entire procedure including the retroperitoneal approach, aortic exposure, and the prosthetic suture.

We respect TASC recommendations for revascularizations by aorto-bifemoral bypasses, and surgery is always decided upon after failure of endovascular treatment.

For aneurysms, robotic surgery is proposed if the case is not suitable for endograft, and after informed patient consent.

The new design of the operating room with the robot, the training of the surgical team, the original design of the technique with placement of robotic ports, explain a mean operative time exceeding 6 hours, and a conversion rate with mini-lumbotomy of 30% of our learning curve in the first 30 cases. Currently, we treat more than 20 patients per year, with an average operative time of less than 5 hours, and with only 5% of surgical conversions by mini-lumbotomies. The progression of technology now allows us to clamp the suprarenal aorta and to perform cases of aneurysms with tubes or bifurcated grafts if we need to go on the primitive iliac arteries.

Our clinical results show a primary patency rate of 96% at the first year, 94% at the third year, and 86% at the fifth year. No postoperative death was related to the aortic pathology, the mortality rate was 96% at the first year, 83% at the third year, and 76% at the fifth year.

In addition, new surgical indications provide the opportunity to use the da Vinci® robot to deal with complex arterial disease: our team was able to treat cases of splenic aneurysms, with direct arterial reconstructions, arterial sutures performed entirely with the robot.

Our experience shows that arterial surgery for large vessels is entirely feasible with the da Vinci® robot. This opens valuable future perspectives, which will depend on the improvement of surgical robotic systems available.
Robotic microsurgery training
Robotic microsurgery is a newly emerging field, which offers several potential advantages to the operating surgeon, including the ability to perform challenging procedures in previously inaccessible locations. As with any new technique, robotic microsurgery requires the acquisition of a novel skillset with a need to overcome the associated learning curve. A review of the available literature suggests that compared to traditional techniques, initial experience with robotic-assisted microsurgery is associated with greater operative times and equivalent surgical outcomes. Although prior robotic experience may help to negate the initial learning curve with robotic microsurgery, existing microsurgical skills appear to be less relevant early on. Longer term, prospective, multi-institutional studies are required to determine if robotic assistance results in earlier technique mastery or improved outcomes as compared to traditional microsurgical approaches. Several modalities are currently available to assist surgeons in improving robotic microsurgical skills including didactics, laboratory simulation with synthetic, in vitro, or in vivo models, dry-dock robotic time, and simulators. Despite clear variability in fidelity of training modalities, performance measures correlate highly and are predictive of intraoperative performance. Given the increasing focus on outcome-based care, initial and subsequent recertification of robotic proficiency will likely be increasingly required.
L Trost
Lecture
4 years ago
189 views
2 likes
0 comments
09:42
Robotic microsurgery training
Robotic microsurgery is a newly emerging field, which offers several potential advantages to the operating surgeon, including the ability to perform challenging procedures in previously inaccessible locations. As with any new technique, robotic microsurgery requires the acquisition of a novel skillset with a need to overcome the associated learning curve. A review of the available literature suggests that compared to traditional techniques, initial experience with robotic-assisted microsurgery is associated with greater operative times and equivalent surgical outcomes. Although prior robotic experience may help to negate the initial learning curve with robotic microsurgery, existing microsurgical skills appear to be less relevant early on. Longer term, prospective, multi-institutional studies are required to determine if robotic assistance results in earlier technique mastery or improved outcomes as compared to traditional microsurgical approaches. Several modalities are currently available to assist surgeons in improving robotic microsurgical skills including didactics, laboratory simulation with synthetic, in vitro, or in vivo models, dry-dock robotic time, and simulators. Despite clear variability in fidelity of training modalities, performance measures correlate highly and are predictive of intraoperative performance. Given the increasing focus on outcome-based care, initial and subsequent recertification of robotic proficiency will likely be increasingly required.
Nerve tumor excision with robots
Chronic peripheral nerve lesion surgery should not only limit recurrence after excision, but it could also limit sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result.
Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A da Vinci S® robot with microsurgical instruments was used for intraneural dissection. One case was performed using a minimally invasive approach.
At the last follow-up, pain ranged from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except in 2 patients whose sensory function was improved. No recurrence was noted.
Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases surgery accuracy. These preliminary results suggest that surgical robots could play an essential role in microsurgery.
P Liverneaux
Lecture
4 years ago
88 views
1 like
0 comments
10:17
Nerve tumor excision with robots
Chronic peripheral nerve lesion surgery should not only limit recurrence after excision, but it could also limit sensory and motor sequelae. The aim of this work was to study the interest of telemicrosurgery to improve this result.
Our series included 7 patients with peripheral nerve neuroma and tumors including two cases of hereditary neurofibromatosis. A da Vinci S® robot with microsurgical instruments was used for intraneural dissection. One case was performed using a minimally invasive approach.
At the last follow-up, pain ranged from 6/10 preoperatively to 3/10 postoperatively. The sensory deficit was stable except in 2 patients whose sensory function was improved. No recurrence was noted.
Telemicrosurgery seems to have two interests in the treatment of chronic peripheral nerve lesions: it reduces the size of incisions and increases surgery accuracy. These preliminary results suggest that surgical robots could play an essential role in microsurgery.
Robotic technology in wound healing osteomyelitis
Introduction:
We initiated the use of robotic instrumentation in the surgical management of complex, recurrent non-healing wounds due to osteomyelitis in July 2012. The primary objective is to demonstrate the benefit of the visual superiority and more precise tissue dissection offered by robotic technology.

