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PubMed2001

Robots in laparoscopic surgery.

BACKGROUND: The Da Vinci Robotic System became available at our institution in late August 2000. We decided to utilize this system to perform advanced laparoscopic procedures. METHODS: This is a review of the status of robotics and its application in surgery. We report our experience using the Da Vinci system. RESULTS: We have used the Da Vinci for 34 advanced laparoscopic cases: 7 gastric bypasses for morbid obesity, 9 Heller myotomies for achalasia, 11 donor nephrectomies, 2 gastrojejunostomies, and single cases of bilateral adrenalectomy, Nissen fundoplication, Toupet fundoplication, and cholecystectomy. No robot-related complications were noted. CONCLUSIONS: This early experience suggests that robotic surgery is a safe and effective alternative to conventional laparoscopic surgery. We believe that robotic surgery, with its ability to restore the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, will allow us to perform complex procedures with greater precision and confidence and better results.

Digestive System Surgical Procedures↗

PubMed2003

The role of robotic surgery in morbid obesity.

The purpose of this review was to form a collaborative opinion regarding the utility of robotic technology, specifically the da Vinci robot (Intuitive Surgical, Inc., Sunnyvale, CA), for bariatric surgery. Eleven surgeons are currently using the da Vinci system to perform laparoscopic bariatric surgery. The surgeons were queried about the type of robotic bariatric surgery and number of cases performed, complications, and any available outcomes data. They were also asked to give their opinion of the current state of robotic bariatric surgery. Ten of the 11 surgeons responded. Six surgeons are currently using the system for Roux-en-Y gastric bypass, three for laparoscopic adjustable gastric banding, and three for biliary pancreatic diversion. Robotic technology is successfully being applied to bariatric surgery in a few advanced minimally invasive surgery centers throughout the United States.

Gastric Bypass↗

PubMed2005

Robot-assisted laparoscopic dismembered pyeloplasty: a combined experience.

BACKGROUND AND PURPOSE: The need for advanced laparoscopic skills limits the implementation of laparoscopic pyeloplasty to centers with extensive experience. The introduction of robotic technology into the field of minimally invasive surgery has facilitated complex surgical dissection and genitourinary reconstruction. We report our experience with robot-assisted laparoscopic pyeloplasty using the daVinci Surgical System at three New York City medical centers. PATIENTS AND METHODS: A retrospective review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 18 female and 17 male patients between April 2001 and January 2004 was performed. The average patient age was 39.0 years (range 15-69 years). All patients had symptoms or radiographic evidence of ureteropelvic junction (UPJ) obstruction. Robotic assistance with the daVinci Surgical System was employed after preparation of the UPJ with a standard laparoscopic approach. RESULTS: The mean operative time and suturing time was 216.4 +/- 52.9 minutes and 63.0 +/- 14.2 minutes, respectively. The average estimated blood loss was minimal at 73.9 +/- 58.3 mL. The mean length of hospitalization was 69.4 hours (range 28-310 hours). The average use of intravenous morphine was 28.4 mg (range 0-162 mg). There were no intraoperative complications or open conversions. A mean follow-up of 7.9 months revealed a success rate of 94%, with two patients requiring further treatment. CONCLUSIONS: This combined multi-institutional series reveals that robot-assisted pyeloplasty with the daVinci Surgical System is safe and reproducible. These intermediate results appear comparable to those of open and laparoscopic pyeloplasty repairs.

Adolescent↗

PubMed2005

Technical modifications for robot-assisted laparoscopic pyeloplasty.

