Comparison of the learning curve of robot -assisted and laparoscopic -assisted gastrectomy / 中南大学学报(医学版)

OBJECTIVES@#Da Vinci robot technology is widely used in clinic,with minimally invasive surgery development. This study aims to explore the possible influence of advanced surgical robotics on the surgery learning curve by comparing the initial clinical learning curves of 2 different surgical techniques: robotic-assisted gastrectomy (RAG) and laparoscopic-assisted gastrectomy (LAG).@*METHODS@#From September 2017 to December 2020, a chief surgeon completed a total of 108 cases of radical gastric cancer from the initial stage, including 27 cases of RAG of the Da Vinci Si robotic system (RAG group) and 81 cases of LAG (LAG group). The lymph node of gastric cancer implemented by the Japanese treatment guidelines of gastric cancer. The surgical results, postoperative complications, oncology results and learning curve were analyzed.@*RESULTS@#There was no significant difference in general data, tumor size, pathological grade and clinical stage between the 2 groups (P>0.05). The incidence of serious complications in the RAG group was lower than the LAG group (P=0.003). The intraoperative blood loss in the RAG group was lower than that in the LAG group (P=0.046). The number of lymph nodes cleaned in the RAG group was more (P=0.003), among which there was obvious advantage in lymph node cleaning in the No.9 group (P=0.038) and 11p group (P=0.015). The operation time of the RAG group was significantly longer than the LAG group (P=0.015). The analysis of learning curve found that the cumulative sum analysis (CUSUM) value of the RAG group decreased from the 10th case, while the CUSUM of the LAG group decreased from the 28th case. The learning curve of the RAG group had fewer closing cases than that of the LAG group. The unique design of the surgical robot might help to improve the surgical efficiency and shorten the surgical learning curve.@*CONCLUSIONS@#Advanced robotics helps experienced surgeons quickly learn to master RAG skills. With the help of robotics, RAG are superior to LAG in No.9 and 11p lymph node dissection and surgical trauma reduction. RAG can clear more lymph nodes than LAG, and has better perioperative effect.

A retrospective comparative study between robotic thyroidectomy through transoral vestibular approach and bilateral breast-axillary approach / 中华外科杂志

Objective: To compare the surgical outcome of robotic thyroidectomy through transoral approach and the bilateral breast-axillary approach. Methods: Retrospective analysis was made on the clinical data of patients who performed transoral robotic thyroidectomy (TORT group) or bilateral breast-axillary approach (BABA group) in the Department of Thyroid and Breast Surgery, the 960th Hospital of People's Liberation Army from July 2020 to May 2022. Both groups received lobectomy with lymph node dissection of the central region. A total of 100 cases were included in the study, including 48 cases in the TORT group and 52 cases in the BABA group. The propensity score matching method was used for 1∶1 matching of patients between the 2 groups, with a match tolerance of 0.03. There were 31 patients in each group successfully matched. In the TORT group, there were 5 males and 26 females, aged (33.2±7.9) years (range: 21 to 53 years). While there were 4 males and 27 females in the BABA group, aged (34.6±9.2) years (range: 19 to 58 years). The t test, Mann-Whitney U test, χ2 test or Fisher exact test were used to compare the clinical efficacy between the two groups. Results: All the patients successfully completed robotic thyroid surgery without conversion to open surgery. Compared with BABA group, the TORT group had longer operation time ((211.3±57.2) minutes vs. (126.2±37.8) minutes, t=6.915, P<0.01), shorter drainage tube retention time ((5.4±1.0) days vs. (6.4±1.2) days, t=-3.544, P=0.001), shorter total hospital stay ((6.6±1.2) days vs. (7.4±1.3) days, t=-2.353, P=0.022), and higher cosmetic score (9.46±0.25 vs. 9.27±0.26, t=2.925, P=0.005). There was no significant difference between the two groups in the number of lymph nodes dissection, metastasis in the central compartment, and the incidence of postoperative complications (all P>0.05). Conclusions: Compared with the bilateral breast-axillary approach, the transoral vestibular approach of robotic thyroidectomy is also safe and effective. It shows similar surgical results to the bilateral breast-axillary approach in strictly selected patients, but the postoperative recovery speed is much faster, and the hospital stay is shorter. Transoral robotic thyroidectomy is a more recommended surgical method for patients with high aesthetic demand.

Neurovascular bundle preservation in robotic-assisted radical prostatectomy: How I do it after 15. 000 cases

ABSTRACT Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

Efficacy of Transversus Abdominis Plane Block in the Reduction of Pain and Opioid Requirement in Laparoscopic and Robot-assisted Hysterectomy: A Systematic Review and Meta-analysis / Eficácia do bloqueio transverso do plano abdominal na redução da dor e da necessidade de opioides em histerectomia laparoscópica e assistida por robô: Uma revisão sistemática e metanálise

Abstract Objective To summarize the available evidence of TAP Block in efficacy in laparoscopic or robotic hysterectomy. Data Sources We searched databases and gray literature for randomized controlled trials in which transversus abdominis plane (TAP) block was compared with placebo or with no treatment in patients who underwent laparoscopic or robot-assisted hysterectomy. Method of Study Selection Two researchers independently evaluated the eligibility of the selected articles. Tabulation, Integration, and Results Seven studies were selected, involving 518 patients. Early postoperative pain showed a difference in the mean mean difference (MD): - 1.17 (95% confidence interval [CI]: - 1.87-0.46) in pain scale scores (I2=68%), which was statistically significant in favor of using TAP block, but without clinical relevance; late postoperative pain: DM 0.001 (95%CI: - 0.43-0.44; I2=69%); opioid requirement: DM 0.36 (95%CI: - 0.94-1.68; I2=80%); and incidence of nausea and vomiting with a difference of 95%CI=- 0.11 (- 0.215-0.006) in favor of TAP. Conclusion With moderate strength of evidence, due to the high heterogeneity and imbalance in baseline characteristics among studies, the results indicate that TAP block should not be considered as a clinically relevant analgesic technique to improve postoperative pain in laparoscopic or robotic hysterectomy, despite statistical significance in early postoperative pain scale scores. Clinical Trial Number and Registry: PROSPERO ID - CRD42018103573.

