Updates on robotic surgery : scientific press

1.- Laparoscopic radical prostatectomy: conventional and robotic.
Authors: Menon M, Shrivastava A, Tewari A., Vattikuti Urology Institute, The Josephine Ford Cancer Center, Henry Ford Health System, Detroit, Michigan 48202, USA. In: Urology. 2005 Nov;66(5 Suppl):101-4.

"By 2015, prostate cancer will become the most commonly diagnosed cancer in men. Radical prostatectomy reduces disease-specific mortality in patients with localized prostate cancer; however, the invasiveness of surgery and its resultant side effects cause many men to seek other treatments. In 2000, laparoscopic radical prostatectomy emerged as a minimally invasive alternative to open surgery; it has been refined recently by the addition of robotic technology. To examine the outcomes of robotic radical prostatectomy and compare them with those from open and conventional laparoscopic radical prostatectomy, we prospectively collected baseline demographic data on all patients undergoing surgery for prostate cancer over a 4-year period at our center. Urinary function and sexual function were evaluated using standardized criteria as well as a questionnaire preoperatively and at 1, 3, 6, 12, and 18 months after their procedure. Operative and postoperative outcomes were compared using values for open radical prostatectomy as the reference standard. A total of 100 men underwent open radical prostatectomy with conventional laparoscopic radical prostatectomy (n = 50) and robotic radical prostatectomy (n = 500). The odds ratios for operative times, blood loss, postoperative pain, complications, and median times to urinary continence and resumption of sexual activity all were lower for robotic than for open or laparoscopic radical prostatectomy. It appears safe to conclude that conventional laparoscopic radical prostatectomy is a reasonable alternative to open radical prostatectomy in the surgical treatment of patients with clinically localized prostate cancer. The incorporation of robotics may result in even better surgical outcomes than conventional laparoscopy. However, the surgical robot is expensive; few centers have access to the technology and even fewer have expertise in the technique. For robotic radical prostatectomy to become the standard of care for the treatment of localized prostate cancer will require economies of cost, dissemination of surgical expertise, and data from randomized trials."

2.- Robot-Assisted Endoscopic Surgery: A Four-Year Single-Center Experience.

Authors: Ruurda JP, Draaisma WA, van Hillegersberg R, Borel Rinkes IH, Gooszen HG, Janssen LW, Simmermacher RK, Broeders IA, Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. In: Dig Surg. 2005 Sep 28;22(5):313-320.

"Background: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. Methods:Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vincitrade mark robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). Results:The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45-420) and the median blood loss was 30 ml (0-800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%).

Conclusion: During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems."
Copyright © 2005 S. Karger AG, Basel.

3.- Laparoscopic morgagni hernia repair in children using robotic instruments.
Authors: Knight CG, Gidell KM, Lanning D, Lorincz A, Langenburg SE, Klein MD, the Maxine and Stuart Frankel Foundation Computer-Assisted Robot-Enhanced Surgery Program at Children's Hospital of Michigan, Detroit, Michigan.
In: Journal of Laparoendoscopic Advanced Surgical Techniques. 2005 Oct;15(5):482-6.

"Background: Robotic surgery enhances minimally invasive surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. We report 2 cases of computer- assisted, robot-enhanced, laparoscopic repair of Morgagni hernia in a 23-month-old weighing 10.2 kg and a 5-year-old weighing 21.6 kg. Methods: Four 5 mm trocars were used to gain access to the abdomen. In the first case, standard laparoscopic instruments were used to dissect the liver from the rim of the defect and then reduce the hernia. In the second, robotic instruments were used for this dissection. In both cases, the robot- enhanced instruments were used to close the hernia defects with interrupted, nonabsorbable suture, using intracorporeal knot tying. Results: Both cases were completed laparoscopically without a patch. The robotic system took 9 minutes to set up and drape. The average operative time was 227 minutes. The older child tolerated oral intake the day of surgery and went home the following day. The younger child tolerated oral intake and went home on postoperative day 2.

Conclusion: Robot-assisted laparoscopic Morgagni hernia repair is feasible."