Material and methods:
After obtaining approval for the use of the da Vinci® robotic surgical system (Intuitive Surgical®) as an “exoscopic” approach at our institution, three patients were enrolled in the protocol wound debridement/osteomyelitis/da Vinci®.
We will be presenting the clinical manifestations and imaging diagnosis of osteomyelitis, as well as outlining the surgical procedure and the use of the robotic system for soft tissue and bone debridement. The complimentary application of bioengineering tissue enhancement material was used in one patient (Cryopreserved amniotic membrane Amniox®), and in two patients (Apligraf Organogenesis, Inc). Comprehensive postoperative wound management will be discussed.

Results:
Two patients had completely healed wounds at 130 and 230 days respectively, without functional joint deficit. Although the third patient had only 3 weeks of follow-up, they appear to be progressing as expected.

Conclusions:
The basic capability of robotic technology (visual and manual control) appears to facilitate the surgical management of osteomyelitis, particularly in restricted anatomical spaces and in proximity to joints. We propose further clinical research and outcome healing measurements with this subgroup of patients that might otherwise require amputation.
B Martinez
Lecture
4 years ago
87 views
3 likes
0 comments
09:44
Robotic technology in wound healing osteomyelitis
Introduction:
We initiated the use of robotic instrumentation in the surgical management of complex, recurrent non-healing wounds due to osteomyelitis in July 2012. The primary objective is to demonstrate the benefit of the visual superiority and more precise tissue dissection offered by robotic technology.

Material and methods:
After obtaining approval for the use of the da Vinci® robotic surgical system (Intuitive Surgical®) as an “exoscopic” approach at our institution, three patients were enrolled in the protocol wound debridement/osteomyelitis/da Vinci®.
We will be presenting the clinical manifestations and imaging diagnosis of osteomyelitis, as well as outlining the surgical procedure and the use of the robotic system for soft tissue and bone debridement. The complimentary application of bioengineering tissue enhancement material was used in one patient (Cryopreserved amniotic membrane Amniox®), and in two patients (Apligraf Organogenesis, Inc). Comprehensive postoperative wound management will be discussed.

Results:
Two patients had completely healed wounds at 130 and 230 days respectively, without functional joint deficit. Although the third patient had only 3 weeks of follow-up, they appear to be progressing as expected.