PURPOSE: Laparoscopic pyeloplasty (LP) is gaining acceptance as a standard of care for the repair of ureteropelvic junction (UPJ) obstruction, with results comparable to those of open repair. However, it remains a technically challenging procedure requiring intracorporeal suturing skills. Recent reports have demonstrated equally effective results with robot-assisted laparoscopy with shorter operative times. We present our modified technique for daVinci robot-assisted LP. PATIENTS AND METHODS: From November 2002 to May 2004, 32 consecutive patients underwent LP with the daVinci robotic system for UPJ obstruction. Just prior to laparoscopy, 31 patients underwent retrograde pyelography and cystoscopic placement of a ureteral catheter just distal to the UPJ, which was prepared into the operative field. The remaining patient had an indwelling stent placed preoperatively. Three transperitoneal ports are placed for the robot. A fourth port is placed for retraction, suction, dissection, and suture passage by the bedside surgeon. This port was placed at McBurney's point in the first two patients and the subxiphoid area in the subsequent 30 patients. A ureteral stent was inserted retrograde intraoperatively with laparoscopic assistance after exchanging the ureteral catheter for a guidewire. A Jackson-Pratt drain was placed in all cases. RESULTS: All procedures were completed laparoscopically. Anderson-Hynes dismembered pyeloplasty was performed in 31 patients, while Fengerplasty was performed in 1 patient. The average operative time was 300 minutes (initial 12 procedures: 384 minutes; last 10 procedures: 197 minutes). The average blood loss was approximately 50 mL and the average hospital stay 1.1 days. A crossing vessel was present in 44% of the cases. Stone extraction was performed in 5 cases (23%) and kidney biopsy in 1 case. The only perioperative complications were one migrated stent, which was repositioned under sedation without sequelae and one urinary tract infection. Of the 18 patients with follow-up exceeding 6 months (average 10.3 months), 16 have improved drainage and function and are asymptomatic. One patient with flank pain has no evidence of obstruction. One with delayed, although improved, drainage is asymptomatic. CONCLUSIONS: The daVinci robot system can be used effectively for LP. Although initial operative times were long, there was a significant decrease after the first 12 cases. Having retrograde access to the ureter allows simple intraoperative stent placement. We found that the subxiphoid placement of the fourth port gave the bedside surgeon the optimal location for suction, dissection, and intracorporeal suture passage. This approach and technique have become standard in our treatment of UPJ obstruction.

Adolescent↗

PubMed1997

Robotic surgical instruments for dexterity enhancement in thoracoscopic coronary artery bypass graft.

OBJECTIVES: Endoscopically sutured vascular anastomoses are complex, time consuming, and require great dexterity. We decided to evaluate performance enhancement using a robotic device to create sutured coronary artery bypass anastomoses with endoscopic techniques in a plastic model. METHODS: Seven coronary artery bypass anastomoses were endoscopically created in a plastic model using a robotic enhancement technology (Computer Motion, Goleta, CA). Anastomoses were created with a single running suture (7-0 monofilament). Our endpoints were operative time, intraoperative incidents, stability and dexterity of the robotic system, surgeon's fatigue, and anastomotic patency. RESULTS: Operative time was 46+/-12 min (mean+/-SD). There were no intraoperative incidents. Patency was confirmed in all anastomoses. The system's stability and dexterity were high. Surgeon's fatigue was mild. CONCLUSION: The use of robotic enhancement technology leads to an efficient performance of sutured coronary artery bypass anastomoses in a plastic model. The robotic device enhances dexterity, precision, and reduces surgeon's fatigue while preserving the quality of hand suturing.

Clinical Competence↗

PubMed2004

Comparative study of human and robotic camera control in laparoscopic biliary and colon surgery.

PURPOSE: Despite the growing clinical use of active robotic camera holders there is still a lack of clinical feasibility studies. PATIENTS AND METHODS: We compared the use of a voice controlled robotic camera holder (AESOP 3000, Computer Motion, Goleta, California) to a human camera holder in a series of laparoscopic cholecystectomies and colectomies. Compliance with AESOP, abnormal operative events or complications, operative time, and the duration of hospitalization were prospectively recorded and compared to data recorded before the introduction of the robotic system. RESULTS: Compliance with AESOP was good. There were no abnormal operative events, no differences in operative time, complications, or the mean duration of hospitalization between the patients operated with a robotic or a human camera holder. CONCLUSION: The use of a robotic camera holder does not alter the length of the operative procedure, the duration of hospitalization, or postoperative morbidity. It is a safe and feasible approach to laparoscopic cholecystectomy or colectomy.

Cholecystectomy↗

PubMed2005

Novel uses of surgical robotics in head and neck surgery.

PURPOSE: To demonstrate the utility of robotically assisted approaches in head and neck surgery. MATERIALS AND METHODS: Two teenage patients, one with a solitary thyroid nodule who was scheduled for a right thyroid lobectomy and the other with intractable seizures who was scheduled for placement of a vagal nerve stimulator were offered the option of a robotically assisted technique using a transaxillary endoscopic approach. RESULTS: Both procedures were completed successfully using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, California). A 12 mm telescope and 5 mm instruments were used. There was sufficient mobility of the robotic arms despite the small working space. There were no complications, minimal pain in the axillary incisions, and patient satisfaction was high. Operative times were 4.5 and 4.2 hours, respectively. CONCLUSION: Transaxillary, endoscopic, robotically assisted approaches to the head and neck are feasible. The addition of robotics improves surgical dexterity in a difficult-to-reach anatomic region. Patient satisfaction appears high because of the avoidance of a cervical incision.

