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1.  Robotically Assisted Laparoscopic Roux-en-Y Hepaticojejunostomy 
Introduction:
This study evaluates the feasibility and safety of using robotically assisted laparoscopy to perform a Roux-en-Y hepaticojejunostomy. This new method was compared with the open and standard laparoscopic approaches.
Methods:
Eighteen pigs underwent a needlescopic common bile duct ligation to create a jaundice model. Three to 5 days later, transabdominal ultrasound was performed, and the common bile duct diameter was documented. For the Roux-en-Y hepaticojejunostomy, the pigs were randomly assigned to the open group (n=6), standard laparoscopy group (n=6), or robotically assisted laparoscopy group (Zeus) (n=6). One surgeon performed all 3 approaches with 1 assistant. Operative times, techniques, and complication rates were documented.
Results:
The open approach was faster in all instances. At the hepaticojejunostomy, no difference was noted between the groups with the total number of stitches used. The robot required fewer stitches and less time in the posterior wall of the hepaticojejunostomy (P=0.0083 and P=0.02049, respectively). The hepaticojejunostomy time was similar for the laparoscopy and robotically assisted groups.
Conclusion:
Robotically assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible procedure. When compared with standard laparoscopy, operating time is similar.
PMCID: PMC3016811  PMID: 15347111
Roux-en-Y hepaticojejunostomy; Laparoscopic Roux-en-Y hepaticojejunostomy; Robotically assisted hepaticojejunostomy
2.  Robotic Surgery in Gynecologic Field 
Yonsei Medical Journal  2008;49(6):886-890.
Operative laparoscopy was initially developed in the field of gynecology earlier on and the advent of laparoscopic surgery led to advances in general surgery as well. In the last few years, a number of articles have been published on the performance of surgical procedures using the robot-assisted laparoscopy. The shortcomings of conventional laparoscopy have led to the development of robotic surgical system and future of telerobotic surgery is not far away, enabling a surgeon to operate at a distance from the operating table. The complete loss of tactile sensation is often quoted as a big disadvantage of working with robotic systems. Although the first generation da Vinci robotic surgical system provides improved imaging and instrumentation, the absence of tactile feedback and the high cost of the technology remain as limitations. New generations of the robotic surgical systems have been developed, allowing visualization of preoperative imaging during the operation. Though the introduction of robotics is very recent, the potential for robotics in several specialties is significant. However, the benefit to patients must be carefully evaluated and proven before this technology can become widely accepted in the gynecologic surgery.
doi:10.3349/ymj.2008.49.6.886
PMCID: PMC2628037  PMID: 19108009
Robotics; uterine cervical neoplasm; hysterectomy
3.  Preliminary Experience With Robot-Assisted Laparoscopic Staging of Gynecologic Malignancies 
Objective:
To evaluate the feasibility of integrating robot-assisted technology in the performance of laparoscopic staging of gynecologic malignancies.
Methods:
Seven patients underwent robot-assisted laparoscopic staging procedures for gynecologic cancers. Data were collected and analyzed as a retrospective case series analysis.
Results:
We attempted 7 robot-assisted laparoscopic staging procedures with no conversions to laparotomy. The median lymph node count for lymphadenectomy was 15 (range, 4 to 29). Mean operating time was 257 minutes (range, 174 to 345). The average estimated blood loss was 50 mL. One patient developed sinusitis and required intravenous antibiotics. The median hospital stay was 2 days.
Conclusion:
Robot-assisted laparoscopic staging is a feasible technique that may overcome the surgical limitations of conventional laparoscopy.
PMCID: PMC3015578  PMID: 15984701
Robot-assisted laparoscopy; Cancer staging; Gynecologic cancer; Surgical technique
4.  Laparoscopy for Colon and Rectal Cancer 
ABSTRACT
Laparoscopy has emerged as a useful tool in the surgical treatment of diseases of the colon and rectum. Specifically, in the application of colon cancer, a laparoscopic-assisted approach offers short-term benefits to patients while maintaining a long-term oncologic outcome. Hand-assisted laparoscopic surgery may help decrease operative times while preserving the benefits of laparoscopy. The literature on the use of laparoscopy for rectal cancer is still in its early stages. Limited data suggest short-term benefits without compromising oncologic outcome; however, data from large multicenter trials will clarify the role of laparoscopy in the treatment of rectal cancer. Robotic proctectomy is a novel technique that may offer considerable advantage and overcome some limitations laparoscopy creates while working in the confines of the pelvis. The improved magnification and visualization offered with the robot may also assist in preserving bladder and sexual function. Transanal endoscopic microsurgery (TEM) for the treatment of T1 rectal cancers with low-risk features appears to be safe. However, TEM has a significantly higher recurrence rate when used to treat invasive cancer. Endoluminal techniques and equipment are under development and could offer more minimally invasive approaches to the treatment of colon and rectal cancer. Credentialing and training of surgeons and teams involved in the use of laparoscopy is important prior to making these techniques ubiquitous.