Resumo Objetivo Resumir as evidências disponíveis sobre a eficácia do bloqueio TAP em histerectomia laparoscópica ou robótica. Fontes de Dados Pesquisamos bancos de dados e literatura cinza por ensaios clínicos randomizados nos quais o bloqueio do plano transverso do abdome (TAP na sigla em inglês) foi comparado com placebo ou com nenhum tratamento em pacientes que foram submetidos a histerectomia laparoscópica ou assistida por robô. Métodos de Seleção de Estudos Dois pesquisadores avaliaram independentemente a elegibilidade dos artigos selecionados. Tabulação, Integração e Resultados Sete estudos foram selecionados envolvendo 518 pacientes. A dor pós-operatória precoce apresentou diferença nasmédias (DM) de: -1 17 (intervalo de confiança [IC] de 95%: - 1 87-0 46) nos escores da escala de dor (I2=68%) o que foi estatisticamente significativo a favor do uso do bloqueio TAP mas sem relevância clínica; dor pós-operatória tardia: DM 0001 (IC95%: - 043-044; I2=69%); necessidade de opioides: DM0 36 (95%CI: - 0 94-168; I2=80%); e incidência de náuseas e vômitos com diferença de 95% CI=- 011 (- 0215-0006) a favor do TAP. Conclusão Com moderada força de evidência devido à alta heterogeneidade e ao desequilíbrio nas características basais entre os estudos os resultados indicam que o bloqueio do TAP não deve ser considerado como uma técnica analgésica clinicamente relevante para melhorar a dor pós-operatória em histerectomia laparoscópica ou robótica apesar da significância estatística nas pontuações da escala de dor pósoperatória inicial. Número e Registro do Ensaio Clínico: PROSPERO ID - CRD42018103573.

Robotic re-TAPP: a minimally invasive alternative for the failed posterior repair / re-TAPP robótico: uma alternativa minimamente invasiva para falha da via posterior

ABSTRACT Objective: to describe the use of the robotic platform in inguinal hernia recurrence after a previous laparoscopic repair. Methods: patients with recurrent inguinal hernias following a laparoscopic repair who have undergone robotic transabdominal preperitoneal between December 2015 through September 2020 were identified in a prospectively maintained database. Outcomes of interest included demographics, hernia characteristics, operative details and rates of 30-day surgical site occurrence, surgical site occurrences requiring procedural interventions, surgical site infection and hernia recurrence were abstracted. Results: nineteen patients (95% male, mean age 55 years, mean body mass index 28) had 27 hernias repaired (N=8 bilateral). Average operative time was 168.9 ± 49.3min (range 90-240). There were two intraoperative complications all of them were bleeding from the inferior epigastric vessel injuries. Three SSOs occurred (N=2 seromas and N=1 hematoma. After a median 35.7 months follow-up (IQR 13-49), no recurrence has been diagnosed. One patient developed chronic postoperative inguinal pain. Conclusions: on a small number of selected patients and experienced hands, we found that the use of the robotic platform for repair of recurrent hernias after prior laparoscopic repair appears to be feasible, safe and effective despite being technically demanding. Further studies in larger cohorts are necessary to determine if this technique provides any benefits in recurrent inguinal hernia scenario.

RESUMO Objetivo: descrevemos nossa experiência com uso da plataforma robótica no tratamento das recidivas operadas previamente por laparoscopia, mantendo assim uma proposta minimamente invasiva a esses pacientes, apesar de haver uma predileção pela via anterior e aberta nestes casos. Métodos: foram incluídos pacientes submetidos a hernioplastia inguinal robótica transabdominal pré-peritoneal como tratamento de recidiva e que foram operados previamente por laparoscopia, entre dezembro de 2015 e setembro de 2020 e mantidos em uma base de dados ambulatorial prospectiva. Variáveis de interesse incluíram dados demográficos, características herniárias, detalhes operatórios, ocorrências do sítio cirúrgico em 30 dias (com ou sem necessidade de intervenção), infeção do sítio cirúrgico, tempo de seguimento e taxa de recidiva. Resultados: dezenove pacientes (95% masculino, média de idade de 55 anos, média de índice de massa corporal 28kg/m2) e 27 hérnias operadas (N=8 bilaterais). Média de tempo cirúrgico 168.9±49.3 min (variando 90-240). N=2 complicações intraoperatórias por lesão de vasos epigástricos inferiores. N=2 seromas e N=1 hematoma foram identificados no pós-operatório; N=1 paciente apresentou dor crônica pós operatória. Após um tempo de seguimento médio de 35.7 meses (intervalo entre quartis 13-49), nenhuma recidiva foi diagnosticada. Conclusões: o uso da plataforma robótica parece ser seguro e efetivo no tratamento das recidivas operadas previamente laparoscopia, nesse pequeno grupo de pacientes selecionados, apesar de requerer expertise em cirurgia robótica. Outros estudos com maiores casuísticas são necessários para estabelecer o papel desta técnica no cenário das hérnias inguinais recidivadas.