Adolescent↗

PubMed2003

Surgical robotic applications in otolaryngology.

OBJECTIVES: To explore the feasibility of performing endo-robotic neck surgery in a porcine model and to compare the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. STUDY DESIGN: Prospective, nonrandomized experimental investigation in a porcine model. METHODS: We performed a consecutive series of endoscopic neck surgeries using the daVinci surgical system (Intuitive Surgical Inc.). The length of time required to establish the operative pocket and to assemble the robotic components, as well as the total duration of each operation, was recorded. The animals were continuously monitored for heart rate, blood pressure, and end-tidal CO(2) pressure, and evaluation for presence of pneumothorax and subcutaneous emphysema was undertaken postoperatively. The specimens were examined histologically. RESULTS: Four different types of neck surgery were successfully performed on both sides of the neck of four animals using the daVinci surgical system. Creation of the operative pocket took, on average (+/-SD), 18.1 +/- 11.9 minutes, and assembly of the robot required 12.5 +/- 9.9 minutes, resulting in a mean preparation time for all procedures of 30.6 +/- 21.0 minutes. The mean operative time for submandibular resection (n = 3) was 19.0 +/- 6.6 minutes, with a total procedure time of 39.0 +/- 10.2 minutes. Selective neck dissections (n = 3) required a mean operative time of 66.0 +/- 18.5 minutes and a total procedure time of 85.7 +/- 16.7 minutes. One partial parotidectomy and one thymectomy were also performed. The median estimated blood loss was 0 mL (range, 0-10 mL). The end-tidal CO(2) pressure fell from the start to the end of the procedures by a mean of 4.4 +/- 7.9 mm Hg. The blood pressure fell by a mean of 1.9 +/- 7.5 mm Hg. There was one case of modest subcutaneous emphysema, and there were no cases of pneumothorax or air embolism. No conversions to open resection were necessary. CONCLUSIONS: Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.

Animals↗

PubMed2003

Robotics and the pediatric surgeon.

Surgical robots are enabling devices for minimally invasive (laparoscopic) surgery (MIS). They use a computer to enhance a surgeon's skills as hand movements are transmitted to robotic arms. The computer filters tremor, which becomes important at high magnifications of 10 to 15 times available in MIS. It also provides motion scaling so that large hand movements are converted to very small movements of the robotic arm. The robotic arms also have wrists that make suturing and knot tying far more accurate and efficient. Surgical robots are currently used clinically for procedures such as MIS Nissen fundoplication, cholecystectomy, and splenectomy. Laboratory experience indicates that they may provide advantages for newborn procedures such as portoenterostomy for biliary atresia and repair of esophageal atresia and tracheoesophageal fistula. They have a potential for making possible MIS procedures, which can only be done open now, and for introducing entirely new procedures as well as for the performance of procedures by operators distant from the patient.

Age Factors↗

PubMed2002

Early experience with robotically assisted laparoscopic donor nephrectomy.

The da Vinci robotic system became available at our institution in late August 2000. We decided to use this system to perform robotically assisted laparoscopic donor nephrectomies. A prospective study was conducted of 10 consecutive patients who underwent robotically assisted laparoscopic donor nephrectomy between January and May 2001. The mean operative time was 166 minutes. The mean hospital stay was 1.8 days. The need for parenteral pain medication was limited to the first postoperative day. All kidneys were transplanted successfully; no rejections occurred. This early experience suggests that the results of robotically assisted laparoscopic donor nephrectomy are similar to those of laparoscopic donor nephrectomy. We believe that robotic surgery, which enables regaining of the hand-eye coordination and three-dimensional view lost in laparoscopic surgery, allows us to perform the donor nephrectomy with greater precision, confidence, and comfort.

Adult↗

PubMed2003

Comparison of task performance of the camera-holder robots EndoAssist and Aesop.

BACKGROUND: Two robotic laparoscopic camera-holders, Endo Assist and Aesop 3000, are compared from a system design viewpoint measuring the time taken to perform certain tasks by the operator. METHODS: EndoAssist and Aesop 3000 robots were tested in a simulated environment. EndoAssist was controlled via a headset-mounted motion axis selection sensor, while Aesop was voice activated. A series of simple and complex tasks were performed moving the camera to different targets. The performance of each task was video taped, and the time from onset to the end of the task was taken from the recording. RESULTS: The results showed the EndoAssist robot to be significantly quicker for most of the tasks studied. This was attributed to increased accuracy of movement in EndoAssist in comparison to the voice recognition errors evident while operating Aesop. CONCLUSION: The time taken to perform tasks yields significantly more information about the integrated human-robot system than simply studying the speed of movement of the robot.