doi:10.1055/s-0030-1247856
PMCID: PMC2850167  PMID: 21286291
Colon cancer; rectal cancer; laparoscopy
5.  Robotic-Assisted Laparoscopic Gynecologic Procedures in a Fellowship Training Program 
An early evaluation of the feasibility of training fellows in robotic surgery suggests that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training at the onset of incorporating this technology into current practice.
Background and Objective:
The robotic surgical platform is an alternative technique to traditional laparoscopy and requires the development of new surgical skills for both the experienced surgeon and trainee. Our goal was to perform an early evaluation of the feasibility of training fellows in robotic-assisted gynecologic procedures at the outset of our incorporation of this technology into clinical practice.
Methods:
A systematic approach to fellow training included (1) didactic and hands-on training with the robotic system, (2) instructional videos, (3) assistance at the operating table, and (4) performance of segments of gynecologic procedures in tandem with the attending physician. Time to complete the entire procedure, individual segments, rate of conversion to laparotomy, and complications were recorded.
Results:
Twenty-one robotic-assisted gynecologic procedures were performed from April 2006 to January 2007. Fellows participated as the console surgeon in 14/21 cases. Thirteen patients (62%) had prior abdominal surgery. Median values with ranges were age 51 years (range, 33 to 90); BMI 28 (range, 19.4 to 43.8); EBL 25 mL (range, 25 to 250); and hospital stay 1 day (range, 1 to 4). No significant difference existed between fellow and attending mean total operative and individual segment times. One conversion to laparotomy was necessary. No major surgical complications occurred.
Conclusion:
These data suggest that it is feasible to incorporate a systematic approach to robotic-assisted laparoscopic training for trainees at the outset of incorporation of this technology into current practice.
doi:10.4293/108680809X12589998403921
PMCID: PMC3030777  PMID: 20202385
Robotics; Laparoscopic surgery; Education; Gynecology
6.  The voice of Holland: Dutch public and patient's opinion favours single-port laparoscopy 
Journal of Minimal Access Surgery  2014;10(3):119-125.
INTRODUCTION:
Single-port laparoscopy is prospected as the future of minimal invasive surgery. It is hypothesised to cause less post operative pain, with a shorter hospitalisation period and improved cosmetic results. Population- and patient-based opinion is important for the adaptation of new techniques. This study aimed to assess the opinion and perception of a healthy population and a patient population on single-port laparoscopy compared with conventional laparoscopy.
MATERIALS AND METHODS:
An anonymous 33-item questionnaire, describing conventional and single-port laparoscopy, was given to 101 patients and 104 healthy volunteers. The survey participants (median age 44 years; range 17-82 years) were asked questions about their personal situation and their expectations and perceptions of the two different surgical techniques; conventional multi-port laparoscopy and single-port laparoscopy.
RESULTS:
A total of 72% of the participants had never heard of single-port laparoscopy before. The most important concern in both groups was the risk of surgical complications. When complication risks remain similar, 80% prefers single-port laparoscopy to conventional laparoscopy. When the risk of complications increases from 1% to 10%, 43% of all participants prefer single-port laparoscopy. A total of 70% of the participants are prepared to receive treatment in another hospital if single-port surgery is not performed in their hometown hospital. The preference for single-port approach was higher in the female population.
CONCLUSION:
Although cure and safety remain the main concerns, the population and patients group have a favourable perception of single-port surgery. The impact of public opinion and patient perception towards innovative techniques is undeniable. If the safety of the two different procedures is similar, this study shows a positive attitude of both participant groups in favour of single-port laparoscopy. However, solid scientific proof for the safety and feasibility of this new surgical technique needs to be obtained before this procedure can be implemented into everyday practice.
doi:10.4103/0972-9941.134874
PMCID: PMC4083543
NOTES; single-port laparoscopy; questionnaire
7.  Making the Transition From Standard Gynecologic Laparoscopy to Robotic Laparoscopy 
Objectives:
To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery.
Method:
To obtain robotic credentialing and gain experience with the robotic system, the surgeons first went through robotic training, then 4 women desiring permanent sterilization had robotically assisted laparoscopic bilateral tubal ligations performed, using the Parkland method.
Results:
Total operating room time varied from 1 hour 25 minutes to 2 hours 31 minutes. Improvement in operating time for each surgeon was noted with each successive case. Best times in robotic cases were similar to those of standard laparoscopy.