4.- Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors.
Authors: Bodner JC, Zitt M, Ott H, Wetscher GJ, Wykypiel H, Lucciarini P, Schmid T., Department of General and Transplant Surgery, Innsbruck Medical University, Innsbruck, Austria. In: Ann. Thorac. Surg. 2005 Oct;80(4):1202-6.

"BACKGROUND:
Robotic surgical systems are most effective for operations in areas that are small and difficult to reach. Ideal indications for this new technology have yet to be established. The esophagus possesses attributes that are interesting for general thoracic robotic surgeons.

METHODS:
Robotic-assisted thoracoscopic surgery (RATS) using the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) was performed in six patients with esophageal tumors. This comprised the dissection of the intrathoracic esophagus including lymph node dissection in four patients suffering from esophageal cancer and the extirpation of a benign lesion (one leiomyoma and one foregut cyst) in the remaining two patients. RESULTS: All procedures were completed successfully with the robot. The median overall operating time was 173 (160-190) minutes in the oncologic cases and 121 minutes in the benign cases, including the robotic act of 147 (135-160) minutes and 94 minutes, respectively. There were no intraoperative complications. One patient had to undergo a redo thoracoscopy because of a persistent lymph fistula. One cancer patient died after 12 months due to tumor progression and another patient had to be stented due to local tumor recurrence 19 months postoperatively.

CONCLUSIONS:
This first small series of various esophageal pathologies treated by robotic-assisted thoracoscopic surgery supports the impression that the esophagus is an ideal organ for a robotic approach. The potential of the da Vinci system, especially for oncologic indications, remains to be proven in future clinical trials."

5.- Technologic advances in Robotic Surgery.
Author: Waseem T., Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, 02115, USA. In: Journal of Coll. Physicians Surg Pak. 2005 Sep;15(9):559-61.

"Medical science has achieved enormous accomplishments during the past couple of decades. These advances encompass the list of techniques involving manipulations of DNA and stem cells to minimally invasive techniques. The recent advances in integration of computer sciences, biomechanics and electronic miniaturization have made it possible to make the surgical techniques less invasive and highly precise. Much progress has been made in integrating robotic technologies with surgical instrumentation, as evident by thousands of successful robot-assisted surgical procedures. Such advances will enable continued progress in surgical instrumentation and, ultimately, surgical care."

6.- Maintenance of Hemostasis in Transoral Robotic Surgery.
Authors: Hockstein NG, Weinstein GS, O'malley Jr BW., Department of Otorhinolaryngology - Head and Neck Surgery, The University of Pennsylvania, Philadelphia, Pa., USA. In: ORL J Otorhinolaryngol Relat Spec. 2005 Sep 5;67(4):220-224.

"Background:
The last decade has seen a tremendous growth in the field of robotic surgery with an increasing number of cardiac and urologic procedures performed each year. Several attributes of this technology may offer advantages to laryngeal and pharyngeal surgery in that it allows for exceptional visualization of the operative field, precise handling of soft tissues, and multiplanar transection of tissues. One potential limitation is the management of bleeding in transoral pharyngeal and laryngeal surgery, which is critical to prevent both intravascular volume loss and aspiration.

Objectives:
To demonstrate methods for management of bleeding in the surgical field during transoral robotic surgery (TORS). Methods: We developed a canine robotic surgery model for the evaluation of the ability to control bleeding in laryngeal and pharyngeal procedures using the daVinci((R)) surgical robot (Intuitive Surgical, Inc., Sunnyvale, Calif., USA). Both large- and small-vessel hemostasis was obtained with both robotically controlled monopolar and bipolar cautery and with robotically controlled small hemoclips. Additionally, manually controlled large hemoclips were applied by an assistant surgeon viewing on a video monitor for management of large arterial vessels. Suction was performed with both flexible suction catheters controlled by the robotic arms and with manually controlled conventional suction catheters. Data were collected with still and video photography.

Results:
The lingual artery as well as small arteries and veins were easily controlled and there were no difficulties with maintenance of hemostasis.

Conclusions:
Effective hemostasis with control of both large and small vessels can be obtained using both surgical hemoclips and electrocautery during TORS in a canine model." Copyright © 2005 S. Karger AG, Basel.