Retropharyngeal lymph node dissection in head and neck cancers treated with transoral robotic surgery / 中华肿瘤杂志

Objective: To evaluate the indications, safety, feasibility, and surgical technique for patients with head and neck cancers undergoing transoral robotic retropharyngeal lymph node (RPLN) dissection. Methods: The current study enrolled 12 consecutive head and neck cancer patients (seven males and four females) who underwent transoral robotic RPLN dissection with the da Vinci surgical robotic system at the Sun Yat-sen University Cancer Center from May 2019 to July 2020. Seven patients were diagnosed as nasopharyngeal carcinoma with RPLN metastasis after initial treatments, 4 patients were diagnosed as thyroid carcinoma with RPLN metastasis after initial treatments, and one patient was diagnosed as oropharyngeal carcinoma with RPLN metastasis before initial treatments. The operation procedure and duration time, intraoperative blood loss volume and complications, nasogastric feeding tube dependence, tracheostomy dependence, postoperative complications, and hospitalization time were recorded and analyzed. Results: All patients were successfully treated by transoral robotic dissection of the metastatic RPLNs, none of which was converted to open surgery. RPLNs were completely resected in 10 patients, and partly resected in 2 patients (both were nasopharyngeal carcinoma patients). The mean number of RPLN dissected was 1.7. The operation duration time and intraoperative blood loss volume were (191.3±101.1) min and (150.0±86.6) ml, respectively. There was no severe intraoperative complication such as massive haemorrhage or adjacent organ injury during surgery. Nasogastric tube use was required in all patients with (17.1±10.6) days of dependence, while tracheotomy was performed in 8 patients with (11.6±10.7) days of dependence. The postoperative hospitalization stay was (8.5±5.7) days. Postoperative complications occurred in 4 patients, including 2 of retropharyngeal incision and 2 of dysphagia. During a follow-up of (6.5±5.1) months, disease-free progression was observed in all patients, 10 patients were disease-free survival and other 2 patients were survival with tumor burden. Conclusions: The transoral robotic RPLN dissection is safety and feasible. Compared with the traditional open surgical approach, it is less traumatic and safer, has fewer complications and good clinical application potentiality. The indications for transoral robotic RPLN dissection include thyroid carcinoma, oropharyngeal carcinoma, and some selected nasopharyngeal carcinoma and other head and neck cancers. Metastatic RPLNs from some nasopharyngeal carcinoma with incomplete capsule, unclear border and adhesion to the surrounding vessels are not suitable for transoral robotic RPLN dissection.

The clinical value of oral robotic surgery in the treatment of oropharyngeal squamous cell carcinoma / 中华肿瘤杂志

Objective: To explore the therapeutic effects of transoral robotic surgery (TORS) and traditional surgical modes in oropharyngeal squamous cell carcinoma (OPSCC). Methods: The clinicopathological data of patients with oropharyngeal squamous cell carcinoma treated at Sun Yat-sen University Cancer Center from 2010 to 2018 were retrospectively analyzed. 135 cases were treated with traditional surgery (non-TORS group), while 52 cases were treated with TORS (TORS group). The prognosis of the two groups of patients were analyzed by Kaplan-Meier method and Log rank test, the influencing factors were analyzed by Cox regression model. Results: The 2-year overall survival (OS, 94.2%) and 2-year progression-free survival (PFS, 93.8%) of patients in the TORS group were better than those in the non-TORS group (71.4% and 71.4%, respectively, P<0.05). The 2-year OS (93.3%) and 2-year PFS (92.8%) of TORS group patients in T1-2 stage were better than those of non-TORS group (73.1% and 72.8%, respectively, P<0.05). The 2-year OS (95.8%) and 2-year PFS (95.2%) of patients with stage Ⅰ to Ⅱ in the TORS group were not significantly different from those in the non-TORS group (84.1% and 83.9%, respectively, P>0.05). The 2-year OS (92.9%) and 2-year PFS rate (92.7%) of patients with stage Ⅲ to Ⅳ in the TORS group were better than those in the non-TORS group (64.7% and 63.9%, respectively, P<0.05). The 2-year OS (94.4%) of HPV-positive patients in the TORS group was not significantly different from that in the non-TORS group (83.3%, P=0.222). The 2-year OS of HPV-negative patients in the TORS group (94.1%) was significantly different from that in the non-TORS group (43.7%, P<0.001). HPV status was an independent prognostic factor (P=0.008). Conclusions: TORS has a better prognosis in the treatment of oropharyngeal squamous cell carcinoma compared with the traditional treatment methods. The patients with T1-T2 can achieve better survival benefits after TORS treatment. The HPV-positive OPSCC patients has a better prognosis than that of HPV-negative OPSCC patients, and regardless of HPV status, OPSCC patients in the TORS group could obtain a better survival prognosis.