Conclusion:
Robotically assisted laparoscopic tubal ligation using the Parkland method is a satisfactory procedure to provide transition for gynecologic surgeons and operating room personnel to gynecologic robotic surgery.
PMCID: PMC3016823  PMID: 15554274
Standard laparoscopy GYN surgery; Robotic laparoscopy GYN surgery
8.  Virtual Reality Robotic Surgery Warm-Up Improves Task Performance in a Dry Lab Environment: A Prospective Randomized Controlled Study 
Background
Pre-operative simulation “warm-up” has been shown to improve performance and reduce errors in novice and experienced surgeons, yet existing studies have only investigated conventional laparoscopy. We hypothesized a brief virtual reality (VR) robotic warm-up would enhance robotic task performance and reduce errors.
Study Design
In a two-center randomized trial, fifty-one residents and experienced minimally invasive surgery faculty in General Surgery, Urology, and Gynecology underwent a validated robotic surgery proficiency curriculum on a VR robotic simulator and on the da Vinci surgical robot. Once successfully achieving performance benchmarks, surgeons were randomized to either receive a 3-5 minute VR simulator warm-up or read a leisure book for 10 minutes prior to performing similar and dissimilar (intracorporeal suturing) robotic surgery tasks. The primary outcomes compared were task time, tool path length, economy of motion, technical and cognitive errors.
Results
Task time (-29.29sec, p=0.001, 95%CI-47.03,-11.56), path length (-79.87mm, p=0.014, 95%CI -144.48,-15.25), and cognitive errors were reduced in the warm-up group compared to the control group for similar tasks. Global technical errors in intracorporeal suturing (0.32, p=0.020, 95%CI 0.06,0.59) were reduced after the dissimilar VR task. When surgeons were stratified by prior robotic and laparoscopic clinical experience, the more experienced surgeons(n=17) demonstrated significant improvements from warm-up in task time (-53.5sec, p=0.001, 95%CI -83.9,-23.0) and economy of motion (0.63mm/sec, p=0.007, 95%CI 0.18,1.09), whereas improvement in these metrics was not statistically significantly appreciated in the less experienced cohort(n=34).
Conclusions
We observed a significant performance improvement and error reduction rate among surgeons of varying experience after VR warm-up for basic robotic surgery tasks. In addition, the VR warm-up reduced errors on a more complex task (robotic suturing) suggesting the generalizability of the warm-up.
doi:10.1016/j.jamcollsurg.2013.02.012
PMCID: PMC4082669  PMID: 23583618
robotic; education; simulation; warm-up; rehearsal; da Vinci; surgery; virtual reality; laparoscopy; SurgTrak™
9.  Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery 
Surgical Endoscopy  2008;23(6):1365-1371.
Background
Robot-assisted surgical systems have been introduced to improve the outcome of minimally invasive surgery. These systems also have the potential to improve ergonomics for the surgeon during endoscopic surgery. This study aimed to compare the user’s mental and physical comfort in performing standard laparoscopic and robot-assisted techniques. Surgical performance also was analyzed.
Methods
In this study, 16 surgically inexperienced participants performed three tasks using both a robotic system and standard laparoscopic instrumentation. Distress was measured using questionnaires and an ambulatory monitoring system. Surgical performance was analyzed with time-action analysis.
Results
The physiologic parameters (p = 0.000), the questionnaires (p = 0.000), and the time-action analysis (p = 0.001) favored the robot-assisted group in terms of lower stress load and an increase in work efficiency.
Conclusion
In this experimental setup, the use of a robot-assisted surgical system was of value in both cognitive and physical stress reduction. Robotic assistance also demonstrated improvement in performance.
doi:10.1007/s00464-008-0184-6
PMCID: PMC2687080  PMID: 18855053
Ergonomics; Laparoscopy; Minimally invasive surgery; Robotics; Stress
10.  Comparison of Surgical Outcomes between Robotic and Laparoscopic Gastrectomy for Gastric Cancer: The Learning Curve of Robotic Surgery 
Journal of Gastric Cancer  2012;12(3):156-163.
Purpose
Laparoscopic gastrectomy is a widely accepted surgical technique. Recently, robotic gastrectomy has been developed, as an alternative minimally invasive surgical technique. This study aimed to evaluate the question of whether robotic gastrectomy is feasible and safe for the treatment of gastric cancer, due to its learning curve.
