“Robotic and laparoscopic surgery: Cost and training.”
Patel, H. R., A. Linares, et al. (2009).
Surg Oncol.
Robotic prostatectomy training as part of mainstream surgical training will be difficult. The primary problems revolve around the inconsistencies of standard sugery. Many surgeons are still in the learning curve, as is the understanding of the true capabilities of the robot. The important elements of robotic surgery actually enhance basic laparoscopic techniques. The prostate has been shown to be an organ where this new technology has a niche. As we move toward cross specialty use the robot although extremely expensive, may be the best way to train the laparoscopic surgeon of the future.
“Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload.”
Stefanidis, D., F. Wang, et al. (2009).
Surg Endosc.
BACKGROUND: Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room. METHODS: Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastro-gastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da Vinci((R))) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects’ self-reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered significant. RESULTS: Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595 +/- 22 s versus 459 +/- 137 s, respectively; p < 0.001), achieve higher overall scores (0 +/- 1 versus 95 +/- 128, respectively; p < 0.001), and commit fewer errors per knot (1.15 +/- 1.35 versus 0.05 +/- 0.26, respectively; p < 0.001). Subjects’ overall score did not improve between the first and third attempt for laparoscopic suturing (0 +/- 0 versus 0 +/- 0; p = NS) but improved significantly for robotic suturing (49 +/- 100 versus 141 +/- 152; p < 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99 +/- 15 versus 57 +/- 23; p < 0.001). CONCLUSIONS: Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed.
“Ergonomics, user comfort, and performance in standard and robot-assisted laparoscopic surgery.”
van der Schatte Olivier, R. H., C. D. Van’t Hullenaar, et al. (2009).
Surg Endosc 23(6): 1365-71.
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.
“Are there advantages to robotic-assisted surgery over laparoscopy from the surgeon’s perspective?”
Van Koughnett, J. A., S. Jayaraman, et al. (2009).
Journal of Robotic Surgery: 1-4.
The advantages of a robotic approach are often difficult to quantify for surgical procedures that can be performed laparoscopically. Using a novel subjective rating scale, this study demonstrates a methodology to measure surgeon assessment of ease of use, comparing complex operations performed robotically and laparoscopically. A subjective assessment scale for robotic surgery was developed that included 13 task-related factors assessing operative challenges and ease of use. As part of a larger study comparing outcomes of laparoscopic and robotic biliary-enteric anastomosis, a surgeon performing 20 choledochojejunal anastomoses in an ex vivo pig model completed this scale after each procedure. Ten anastomoses were performed laparoscopically and ten using da Vinci robot assistance. Overall difficulty was also assessed using a 10-cm visual analog scale. Robotic surgery was associated with superior ease to laparoscopy in 8 of the 13 factors, including image quality, depth perception, comfort, eye fatigue, dexterity, precision of motion, speed of motion, and range of motion. The visual analog scale also showed a significant benefit in overall ease of the robotic over laparoscopic procedure. Nonsignificant trends favoring robotics were seen with fluidity of motion and equipment setup. Based on these results this study suggest that surgeon ease of use may be quantified using this assessment scale and that robot assistance may be advantageous over laparoscopy when performing complex surgical tasks in an ex vivo model from the surgeon’s perspective. © 2009 Springer-Verlag London Ltd.
“Can surgeon’s hand be replaced with a smart surgical instrument in esophagectomy?”
Farkoush, S. H. and S. Najarian
Medical Hypotheses.
Esophageal cancer is the eighth most common cancer in the world. The most common surgical procedures for esophageal cancer are transhiatal esophagectomy and transthoracic esophagectomy. Thoracic esophagectomy involves an abdominal incision and a thoracotomy, but transhiatal esophagectomy involves both an abdominal incision and a cervical incision. It can reduce postoperative morbidities and fast recovery. In transhiatal esophagectomy, part of dissection is blind and lack of sufficient vision during operation increases the dangers of this kind of surgery. In this paper, we propose a hypothesis about replacing surgeon’s hand with surgical instrument in esophagectomy. The proposed instrument is one-forth of surgeon’s hand volume and it can surround the esophagus radially. So, it would be able to sheer and dissect all the adhesive tissues around the esophagus. For determining possible threshold of causing traumas in delicate tissues during esophagectomy, various tactile sensors can be incorporated into the surgical instrument to detect and control the contact force of the instrument with delicate biological structures. For evaluating the proposed hypothesis, we analyzed the function of the instrument with finite element method and finally we constructed an initial prototype of the designed instrument. © 2009 Elsevier Ltd. All rights reserved.
“In situ measurement and modeling of biomechanical response of human cadaveric soft tissues for physics-based surgical simulation.”
Lim, Y. J., D. Deo, et al. (2009).
Surg Endosc 23(6): 1298-307.
BACKGROUND: Development of a laparoscopic surgery simulator that delivers high-fidelity visual and haptic (force) feedback, based on the physical models of soft tissues, requires the use of empirical data on the mechanical behavior of intra-abdominal organs under the action of external forces. As experiments on live human patients present significant risks, the use of cadavers presents an alternative. We present techniques of measuring and modeling the mechanical response of human cadaveric tissue for the purpose of developing a realistic model. The major contribution of this paper is the development of physics-based models of soft tissues that range from linear elastic models to nonlinear viscoelastic models which are efficient for application within the framework of a real-time surgery simulator. METHODS: To investigate the in situ mechanical, static, and dynamic properties of intra-abdominal organs, we have developed a high-precision instrument by retrofitting a robotic device from Sensable Technologies (position resolution of 0.03 mm) with a six-axis Nano 17 force-torque sensor from ATI Industrial Automation (force resolution of 1/1,280 N along each axis), and used it to apply precise displacement stimuli and record the force response of liver and stomach of ten fresh human cadavers. RESULTS: The mean elastic modulus of liver and stomach is estimated as 5.9359 kPa and 1.9119 kPa, respectively over the range of indentation depths tested. We have also obtained the parameters of a quasilinear viscoelastic (QLV) model to represent the nonlinear viscoelastic behavior of the cadaver stomach and liver over a range of indentation depths and speeds. The models are found to have an excellent goodness of fit (with R (2) > 0.99). CONCLUSIONS: The data and models presented in this paper together with additional ones based on the principles presented in this paper would result in realistic physics-based surgical simulators.