Accuracy and safety of robot assisted pedicle screw placement / 中国骨伤

OBJECTIVE@#To investigate the accuracy and safety of pedicle screw placement assisted by orthopedic robot and C-arm fluoroscopy.@*METHODS@#The clinical data of 36 patients with spinal diseases underwent surgical treatment from January 2019 to August 2020 was retrospectively analyzed. Among them, 18 cases were implanted pedicle screws assisted by orthopaedic robot(observation group), including 12 males and 6 females, aged from 16 to 61 years with an average of (38.44±3.60) years;there were 1 case of adolescent scoliosis, 1 case of spinal tuberculosis, 7 cases of lumbar spondylolisthesis, 4 cases of thoracic fracture and 5 cases of lumbar fracture. Another 18 cases were implanted pedicle screws assisted by C-arm fluoroscopy(control group), including 10 males and 8 females, aged from 18 to 58 years with an average of (43.22±2.53) years;there were 1 case of adolescent scoliosis, 6 cases of lumbar spondylolisthesis, 6 cases of thoracic fracture and 5 cases of lumbar fracture. The intraoperative fluoroscopy times, nail placement time and postoperative complications were recorded in two groups. CT scan was performed after operation. The Gertzbein-Robbins standard was used to evaluate the accuracy of pedicle screw placement which was calculated.@*RESULTS@#The number of intraoperative fluoroscopy in observation group was(6.89±0.20) times, which was significantly higher than that in control group(14.00±0.18)times(P<0.05). The placement time of each screw in observation group was(2.56±0.12) min, which was significantly different from that in control group(4.22±0.17) min (P<0.05). One case of incision infection occurred in control group after operation, and recovered after active dressing change. During the follow-up period, no serious complications such as screw loosening and fracture occurred in two groups, and there was no significant difference in complications between two groups(P>0.05). A total of 107 screws were placed in observation group, including 101 screws in class A, 4 in class B, 2 in class C, 0 in class D and 0 in class E, the accuracy rate of pedicle screw placement=[(number of screws in class A+B) / the number of all screws placed in the group] ×100%=98.1%(105/107); and a total of 104 screws were placed in control group, including 90 screws in class A, 4 in class B, 5 in class C, 5 in class D and 0 in class E, the accuracy rate of pedicle screw implantation=[(number of screws in class A+B/the number of all screws placed in the group]×100%=90.3% (94/104); there was significant difference between two groups (P<0.05).@*CONCLUSION@#Orthopaedic robot assisted pedicle screw placement has the advantages of less fluoroscopy times, shorter screw placement time and higher accuracy, which can further improve the surgical safety and has a broad application prospect in the orthopaedic.

Research on real-time detection system of catheter delivering force in vascular interventional robots / 生物医学工程学杂志

In existing vascular interventional surgical robots, it is difficult to accurately detect the delivery force of the catheter/guidewire at the slave side. Aiming to solve this problem, a real-time force detection system was designed for vascular interventional surgical (VIS) robots based on catheter push force. Firstly, the transfer process of catheter operating forces in the slave end of the interventional robot was analyzed and modeled, and the design principle of the catheter operating force detection system was obtained. Secondly, based on the principle of stress and strain, a torque sensor was designed and integrated into the internal transmission shaft of the slave end of the interventional robot, and a data acquisition and processing system was established. Thirdly, an ATI high-precision torque sensor was used to build the experimental platform, and the designed sensor was tested and calibrated. Finally, sensor test experiments under ideal static/dynamic conditions and simulated catheter delivery tests based on actual human computed tomography (CT) data and vascular model were carried out. The results showed that the average relative detection error of the designed sensor system was 1.26% under ideal static conditions and 1.38% under ideal dynamic stability conditions. The system can detect on-line catheter operation force at high precision, which is of great significance towards improving patient safety in interventional robotic surgery.

Feasibility and perioperative safety of transoral robotic surgery with da Vinci Xi platform / 中华耳鼻咽喉头颈外科杂志

Objective: To explore the feasibility and perioperative safety of transoral robotic surgery with da Vinci Xi platform for pharyngolaryngeal tumors. Methods: A retrospective analysis was performed on 55 consecutive cases with resection of pharyngolaryngeal tumors by transoral robotic surgery with da Vinci Xi platform from July 27, 2020 to October 31, 2021 in the Department of Head and Neck Surgery, Fudan University Eye, Ear, Nose and Throat Hospital, including 44 males and 11 females, aged 25-79 years. There were 41 cases of oropharyngeal tumors, 9 cases of parapharyngeal space tumors, 2 cases of laryngeal tumors, 2 cases of hypopharyngeal tumors and 1 case of retropharyngeal space tumor. Operative time, intraoperative blood loss, postoperative hospital stay, perioperative tracheotomy, nasal feeding, hemorrhage and other complications were analyzed. Results: Of the 55 patients, 54 received resection of pharyngolaryngeal tumors by da Vinci robot through oral approach, and only 1 case of pyriform sinus carcinoma underwent a conversion to open surgery due to poor exposure of lower margin. The average surgical time for the patients with transoral robotic surgeries was 64.4 min, the average blood loss was 24.8 ml, the average postoperative hospital stay was 6.9 d, and the average oral feeding time was 11.1 d. Seventeen patients (30.9%) underwent preventive tracheotomy during surgery. Among 38 cases of laryngeal cancer, 28 underwent simultaneously neck dissection. No serious complications occurred in all patients during and after operation. The follow-up time was 1-15 months. Aside from 1 patient had a relapse 10 months after surgery, other patients had no recurrence or metastasis. Conclusion: Transoral robotic surgery with da Vinci Xi is safe, effective and minimally invasive for resection of pharyngolaryngeal tumors under reasonable indications.

