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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

Conclusion
The Da Vinci robot has been largely developed over these last years and therefore will replace the CO2 laser for some surgical procedures.
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
J Selber
Lecture
5 years ago
401 views
10 likes
0 comments
14:26
Robotic microsurgery: small vessel anastomosis
In 1902, Alexis Carrel developed the technique of end-to-end anastomosis of blood vessels. In 1960, Jules Jacobson described the use of the operating microscope for microvascular surgery. In the late 60’s, Harry Buncke developed the first micro-instruments, and small needles were swaged. Since then, very little has changed about microsurgery, in spite of increasing technical demands, including supermicrosurgery, perforator to perforator anastomosis and lymphatic anastomosis. The surgical robot affords super human levels of precision with high-fidelity, 3-dimensional magnification. This combination of attributes makes it exceedingly well suited for microsurgery. Robotic microsurgery combines the executive functions of the human mind with the precision of a machine. Specific advantages of the robotic platform for microsurgery include: 1) Superhuman precision - this comes in the form of 100% tremor elimination, and up to 5 to 1 motion scaling 2) Physician comfort – the ergonomics of microsurgery can be a challenge and the robot eliminates any physical discomfort or long-term sequel related to surgeon positioning 3) Reduction of physical constraint requirements – access to vessels can be a challenge and the ability to successfully perform an anastomosis requires wide exposure. The robot eliminates this need with long, thin, precise arms. Specific disadvantages include: 1) Lack of haptic feedback, 2) inferior optics as compared to the operating microscope and 3) instrumentation which is ill-suited to microsurgery. It is worth noting that all the advantages to robotic microsurgery are inherent to the field, while all of the disadvantages are platform-specific, and likely to be overcome in the near future.
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.
J Selber
Lecture
5 years ago
175 views
4 likes
0 comments
17:18
Robotics muscle harvest
Free and pedicled muscle flaps have been in use by plastic surgeons for a variety of applications since World War I, and remain work horses in scalp, extremity, head, neck and breast reconstruction. Harvest of muscle flaps traditionally requires incisions that allow access to muscle origin, insertion and pedicle. Because some muscles such as the latissimus dorsi and rectus abdominis are large, incisions can be anywhere from 20 to 40 centimeters in length. These donor sites are conspicuously located on the abdomen and back, and are a source of morbidity in the form of cosmesis, seroma and hernia. Because of the desirability of minimally invasive harvest, endoscopic and laparoscopic techniques have been attempted, but have not achieved broad acceptance due to technical challenges related to exposure, retraction and lack of appropriately precise instrumentation. The robotic interface has supplied the necessary exposure and picture clarity through high resolution, three dimensional optics, and the necessary precision instrumentation through wristed motion at the instrument tips to accomplish both muscle and pedicle dissection. For this reason, robotic muscle harvest holds excellent promise in reducing donor site morbidity for these common reconstructive procedures. The author has designed and refined the technique to harvest the latissimus dorsi muscle. This approach involves a short axillary incision, two additional ports and insufflation. The entire muscle can be harvested and brought through the small incision, and has many uses as a free and pedicled flap, including partial breast reconstruction and implant coverage, as well as free flap applications. The rectus abdominis muscle can be harvested through three ports on the contralateral side of the muscle and uses an intraperitoneal approach. The muscle can then be used as a pedicled flap for abdominoperitoneal reconstruction and a free flap for scalp and extremity. Robotic harvest of both of these muscles is safe and effective, and has a significant role to play in the future of reconstructive surgery.