“Robotic assisted minimally invasive surgery.”
Palep, J. H. (2009).
Journal of Minimal Access Surgery 5(1): 1-7.
The term “robot” was coined by the Czech playright Karel Capek in 1921 in his play Rossom′s Universal Robots. The word “robot” is from the check word robota which means forced labor.The era of robots in surgery commenced in 1994 when the first AESOP (voice controlled camera holder) prototype robot was used clinically in 1993 and then marketed as the first surgical robot ever in 1994 by the US FDA. Since then many robot prototypes like the Endoassist (Armstrong Healthcare Ltd., High Wycombe, Buck, UK), FIPS endoarm (Karlsruhe Research Center, Karlsruhe, Germany) have been developed to add to the functions of the robot and try and increase its utility. Integrated Surgical Systems (now Intuitive Surgery, Inc.) redesigned the SRI Green Telepresence Surgery system and created the daVinci Surgical System ® classified as a master-slave surgical system. It uses true 3-D visualization and EndoWrist®. It was approved by FDA in July 2000 for general laparoscopic surgery, in November 2002 for mitral valve repair surgery. The da Vinci robot is currently being used in various fields such as urology, general surgery, gynecology, cardio-thoracic, pediatric and ENT surgery. It provides several advantages to conventional laparoscopy such as 3D vision, motion scaling, intuitive movements, visual immersion and tremor filtration. The advent of robotics has increased the use of minimally invasive surgery among laparoscopically nave surgeons and expanded the repertoire of experienced surgeons to include more advanced and complex reconstructions.
“The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review.”
van der Meijden, O. A. and M. P. Schijven (2009).
Surg Endosc 23(6): 1180-90.
BACKGROUND: Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation. METHODS: A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education. RESULTS: The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. CONCLUSIONS: In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.
“Face, content, and construct validity of dV-trainer, a novel virtual reality simulator for robotic surgery.”
Kenney, P. A., M. F. Wszolek, et al. (2009).
Urology 73(6): 1288-92.
OBJECTIVES: To assess the face, content, and construct validity of the dV-Trainer. The dV-Trainer is a virtual reality simulator for the da Vinci Surgical System that is in beta development. METHODS: Medical students, residents, and attending surgeons were enrolled in a prospective, institutional review board-approved study. The subjects were prospectively categorized as novice or experienced. Each subject completed 2 EndoWrist modules and 2 needle-driving modules. The performance was recorded using a built-in scoring algorithm. Each subject completed a questionnaire after finishing the modules. RESULTS: The novice group (n = 19) consisted of 3 students (16%), 11 residents (58%), and 5 attending surgeons (26%). The novices had operated an average of 1.3 +/- 2.2 hours at the da Vinci console before using the simulator. The experienced subjects (n = 7) had performed an average of 140 robotic cases (range 30-320). Experienced robotic surgeons outperformed novices in nearly all variables, including total score, total task time, total instrument motion, and number of instrument collisions (P < .01). All experienced surgeons ranked the simulator as useful for training and agreed with incorporating the simulator into a residency curriculum. The virtual reality and instrumentation achieved acceptability. The needle-driving modules did not exceed the acceptability threshold. CONCLUSIONS: The results of the present study have shown that the dV-Trainer has face, content, and construct validity as a virtual reality simulator for the da Vinci Surgical System. The needle-driving modules need to be refined. Studies are underway to assess the concurrent and predictive criterion validity. The dV-Trainer could become a beneficial training simulator for robotic surgery.
“Validation of a novel virtual reality robotic simulator.”
Sethi, A. S., W. J. Peine, et al. (2009).
Journal of endourology / Endourological Society 23(3): 503-508.
PURPOSE: We evaluated the face, content, and construct validity of what is, to our knowledge, the only available virtual reality simulator based on a complete kinematic representation of the da Vinci surgical system. MATERIALS AND METHODS: A total of 5 experts (EPs) and 15 novices (NVs) completed exercises on the Mimic dV-Trainer (MdVT). All participants completed three repetitions of the following tasks: (1) Ring and Cone, (2) String Walk, and (3) Letterboard. Participants rated parameters of face and content validity on a five-point Likert-scale questionnaire. Workload imposed by the simulator was assessed using a NASA Task Load Index questionnaire (TLX). RESULTS: Face validity of the MdVT was established as all 20 participants rated the simulator between average to easy-to-use and above-average to high in all parameters of realism. Participants in both EP and NV groups rated the MdVT’s overall relevance to robotic surgery as very high. All five EPs assessed the simulator to be a very good practice format and very useful for training residents, thereby affirming content validity. A preliminary assessment of construct validity suggested that the MdVT could differentiate EPs from NVs. The overall TLX workload scores were lower in the EP group for all parameters except for temporal demand. CONCLUSIONS: The MdVT demonstrated excellent face and content validity as well as reasonable workload parameters. The use of this simulator in resident training may help bridge the gap between the safe acquisition of surgical skills and effective performance during live robot-assisted surgery.
“The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review.”
van der Meijden, O. A. and M. P. Schijven (2009).
Surg Endosc 23(6): 1180-90.
BACKGROUND: Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation. METHODS: A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education. RESULTS: The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. CONCLUSIONS: In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.