Materials and Methods
We retrospectively reviewed the prospectively collected data of 100 consecutive robotic gastrectomy patients, from November 2008 to March 2011, and compared them to 282 conventional laparoscopy patients during the same period. The robotic gastrectomy patients were divided into 20 initial cases; and all subsequent cases; and we compared the clinicopathological features, operating times, and surgical outcomes between the three groups.
Results
The initial 20 robotic gastrectomy cases were defined as the initial group, due to the learning curve. The initial group had a longer average operating time (242.25±74.54 minutes vs. 192.56±39.56 minutes, P>0.001), and hospital stay (14.40±24.93 days vs. 8.66±5.39 days, P=0.001) than the experienced group. The length of hospital stay was no different between the experienced group, and the laproscopic gastrectomy group (8.66±5.39 days vs. 8.11±4.10 days, P=0.001). The average blood loss was significantly less for the robotic gastrectomy groups, than for the laparoscopic gastrectomy group (93.25±84.59 ml vs. 173.45±145.19 ml, P<0.001), but the complication rates were no different.
Conclusions
Our study shows that robotic gastrectomy is a safe and feasible procedure, especially after the 20 initial cases, and provides a satisfactory postoperative outcome.
doi:10.5230/jgc.2012.12.3.156
PMCID: PMC3473222  PMID: 23094227
Robotic; Laparoscopy; Compared; Gastrectomy; Learning curve
11.  Can Routine Laparoscopy Help to Reduce the Rate of Explorative Laparotomies for Gastric Cancer? Laparoscopy in Gastric Cancer 
1. Background We developed this surgical protocol about performing intraoperative laparoscopy for staging in every patient affected by stomach cancer. Sensitivity and specificity of intraoperative laparoscopy are compared with conventional preoperative staging techniques.
2. Methods From January 1994 to June 1999, 83 patients affected by stomach cancer were accepted in our department: 12 patients (14.5%) were excluded from our study after the preoperative staging; in 71 patients (85.5%) an explorative laparoscopy as the first step of the operation was performed.
3. Results Laparoscopy confirmed preoperative staging in 53 cases (74.6%), in 12 patients demonstrated an overstaging. Laparoscopy demonstrated in 6 patients unsuspected causes of unresectability.
4. Conclusions When performed in patients affected by malignant neoplasm and declared resectable, intraoperative laparoscopy can demonstrate conditions not detectable by traditional preoperative investigations, consequently reducing to zero explorative laparotomies.
doi:10.1155/DTE.6.125
PMCID: PMC2362746  PMID: 18493515
12.  Achieving proficiency with robot-assisted radical prostatectomy: Laparoscopic-trained versus robotics-trained surgeons 
Canadian Urological Association Journal  2013;7(11-12):E711-E715.
Background
Initiating a robotics program is complex, in regards to achieving favourable outcomes, effectively utilizing an expensive surgical tool, and granting console privileges to surgeons. We report the implementation of a community-based robotics program among minimally-invasive surgery (MIS) urologists with and without formal robotics training.
Methods:
From August 2008 to December 2010 at Kaiser Permanente Southern California, 2 groups of urologists performing robot-assisted radical prostatectomy (RARP) were followed since the time of robot acquisition at a single institution. The robotics group included 4 surgeons with formal robotics training and the laparoscopic group with another 4 surgeons who were robot-naïve, but skilled in laparoscopy. The laparoscopic group underwent an initial 7-day mentorship period. Surgical proficiency was measured by various operative and pathological outcome variables. Data were evaluated using comparative statistics and multivariate analysis.
Results:
A total of 420 and 549 RARPs were performed by the robotics and laparoscopic groups, respectively. Operative times were longer in the laparoscopic group (p = 0.002), but estimated blood loss was similar. The robotics group had a significantly better overall positive surgical margin rate of 19.9% compared to the laparoscopic group (27.8%) (p = 0.005). Both groups showed improvements in operative and pathological parameters as they accrued experience, and achieved similar results towards the end of the study.
Conclusions:
Robot-naïve laparoscopic surgeons may achieve similar outcomes to robotic surgeons relatively early after a graduated mentorship period. This study may apply to a community-based practice in which multiple urologists with varied training backgrounds are granted robot privileges.
doi:10.5489/cuaj.360
PMCID: PMC3840530  PMID: 24282463
13.  Reverse-Hybrid Robotic Mesorectal Excision for Rectal Cancer 
Diseases of the colon and rectum  2012;55(2):228-233.
Purpose
The robotic system offers potential technical advantages over laparoscopy for total mesorectal excision with radical lymphadenectomy for rectal cancer. However, the requirement for fixed docking limits its utility when the working volume is large or patient repositioning is required. The purpose of this study was to evaluate short-term outcomes associated with a novel setup to perform total mesorectal excision and radical lymphadenectomy for rectal cancer by the use of a “reverse” hybrid robotic-laparoscopic approach.
