Cutting the optical leash: rethinking the “robot” in robotic surgery

Totally endoscopic robotic-assisted excision of right ventricular papillary fibroelastoma Abstract Although they comprise a small number of primary tumors of the heart, papillary fibroelastomas (PFEs) are the second most common type of benign cardiac tumor. PFEs of the right heart are uncommon, and those arising from the right-ventricular (RV) wall are extremely rare, with only a handful of reported cases in the literature. Removal of these tumors has been described, primarily through a median sternotomy approach, with only one report of using a right-sided mini-thoracotomy technique. The advantages of endoscopic robotic-assisted cardiac surgery have been demonstrated and described extensively. We report on a case of an incidentally found PFE in the RV that was successfully removed with a totally endoscopic robotic-assisted approach. The focus of our report is on the uniqueness of both the right-sided nonvalvular PFE and the treatment with a robotic totally endoscopic surgical approach.

Robotic surgery in patients with achondroplastic dwarfism: evaluation of risks and issues in an anatomical challenging bilateral partial nephrectomy Abstract The reports on the performance of robotic surgery in patients with dwarfism are anecdotal; anesthesiological issues and a challenging anatomy are the main factors that lead most of surgeons to prefer a more traditional approach. We present a case of bilateral robotic partial nephrectomy in a patient affected by achondroplastic dwarfism and aim to evaluate risks and issues in this type of surgery.

The role of hand-assisted laparoscopic splenectomy for mega spleens in the da Vinci era

Robotic urologic surgery: trends in litigation over the last decade Abstract There is a lack of information regarding malpractice claims and indemnity payments associated with robotic cases in surgery. Malpractice claims and indemnity payouts will elucidate and mitigate harms of future adoption of new technology into surgery. We analyzed claims filed against Intuitive Surgical, Inc. from 2000 to 2017. A law librarian identified product liability claims from 2000 to 2017 with the defendant “Intuitive Surgical, Inc.” using the Bloomberg Law database. We reviewed all available legal documents pertaining to identified claims, and extracted data points including filing date, surgery date, surgery type, robot type, instrument type, complications, and case outcomes. Since 2000, 123 claims were filed; 108 met criteria for inclusion. Gynecologic surgeries comprised the majority of claims (62%, 67 claims), followed by urologic surgeries (20%, 22 claims). Number of claims filed peaked in 2013 (30%, 32 claims) and then decreased each year, with 6% (7 claims) filed in 2016, and only 1% (1 claim) filed in 2017. Of the 22 claims regarding robotic urologic surgeries, 19 claims (86%) pertained to prostatectomy. Commonly alleged injuries in urologic cases were bowel injury (8 claims), erectile dysfunction (5 claims), bowel fistulas (4 claims), and incontinence (4 claims). Device failure was cited in only 2 claims. Early adopters of robotic surgery were at highest risk of litigation. This risk subsequently decreased despite the wide spread adoption of this technology. Almost all claims were secondary to surgical complications and not device failure, thus demonstrating a need for more systematic training for novel devices and early adopters.

Minimally invasive surgery for deep-infiltrating endometriosis and its impact on fertility: can robotic surgery play a role?

Novel minimally invasive transoral surgery bleeding model implemented in a nationwide otolaryngology emergencies bootcamp Abstract Post-operative hemorrhage is the most concerning complication after minimally invasive transoral surgery, as can result in airway compromise. Simulation-based medical education provides trainees with structured learning in an intensive and immersive environment allowing deliberate practice of skills and behaviors in the management of real-life situations. We implemented a novel post-oropharyngeal surgery bleeding model in a nationwide otolaryngology emergencies bootcamp, to teach and evaluate technical and non-technical skills required to competently manage this clinical scenario. 28 Otolaryngology residents from 11 programs in Canada participated in the annual Otolaryngology Emergencies Bootcamp of Western University in London, Ontario. After teaching technical aspects of emergency surgical airways in models, the course culminated with a complex scenario of a post-minimally invasive transoral surgery bleeding model using a fresh cadaver. The Non-Technical Skills for Surgeons (NOTSS) rating scale was applied to video analysis and a scenario-specific Medical Expert Checklist was implemented. The model design in a cadaveric torso is described for use in a simulation of a high-volume oropharyngeal bleed after a minimally invasive approach. Participants agreed that the model evoked an elevated degree of realism and conveyed the emotion of a life-threatening event. NOTSS analysis identified a marginal score in the domains of decision-making and communication and teamwork. Critical action checklist analysis highlighted the early mobilization of available resources and time to decision for surgical airway. We present the first report of a post-minimally invasive transoral surgery bleeding model. It was successful in recreating with high fidelity such a high-stake event and to teach technical and non-technical skills.