Conclusions:
The basic capability of robotic technology (visual and manual control) appears to facilitate the surgical management of osteomyelitis, particularly in restricted anatomical spaces and in proximity to joints. We propose further clinical research and outcome healing measurements with this subgroup of patients that might otherwise require amputation.
Neurotisation to the axillary nerve by the nerve to the triceps
Nerve transfer to the deltoid muscle using the nerve of the long head of the triceps is a reliable method for deltoid function restoration. The aim of this retrospective study was to report the results of the nerve transfer procedure to the deltoid muscle using the nerve of the long head of the triceps by means of a robot.
Our series included six patients (mean age: 36.3 years) with total deltoid muscle paralysis. A da Vinci S® robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, then robotically sutured with two 10/0 Nylon stitches. In 2 cases, an endoscopic procedure was attempted under carbon dioxide insufflation.
In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No elbow extension weakness was observed. In 2 cases with the endoscopic technique, vision was blurred and conversion to the open technique was performed.
The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremors. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without sensory feedback. The robot-assisted nerve transfer to the deltoid muscle using the nerve of the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury.
H Miyamoto
Lecture
4 years ago
64 views
2 likes
0 comments
07:07
Neurotisation to the axillary nerve by the nerve to the triceps
Nerve transfer to the deltoid muscle using the nerve of the long head of the triceps is a reliable method for deltoid function restoration. The aim of this retrospective study was to report the results of the nerve transfer procedure to the deltoid muscle using the nerve of the long head of the triceps by means of a robot.
Our series included six patients (mean age: 36.3 years) with total deltoid muscle paralysis. A da Vinci S® robot was placed in position. After dissection of the quadrilateral and triangular spaces, the anterior branch of the axillary nerve and the branch to the long head of the triceps were transected, then robotically sutured with two 10/0 Nylon stitches. In 2 cases, an endoscopic procedure was attempted under carbon dioxide insufflation.
In all patients except one, deltoid function against resistance (M4) was obtained at the last follow-up evaluation. The average shoulder abduction was 112 degrees. No elbow extension weakness was observed. In 2 cases with the endoscopic technique, vision was blurred and conversion to the open technique was performed.
The advantages of robotic microsurgery are motion scaling and disappearance of physiological tremors. Reasons for failure of the endoscopic technique could be explained by insufficient pressure. We had no difficulty using the robot without sensory feedback. The robot-assisted nerve transfer to the deltoid muscle using the nerve of the long head of the triceps was a feasible application for restoration of shoulder abduction after brachial plexus or axillary nerve injury.
Oberlin's procedure for restoration of elbow flexion with a da Vinci® robot
Robotics allow visual magnification up to 40 times, and a 10 time-magnification of the surgeon’s movements, as well as the elimination of physiological tremors. These properties should allow for the development of minimally invasive limb surgery, especially brachial plexus surgery. The purpose of this work was to test the feasibility of elbow flexion restoration according to the technique of Oberlin using a da Vinci® robot. Our series included 4 patients (mean age: 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S® robot. In three patients, the open technique (technique 1) was used, and the minimally invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1 year of follow-up, all patients recovered elbow flexion. No sensory nor motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 due to the difficulty in visualizing the operative field. The results of our series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the minimally invasive technique.
K Naito
Lecture
4 years ago
103 views
2 likes
0 comments
07:00
Oberlin's procedure for restoration of elbow flexion with a da Vinci® robot
Robotics allow visual magnification up to 40 times, and a 10 time-magnification of the surgeon’s movements, as well as the elimination of physiological tremors. These properties should allow for the development of minimally invasive limb surgery, especially brachial plexus surgery. The purpose of this work was to test the feasibility of elbow flexion restoration according to the technique of Oberlin using a da Vinci® robot. Our series included 4 patients (mean age: 31 years) presenting with elbow flexion paralysis. They were operated on 8 months after injury using a da Vinci S® robot. In three patients, the open technique (technique 1) was used, and the minimally invasive approach (technique 2) was used for the last one. Strength of elbow flexion was measured. After 1 year of follow-up, all patients recovered elbow flexion. No sensory nor motor deficit was found in the ulnar nerve territory. There was no difficulty with technique 1; technique 2, however, required a conversion to technique 1 due to the difficulty in visualizing the operative field. The results of our series show the feasibility of the robot-assisted technique for the Oberlin procedure. The lack of sensory feedback was not an issue. The development of specific retractors and instruments should improve the minimally invasive technique.