Methods
This is a prospective consecutive cohort observational study of patients who underwent robotic rectal cancer resection from January 2009 to March 2011. During the study period a technique of reverse-hybrid robotic-laparoscopic rectal resection with radical lymphadenectomy was developed. This technique involves reversal of the operative sequence with lymphovascular and rectal dissection to precede proximal colonic mobilization. This technique evolved from a conventional hybrid resection with laparoscopic vascular control, colonic mobilization, and robotic pelvic dissection. Perioperative, and short-term oncologic outcomes were analyzed.
Results
Thirty patients underwent reverse-hybrid resection. Median tumor location was 5 cm (interquartile range 3-9) from the anal verge. Median BMI was 27.6 (interquartile range 25.0-32.1 kg/m2). Twenty (66.7%) received neoadjuvant chemoradiation. There were no conversions. Median blood loss was 100 mL (interquartile range 75-200). Total operation time was a median 369 (interquartile range 306-410) minutes. Median docking time was 6 (interquartile range 5-8) minutes and console time was 98 (interquartile range 88-140) minutes. Resection was R0 in all patients with no patients had an incomplete mesorectal resection. Six patients (20%) underwent extended lymph node dissection or en bloc resection.
Conclusions
Reverse-hybrid robotic surgery for rectal cancer maximizes the therapeutic applicability of the robotic and conventional laparoscopic techniques for optimized application in minimally invasive rectal surgery.
doi:10.1097/DCR.0b013e31823c0bd2
PMCID: PMC3546550  PMID: 22228169
Robotic surgery; Rectal cancer; Laparoscopy
14.  The technique of robotic assisted laparoscopic surgery in gynaecology, its introduction into the clinical routine of a gynaecological department and the analysis of the perioperative courses - a German experience 
Objective
Robotic assisted surgery is an advancement on conventional laparoscopy. The first and single FDA-approved device is the da-Vinci™ system, which provides means to overcome the limitations of conventional laparoscopy. In Germany the use of the robotic system in gynaecology is at the threshold of a promising development. There is a wide spectrum of indications, such as simple and radical hysterectomies, including pelvic and paraaortic lymph node dissection. The introduction of the robotic system into the clinical routine is demonstrated.
Material and Methods
Robotic assisted laparoscopic interventions have been performed in the reporting hospital since April 2008. In the course of treatment of 172 cases, an increasing rise of complexity of surgical procedure has been achieved. The daVinci™ system is well adaptable in clinical routine. Hitherto, the clinical outcome has been favourable, higher-grade specific complications occurred very rarely. The short time advantages are a decrease of postoperative length of stay, a reduction of postinterventional need of analgetics and an overall accelerated period of recovery has been demonstrated compared to conventional abdominal procedures. It also shows that a drastic decrease of open conventional abdominal procedures concerning uterine pathologies appeared in the reporting department.
Results
Perioperative advantages of robotic assisted laparoscopic interventions are, above all, the decrease of morbidity (concerning blood loss, need of analgetics, length of stay, etc.). Surgical advantages are the more complex applicability, improved precision, dexterity and vision (3D), a greater autonomy of the surgeon, a smaller learning curve and an increase of preparation consistent with the anatomical structures. In contrast, disadvantages concern an initial greater time investment, the potentially different management of complications, the limited applicability in multiquadrant surgery and the difficulty regarding cost coverage respective to recovery.
Conclusions
In conclusion, robotic assisted minimal invasive surgery has an enormous potential in gynaecology; by simplifying the essential surgical procedure. The advantages of this technique will be approachability for a majority of gynaecological patients. The feasibility of a multitude of gynaecological surgical interventions has already been approved partially in a small number of cases. The upcoming challenge now is to verify the short and long term advantages of robotic surgery in prospective trials, especially concerning gynaecological oncology.
doi:10.5152/jtgga.2011.23
PMCID: PMC3939114  PMID: 24591970
Robotic surgery; gynaecology; daVinci technique; oncological gynaecology
15.  Robot-Assisted vs. Conventional Laparoscopic Rectopexy for Rectal Prolapse: A Comparative Study on Costs and Time 
Diseases of the Colon and Rectum  2007;50(11):1825-1830.
Purpose
Laparoscopic rectopexy has become one of the most advocated treatments for full-thickness rectal prolapse, offering good functional results compared with open surgery and resulting in less postoperative pain and faster convalescence. However, laparoscopic rectopexy can be technically demanding. Once having mastered dexterity, with robotic assistance, laparoscopic rectopexy can be performed faster. Moreover, it shortens the learning curve in simple laparoscopic tasks. This may lead to faster and safer laparoscopic surgery. Robot-assisted rectopexy has been proven safe and feasible; however, until now, no study has been performed comparing costs and time consumption in conventional laparoscopic rectopexy vs. robot-assisted rectopexy.