7.- Computer-assisted laparoscopic colon resection with the Da Vinci system: our first experiences.
Authors: Braumann C, Jacobi CA, Menenakos C, Borchert U, Mueller JM, Rueckert JC, Department of General, Visceral, Vascular and Thoracic Surgery, Medical Faculty Charite, Humboldt University, Berlin, Germany. In: Dis Colon Rectum. 2005 Sep;48(9):1820-7.

"PURPOSE:
Telerobotic surgery is a developing and promising modality that highly improves the laparoscopic dexterity. We have performed more than 100 laparoscopic and thoracoscopic procedures since December 2002 with the aid of the Da Vinci robotic system. This study was designed to assess the value of robots in colonic laparoscopic surgery. We present our first cases of robotic-assisted colectomies.

METHODS:
Two patients underwent a telerobotic-assisted sigmoidectomy for sigmadiverticulitis. One of these cases was complicated with a sigmoid-bladder fistula. Three other patients were submitted to a colon resection for cancer: sigmoidectomy (n = 2), and right colectomy (n = 1). A four-trocar technique was used for all operations. Tissue dissection of colonic adhesions, mobilization of the colon, management of the fistula, mesenteric dissection and division, and bowel resection were fully performed with the telerobotic system.

RESULTS:
Three operations were completed using the Da Vinci system without any problems in acceptable times. In two patients, the operation had to be converted to laparotomy because of severe adhesions and locally extended tumor growth. Postoperative courses of all patients were uneventful. Patients were discharged between postoperative Days 9 and 20, and were well six months later.

CONCLUSIONS:
Colonic telerobotic surgery can be performed safely. Benefits were seen during dissection of the rectum in the small pelvis. A major limitation is a lack of a large operation field especially if there is the need to dissect a colonic flexure in the upper abdomen. The enormous costs and the lack of appropriate instruments can be a major problem in the further expansion of the telerobotic surgery."

8.- Robotic coronary artery surgery: past, present and future.
Authors: Dogan S, Akbulut B, Aybek T, Mierdl S, Moritz AR, Wimmer-Greinecker G., Department of Cardiovascular and Thorax Surgery, Johann Wolfgang Goethe University, D-60590, Frankfurt, Germany. In: Anadolu Kardiyol Derg. 2005 Sep;5(3):210-5.

"Minimally invasive endoscopic procedures in cardiac surgery have only become possible since the introduction of telemanipulator systems. In this study we review robotic assisted telemanipulation systems and procedures on beating and arrested heart for total endoscopic revascularization. Robotic surgery is still under development. The most important factors limiting this new technique are high costs and the fact that only selected patients are able to be operated on. But studies on technology especially to improve anastomotic techniques are going on to produce an alternative for coronary revascularisation. We did not yet hit all goals but the future seems promising."

9.- Adhesiolysis is facilitated by robotic technology in reoperative cardiac surgery.
Authors: Martens TP, Morgan JA, Hefti MM, Brunacci DA, Cheema FH, Kesava SK, Xydas S, Dang NC, Vigilance DW, Kohmoto T, Gorenstein LA, Smith CR Jr, Argenziano M., Department of Surgery, Columbia University, College of Physicians and Surgeons, New York, New York, USA. In: Ann Thorac Surg. 2005 Sep;80(3):1103-5.

"Over a 2-year period, 5 patients who required reoperative chest surgery underwent robotic adhesiolysis with the da Vinci (Intuitive, Sunnyvale, CA) system. Resternotomy was performed under direct visualization for coronary revascularization (n = 2) or valve replacement (n = 1). A fourth patient required coronary revascularization after a previous axilloaxillary bypass. The final case involved the preparation of a substernal pathway for a gastric pull-up. In all cases adhesions were taken down without injury to the underlying structures. All grafts were preserved, and all patients recovered uneventfully. Robotic adhesiolysis is a versatile technique that allows careful lysis of adhesions and minimizes the risk of major complication during reoperative chest surgery."

10.- Comparison of laparoscopic pyeloplasty with and without robotic assistance.
Authors: Bernie JE, Venkatesh R, Brown J, Gardner TA, Sundaram CP., Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
In: JSLS. 2005 Jul-Sep;9(3):258-61.

