Perspectivas em cirurgia robótica: a visão do cirurgião / Robotic surgery: the surgeon's perspective

Introdução: Avaliar os níveis de conhecimento, interesse e treinamento dos cirurgiões inscritos no Colégio Brasileiro dos Cirurgiões (CBC) da cidade de Porto Alegre, Rio Grande do Sul, em relação à cirurgia robótica. Métodos: Estudo transversal, baseado em informações coletadas por meio de questionário enviado via plataforma digital para potenciais participantes. O formulário continha perguntas estruturadas e autoaplicáveis, a fim de caracterizar o perfil profissional, capacitação em cirurgia minimamente invasiva, conhecimento, opinião e treinamento específico em cirurgia robótica. Resultados: Dos 146 membros inscritos no CBC na cidade de Porto Alegre, 99 (67,8%) responderam ao questionário. Houve predomínio do sexo masculino (88%) e a mediana de idade dos participantes foi de 48 anos. Os procedimentos videolaparoscópicos ou vídeo-assistidos foram maioria na rotina dos cirurgiões. Da totalidade da amostra, a maior parte (78%) já assistiu ao menos um procedimento robótico, e um terço (n = 30) já realizou algum tipo de treinamento ou simulação em cirurgia robótica. Entre os que não realizaram, dois terços pretendem se qualificar no futuro. Apenas 10% dos cirurgiões possuem certificação na área. Conclusão: A maioria dos cirurgiões respondentes inscritos no CBC em Porto Alegre tem em sua rotina predominância de procedimentos minimamente invasivos e acredita que a plataforma robótica será o futuro da cirurgia. Embora ainda não disponível na maioria dos serviços gaúchos, espera-se que o desenvolvimento de novas plataformas e a redução dos custos envolvidos na aquisição de equipamento e de capacitação do cirurgião facilitem a disseminação dessa tecnologia.

Introduction: To assess the practical knowledge, interest, and training levels of surgeons enrolled in the Brazilian College of Surgeons (CBC) of the municipality of Porto Alegre, Rio Grande do Sul, regarding robotic surgery. Methods: Cross-sectional study, based on information collected with a questionnaire sent to potential participants via digital platform. The form contained structured and self-administered questions, to characterize their professional profile, skills in minimally invasive surgery, knowledge, opinion, and specific training in robotic surgery. Results: Of the 146 members enrolled in the CBC of the municipality of Porto Alegre, 99 (67.8%) responded to the questionnaire. Most were males (88%) with a mean age of 48 years. Video-laparoscopic or video-assisted procedures were the most frequent in the participants' practice. Of the sample, most (78%) already watched at least one robotic surgery, and one third (n = 30) had already completed some sort of training or simulation course in robotic surgery. Among those who did not, two thirds intend to pursue formal training in the future. Only 10% of participating surgeons are certified in the area. Conclusion: Most responding surgeons enrolled in the CBC in Porto Alegre perform mostly minimally invasive procedures daily and believe that the robotic technology will be the future of surgery. Although not yet available in most services of the state of Rio Grande do Sul, it is expected that the development of new platforms and the reduction of costs involved in equipment acquisition and surgical training will facilitate the dissemination of this technology.

Training of Brazilian Urology residents in laparoscopy: results of a national survey

ABSTRACT Objectives To evaluate the familiarity of Brazilian urology residents with laparoscopy, methods of training and perspectives. Material and methods a questionnaire with 23 questions was sent by e-mail to all urological residents of 86 Urology Residence Programs certified by the Brazilian Society of Urology (BSU). Results 225 valid answers (85% of all residents) responded. Most residences belong to academic hospitals mainly in the Southeast region of Brazil. Women account for 5% of residents and 82% of programs perform less than 100 procedures per year. Residents have access to LESS, RAL and 98% to surgical laparoscopy and 87% of these participate actively at the surgery, but 84.9% do not have access to RAL. The most common laparoscopic procedure is radical nephrectomy (73.2%), but only 28.8% of residents acted as surgeons, and third year residents (R3) are those that mainly performed this procedure (statistical significance, p <0.05). 61% of residents do not participate in hands-on courses or fellowship in laparoscopy, among those who attended these fellowships, 23.47% were sponsored by BSU in equal regions of the country. Although there are several opportunities of training in laparoscopy, 42% of residents do not have access to any kind of preparation and 52% have no structured specific program. R3 perception of laparoscopy experience is significantly higher than R2 and R1 residents. Almost 30% of them affirms that they are prepared for professional life regarding urologic laparoscopy. Conclusion Brazilian urologic residents have access to laparoscopy and actively participate in the learning process. Robotic surgery is expanding in the country, although still very far from residents. Brazilian resident, at the end of medical residency, is motivated to perform laparoscopic procedures.