Methods
Our first 14 cases of robot-assisted laparoscopic rectopexy were reviewed and compared with 19 patients who underwent conventional laparoscopic rectopexy in the same period.
Results
Robot-assisted laparoscopic rectopexy did not show more complications. However, the average operating time was 39 minutes longer, and costs were -57.29 (or: $745.09) higher.
Conclusion
Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.
doi:10.1007/s10350-007-9017-2
PMCID: PMC2071956  PMID: 17690936
Laparoscopic; Laparoscopy; Robot; Robotic; Rectal; Procidentia; Prolapse; Surgery; Rectopexy; Wells; D’Hoore
16.  Current Status of Robotic Surgery 
The Indian Journal of Surgery  2012;74(3):242-247.
Surgery has increasingly become a technology-driven specialty. Robotic assistance is considered one innovation within abdominal surgery over the past decade that has the potential to compensate for the drawbacks of conventional laparoscopy. The dramatic evolution of robotic surgery over the past 10 years is likely to be eclipsed by even greater advances over the next decade. We review the current status of robotic technology in surgery. The Medline database was searched for the terms “robotic surgery, telesurgery, and laparoscopy.” A total of 2,496 references were found. All references were considered for information on robotic surgery in advanced laparoscopy. Further references were obtained through cross-referencing the bibliography cited in each work. There is a paucity of control studies on a sufficient number of subjects in robot-assisted surgeries in all fields. Studies that meet more stringent clinical trials criteria show that robot-assisted surgery appears comparable to traditional surgery in terms of feasibility and outcomes but that costs associated with robot-assisted surgery are higher because of longer operating times and expense of equipment. While a limited number of studies on the da Vinci robotic system have proven the benefit of this approach in regard to patient outcomes, including significantly reduced blood loss, lower percentage of postoperative complications, and shorter hospital stays, there are mechanical and institutional risks that must be more fully addressed. Robotic assistance will remain an intensively discussed subject since clinical benefits for most procedures have not yet been proven. While the benefit still remains open to discussion, robotic systems are spreading and are available worldwide in tertiary centers.
doi:10.1007/s12262-012-0595-4
PMCID: PMC3397190  PMID: 23730051
Robotic surgery; Laparoscopy; Minimally invasive surgery
17.  Robotic-Assisted Laparoscopic Management of Vesicoureteral Reflux 
Advances in Urology  2008;2008:732942.
Robotic-assisted laparoscopy (RAL) has become a promising means for performing correction of vesicoureteral reflux disease in children through both intravesical and extravesical techniques. We describe the importance of patient selection, intraoperative patient positioning, employing certain helpful techniques for exposure, and recognizing the limitations and potential complications of robotic reimplant surgery. As more clinicians embrace robotic surgery and more urology residents are trained in robotics, we anticipate an expansion of the applications of robotics in children. We believe that it is necessary to develop robotic surgery curricula for novice roboticists and residents so that patients may experience improved surgical outcomes.
doi:10.1155/2008/732942
PMCID: PMC2494606  PMID: 18682821
18.  Adhesions and Adhesiolysis: The Role of Laparoscopy 
Background:
Adhesions commonly result from abdominal and pelvic surgical procedures and may result in intestinal obstruction, infertility, chronic pain, or complicate subsequent operations. Laparoscopy produces less peritoneal trauma than does conventional laparotomy and may result in decreased adhesion formation. We present a review of the available data on laparoscopy and adhesion formation, as well as laparoscopic adhesiolysis. We also review current adjuvant techniques that may be used by practicing laparoscopists to prevent adhesion formation.
Database:
A Medline search using “adhesions,” “adhesiolysis,” and “laparoscopy” as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.
Discussion:
The majority of studies indicate that laparoscopy may reduce postoperative adhesion formation relative to laparotomy. However, laparoscopy by itself does not appear to eliminate adhesions completely. A variety of adjuvant materials are available to surgeons, and the most recent investigation has demonstrated significant potential for intraperitoneal barriers. Newer technologies continue to evolve and should result in clinically relevant reductions in adhesion formation.
PMCID: PMC3043408  PMID: 12113430
Adhesions; Adhesiolysis; Laparoscopy
19.  The current status of robot-assisted radical prostatectomy 
Asian Journal of Andrology  2008;11(1):90-93.