Application of transoral robotic surgery in treatment of oropharyngeal squamous cell carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective: To evaluate the therapeutic and prognostic outcomes of transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OSCC). Methods: A retrospective study of 99 OSCC patients treated with TORS in Department of Head and Neck Surgery, Sun Yat-sen University Cancer Center between April 2017 and May 2021 was conducted. There were 84 males and 15 females, with an age range of 35-85 years. Patients' clinical characteristics, including clinical staging, HPV infection status, perioperative management and postoperative adjuvant treatment, were recorded. The overall survival (OS) and progression-free survival (PFS) were analyzed. The survival outcomes were analyzed with Kaplan-Meier method and Log-rank test. Results: The hospital stay of OSCC patients with TORS was (5.3±2.9) days and the average time of postoperative nasal feeding tube indwelling was (15.2±10.8) days. Among the 99 patients, 21 (21.2%) received tracheotomy and the average time of tracheotomy tube indwelling was (11.9±11.4) days. The two-year OS and PFS in patients with follow-up over two years were 94.0% and 87.7%, respectively and the three-year OS and PFS of patients with follow-up over three years were 94.0% and 78.9%, respectively. The two-year OS and PFS were respectively 97.4% and 88.9%, for patients with stages I-II and 86.8% and 88.9% for patients with stages III-IV. HPV-negative and HPV-positive patients had respectively two-year OS (100.0% vs. 91.5%) and PFS (88.9% vs. 87.2%). There was no significantly statistical difference in survival between patients with and without adjuvant radiotherapy after TORS (82.6% vs. 90.5%, HR=0.52, 95%CI: 0.12-2.23, P=0.400). Conclusions: TORS is more suitable for the treatment of patients with early (Ⅰ-Ⅱ) or HPV-positive oropharyngeal squamous cell carcinoma, and the recovery after TORS treatment is good.

Resultados quirúrgicos y oncológicos de pacientes operados por cáncer de recto con asistencia robótica / Surgical and oncological results of patients operated for rectal cancer with robotic assistance

Resumen Objetivo: Analizar los resultados quirúrgicos y oncológicos de pacientes con adenocarcinoma de recto (AR) operados con asistencia robótica. Materiales y Método: Cohorte prospectiva entre 2014-2019. Criterios de inclusión: pacientes con AR primario, sometidos a una resección de recto con asistencia robótica con intención curativa. Criterios de exclusión: histología no adenocarcinoma. Evaluación de datos clínico-quirúrgicos. Análisis estadístico descriptivo. Resultados: Se incluyeron 37 pacientes; 20 (54%) fueron hombres y la edad promedio fue 58,7 años. La distancia promedio desde el margen anal al borde distal del tumor fue 6,6 cm (i: 2-12 cm). La quimiorradioterapia (neoadyuvancia) se indicó en 26 pacientes. La cirugía más frecuente fue la resección anterior baja de recto y el tiempo operatorio promedio fue 266 min. Se realizaron dos conversiones a laparotomía. Una o más complicaciones se observaron en 17 (45,9%) pacientes, 9 de ellos fueron Clavien-Dindo III o IV y se reoperaron 5 pacientes (13%). No hubo transfusiones sanguíneas ni mortalidad posoperatoria. La estancia hospitalaria postoperatoria promedio fue 9,6 días (i: 3-34 d). El promedio de linfonodos resecados fue 15 (i 4-45). Los márgenes quirúrgicos fueron negativos en todos los pacientes. Se restituyó el tránsito intestinal en 28/32 (87,5%) pacientes. El promedio de seguimiento fue 21 meses (1-56), la sobrevida global y libre de enfermedad fue 100%. Discusión y Conclusión: La proctectomía con asistencia robótica ha demostrado ser segura en términos de resultados quirúrgicos tempranos y en criterios oncológicos de la pieza operatoria.

Aim: To analyze the surgical and oncological results of patients with rectal adenocarcinoma (RA) operated with robotic assistance. Materials and Method: Prospective cohort study, consecutive sample of patients between 2014-2017. Inclusion criteria: patients with primary RA, undergoing rectal resection, with robotic assistance with curative intention. Exclusion criteria: histology not adenocarcinoma. Evaluation of clinical-surgical data. Descriptive statistical analysis. Results: 37 patients were included; 20 (54%) were men and average age was 58.7 years. The average distance from the anal margin to the distal edge of the tumor was 6.6 cm (2-12 cm). Chemoradiotherapy (neoadyuvant) was indicated in 26 patients. The most frequent surgery was low anterior resection of the rectum and the average operating time was 266 minutes. Two conversions to laparotomy were performed. One or more complications were observed in 17 (45.9%) patients, 9 of them were Clavien-Dindo III or IV, 5 patients (13%) were reoperated. There were no blood transfusions and no postoperative mortality. The average postoperative hospital stay was 9.6 days (3-34). The average of resected lymph nodes was 15. Surgical margins were negative in all patients. Intestinal transit was restored in 28/32 (87.5%) patients. The average follow-up was 21 months (1-56), the overall and disease-free survival was 100%. Discussion and Conclusion: Proctectomy with robotic assistance has proved to be safe in terms of early surgical results and oncologic indicators of the surgical piece.