"OBJECTIVES:
The benefits of laparoscopic surgery with robotic assistance (da Vinci Robotic Surgical System, Intuitive Surgical, Sunnyvale, CA) includes elimination of tremor, motion scaling, 3D laparoscopic vision, and instruments with 7 degrees of freedom. The benefit of robotic assistance could be most pronounced with reconstructive procedures, such as pyeloplasty. We aimed to compare laparoscopic pyeloplasty, with and without robotic assistance, during a surgeon's initial experience to determine whether robotic assistance has distinct advantages over the pure laparoscopic technique.

METHODS:
We retrospectively compared the first 7 laparoscopic pyeloplasties with the first 7 robotic pyeloplasties performed by a single surgeon. All patients were preoperatively evaluated with computed tomographic angiography with 3D reconstruction to image crossing vessels at the ureteropelvic junction. All patients were followed up by lasix renograms and routine clinic visits.

RESULTS:
Patients were similar with respect to mean age (34 in laparoscopic pyeloplasty group vs 32 in the robotic pyeloplasty group), operative time (5.2 hours vs 5.4 hours), estimated blood loss (40 mL vs 60 mL), and hospital stay (3 days vs 2.5 days). Two patients in the laparoscopic pyeloplasty group had small anastomotic leaks managed conservatively, and one patient in the robotic pyeloplasty group had a febrile urinary tract infection necessitating treatment with intravenous antibiotics. Another patient in the robotic pyeloplasty group was readmitted with hematuria that was treated conservatively without transfusion. No recurrences were detected in either group.

CONCLUSIONS:
Operating times and outcomes during the learning curve for laparoscopic pyeloplasty were similar to those for robotic pyeloplasty. Long-term data with greater experience is needed to make definitive conclusions about the superiority of either technique and to justify the expense of robotic pyeloplasty."

11.- Robot-assisted laparoscopic dismembered pyeloplasty.
Authors: Palese MA, Munver R, Phillips CK, Dinlenc C, Stifelman M, DelPizzo JJ., the Mount Sinai School of Medicine, Department of Urology, New York, New York, USA.
In: JSLS. 2005 Jul-Sep;9(3):252-7.

"OBJECTIVE:
Advanced laparoscopic skills limit 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 da Vinci Robotic Surgical System at 3 New York City medical centers.

METHODS:
A review of all robot-assisted laparoscopic Anderson-Hynes dismembered pyeloplasty cases in 38 patients (21 females, 17 males) between April 2001 and January 2004 was performed. All patients had symptoms or radiographic evidence of ureteropelvic junction obstruction. Robotic assistance with the da Vinci Robotic Surgical System was used after preparation of the ureteropelvic junction with a standard laparoscopic approach.

RESULTS:
The average patient age was 39.3 years (range, 15 to 69). The mean operative time and suturing time were 225.6+/-59.3 minutes and 64.2+/-14.6 minutes. The average estimated blood loss was minimal at 77.3+/-55.3 mL. The mean length of hospitalization was 69.6 hours (range, 28 to 310). The average use of intravenous morphine was 26.5 mg (range, 0 to 162). No intraoperative complications occurred, and open conversions were not necessary. A mean follow-up of 12.2 months revealed a success rate of 94.7% with 2/38 patients requiring further treatments.

CONCLUSIONS:
This combined multi-institutional series reveals that robot-assisted pyeloplasty with the da Vinci Surgical System is safe and reproducible. These intermediate results appear comparable to results with open and laparoscopic pyeloplasty repairs."

12.- Innovative techniques in coronary bypass surgery.
Author: Loisance D., Academie Nationale de Medecine. In: Bull Acad Natl Med. 2005 Feb;189(2):269-82; discussion 283.

"Coronary artery surgery is now being challenged by percutaneous techniques of coronary revascularization, coronary dilatation and arterial stenting. Improvements are being made in three directions, namely selection of optimal conduits, with the aim of improving long-term graft patency; minimizing complications of cardiopulmonary circulation (or avoiding it altogether), and improving access to coronary vessels. The ultimate goal is robotic keyhole surgery of the beating heart. This paper offers a critical analysis of these developments."