Serving as a bedside surgeon before performing robotic radical prostatectomy improves surgical outcomes

ABSTRACT Introduction: To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy. Materials and Methods: The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while Group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate. Results: Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant. Conclusion: Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.

Cirugía robótica en artroplastia de rodilla / Robotic surgery in knee arthroplasty

La cirugía protésica de rodilla es un procedimiento ampliamente aceptado como etapa final del tratamiento de la artrosis de rodilla, con sobrevida que supera el 90% a 10­15 años. Dentro de las principales causas de fallo, se encuentran la infección (20,4%) y el aflojamiento mecánico (20,3%). El uso de ayudas tecnológicas en cirugía está en constante desarrollo, con el objetivo de mejorar la precisión del acto quirúrgico. En ese escenario, la Cirugía Asistida por Computador (CAS) en artroplastia de rodilla, crece de forma exponencial, y apunta a mejorar el posicionamiento y selección del tamaño de los componentes protésicos, aumentar la precisión de las resecciones óseas y mejorar el balance de los tejidos blandos, logrando así una mayor sobrevida del implante. En comparación a las técnicas convencionales, la cirugía robótica ha mostrado mejores resultados funcionales, al primer año de seguimiento, en términos de rango articular, menor dolor post-operatorio y menor tiempo de estadía hospitalaria. Pero todavía es necesario establecer si, a largo plazo, esas diferencias funcionales se traducirán en mejores resultados clínicos que permitan, de forma consistente, inclinar la balanza en favor de la técnica asistida por robot por sobre las técnicas tradicionales.

Prosthetic knee surgery is a widely accepted procedure as the final stage in the treatment of knee osteoarthritis, with survival rate over 90% at 10 - 15 years. Among the main causes of failure are infection (20.4%) and mechanical loosening (20.3%). The use of technological aids in surgery is in constant development, with the aim of improving the accuracy of the surgical act. In this scenario, Computer-Aided Surgery (CAS) in knee arthroplasty grows exponentially, and aims to improve the positioning and selection of the size of the prosthetic components, increase the accuracy of bone resections and improve the balance of soft tissues, thus achieving a greater survival of the implant. Compared to conventional techniques, robotic surgery has shown better functional results at the first year of follow-up, in terms of joint range, less post-operative pain and shorter hospital stay. It is still necessary to establish whether, in the long term, these functional differences will result in better clinical results that will allow - in a consistent manner - to tip the balance in favor of robot-assisted technique over traditional techniques.

Does the experience of the bedside assistant effect the results of robotic surgeons in the learning curve of robot assisted radical prostatectomy?

ABSTRACT Introduction: The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP. Materials and Methods: We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately. Results: There were no significant differences between the groups in terms of age, comorbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min, p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively). Conclusion: Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time.