Robot-assisted radical prostatectomy (RARP) is a rapidly evolving technique for the treatment of localized prostate cancer. In the United States, over 65% of radical prostatectomies are robot-assisted, although the acceptance of this technology in Europe and the rest of the world has been somewhat slower. This article reviews the current literature on RARP with regard to oncological, continence and potency outcomes–the so-called 'trifecta'. Preliminary data appear to show an advantage of RARP over open prostatectomy, with reduced blood loss, decreased pain, early mobilization, shorter hospital stay and lower margin rates. Most studies show good postoperative continence and potency with RARP; however, this needs to be viewed in the context of the paucity of randomized data available in the literature. There is no definitive evidence to show an advantage over standard laparoscopy, but the fact that this technique has reached parity with laparoscopy within 5 years is encouraging. Finally, evolving techniques of single-port robotic prostatectomy, laser-guided robotics, catheter-free prostatectomy and image-guided robotics are discussed.
doi:10.1038/aja.2008.11
PMCID: PMC3735203  PMID: 19050687
da Vinci robot; prostate cancer; robot-assisted radical prostatectomy
20.  Robotics for Pelvic Reconstruction 
Robotic-assisted laparoscopy is increasingly used in female pelvic reconstructive surgery to combine the benefits of abdominally placed mesh for prolapse outcomes with the quicker recovery time associated with minimally invasive procedures. Level III data suggest that early outcomes of robotic sacrocolpopexy are similar to those of open sacrocolpopexy. A single randomized trial has provided level I evidence that robotic and laparoscopic approaches to sacrocolpopexy have similar short-term anatomic outcomes, although operating times, postoperative pain, and cost are increased with robotics. Patient satisfaction and long-term outcomes of both robotic and laparoscopic sacrocolpopexy are insufficiently studied despite their widespread use in the treatment of prolapse. Given the high reoperative rates for prolapse repairs, long-term follow-up is essential, and well-designed comparative effectiveness research is needed to evaluate pelvic floor surgery adequately.
doi:10.1007/s11884-011-0099-2
PMCID: PMC3161411  PMID: 21874147
Robotic surgery; Robotics; Sacrocolpopexy; Pelvic reconstruction; Pelvic organ prolapse; Female pelvic medicine and reconstructive surgery; Pelvic floor disorders; Laparoscopy; Minimally invasive gynecology
21.  Robotic-Assisted Laparoscopy in Gynecological Surgery 
Background:
Laparoscopic surgery has revolutionized the concept of minimally invasive surgery for the last 3 decades. Robotic-assisted surgery is one of the latest innovations in the field of minimally invasive surgery. Already, many procedures have been performed in urology, cardiac surgery, and general surgery. In this article, we attempt to report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries. We sought to evaluate the role of robotic-assisted laparoscopy in gynecological surgeries.
Methods:
The study was a case series of 15 patients who underwent various gynecologic surgeries for combined laparoscopic and robotic-assisted laparoscopic surgery. The da Vinci robot was used in each case at a tertiary referral center for laparoscopic gynecologic surgery. An umbilicus, suprapubic, and 2 lateral ports were inserted. These surgeries were performed both using laparoscopic and robotic-assisted laparoscopic techniques. The assembly and disassembly time to switch from laparoscopy to robotic-assisted surgery was measured. Subjective advantages and disadvantages of using robotic-assisted laparoscopy in gynecological surgeries were evaluated.
Results:
Fifteen patients underwent a variety of gynecologic surgeries, such as myomectomies, treatment of endometriosis, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, and Moskowitz procedure. The assembly time to switch from laparoscopy to robotic-assisted surgery was 18.9 minutes (range, 14 to 27), and the disassembly time was 2.1 minutes (range, 1 to 3). Robotic-assisted laparoscopy acts as a bridge between laparoscopy and laparotomy but has the disadvantage of being costly and bulky.
Conclusion:
Robotic-assisted laparoscopic surgeries have advantages in providing a 3-dimensional visualization of the operative field, decreasing fatigue and tension tremor of the surgeon, and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly and the bulkiness of the equipment.