13.- Treatment of double vessel coronary artery disease by totally endoscopic bypass surgery and drug-eluting stent placement in one simultaneous hybrid session.
Authors: Bonatti J, Schachner T, Bonaros N, Jonetzko P, Ohlinger A, Lockinger A, Stalzer B, Eschertzhuber S, Friedrich G., Departments of Cardiac Surgery, Cardiac Anesthesiology, and Cardiology, Innsbruck Medical University, Innsbruck, Austria.
In: Heart Surg Forum. 2005;8(4):E284-6.

"Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheter-based coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci(TM) telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure."

14.- Total Endoscopic CABG* Using Robotics on Beating Heart.
* CABG = Coronary Artery Bypass Graft
Authors: Fleck T, Tschernko E, Hutschala D, Simon-Kupilik N, Bader T, Wolner E, Wisser W., Department of Cardiothoracic Surgery, Medical University Vienna, Austria.
In: Heart Surg Forum. 2005;8(4):E266-8.

"Background:
The implementation of a total endoscopic coronary surgery on the beating heart with the aid of the Da Vinci surgical system (Intuitive, Sunnyvale, CA) requires a stepwise learning process. After cadaveric training and clinical start of the program in November 2002, we gained experience with arrested heart procedures starting in May 2003. In November 2003, we moved to beating heart surgery.

Methods:
From November 2003 to January 2005, 14 patients with coronary artery disease (mean age of 62 +/- 5 years, female to male ratio 2:12) were operated with the intention to perform a beating heart TECAB (totally endoscopic coronary artery bypass grafting) procedure.

Results:
Total conversion rate was 35% (5/14), due to pleural adhesions in 2 patients, injury of the lung during port placement, inability to occlude the LAD with saddle loops, atherosclerotic diseased mammary artery in 1 patient each. Mean operating time was 298 +/- 110 minutes with a steady decline throughout the study period (first 5 patients: 342 +/- 61 minutes, patients 6 to 9: 337 +/- 87 minutes, last 4 patients: 290 +/- 53 minutes), resulting in a 60 minute shorter operating time. Mean ICU stay was 1.3 days and hospital stay lasted on average 8.4 +/- 2.8 days.

Conclusion:
Total endoscopic bypass surgery on the beating heart with the Da Vinci surgical system can be safely implemented in clinical use. The learning curve results in a constantly decreasing procedure time due to a more effective table team-console surgeon-robotic system interaction and a moderate conversion rate."

15.- Robotic mitral valve repair: a community hospital experience.
Authors: Jones BA, Krueger S, Howell D, Meinecke B, Dunn S., BryanLGH Heart Institute, Lincoln, Nebraska 68516, USA. In: Tex Heart Inst J. 2005;32(2):143-6.

"Robotically assisted cardiac surgery has been presented as less invasive than conventional surgery, with shortened hospital stays and faster return to daily activities. We evaluated our experience with the da Vinci robot to determine whether we could in fact demonstrate those findings. All mitral and tricuspid valve repairs were performed by the same surgeon. Cardiopulmonary bypass was performed with femoral cannulation, antegrade cardioplegia, and transthoracic aortic cross-clamping. Multiple valve repair techniques were used, including quadrant resection, cord replacement, Alfieri leaflet coaptation, and ring annuloplasty. Access was by 2 ports and a 5-cm right anterolateral thoracotomy. All annuloplasty rings were secured using surgical clips. From October 2003 through September 2004, 32 patients underwent robotically assisted mitral valve repair. The mean age of our population was 676 years (range, 43-82 years). Four patients also underwent the 1st tricuspid valve repair using the da Vinci robot in the United States. There were 3 conversions for irreparable valves, 1 stroke, and 2 deaths. The average procedure time, cardiopulmonary bypass time, and aortic cross-clamp time were all reduced, when the first 20 patients were compared with the last 12. Length-of-stay also improved. One patient required early mitral valve replacement for recurrent regurgitation. Two patients required late (> 3 month) mitral valve replacement for recurrent regurgitation. We have shown that a dedicated nonacademic institute can develop a robotic cardiac surgery program and perform mitral and tricuspid valve repairs successfully. There is a several-case learning curve, and patient selection is paramount."

16.- Totally robotic Roux-en-Y gastric bypass.
Authors: Mohr CJ, Nadzam GS, Curet MJ., Department of Surgery, Stanford School of Medicine, Stanford Hospital, Stanford, CA 94305, USA. In: Arch Surg. 2005 Aug;140(8):779-86.