Learning robotic pyeloplasty without simulators: an assessment of the learning curve in the early robotic era

OBJECTIVE: To analyze our experience and learning curve for robotic pyeloplasty during this robotic procedure. METHODS: Ninety-nine patients underwent 100 consecutive procedures. Cases were divided into 4 groups of 25 consecutive procedures to analyze the learning curve. RESULTS: The median anastomosis times were 50.0, 36.8, 34.2 and 29.0 minutes (p=0.137) in the sequential groups, respectively. The median operative times were 144.6, 119.2, 114.5 and 94.6 minutes, with a significant difference between groups 1 and 2 (p=0.015), 1 and 3 (p=0.002), 1 and 4 (p<0.001) and 2 and 4 (p=0.022). The mean hospital stay was 7.08, 4.76, 4.88 and 4.20 days, with a difference between groups 1 and 2 (p<0.001), 1 and 3 (p<0.001) and 1 and 4 (p<0.001). Clinical and radiological improvements were observed in 98.9% of patients. One patient presented with recurrent obstruction. CONCLUSIONS: Our results demonstrate a high success rate with low complication rates. A significant decrease in hospital stay and surgical time was evident after 25 cases.

New trends in translational microsurgery

Abstract Technological advances such as optical instruments and surgical tools have enabled the considerable contributions of microsurgery to surgical therapies. Accordingly, surgical therapeutics has provided the latest information across a wide range of medical specialties, including immunology and pharmacology, despite specialization according to organs and organ systems. The International Society for Experimental Microsurgery, an academic organization, has utilized experimental microsurgery technology in the identification of curative concepts for diseases that remain difficult to treat. For this publication to mark the 32nd anniversary of the Brazilian Surgical Society, I introduced the following types of technology related to the further development of microsurgical technological innovations in the future: high-resolution three-dimensional (3D) video and touch-sensitive microsurgery robots.

Towards development and validation of an intraoperative assessment tool for robot-assisted radical prostatectomy training: results of a Delphi study

ABSTRACT Introduction As urology training shifts toward competency-based frameworks, the need for tools for high stakes assessment of trainees is crucial. Validated assessment metrics are lacking for many robot-assisted radical prostatectomy (RARP). As it is quickly becoming the gold standard for treatment of localized prostate cancer, the development and validation of a RARP assessment tool for training is timely. Materials and methods We recruited 13 expert RARP surgeons from the United States and Canada to serve as our Delphi panel. Using an initial inventory developed via a modified Delphi process with urology residents, fellows, and staff at our institution, panelists iteratively rated each step and sub-step on a 5-point Likert scale of agreement for inclusion in the final assessment tool. Qualitative feedback was elicited for each item to determine proper step placement, wording, and suggestions. Results Panelist's responses were compiled and the inventory was edited through three iterations, after which 100% consensus was achieved. The initial inventory steps were decreased by 13% and a skip pattern was incorporated. The final RARP stepwise inventory was comprised of 13 critical steps with 52 sub-steps. There was no attrition throughout the Delphi process. Conclusions Our Delphi study resulted in a comprehensive inventory of intraoperative RARP steps with excellent consensus. This final inventory will be used to develop a valid and psychometrically sound intraoperative assessment tool for use during RARP training and evaluation, with the aim of increasing competency of all trainees.

Modelo de programa de treinamento em cirurgia robótica e resultados iniciais / Model of a training program in robotic surgery and its initial results

RESUMO Objetivo: descrever a implantação de um programa de treinamento em cirurgia robótica e apontar as operações em Cirurgia Geral que podem ser feitas com vantagens utilizando a plataforma robótica. Métodos: estudo prospectivo do Grupo de Cirurgia Robótica em Cirurgia Geral e Colorretal do Hospital Samaritano (Rio de Janeiro, Brasil), de outubro de 2012 a dezembro 2015. São descritas as etapas do treinamento e particularidades. Resultados: no período do estudo foram realizadas 293 operações robóticas em Cirurgia Geral: 108 cirurgias para obesidade mórbida, 59 colorretais, 55 cirurgias na área da transição esôfago-gástrica, 16 colecistectomias, 27 hérnias da parede abdominal, 13 hernioplastias inguinais, duas gastrectomias com linfadenectomia à D2, uma vagotomia, duas hernioplastias diafragmáticas, quatro cirurgias hepáticas, duas adrenalectomias, duas esplenectomias, uma pancreatectomia, uma anastomose biliodigestiva. O índice de complicações foi de 2,4% sem complicações maiores. Conclusão: o Programa de Cirurgia Robótica do Hospital Samaritano foi implementado de forma segura e com resultados iniciais acima da literatura. Parece haver benefício em se utilizar a plataforma robótica nos super obesos, nas reoperações de cirurgia de obesidade e de hérnias de hiato, hérnias de hiato gigantes e para-esofágicas, hérnias ventrais com múltiplos defeitos e ressecções baixas de reto.