Small vessels endoscopic anastomosis: feasibility study
The size of incisions for free muscle flaps is often very large, and a source of deep adhesions and unesthetic scars but it is justified by performing the microsurgical step comfortably. In the hope of shortening the size of incisions, the objective of this work was to study the feasibility of vascular micro-anastomoses using an endoscopic approach. The material consisted of 2 cadavers, a tele-manipulator, and a vascular clamp. The antebrachial skin was detached, then distended by gas insufflations. Four incisions, one centimeter each, allowed for the set-up of 4 trocars connected to the tele-manipulator. The artery was dissected (radial or ulnar) and the vascular clamp was introduced under the skin through one of the trocars, and then positioned on the dissected artery. The vascular anastomosis was performed with the use of a 10/0 Nylon suture. The anastomosis lasted 2 hours under insufflation with no leaks. The 2 arteries were identified, then dissected without difficulty. The anastomosis was performed in adequate conditions. The mounting and demounting of the clamp were time-consuming. The main difficulties were caused by a long suture and a very fragile needle. Our results demonstrate the feasibility of vascular micro-anastomosis using an endoscopic approach. The next step is to perform the first clinical case (e.g., on a latissimus dorsi free muscle flap).
E Robert
Lecture
4 years ago
135 views
3 likes
0 comments
08:37
Small vessels endoscopic anastomosis: feasibility study
The size of incisions for free muscle flaps is often very large, and a source of deep adhesions and unesthetic scars but it is justified by performing the microsurgical step comfortably. In the hope of shortening the size of incisions, the objective of this work was to study the feasibility of vascular micro-anastomoses using an endoscopic approach. The material consisted of 2 cadavers, a tele-manipulator, and a vascular clamp. The antebrachial skin was detached, then distended by gas insufflations. Four incisions, one centimeter each, allowed for the set-up of 4 trocars connected to the tele-manipulator. The artery was dissected (radial or ulnar) and the vascular clamp was introduced under the skin through one of the trocars, and then positioned on the dissected artery. The vascular anastomosis was performed with the use of a 10/0 Nylon suture. The anastomosis lasted 2 hours under insufflation with no leaks. The 2 arteries were identified, then dissected without difficulty. The anastomosis was performed in adequate conditions. The mounting and demounting of the clamp were time-consuming. The main difficulties were caused by a long suture and a very fragile needle. Our results demonstrate the feasibility of vascular micro-anastomosis using an endoscopic approach. The next step is to perform the first clinical case (e.g., on a latissimus dorsi free muscle flap).
Robotic surgery training center, a Brazilian experience
Introduction:
As there is no training protocol for robotic microsurgery established by Intuitive Surgical®, we chose to prepare a bibliographic revision about microsurgery training protocols, associating training with inanimate objects and practical training in biological material (animal model).
Methods:
A systematic review was performed crossing the words education and robotics using the PUBMED database. The search presented a result of 249 articles. We considered articles published in English over the past 10 years, having as a selection criteria for inclusion, the description of one of the following items: 1) techniques of teaching; 2) the learning curve or the training of basic principles of surgery as the basis of a training program; 19 published articles were eligible.
Discussion:
The possibility to adapt teaching techniques which are used in robotic laparoscopic videos and connecting theory with practice. The learning process has been organized in different levels of teaching.
Conclusion:
The fact that there are no recognized protocols for robotic microsurgery by Intuitive Surgical®, creates a necessity to develop teaching methodology standards for the robotic microsurgeon in order to be trained in a safer, faster, more efficient and more intuitive way and having as a result a more positive patient clinical outcome.
M Cerdan Torres
Lecture
4 years ago
213 views
3 likes
0 comments
05:10
Robotic surgery training center, a Brazilian experience
Introduction:
As there is no training protocol for robotic microsurgery established by Intuitive Surgical®, we chose to prepare a bibliographic revision about microsurgery training protocols, associating training with inanimate objects and practical training in biological material (animal model).
