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.
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.
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.
Robotically assisted laparoscopic Roux-en-Y hepaticojejunostomy is a feasible procedure. When compared with standard laparoscopy, operating time is similar.
Roux-en-Y hepaticojejunostomy; Laparoscopic Roux-en-Y hepaticojejunostomy; Robotically assisted hepaticojejunostomy
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.
Robotics; uterine cervical neoplasm; hysterectomy
To evaluate the feasibility of integrating robot-assisted technology in the performance of laparoscopic staging of gynecologic malignancies.
Seven patients underwent robot-assisted laparoscopic staging procedures for gynecologic cancers. Data were collected and analyzed as a retrospective case series analysis.
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.
Robot-assisted laparoscopic staging is a feasible technique that may overcome the surgical limitations of conventional laparoscopy.
Robot-assisted laparoscopy; Cancer staging; Gynecologic cancer; Surgical technique
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.
Colon cancer; rectal cancer; laparoscopy
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.
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.
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.
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.
Robotics; Laparoscopic surgery; Education; Gynecology
To determine the feasibility of using a simple procedure, a bilateral tubal ligation, as a transition procedure when adopting robotic laparoscopy for gynecologic surgery.
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.
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.
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.
Standard laparoscopy GYN surgery; Robotic laparoscopy GYN surgery
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.
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.
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.
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.
Ergonomics; Laparoscopy; Minimally invasive surgery; Robotics; Stress
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.
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.
Our study shows that robotic gastrectomy is a safe and feasible procedure, especially after the 20 initial cases, and provides a satisfactory postoperative outcome.
Robotic; Laparoscopy; Compared; Gastrectomy; Learning curve
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.
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.
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.
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.
Robotic surgery; Rectal cancer; Laparoscopy
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.
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.
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.
Robot-assisted laparoscopic rectopexy is a safe and feasible procedure but results in increased time and higher costs than conventional laparoscopy.
Laparoscopic; Laparoscopy; Robot; Robotic; Rectal; Procidentia; Prolapse; Surgery; Rectopexy; Wells; D’Hoore
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
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.
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.
Robotic surgery; Laparoscopy; Minimally invasive surgery
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.
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.
Robotic surgery; Robotics; Sacrocolpopexy; Pelvic reconstruction; Pelvic organ prolapse; Female pelvic medicine and reconstructive surgery; Pelvic floor disorders; Laparoscopy; Minimally invasive gynecology
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.
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.
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.
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.
da Vinci robot; Robotic-assisted laparoscopy
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.
da Vinci robot; prostate cancer; robot-assisted radical prostatectomy
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.
Robot surgery; Stomach; Minimally invasive surgery
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.
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.
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.
Adhesions; Adhesiolysis; Laparoscopy
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.
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.
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.
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.
Robotic Surgery; Minimally Invasive; Cardiac; Force Feedback; Haptics
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.
Robotic hysterectomy; single incision laparoscopic surgery; single port laparoscopy
The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported.
Patients and Methods
March and May 2007, we performed 3 robot-assisted left lateral sectionectomies of the liver. Case 1 had a hepatocellular carcinoma (HCC), case 2 had colon cancer with liver metastasis, and case 3 had intrahepatic duct stones.
had successful operation and recovered without complications. Shorter length of hospital stays, earlier start of oral feeding and less amount of ascites were found. However, case 1 had recurrent HCC at 3 months after operation.
Robotic-assisted liver surgery is still a new field in its developing stage. In patients with small malignant tumors and benign liver diseases, robotic-assisted laparoscopic resection is feasible and safe. Through experience, the use of robotics is expected to increase in the treatment of benign diseases and malignant neoplsms. However, careful patient selection is important and long-term outcomes need to be evaluated.
Hepatocellular carcinoma; robotic liver resection; minimally invasive surgery
Robot-assisted procedures are being increasingly incorporated in gynaecologic oncology. Several studies have confirmed the feasibility and safety of robotic radical hysterectomy for selected patients with early-stage cervical cancer. It has been demonstrated that robotic radical hysterectomy offers an advantage over other surgical approaches with regard to operative time, blood loss, and hospital stay. Also initial evidences concerning oncological outcomes seem to confirm the equivalence to traditional open technique. Despite the fact that costs of robotic system are still high, they could be partially offset by several health-related and social benefits: less pain, faster dismissal, and return to full activity than other surgical approaches. The development of robotic technology may facilitate the spread of minimally invasive surgery in gynaecological oncology, overcoming some drawbacks of laparoscopic technique for challenging intervention such as radical hysterectomy. Further studies are needed to evaluate overall and disease-free survival of this technique and associated morbidity after adjuvant therapies.
Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.
Laparoscopic liver resection; Laparoscopic hepatectomy; Minimally invasive liver surgery; Hand-assisted technique; Hybrid technique
Robotic-assisted laparoscopic surgery appears to be safe and feasible for definitive management of patients with severe endometriosis.
The primary objective was to examine the safety and feasibility of robotic-assisted laparoscopy in a cohort of women treated surgically for stage III and IV endometriosis. The secondary objective was to explore whether the stage of endometriosis affected surgical outcome.
In this cohort study, 43 women with severe endometriosis were treated with robot-assisted laparoscopic hysterectomy with unilateral or bilateral salpingo-oophorectomy for stage III (n = 19) or stage IV (n = 24) disease.
Histopathologic evaluation confirmed endometriosis in all patients, and fibroids were also shown in 12 patients. The median actual operative time was 145 min (range, 67–325 min), and the median blood loss was 100 mL (range, 20–400 mL). All but one of the procedures were completed successfully robotically. The length of hospital stay was 1 d for 95% of patients (41 of 43), and 2 patients had prolonged stays of 4 d and 5 d, respectively. One patient was readmitted for a vaginal cuff abscess; this represented the only complication identified in this series.
Robot-assisted laparoscopic surgery appears to be a reasonably safe and feasible method for the definitive surgical management of women with severe endometriosis.
Robotics; Endometriosis; Surgery
Since the introduction of laparoscopic surgery, the promise of lower postoperative morbidity and improved cosmesis has been achieved. Laparoendoscopic single-site surgery (LESS) potentially takes this further. Following the first human urological LESS report in 2007, numerous case series have emerged, as well as comparative studies comparing LESS with standard laparoscopy. However, comparative series between conventional laparoscopy and LESS for different procedures suggest a non-inferiority of LESS over standard laparoscopy, but the only objective benefit remains an improved cosmetic outcome. Challenging ergonomics, instrument clashing, lack of true triangulation, and in-line vision are the main concerns with LESS surgery. Various new instruments have been designed, but only experienced laparoscopists and well-selected patients are pivotal for a successful LESS procedure. Robotic-assisted LESS procedures have been performed. The available robotic platform remains bulky, but development of instrumentation and application of robotic technology are expected to define the actual role of these techniques in minimally invasive urologic surgery.
Laparoscopy; Minimally invasive surgical procedures; Robotics