ABSTRACT Objective: to describe the implementation of a training program in robotic surgery and to point the General Surgery procedures that can be performed with advantages using the robotic platform. Methods: we conducted a retrospective analysis of data collected prospectively from the robotic surgery group in General and Colo-Retal Surgery at the Samaritan Hospital (Rio de Janeiro, Brazil), from October 2012 to December 2015. We describe the training stages and particularities. Results: two hundred and ninety three robotic operations were performed in general surgery: 108 procedures for morbid obesity, 59 colorectal surgeries, 55 procedures in the esophago-gastric transition area, 16 cholecystectomies, 27 abdominal wall hernioplasties, 13 inguinal hernioplasties, two gastrectomies with D2 lymphadenectomy, one vagotomy, two diaphragmatic hernioplasties, four liver surgeries, two adrenalectomies, two splenectomies, one pancreatectomy and one bilio-digestive anastomosis. The complication rate was 2.4%, with no major complications. Conclusion: the robotic surgery program of the Samaritan Hospital was safely implemented and with initial results better than the ones described in the current literature. There seems to be benefits in using the robotic platform in super-obese patients, re-operations of obesity surgery and hiatus hernias, giant and paraesophageal hiatus hernias, ventral hernias with multiple defects and rectal resections.

Concurrent and predictive validation of robotic simulator Tube 3 module

PURPOSE: We previously described a new procedure specific module (Tube 3) to allow the practice of vesicourethral anastomosis after robot-assisted radical prostatectomy. Herein, we report a predetermined proficiency level of Tube 3 and preliminary validation to explore whether this new module can lead to performance improvement in the da Vinci system. MATERIALS AND METHODS: Eight urology residents and three urology fellows performed the Tube 3 module 1 hour daily for 7 days. The learning curve was depicted through a scatterplot and the stable point was identified through the cumulative sum chart. Concurrent and predictive validations were performed with the da Vinci system. The mean time to complete the task and end product rating score between Tube 3 training group and no Tube 3 training group were compared. RESULTS: Concerning the learning curve, about 41 repetitions comprising about 5 hours were needed to achieve this stable point when the mean time to complete Tube of 384 seconds was set as a target. With regarding to the concurrent and predictive validation, there significant differences were evident in the mean time to complete 16 needle passages and the vesicourethral anastomosis and the end product rating score. CONCLUSIONS: The virtual reality (VR) simulator can yield sufficient improvement in technical performance in Tube 3 within 5 hours. The acquired proficiency can be transferable to the vesicourethral anastomosis using the da Vinci system.

Current status of robotic surgery in Japan

The da Vinci S surgical system (Intuitive Surgical) was approved as a medical device in 2009 by the Japanese Ministry of Health, Labour and Welfare. Robotic surgery has since been used in gastrointestinal, thoracic, gynecological, and urological surgeries. In April 2012, robotic-assisted laparoscopic radical prostatectomy (RALP) was first approved for insurance coverage. Since then, RALP has been increasingly used, with more than 3,000 RALP procedures performed by March 2013. By July 2014, 183 institutions in Japan had installed the da Vinci surgical system. Other types of robotic surgeries are not widespread because they are not covered by public health insurance. Clinical trials using robotic partial nephrectomy and robotic gastrectomy for renal and gastric cancers, respectively, have recently begun as advanced medical treatments to evaluate health insurance coverage. These procedures must be evaluated for efficacy and safety before being covered by public health insurance. Other types of robotic surgery are being evaluated in clinical studies. There are several challenges in robotic surgery, including accreditation, training, efficacy, and cost. The largest issue is the cost-benefit balance. In this review, the current situation and a prospective view of robotic surgery in Japan are discussed.