Methods:
A systematic review was performed crossing the words education and robotics using the PUBMED database. The search presented a result of 249 articles. We considered articles published in English over the past 10 years, having as a selection criteria for inclusion, the description of one of the following items: 1) techniques of teaching; 2) the learning curve or the training of basic principles of surgery as the basis of a training program; 19 published articles were eligible.
Discussion:
The possibility to adapt teaching techniques which are used in robotic laparoscopic videos and connecting theory with practice. The learning process has been organized in different levels of teaching.
Conclusion:
The fact that there are no recognized protocols for robotic microsurgery by Intuitive Surgical®, creates a necessity to develop teaching methodology standards for the robotic microsurgeon in order to be trained in a safer, faster, more efficient and more intuitive way and having as a result a more positive patient clinical outcome.
Robotic thoracoscopy: intercostal nerves and phrenic nerve harvesting
The aim of this study was to report the feasibility of robotic intercostal nerve harvesting in a pig model. A surgical robot (the da Vinci S® system, Intuitive Surgical, Sunnyvale, CA) was installed with three ports on the pig’s left chest. The posterior edges of the 4th, 5th, and 6th intercostal nerves were isolated to the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvests were successfully performed in 40 minutes without major complications. The advantages of robotic microsurgery for intercostal nerve harvesting are motion scaling up to 5 times, elimination of physiological tremors, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvesting for brachial plexus reconstruction.
H Miyamoto
Lecture
4 years ago
145 views
5 likes
0 comments
06:07
Robotic thoracoscopy: intercostal nerves and phrenic nerve harvesting
The aim of this study was to report the feasibility of robotic intercostal nerve harvesting in a pig model. A surgical robot (the da Vinci S® system, Intuitive Surgical, Sunnyvale, CA) was installed with three ports on the pig’s left chest. The posterior edges of the 4th, 5th, and 6th intercostal nerves were isolated to the level of the anterior axillary line. The anterior edges of the nerves were transected at the rib cartilage zone. Three intercostal nerve harvests were successfully performed in 40 minutes without major complications. The advantages of robotic microsurgery for intercostal nerve harvesting are motion scaling up to 5 times, elimination of physiological tremors, and free movement of joint-equipped robotic arms. Robot-assisted neurolysis may be clinically useful for intercostal nerve harvesting for brachial plexus reconstruction.
Image-guided surgery: the augmented reality assistance
Medical imaging quality and accuracy of the human body (MRI, CT-scan, US, PET-scan) currently enable practitioners to establish a very precise diagnosis and to plan surgical interventions (open and laparoscopic surgery). Additionally, from CT-scan or MRI sections, the latest systems allow to display organs and pathological structures of patients in 3 dimensions, thereby facilitating the spatial understanding of practitioners. However, fully exploiting this precious information remains a challenge. In this presentation, the author explains how 3D patient model can be used to improve surgical planning. The author then describes how these 3D models can be brought to the operating room using augmented reality. Finally, the author provides an overview of the latest techniques about augmented reality guidance during minimally invasive surgery, and the main problems that still need to be overcome.
S Nicolau
Lecture
4 years ago
325 views
5 likes
0 comments
08:23
Image-guided surgery: the augmented reality assistance
Medical imaging quality and accuracy of the human body (MRI, CT-scan, US, PET-scan) currently enable practitioners to establish a very precise diagnosis and to plan surgical interventions (open and laparoscopic surgery). Additionally, from CT-scan or MRI sections, the latest systems allow to display organs and pathological structures of patients in 3 dimensions, thereby facilitating the spatial understanding of practitioners. However, fully exploiting this precious information remains a challenge. In this presentation, the author explains how 3D patient model can be used to improve surgical planning. The author then describes how these 3D models can be brought to the operating room using augmented reality. Finally, the author provides an overview of the latest techniques about augmented reality guidance during minimally invasive surgery, and the main problems that still need to be overcome.
Plastic and reconstructive robotic surgery: 5 cases and a systematic review
Introduction
We sought to determine the feasibility of robotic microvascular surgery in reconstructive surgery. Additionally, we performed a systematic review to assess the current developments in robotic plastic surgery.