Robotic TAPP inguinal hernia repair: lessons learned from 97 cases / Hernioplastia inguinal transabdominal pré-peritoneal (TAPP) robótica: experiência inicial de 97 casos

ABSTRACT Objectives: minimally invasive inguinal hernia repair has proven advantages over open procedures including less pain and earlier return to normal activity. Robotic surgery adds ergonomics, a three-dimensional high definition camera and articulating instruments overcoming some laparoscopic limitations. We aimed to report the outcomes of the early experience of over 97 robotic inguinal hernia repairs performed by a referred surgical group in Brazil. Methods: a review of a prospective mantined database was conducted in patients submitted to robotic transabdominal preperitoneal (TAPP) inguinal hernia repairs between March 2016 and February 2020. Descriptive statistics were performed. Surgical outcomes data and patient follow-ups are reported. Results: retrospective chart review identified 97 patients submitted to robotic TAPP inguinal hernia repair. Mean age was 36.4 years, with median BMI of 26.9 kg/m2. Mean console time was 58 min (range 40-150) and patients were discharged within 24 hours of their stay in a majority of cases. Mesh was placed in all procedures and there were no conversion rates. Complications were low grade and no recurrence was seen after a mean follow-up of 642 days. Conclusion: this study represents to-date the first brazilian case series of robotic TAPP inguinal hernia repair. Our results encourage that robotic assisted TAPP inguinal hernia repair appears to be technically feasible and safe in experienced hands, with good outcomes achieving high health-related quality of life and low recurrence rates in the short and long term.

RESUMO Objetivo: a cirurgia minimamente invasiva das hérnias inguinais apresenta vantagens comprovadas em relação aos procedimentos convencionais, incluindo menos dor e retorno precoce às atividades rotineiras. A cirurgia robótica acrescenta uma melhor ergonomia, ótica estável tridimensional de alta definição e instrumentos articulados, superando algumas limitações laparoscópicas. O objetivo deste estudo é relatar os resultados da experiência inicial de 97 cirurgias de correção de hérnias inguinais robóticas pela técnica transabdominal pré-peritoneal (TAPP) realizadas por um grupo cirúrgico referência no Brasil. Métodos: foi realizada uma revisão de um banco de dados mantido prospectivamente de pacientes submetidos a cirurgias de hérnia inguinal TAPP robótica entre março de 2016 e fevereiro de 2020. Uma análise detalhada dos resultados foi feita e dados dos resultados cirúrgicos e acompanhamento dos pacientes são relatados. Resultados: a revisão retrospectiva do prontuário identificou 97 pacientes submetidos à cirurgia de hérnia inguinal TAPP robótica. A idade média foi de 36,4 anos, com IMC médio de 26,9 kg/m2. O tempo médio de procedimento cirúrgico no console robótico foi de 58 minutos. A colocação de prótese foi realizada em todos os procedimentos e não houve taxas de conversão ou intercorrências. Conclusão: este estudo representa a primeira série de casos de cirurgia robótica de hérnia inguinal pela técnica transabdominal pré-peritoneal no Brasil. Os resultados descritos reforçam que a hernioplastia inguinal robótica apresenta-se como tecnicamente viável e segura em mãos experientes, com bons resultados quanto a qualidade de vida e baixas taxas de recidiva a curto e longo prazo.

S100B level and cognitive dysfunction after robotic-assisted laparoscopic radical prostatectomy procedures: a prospective observational study / Nível de S100B e disfunção cognitiva após prostatectomia radical laparoscópica assistida por robô: estudo observacional prospectivo

Abstract Background: The present study investigated the association between Postoperative Cognitive Dysfunction (POCD) and increased serum S100B level after Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). Methods: The study included 82 consecutive patients who underwent RALRP. Serum S100B levels were determined preoperatively, after anesthesia induction, and at 30 minutes and 24 hours postoperatively. Cognitive function was assessed using neuropsychological testing preoperatively, and at 7 days and 3 months postoperatively. Results: Twenty four patients (29%) exhibited POCD 7 days after surgery, and 9 (11%) at 3 months after surgery. Serum S100B levels were significantly increased at postoperative 30 minutes and 24 hours in patients displaying POCD at postoperative 7 days (p = 0.0001 for both) and 3 months (p = 0.001 for both) compared to patients without POCD. Duration of anesthesia was also significantly longer in patients with POCD at 7 days and 3 months after surgery compared with patients without POCD (p = 0.012, p = 0.001, respectively), as was duration of Trendelenburg (p = 0.025, p = 0.002, respectively). Composite Z score in tests performed on day 7 were significantly correlated with duration of Trendelenburg and duration of anesthesia (p = 0.0001 for both). Conclusions: S100B increases after RALRP and this increase is associated with POCD development. Duration of Trendelenburg position and anesthesia contribute to the development of POCD. Trial Registry Number: Clinicaltrials.gov (N° NCT03018522).