PMCID: PMC3015696  PMID: 17212887
da Vinci robot; Robotic-assisted laparoscopy
22.  Current status of robot-assisted gastric surgery 
In an effort to minimize the limitations of laparoscopy, a robotic surgery system was introduced, but its role for gastric cancer is still unclear. The objective of this article is to assess the current status of robotic surgery for gastric cancer and to predict future prospects. Although the current study was limited by its small number of patients and retrospective nature, robot-assisted gastrectomy with lymphadenectomy for the treatment of gastric cancer is a feasible and safe procedure for experienced laparoscopic surgeons. Most studies have reported satisfactory results for postoperative short-term coutcomes, such as: postoperative oral feeding, gas out, hospital stay and complications, compared with laparoscopic surgery; the difference is a longer operation time. However, robotic surgery showed a shallow learning curve compared with the familarity of conventional open surgery; after the accumulation of several cases, robotic surgery could be expected to result in a similar operation time. Robotic-assisted gastrectomy can expand the indications of minimally invasive surgery to include advanced gastric cancer by improving the ability to perform lymphadenectomy. Moreover, ”total” robotic gastrectomy can be facilitated using a robot-sewing technique and gastric submucosal tumors near the gastroesophageal junction or pylorus can be resected safely by this novel technique. In conclusion, robot-assisted gastrectomy may offer a good alternative to conventional open or laparoscopic surgery for gastric cancer, provided that long-term oncologic outcomes can be confirmed.
doi:10.4251/wjgo.v3.i10.137
PMCID: PMC3205112  PMID: 22046490
Robot surgery; Stomach; Minimally invasive surgery
23.  Single port robotic hysterectomy technique improving on multiport procedure 
The benefits of laparoscopic surgery over conventional abdominal surgery have been well documented. Reducing postoperative pain, decreasing postoperative morbidity, hospital stay duration, and postoperative recovery time have all been demonstrated in recent peer-review literature. Robotic laparoscopy provides the added dimension of increased fine mobility and surgical control. With new single port surgical techniques, we have the added benefit of minimally invasive surgery and greater patient aesthetic satisfaction, as well as all the other benefits laparoscopic surgery offers. In this paper, we report a successful single port robotic hysterectomy and the simple process by which this technique is performed.
doi:10.4103/0972-9941.103130
PMCID: PMC3523456  PMID: 23248446
Robotic hysterectomy; single incision laparoscopic surgery; single port laparoscopy
24.  Effects of Visual Force Feedback on Robot-Assisted Surgical Task Performance 
Background
Direct haptic (force or tactile) feedback is negligible in current surgical robotic systems. The relevance of haptic feedback in robot-assisted performances of surgical tasks is controversial. We studied the effects of visual force feedback (VFF), a haptic feedback surrogate, on tying surgical knots with fine sutures similar to those used in cardiovascular surgery.
Methods
Using a modified da Vinci robotic system (Intuitive Surgical, Inc.) equipped with force-sensing instrument tips and real-time VFF overlays in the console image, ten surgeons each tied 10 knots with and 10 knots without VFF. Four surgeons had significant prior da Vinci experience while the remaining six surgeons did not. Performance parameters, including suture breakage and secure knots, peak and standard deviation of applied forces, and completion times using 5-0 silk sutures were recorded. Chi-square and Student’s t-test analyses determined differences between groups.
Results
Among surgeon subjects with robotic experience, no differences in measured performance parameters were found between robot-assisted knot ties executed with and without VFF. Among surgeons without robotic experience, however, VFF was associated with lower suture breakage rates, peak applied forces, and standard deviations of applied forces. VFF did not impart differences in knot completion times or loose knots for either surgeon group.
Conclusions
VFF resulted in reduced suture breakage, lower forces, and decreased force inconsistencies among novice robotic surgeons, although elapsed time and knot quality were unaffected. In contrast, VFF did not affect these metrics among experienced da Vinci surgeons. These results suggest that VFF primarily benefits novice robot-assisted surgeons, with diminishing benefits among experienced surgeons.
doi:10.1016/j.jtcvs.2007.08.043
PMCID: PMC2674617  PMID: 18179942
Robotic Surgery; Minimally Invasive; Cardiac; Force Feedback; Haptics
25.  Robotic mitral valve surgery—current status and future directions 
Annals of Cardiothoracic Surgery  2013;2(6):814-817.
Robotic mitral valve surgery is the most common robotic cardiac procedure performed today. Benefits include smaller, less invasive incisions resulting in less pain, shorter length of hospital stay, improved cosmesis, quicker return to preoperative level of functional activity, and decreased blood transfusion requirements. The history and evolution of robotic mitral valve surgery is detailed in this article. Our institution has performed over 800 robotic mitral valve surgeries, and our technique and outcomes are described. Outcomes and operative times are similar to that for sternotomy and minimally invasive approaches to mitral valve surgery. The benefits and limitations of robotic mitral valve surgery are compared with conventional approaches, and future directions are also discussed.
doi:10.3978/j.issn.2225-319X.2013.10.04
PMCID: PMC3856989  PMID: 24349987
Robotic surgery; robotic cardiac surgery; mitral valve surgery; mitral valve repair; minimally invasive cardiac surgery

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