Methods
Between February 2009 and June 2010, five patients underwent robotic microvascular anastomoses for delayed, free-tissue breast reconstruction, using the deep inferior epigastric artery (DIEP) flap. A PubMed and MEDLINE search was also performed using specific search terms.

Results
Mean patient age was 55.4 years. Mean robotic anastomotic time was 96 minutes. There were no additional errors of management (EOM). Figure 1 shows anastomotic times. No intraoperative or postoperative flap-related complications were encountered.
The literature search yielded 338 articles. Only 19 publications were relevant and further analyzed. The majority of authors report outcomes of microvascular surgery in laboratory conditions. Robotic microsurgery is accurate but consistently takes longer than with the microscope. Investigators consistently report poor haptic feedback.

Conclusion
Robotic microsurgery is safe in our experience. The current literature illustrates comparable vascular patency rates at the cost of longer operative times. Comparing robotic and standard microsurgery may be hampering the evolution of robotic plastic surgery because of this focus. The ability to perform microsurgery in confined anatomical spaces will reduce patient morbidity and potentially reduce in-patient stay. The ability to raise and inset flaps and explore neural and vascular structures, whilst avoiding large access wounds at both donor and recipient sites, is very attractive. Consequently, we believe that there any many reconstructive applications, and collaboration to produce meaningful clinical outcomes is required.
D Saleh
Lecture
4 years ago
322 views
16 likes
0 comments
10:28
Plastic and reconstructive robotic surgery: 5 cases and a systematic review
Introduction
We sought to determine the feasibility of robotic microvascular surgery in reconstructive surgery. Additionally, we performed a systematic review to assess the current developments in robotic plastic surgery.

Methods
Between February 2009 and June 2010, five patients underwent robotic microvascular anastomoses for delayed, free-tissue breast reconstruction, using the deep inferior epigastric artery (DIEP) flap. A PubMed and MEDLINE search was also performed using specific search terms.

Results
Mean patient age was 55.4 years. Mean robotic anastomotic time was 96 minutes. There were no additional errors of management (EOM). Figure 1 shows anastomotic times. No intraoperative or postoperative flap-related complications were encountered.
The literature search yielded 338 articles. Only 19 publications were relevant and further analyzed. The majority of authors report outcomes of microvascular surgery in laboratory conditions. Robotic microsurgery is accurate but consistently takes longer than with the microscope. Investigators consistently report poor haptic feedback.