Resumo Introdução: O presente estudo investigou a associação entre Disfunção Cognitiva Pós-Operatória (DCPO) e aumento do nível sérico de S100B após Prostatectomia Radical Laparoscópica Assistida por Robô (PRLAR). Métodos: O estudo incluiu 82 pacientes consecutivos submetidos à PRLAR. Os níveis séricos de S100B foram determinados: no pré-operatório, após indução anestésica, e aos 30 minutos e 24 horas do pós-operatório. A função cognitiva foi avaliada com testes neuropsicológicos no pré-operatório, no 7° dia pós-operatório (7 DPO) e aos 3 meses após a cirurgia (3 MPO). Resultados: Observamos 24 pacientes (29%) com DCPO no 7 DPO e 9 pacientes com DCPO (11%) após 3 meses da cirurgia. Quando comparados com os pacientes sem DCPO, os níveis séricos de S100B estavam significantemente aumentados aos 30 minutos e às 24 horas do pós-operatório nos pacientes que apresentaram DCPO no 7 DPO (p= 0,0001 para os dois momentos) e 3 meses após a cirurgia (p= 0,001 para os dois momentos) A duração anestésica também foi significantemente maior em pacientes com DCPO no 7 DPO e 3 MPO em comparação com pacientes sem DCPO (p= 0,012, p= 0,001, respectivamente), assim como a duração da posição de Trendelenburg (p= 0,025, p= 0,002, respectivamente). O escore Z composto nos testes realizados no 7 DPO foi significantemente correlacionado com a duração da posição de Trendelenburg e a duração da anestesia (p= 0,0001 para ambos). Conclusão: S100B aumenta após PRLAR e o aumento está associado ao desenvolvimento de DCPO. A duração anestésica e o tempo decorrido em posição de Trendelenburg contribuem para o desenvolvimento de DCPO. Número de registro do estudo: Clinicaltrials.gov (n° NCT03018522)

Robotic transanal ressection for rectal tumor: a description of the technique / Ressecção transanal robótica para tumor retal: uma descrição da técnica

ABSTRACT Introduction: Robotic transanal surgery (RTS) is the analog of TAMIS and represents a new focus for the advancement of transanal platforms robotic transanal surgery is sometimes referred to as robotic TAMIS. Though limited to only a few centers world-wide, experience with robotic transanal surgery has been encouraging. Most research with robotic transanal surgery has concentrated on local excision of rectal neoplasia, although more complex procedures such as transanal proctectomy are possible using the robotic approach. This article reports the surgical technique of R-TAMIS performed in the Brazilian National Cancer Institute (INCA, Rio de Janeiro). Methods: 71-year-old, female with cardiologic disease (heart failure), with a 1.5 cm rectal neoplasm at 4 cm from the anal verge in the right anterolateral position. Biopsy revealed neuroendocrine tumor. A compete colonoscopy revealed no evidence of synchronous lesions. Work-up included 3D endorectal ultrasonography and magnetic resonance imaging, which demonstrated the lesion to be uT1uN0. The patient was counseled about surgical options − local excision versus low anterior resection. Due to the cardiologic condition, the patient was elected to proceed with local excision with robotic transanal surgery. Conclusion: Robotic TAMIS is a safe and effective operative procedure for high selected cases of rectal neoplasm. It enhances surgeon ergonomics and facilitates tumor removal and suture in the transanal approach.

RESUMO Introdução: A cirurgia transanal robótica (RTS,Robotic Transanal Surgery) é análoga da TAMIS (cirurgia minimamente invasiva transanal) e representa um novo foco para o avanço das plataformas transanais. A cirurgia transanal robótica é algumas vezes chamada de TAMIS robótica. Embora limitada a apenas alguns centros em todo o mundo, a experiência com a cirurgia transanal robótica tem sido encorajadora. A maioria das pesquisas com cirurgia transanal robótica tem se concentrado na excisão local da neoplasia retal, embora procedimentos mais complexos, como a proctectomia transanal, sejam possíveis utilizando a abordagem robótica. Este artigo relata a técnica cirúrgica de R-TAMIS realizada no Instituto Nacional do Câncer (INCA, Rio de Janeiro). Métodos: paciente de 71 anos, sexo feminino, com doença cardiológica (insuficiência cardíaca), com neoplasia retal de 1,5 cm a 4 cm da borda anal em posição anterolateral direita. A biópsia revelou tumor neuroendócrino. Uma colonoscopia completa não revelou evidências de lesões sincrônicas. A investigação incluiu ultrassonografia endorretal em 3D e ressonância magnética, que demonstrou que a lesão era uT1uN0. A paciente foi aconselhada sobre as opções cirúrgicas - excisão localversus ressecção anterior baixa. Devido à condição cardiológica, optou-se por proceder à excisão local com cirurgia transanal robótica. Conclusão: A TAMIS robótica é um procedimento cirúrgico seguro e eficaz para casos altamente selecionados de neoplasia retal. Ela melhora a ergonomia do cirurgião e facilita a remoção do tumor e a sutura na abordagem transanal.

Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis / Desafios perioperatórios e pontos de atenção no bloqueio neuromuscular durante timectomia robótica para miastenia gravis

Abstract Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Resumo Miastenia Gravis (MG) é uma doença autoimune que se caracteriza por fraqueza e fadiga da musculatura esquelética, com melhora após o repouso. É uma doença de grande interesse para o anestesiologista, pois compromete a junção neuromuscular. Recentemente, a timectomia robótica tem sido empregada por apresentar as vantagens da abordagem minimamente invasiva. O procedimento introduz uma série de novos desafios para a equipe de anestesia. Relatamos aqui as várias considerações anestésicas e o cuidado perioperatório em uma série de 20 pacientes submetidos a timectomia robótica. Sendo um procedimento recente, há limitada literatura discutindo esse tópico e, além disso, a maior parte da literatura disponível concentra a atenção na Ventilação Monopulmonar (VMP) e na peridural torácica. A nosso ver, este é a primeiro relato na literatura sem o emprego de VMP e peridural torácica para o manejo da timectomia robótica.