Humans↗

PubMed2003

Robotic assisted laparoscopic sural nerve grafting during radical prostatectomy: initial experience.

PURPOSE: Sural nerve grafting has been done in select patients undergoing radical prostatectomy with unilateral or bilateral wide excision of the neurovascular bundle in an effort to preserve potency. We describe a novel technique of laparoscopic sural nerve grafting after radical prostatectomy using the da Vinci (Intuitive Surgical, Mountain View, California) robot. MATERIALS AND METHODS: The procedure was performed successfully in 3 potent men 48, 49 and 59 years old, respectively. In patient 1 the entire procedure was performed robotically using a 6 port transperitoneal approach. In patients 2 and 3 the robot was used only for sural nerve grafting and urethrovesical anastomosis, while radical prostatectomy was performed by conventional laparoscopy. After the completion of radical prostatectomy with deliberate wide resection of the 2 neurovascular bundles in patients 1 and 3, and unilateral excision of the left neurovascular bundle in patient 2 a plastic surgery team harvested 10 to 15 cm of sural nerve from the left calf. Sural nerve grafts were interposed robotically by placing 4 to 6 interrupted perineural stitches of 6 or 7-zero polypropylene sutures. RESULTS: Mean operative time was 6.5 hours, mean blood loss was 216 cc and mean hospital stay was 2.3 days. Surgical margins were focally positive at the apex in the patients 1 and 3. During a followup of 7, 5 and 1 months patient 1 reported penile engorgement with sildenafil not sufficient for penetration, patient 2 with unilateral nerve preservation was potent without any medication and patient 3 did not achieve any degree of erection, respectively. CONCLUSIONS: The da Vinci remote robotic system technically facilitates sural nerve grafting during laparoscopic radical prostatectomy. Long-term potency data are essential to validate the technical success.

Adenocarcinoma↗

PubMed2005

Robotic radical prostatectomy in the community setting--the learning curve and beyond: initial 200 cases.

PURPOSE: The introduction of robotic assistance has the potential to improve surgical outcomes and reduce the steep learning curve associated with conventional laparoscopic radical prostatectomy. We report on our experience with robotic radical prostatectomy in the community setting. MATERIALS AND METHODS: A total of 200 patients underwent robotic radical prostatectomy during 18 months. Prospective data collection included a quality of life (Expanded Prostate Cancer Index Composite) questionnaire, basic demographics, prostate specific antigen (PSA), clinical stage and Gleason grade. Operative outcome measures included operative time, estimated blood loss and complications. Postoperative outcome measures included hospital stay, catheter time, pathology, PSA and return of continence. RESULTS: Average operative time was 141 minutes with an estimated blood loss of 75 cc. The intraoperative complication rate was 1% with no mortality, reexploration or transfusion. Of the patients 95% were discharged home on postoperative day 1 (1 to 3) with hematocrit averaging 34.5 (range 25 to 45). The average difference in preoperative and postoperative hematocrit was 3 points (range -2 to 15). Average catheter time was 7.2 days (range 5 to 15). The positive margin rate was 10.5% for the entire series, 5.7% for T2 tumors, 28.5% (T3a), 20% (T3b) and 33% (T4a). Of the patients 95% had undetectable PSA (less than 0.1 ng/ml) at average followup of 9.7 months. Continence at 1, 3, 6, 9 and 12 months was 47%, 78%, 89%, 92% and 98%, respectively. CONCLUSIONS: Our initial experience with robotic radical prostatectomy is promising. The learning curve was approximately 20 to 25 cases. With a structured methodical approach we were able to implement robotics safely and effectively into our community practice with minimal patient morbidity, and good oncological and functional outcomes.

Adult↗

PubMed2006

Transoral robotic surgery (TORS) for base of tongue neoplasms.