Conclusion
Robotic microsurgery is safe in our experience. The current literature illustrates comparable vascular patency rates at the cost of longer operative times. Comparing robotic and standard microsurgery may be hampering the evolution of robotic plastic surgery because of this focus. The ability to perform microsurgery in confined anatomical spaces will reduce patient morbidity and potentially reduce in-patient stay. The ability to raise and inset flaps and explore neural and vascular structures, whilst avoiding large access wounds at both donor and recipient sites, is very attractive. Consequently, we believe that there any many reconstructive applications, and collaboration to produce meaningful clinical outcomes is required.
Functional reconstruction with motoneuron integrated striated muscles (MISM)
This study is made up of two parts. The first part is an animal experiment to develop a novel surgical technology named motoneuron-integrated striated muscles (MISM) technology. The second part is the introduction of a new human machine interface technology based on tacit learning. By combining the two advanced technologies, we have been trying to develop a future treatment for currently untreatable nerve palsies.
Re-innervation of denervated muscle by motoneurons transplanted into the peripheral nerve may provide the potential to excite muscles artificially with functional electrical stimulation (FES). We transplanted embryonic motoneurons into the peripheral nerve of adult Fischer 344 rats after transection of the sciatic nerve. One week after sciatic nerve transection, medium with or without dissociated embryonic spinal neurons was injected into the distal stump. Electrophysiological and tissue analyses were performed 12 weeks after transplant, as well as a naive control group which received no surgery. In the cell transplant group, the ankle angle was measured during gait with and without FES of the peroneal nerve. Transplanted motoneurons survived in the peripheral nerve and formed functional motor units. In the cell transplantation group, ankle angle at mid-swing was more flexed during gait with FES (26.6 ± 8.7°) than gait without FES (51.4 ± 12.8°, p=0.011), indicating that transplanted motoneurons in conjunction with FES restored ankle flexion in gait, even though no neural connection between central nervous system and muscle was present. These results indicate that transplant of embryonic motoneurons into peripheral nerve combined with FES can provide a new treatment strategy for paralyzed muscles. For the successful clinical application of MISM technology, the development of a human machine interface is key. We have developed a novel computer program, the tacit learning program, which can analyze patient intention and automatically adjust limb motion with minimum mental/physical burden on the human side. I am going to introduce a newly developed multi-degree of freedom electric-powered arm based on tacit learning to demonstrate the efficacy of the technology.
H Hirata
Lecture
4 years ago
169 views
5 likes
0 comments
12:07
Functional reconstruction with motoneuron integrated striated muscles (MISM)
This study is made up of two parts. The first part is an animal experiment to develop a novel surgical technology named motoneuron-integrated striated muscles (MISM) technology. The second part is the introduction of a new human machine interface technology based on tacit learning. By combining the two advanced technologies, we have been trying to develop a future treatment for currently untreatable nerve palsies.
Re-innervation of denervated muscle by motoneurons transplanted into the peripheral nerve may provide the potential to excite muscles artificially with functional electrical stimulation (FES). We transplanted embryonic motoneurons into the peripheral nerve of adult Fischer 344 rats after transection of the sciatic nerve. One week after sciatic nerve transection, medium with or without dissociated embryonic spinal neurons was injected into the distal stump. Electrophysiological and tissue analyses were performed 12 weeks after transplant, as well as a naive control group which received no surgery. In the cell transplant group, the ankle angle was measured during gait with and without FES of the peroneal nerve. Transplanted motoneurons survived in the peripheral nerve and formed functional motor units. In the cell transplantation group, ankle angle at mid-swing was more flexed during gait with FES (26.6 ± 8.7°) than gait without FES (51.4 ± 12.8°, p=0.011), indicating that transplanted motoneurons in conjunction with FES restored ankle flexion in gait, even though no neural connection between central nervous system and muscle was present. These results indicate that transplant of embryonic motoneurons into peripheral nerve combined with FES can provide a new treatment strategy for paralyzed muscles. For the successful clinical application of MISM technology, the development of a human machine interface is key. We have developed a novel computer program, the tacit learning program, which can analyze patient intention and automatically adjust limb motion with minimum mental/physical burden on the human side. I am going to introduce a newly developed multi-degree of freedom electric-powered arm based on tacit learning to demonstrate the efficacy of the technology.
Transaxillary first rib resection from an endoscopic concept to robotic technology, 30 years of experience
Introduction:
Our interest in minimally invasive vascular surgery dates back to 1982. We designed our endoscope, attached to a micro-video camera, making the transaxillary first rib and cervical band resection safer for the surgical treatment of disabling thoracic outlet syndrome. Over the following two decades, we evolved with the rapid technological development of minimally invasive surgery.

