A new retractor system for thoracoscopic thymectomy using the anterior chest wall-lifting method.
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Cadaver↗
Biomedical subjects
L W Nifong
Publications and source records attributed to L W Nifong.
Thoracoscopic robot-assisted bronchoplasty.
BACKGROUND: In robotic surgery, the ideal position of the system, as well as the optimal working angles and the proper positioning of the thoraco ports position is very important. No robot-assisted bronchoplasty has been reported. Our study describes use of the da VinciTM surgical system (Intuitive Surgical, Inc.) for robotic sleeve upper lobectomy in a human fresh cadaver. METHODS: A male cadaver was placed in the left lateral decubitus position. After thoracoscopic upper lobectomy was performed through the working port and the two ports, the robotic system was then set up behind the cadaver. The working port allowed introduction of the optical scope and the robotic surgical arms were inserted into the thoraco ports. The right bronchus was dissected and wedge was cut out with the robotic scissors. After standard lymph node dissection, end-to-end bronchial anastomosis was performed with robotic instruments. Once the anastomosis was complete, air leakage was checked with saline solution placed in the pleural cavity. RESULTS: Thoracoscopic robot-assisted bronchoplasty was performed successfully. CONCLUSIONS: In evaluating various positions of the system we demonstrated that our technique is sufficient approaches to robotic bronchoplasty. This procedure offers specific advantages over conventional bronchoplasty with accuracy and safety.
Anastomosis, Surgical↗
Intraoperative transesophageal echocardiography with a special focus on a patient undergoing advanced robotic-assisted procedures.
Intraoperative echocardiography (IOE) has earned a major role in surgical decision-making and helps the cardiac surgeon decide and proceed with appropriate intervention based on the visualized pathology. With the advent of minimally invasive surgical techniques and robotic-assisted operations, more emphasis and dependence has been placed on IOE. We describe our experience with IOE during mitral valve repair at our center, which is one of the pioneer centers for these telemanipulation techniques.
Cooperative Behavior↗
Evolution of mitral valve surgery: toward a totally endoscopic approach.
BACKGROUND: Our study evaluates a series of video-assisted minimally invasive mitral operations, showing safe progression toward totally endoscopic techniques. METHODS: Consecutive patients with isolated mitral valve disease underwent either manually directed (n = 55) or voice-activated robotically directed (n = 72) video-assisted mitral operations. Cold blood cardioplegia, a transthoracic aortic clamp, a 5-mm endoscope, and a 5-cm minithoracotomy were used. This video-assisted minimally invasive mitral operation cohort was compared with a previous sternotomy-based mitral operation cohort (n = 100). RESULTS: Group demographics, New York Heart Association classification, and cardiac function were similar. Repairs were performed in 61.8% manually directed (n = 34), 75.0% robotically directed (n = 54), and 54% sternotomy-based (N = 54) mitral operations. The robotically directed technique showed a significant decrease in blood loss, ventilator time, and hospitalization compared with the sternotomy-based technique. Manually directed mitral operations compared with robotically directed mitral operations had decreased arrest times (128.0 +/- 4.5 minutes compared with 90.0 +/- 4.6 minutes; p < 0.001) and decreased perfusion times (173.0 +/- 5.7 minutes compared with 144.0 +/- 4.6 minutes; p < 0.001). In the minimally invasive mitral operation cohort, complications included reexploration for bleeding (2.4%; n = 3) and one stroke (0.8%), whereas the 30-day mortality was 2.3% (n = 3). CONCLUSIONS: Video-assisted mitral surgery provides safe and effective results when compared with conventional sternal approaches. These positive results show a safe and stepwise evolution toward a totally endoscopic mitral valve operation.
Adult↗
Robotic Nissen fundoplication: alternative surgical technique for the treatment of gastroesophageal reflux disease.
The first robotic Nissen fundoplication using the da Vinci robotic surgical system was performed on a 56-year-old woman with a 20-year history of severe gastroesophageal reflux disease refractory to medical management. The recovery was uneventful, and follow-up continues.
Female↗
Robotic surgical training in an academic institution.
OBJECTIVE: To detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams. SUMMARY BACKGROUND DATA: Remote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically. METHODS: Advanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors' two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics. RESULTS: Established surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding. CONCLUSION: Robotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.
Academic Medical Centers↗
Robotic cardiac valve surgery: transcending the technologic crevasse!
"The man with a new idea is a crank until the idea succeeds."--Mark Twain. With the profound public stress for minimally invasive surgery that guided General Surgery, Cardiothoracic Surgery has progressed with warranted enthusiasm. The explosion of technological advancements in optics, instrumentation and cardiopulmonary bypass has permitted minimally invasive cardiac procedures to be performed with safety, efficiency, and efficacy. In this chapter, we review the evolution of minimally invasive cardiac valve surgery. The articles of leading minimally invasive valve surgeons, both European and American, are reviewed. The indications for minimally invasive surgery are explained. Furthermore, the present day state of "robotic" mitral valve surgery is described.