OBJECTIVE: To develop a minimally invasive surgical technique for the treatment of base of tongue neoplasms using the optical and technical advantages of robotic surgical instrumentation. STUDY DESIGN: Ten experimental procedures including tongue base exposure and dissections were performed on three cadavers and two mongrel dogs. Transoral robotic surgery (TORS) was then performed on three human patients with tongue base cancers in a prospective human trial. METHODS: Using the da Vinci Surgical Robot (Intuitive Surgical, Inc., Sunnyvale, CA), we performed a total of 10 base of tongue resections on edentulous and dentate cadavers as well as live mongrel dogs. In the cadaver models, exposure was evaluated using three different retractors, the Dingman, Crowe Davis, and FK retractors. The three human patients underwent TORS surgery of their tongue base cancers under an institutional review board approved prospective clinical trial. The ability to identify and preserve or resect key anatomic structures such as the glossopharyngeal, hypoglossal, and lingual nerves as well as techniques for identifying the lingual artery and achieving hemostasis were developed. RESULTS: The da Vinci Surgical Robot provided excellent visualization and enabled removal of the posterior one third to one half of the oral tongue in cadavers, dogs, and human patients. Among the three retractors evaluated, the FK retractor offered the greatest versatility and overall exposure for robotic instrument maneuverability. Complete resection to negative surgical margins with excellent hemostasis and no complications was achieved in the live patient surgeries. CONCLUSIONS: TORS provided excellent three-dimensional visualization and instrument access that allowed successful surgical resections from cadaver models to human patients. TORS is a novel and minimally invasive approach to tongue neoplasms that has significant advantages over classic open surgery or endoscopic transoral laser surgery.

Animals↗

PubMed2003

Evolving spike-timing-dependent plasticity for single-trial learning in robots.

Single-trial learning is studied in an evolved robot model of synaptic spike-timing-dependent plasticity (STDP). Robots must perform positive phototaxis but must learn to perform negative phototaxis in the presence of a short-lived aversive sound stimulus. STDP acts at the millisecond range and depends asymmetrically on the relative timing of pre- and post-synaptic spikes. Although it has been involved in learning models of input prediction, these models require the iterated presentation of the input pattern, and it is hard to see how this mechanism could sustain single-trial learning over a time-scale of tens of seconds. An incremental evolutionary approach is used to answer this question. The evolved robots succeed in learning the appropriate behaviour, but learning does not depend on achieving the right synaptic configuration but rather the right pattern of neural activity. Robot performance during positive phototaxis is quite robust to loss of spike-timing information, but in contrast, this loss is catastrophic for learning negative phototaxis where entrained firing is common. Tests show that the final weight configuration carries no information about whether a robot is performing one behaviour or the other. Fixing weights, however, has the effect of degrading performance, thus demonstrating that plasticity is used to sustain the neural activity corresponding both to the normal phototaxis condition and to the learned behaviour. The implications and limitations of this result are discussed.

Action Potentials↗

PubMed2003

Oscillators and crank turning: exploiting natural dynamics with a humanoid robot arm.

This paper presents an approach to robot-arm control that exploits the natural dynamics of the arm. This is in contrast to traditional approaches, which either ignore or cancel out arm dynamics. While the traditional approaches are more general, they often result in systems and robot designs that are not robust. The alternative approach gives systems that are computationally simple, robust to variation in system parameters, robust to changes in the dynamics themselves, and versatile. The approach is examined using the example of a compliant robot arm, controlled by independent neural oscillators, in a crank-turning task. A model is constructed, and the robot behaviour compared with the model. These data show that the arm-oscillator system is exploiting the natural dynamics by finding and exciting the resonant mode of the underlying mechanical system. Since this is a natural behaviour of the system, the robot behaviour is robust. The paper concludes by discussing the opportunities and limitations of this approach.

Arm↗

PubMed2007

Honda humanoid robots development.

Honda has been doing research on robotics since 1986 with a focus upon bipedal walking technology. The research started with straight and static walking of the first prototype two-legged robot. Now, the continuous transition from walking in a straight line to making a turn has been achieved with the latest humanoid robot ASIMO. ASIMO is the most advanced robot of Honda so far in the mechanism and the control system. ASIMO's configuration allows it to operate freely in the human living space. It could be of practical help to humans with its ability of five-finger arms as well as its walking function. The target of further development of ASIMO is to develop a robot to improve life in human society. Much development work will be continued both mechanically and electronically, staying true to Honda's 'challenging spirit'.

Artificial Intelligence↗

PubMed1998

Robot-aided neurorehabilitation.

Our goal is to apply robotics and automation technology to assist, enhance, quantify, and document neurorehabilitation. This paper reviews a clinical trial involving 20 stroke patients with a prototype robot-aided rehabilitation facility developed at the Massachusetts Institute of Technology, Cambridge, (MIT) and tested at Burke Rehabilitation Hospital, White Plains, NY. It also presents our approach to analyze kinematic data collected in the robot-aided assessment procedure. In particular, we present evidence 1) that robot-aided therapy does not have adverse effects, 2) that patients tolerate the procedure, and 3) that peripheral manipulation of the impaired limb may influence brain recovery. These results are based on standard clinical assessment procedures. We also present one approach using kinematic data in a robot-aided assessment procedure.

Aged↗