Comparison between single-site and multiport robot-assisted myomectomy Abstract Minimizing the number of port incisions during minimally invasive surgery is associated with improved outcomes and patient satisfaction. We designed this work to study the perioperative outcomes of robotic single-site myomectomy (RSSM) in comparison to robotic multiport myomectomy (RMM) in a certain subset of patients. The design of the study is a multicenter retrospective analysis (Canadian Task Force classification III). The setting was three university hospitals. Eighty patients with symptomatic uterine fibroids undergoing robot-assisted single-site myomectomy were selected for the study. These 80 consecutive RSSM patients were matched at the uterine fibroid tumor burden level with 95 consecutive RMM patients performed at the same institutions, by the same surgeons, within a similar time frame. The main outcome measures were estimated blood loss (EBL), operative time, overnight admission, and post-operative complications. Of the 175 women, 95 (54.2%) underwent RMM and 80 (45.7%) underwent RSSM. Single-site vs. multiport patient demographics differed significantly in mean age (39.1 vs. 35.6, p < 0.001), and BMI (25.3 vs. 27.5, p < 0.04). Pre-operative MRI fibroid characteristics were matched between the two cohorts. Fibroid size on imaging (5.8 cm vs. 5.9 cm, p = 0.4) and the number of fibroids removed (2.5 vs. 2.3, p = 0.08) were similar between the two groups. After adjustment for multiple covariates with regression models, single-site myomectomy and multiport myomectomy has comparable EBL (83.3 mL vs. 109.2 mL, p = 0.34), operative time (162.4 min vs. 162.4 min, p = 0.99), overnight admission (OR = 1.54, p = 0.44) and a post-operative complication (OR = 1.3, p = 0.78). In selected patients, robotic single-site myomectomy is equivalent to its multiport counterpart. Both surgical approaches are associated with low rates of intra-operative and post-operative complications.

A robotic teaching session: separating tool from technique to emphasize a cognitive focused teaching environment Abstract Most robotic curriculum requires simulation on a console prior to operative exposure. This practice does not permit experiencing the physical collisions with the robotic tools, which occurs during surgery. We designed and evaluated an innovative curriculum to address cognitive components and trouble-shoot robotic collisions when the surgeon lacks haptic feedback. We adapted our previous curriculum, designed to teach and document proficiency of robotic docking and instrument exchange, to include robotic collisions. Participants received a 10-min, didactic presentation describing finger grips, internal and external collisions, and instruction on how to trouble-shoot each type. Residents worked in pairs, one at the console and the other at bedside, to complete two simulation exercises. Participants manipulated the robot to determine how best to resolve the situations. Residents completed retrospective post-course surveys and instructors completed a final survey. For comparison, non-participants, PGY-matched surgical trainees, also completed a survey. All participants demonstrated proficiency in docking and instrument exchange. Compared to pre-session, post-session knowledge and confidence improved in five domains reflecting session objectives (p < 0.05). Participants could list and troubleshoot collisions more than the non-participant matched peers (p < 0.05). Instructors supported the additional collision components, but noted learners needed more time. Two of three non-participants expressed interest in a teaching session to address these components. Collisions occur using robotic technology and rarely get addressed in surgical training. We describe an opportunity for surgeons to trouble-shoot robotic collisions in a safe, simulated environment. This easily transferable curriculum represents one of the first industry-independent robotic teaching sessions for surgical trainees.

Robotic choledochoduodenostomy for benign distal common bile duct stricture: how we do it Abstract Benign bile duct stricture poses a significant challenge for gastroenterologists and general surgeons due to the inherent nature of the disease, difficulty in sustaining long-term solutions and fear of pitfalls in performing biliary tract operations. Operative management with an open biliary bypass is mainly reserved for patients who have failed multiple attempts of endoscopic and percutaneous treatments. However, recent advances in minimally invasive technology, notably in the form of the robotics, have provided a new approach to tackling biliary disease. In this technical report, we describe our standardized method of robotic choledochoduodenostomy in a 59-year-old woman with history of Roux-en-Y gastric bypass who presents with benign distal common bile duct stricture following failure of non-operative management. Key steps in this approach involved adequate duodenal Kocherization, robotic portal dissection and creation of a side-to-side choledochoduodenal anastomosis. The operative time was 200 min with no intraoperative complications and estimated blood loss was less than 50 mL. No abdominal drains were placed. The patient was discharged home on postoperative day 1 tolerating regular diet and able to resume her usual activities within 1 week of her operation. A video is attached to this report.