"HYPOTHESIS:
We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery. DESIGN: Retrospective case comparison study.

SETTING:
Academic tertiary care center. PATIENTS: Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process. INTERVENTION: A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery.

MAIN OUTCOME MEASURES:
Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications.

RESULTS: No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04).

CONCLUSIONS:
This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach."

17.- Nerve-sparing Axillary Dissection Using the da Vinci Surgical System.
Authors: Lim SM, Kum CK, Lam FL., Centre for Breast Screening and Surgery, Centre for Robotic Surgery, Mount Elizabeth Medical Centre, S228510 , Singapore. In: World J Surg. 2005 Sep 15.

"This is an initial report of a new method of axillary dissection via a periareolar incision and an 8 mm incision in the axilla with the da Vinci Surgical System. The 10x magnification and three-dimensional image, together with the versatility and precision of the robotic telemanipulators, has enabled us to perform nerve-sparing axillary dissection in four patients with invasive ductal carcinoma of the breast undergoing segmental (conservative) excision and level II axillary dissection. The time for the robotic axillary dissection ranged from 30 to 105 minutes (average 70.5 minutes). The average number of lymph nodes retrieved was 13 (11, 11, 13, and 17, respectively). Postoperatively all four patients recovered well and were discharged the next day. The robotic system can enhance the surgeon's ability by providing a high-definition, magnified, three-dimensional view of the operative field, intuitively controlled articulating instruments, and elimination of tremors; and it has potential benefits for the patient."

18.- Use of fourth arm in da Vinci robot-assisted extraperitoneal laparoscopic prostatectomy: novel technique.
Authors: Esposito MP, Ilbeigi P, Ahmed M, Lanteri V., Department of Urology, Hackensack University Medical Center, Hackensack, New Jersey 07601, USA. In: Urology. 2005 Sep;66(3):649-52.

"INTRODUCTION:
The da Vinci robot-assisted laparoscopic radical prostatectomy is a relatively new approach that is revolutionizing the surgical treatment of localized prostate cancer. Since its introduction, several improvements have been made in the robot design model, as well as in the surgical technique for prostatectomy. One of the more recent advances in this technology has been the introduction of a four-arm robot model. This modified system allows the operating surgeon to use the fourth arm for key steps and maneuvers during the operation, thereby decreasing the reliance on advanced assistant laparoscopic skills. In this report, we describe our modifications for the extraperitoneal approach for laparoscopic removal of the prostate using the four-arm da Vinci surgical system.

TECHNICAL CONSIDERATIONS:
During a 24-month period, 154 consecutive patients with clinically localized prostate cancer underwent extraperitoneal robot-assisted laparoscopic radical prostatectomy using the four-arm da Vinci robot system. All cases were videotaped and subsequently reviewed. Important factors regarding extraperitoneal access, patient positioning, port placement, and assistant role with or without the fourth arm were defined.

CONCLUSIONS: Our experience has revealed that the extraperitoneal approach allows for a more natural patient position during the operation and avoids intraperitoneal organ injury. The addition of the fourth arm to the da Vinci robot provides the operating surgeon with a great deal of independence, which facilitates all aspects of robot-assisted laparoscopic prostatectomy. It allows the operating surgeon to retract tissue during critical steps in this challenging operation and reduces the reliance on highly trained laparoscopic assistants."

19.- Use of robotics during laparoscopic gastric bypass for morbid obesity.
Authors: Artuso D, Wayne M, Grossi R., Department of Surgery, Cabrini Medical Center, New York, New York, USA. In: JSLS. 2005 Jul-Sep;9(3):266-8.

"To evaluate the theoretical increased precision offered by utilization of the robotic instrument, we attempted to determine whether incorporation of its use into traditional laparoscopic gastric bypass would duplicate or improve the success of the operation without increasing complications. The Roux-en-Y gastric bypass is the most commonly performed procedure for morbid obesity in the United States. We performed 120 gastric bypass procedures with traditional laparoscopy during a 30-month period. We began introducing the da Vinci Robotic Surgical System into our laparoscopic gastric bypass procedure and evaluated its effectiveness."

Sources:PubMed