Heart Valve Diseases↗
Robotic mitral valve repair: trapezoidal resection and prosthetic annuloplasty with the da vinci surgical system.
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Aged↗
Hepatic insulin extraction after major hepatectomy.
BACKGROUND: After major hepatectomy, the remaining liver compensates for its reduced mass and maintains euglycemia through increased hepatic glucose output. The mechanism of this compensation may be a diminished hepatic extraction of portal insulin, which thereby decreases the suppressive effects of insulin on gluconeogenesis. METHODS: Extraction of insulin by the liver was measured using the isolated perfused rat liver model. Fasted Sprague-Dawley rats were studied at 1, 2, 3, 4, 6, and 14 days after 70% hepatectomy. Control rats had no operation, and sham rats were studied 1 day after a sham laparotomy. The difference between portal and caval insulin concentrations was determined and reported as micromoles of insulin extracted per gram liver per minute. RESULTS: Insulin extraction decreased from 191 +/- 22 microU/gm liver/min in control rats to 87 +/- 13.2 microU/gm liver/min at postoperative day 1 (p = 0.0001). Extraction normalized by postoperative day 6. Extraction rates in rats recovering from sham laparotomy were similar to control rats (p = 0.088), suggesting that decreased extraction in hepatectomized rats was not due to postoperative stress. CONCLUSIONS: After 70% hepatectomy, the remaining liver extracts less insulin per gram. This may explain the ability of the reduced liver mass to maintain euglycemia after major hepatectomy.
Analysis of Variance↗
The evolution and early experience with robot-assisted mitral valve surgery.
Cardiac surgeons, with a warranted enthusiasm, have embraced minimally invasive surgery. The acceleration of technological advances in optics, instrumentation, and cardiopulmonary bypass has allowed safe, effective, and efficient minimally invasive cardiac procedures. In this Technology Focus section, we review the evolution and early experience with robot-assisted mitral valve surgery. The articles of leading minimally invasive cardiac surgeons, both American and European, are reviewed to define the development toward cardiac robotic surgery. The current state of robotic mitral surgery is described.
Journal Article↗
Minimally invasive videoscopic mitral valve surgery: the current role of surgical robotics.
OBJECTIVE: Recently, the efficacy of video-assisted mitral valve surgery has been demonstrated. The evolution of this technology has been relatively rapid. In this article we review this development and predict the future of endoscopic and robotic-enabling technology for cardiac valve operations. METHODS: A new video-assisted mitral valve operation is described and results discussed. The majority of each valve operation was done through assisted vision and near endoscopically. Cardiopulmonary bypass was established via femoral cannulation, and blood cardioplegic arrest induced using a new percutaneous, transthoracic cross-clamp. A 5 to 6-cm minithoracotomy was used in each patient. Videoscopy was helpful for suture placement, chord reconstruction, leaflet resection, knot tying, and valve ring or prosthesis positioning. A voice-activated robotic arm was used to direct the camera in many instances. RESULTS: Thus far a total of 110 patients have undergone this operation successfully with a 0.9% operative mortality. Our early series (N = 31), published with cost data, is reviewed in detail. Cardiopulmonary perfusion and cross-clamp times for all 100 patients were longer than for conventional sternotomy patients at 158 +/- 3.9 and 110 +/- 3.6 minutes, respectively, versus 121 +/- 4.6 and 90 +/- 4.6 (N = 105); however, there have been less complications. Operative, perfusion, and arrest times have fallen progressively to 144 +/- 4.5 and 90 +/- 4.5, respectively (N = 55 Aesop 3000 cases). Complex repairs and replacements have become routine with anterior leaflet pathology addressed. Bleeding, ventilatory times, blood transfusions, and hospital stay have been reduced. One patient required reoperation for a technically failed repair and two renal patients had late endocarditis. We have used voice-activated, robotic (Aesop 3000) assistance for camera control in 51 of these patients. This addition has decreased camera motion artifact and lens cleaning, while providing direct "cerebral-eye" tracking of instruments for the surgeon. We were the first in the United States to apply the DaVinci articulated wrist robot to do a complete mitral repair and have done multiple repair with this articulated wrist device. CONCLUSIONS: From this and other work reviewed, we conclude that video-assisted and computer-assisted robotic techniques are safe and may be the pathway to truly endoscopic mitral valve operations. We are encouraged regarding the use of this new technology for mitral valve operations.
Cardiopulmonary Bypass↗