Material and methods:
644 total surgical procedures were performed between 1983 and 2013, including various stages. Video presentation of the “final product” in evolution during the past 10 years using the da Vinci® robotic system will be shown.

Results:
There were no mortalities, no permanent nerve, artery, or vein damage. The following could be noted: 8% complications, 4% respiratory, 3% temporary neurological dysfunctions, 0.8% infection, 0.4% transient renal insufficiency. Conversion rate was 1.1%, scar tissue formation of 0.4%, and length of stay: 3.3 days.

Conclusions:
The endoscopic transaxillary approach has helped us to understand the pathogenesis of the cervical bands frequently present in thoracic outlet syndrome. The procedure has evolved over the last 3 decades and the da Vinci® robotic system definitely offers great advantages, improving the surgical procedure and clinical outcome.
B Martinez
Lecture
4 years ago
320 views
7 likes
0 comments
14:10
Transaxillary first rib resection from an endoscopic concept to robotic technology, 30 years of experience
Introduction:
Our interest in minimally invasive vascular surgery dates back to 1982. We designed our endoscope, attached to a micro-video camera, making the transaxillary first rib and cervical band resection safer for the surgical treatment of disabling thoracic outlet syndrome. Over the following two decades, we evolved with the rapid technological development of minimally invasive surgery.

Material and methods:
644 total surgical procedures were performed between 1983 and 2013, including various stages. Video presentation of the “final product” in evolution during the past 10 years using the da Vinci® robotic system will be shown.

Results:
There were no mortalities, no permanent nerve, artery, or vein damage. The following could be noted: 8% complications, 4% respiratory, 3% temporary neurological dysfunctions, 0.8% infection, 0.4% transient renal insufficiency. Conversion rate was 1.1%, scar tissue formation of 0.4%, and length of stay: 3.3 days.

Conclusions:
The endoscopic transaxillary approach has helped us to understand the pathogenesis of the cervical bands frequently present in thoracic outlet syndrome. The procedure has evolved over the last 3 decades and the da Vinci® robotic system definitely offers great advantages, improving the surgical procedure and clinical outcome.
Use of Konnyaku Shirataki for robotic microsurgery training
The aim of this study was to test the potential implementation of a type of Japanese noodle, named konnyaku shirataki, for microsurgery training in the operating room.
Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: rat femoral artery model (control) and one on a konnyaku shirataki model. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and watertightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anatomosis was significantly higher in the control group. The number of stitches was similar in the 2 groups. Patency of the anastomosis was significantly lower in the control group. Watertightness of the anastomosis was significantly higher in the control group.
The konnyaku shirataki model, by its availability, low cost and close structure to the animal model could improve the teaching of microsurgery and tele-microsurgery (robotic microsurgery).
G Prunières
Lecture
4 years ago
276 views
6 likes
0 comments
07:54
Use of Konnyaku Shirataki for robotic microsurgery training
The aim of this study was to test the potential implementation of a type of Japanese noodle, named konnyaku shirataki, for microsurgery training in the operating room.
Thirteen surgical residents without experience in microsurgery had to perform two microsurgical anastomoses: rat femoral artery model (control) and one on a konnyaku shirataki model. Two quantitative variables (time in minutes and number of stitches to perform the anastomosis) and two qualitative variables (patency and watertightness of the anastomosis) were measured. Sixty anastomoses were performed with the control model and 62 anastomoses with the konnyaku model. The time of the anatomosis was significantly higher in the control group. The number of stitches was similar in the 2 groups. Patency of the anastomosis was significantly lower in the control group. Watertightness of the anastomosis was significantly higher in the control group.
The konnyaku shirataki model, by its availability, low cost and close structure to the animal model could improve the teaching of microsurgery and tele-microsurgery (robotic microsurgery).