How far is too far? Exploring the indications for robotic partial nephrectomy in a highly complex kidney tumor

ABSTRACT Purpose: The conservative management of localized renal masses has been recently widened to cT2 tumors showing encouraging functional and oncological outcomes (1). This video aims to report the conservative management of a highly complex renal tumor treated with robotic pure enucleation in our center, specifically focusing on preoperative work-up, video-reported surgical steps and perioperative outcomes. Materials and Methods: A 63 year-old lady underwent CT scan revealing a single 75 x 68mm, mainly endophytic, right renal mass dislocating the vascular pedicle (cT3a). Two renal arteries and two veins were identified. PADUA, RENAL and simplified SPARE scores were 14a, 12a and 12 respectively. Since the contralateral kidney was hypotrophic, the indication for nephron-sparing approach was considered absolute. Preoperative surgical planning included the employment of 3D-virtual models (2). Results: Operative time was 150 minutes and warm ischemia time was 25 minutes. No major complication occurred. Histopathological analysis revealed a cromophobe renal cell carcinoma with extension to perirenal fat tissue (pT3a). Resection technique was classified as pure enucleation since Surface-Intermediate-Base (SIB) score was 0-0-0 (3, 4). At seven-months follow-up no signs of local or systemic recurrence were recorded. Postoperative CT-scan revealed optimal parenchymal volume preservation with last creatinine blood level of 1.16mg/dL. Conclusion: This video highlights how, in experienced hands, robotic partial nephrectomy represents a feasible, effective treatment option for surgical management of highly complex renal tumors. The employment of intraoperative ultrasonography and 3D-virtual models allowed to accurately tailor surgical approach, improving the perception of tumor anatomy and its vascularization and maximizing perioperative outcomes.

Laparoscopic and robotic urology surgery during global pandemic COVID-19

ABSTRACT Known laparoscopic and robotic assisted approaches and techniques for the surgical management of urological malignant and benign diseases are commonly used around the World. During the global pandemic COVID-19, urology surgeons had to reorganize their daily surgical practice. A concern with the use of minimally invasive techniques arose due to a proposed risk of viral transmission of the coronavirus disease with the creation of pneumoperitoneum. Due to this, we reviewed the literature to evaluate the use of laparoscopy and robotics during the pandemic COVID-19. A literature review of viral transmission in surgery and of the available literature regarding the transmission of the COVID-19 virus was performed up to April 30, 2020. We additionally reviewed surgical society guidelines and recommendations regarding surgery during this pandemic. Few studies have been performed on viral transmission during surgery. No study has been made regarding this area during minimally invasive urology cases. To date there is no study that demonstrates or can suggest the ability for a virus to be transmitted during surgical treatment whether open, laparoscopic or robotic. There is no society consensus on restricting laparoscopic or robotic surgery. However, there is expert consensus on modification of standard practices to minimize any risk of transmission. During the pandemic COVID-19 we recommend the use of specific personal protective equipment for the surgeon, anesthesiologist and nursing staff in the operating room. Modifications of standard practices during minimally invasive surgery such as using lowest intra-abdominal pressures possible, controlled smoke evacuation systems, and minimizing energy device usage are recommended.

Cirugía robótica colorectal, en un hospital de comunidad cerrada: experiencia inicial leído en sesión SACP, 11 de octubre de 2019 / Colorectal robotic surgery in a closed community hospital: initial experience read in SACP session, october 11, 2019

Introducción: La introducción del sistema Da Vinci, ha revolucionado el campo de la cirugía mínima invasiva en el cual el cirujano tiene control de la cámara 3D y los instrumentos son de gran destreza y confort ergonómico, acortando la curva de aprendizaje quirúrgica. Objetivo: Describir nuestra experiencia inicial de cirugía robótica colorectal en un hospital de comunidad cerrada de la Ciudad Autónoma de Buenos Aires. Materiales y Método: Estudio retrospectivo descriptivo sobre una base prospectiva de cirugías colorectales robóticas realizadas por el mismo equipo quirúrgico desde mayo de 2016 a abril de 2019. Resultados: Se operaron 41 pacientes. Trece de ellos fueron colectomías derechas, 17 colectomías izquierdas y 11 cirugías de recto. El tiempo quirúrgico promedio fue de 170 minutos (90-330), la estadía hospitalaria de 4 días (3-30), la tasa de conversión de 7,31% (3/41 pacientes) y la tasa de dehiscencia anastomótica del 9,75% (4/41 pacientes). Morbilidad global del 19.5% (8/41 pacientes). Conclusión: Hemos repasado los resultados iniciales de nuestra experiencia en cirugía robótica colorectal en un número reducido de casos, pero suficiente para evaluar la seguridad y reproducibilidad del método al comienzo de una curva de aprendizaje.

Introduction: The introduction of the Da Vinci System, has revolved the field of invasive minimal surgery in which the surgeon has control of the 3d camera and the instruments are of great strength and ergonomic comfort by cutting the surgical learning curve. Objective: Of this preliminary presentation is to describe our initial experience of colorectal robotic surgery in a closed community hospital of the Autonomous City of Buenos Aires. Materials and Method: Retrospective descriptive study on a prospective basis of robotic colorectal surgeries performed by the same surgical team from May 2016 to April 2019.Results: 41 patients were operated. 13 of them were right colectomies, 17 left colectomies and 11 rectum surgeries. The average surgical time was 170 minutes (90-330), the average hospital stay of 4 days (3-30), the conversion rate of 7.31% (3/41 patients) and the anastomotic dehiscence rate of 9 , 75% (4/41 patients). Overall morbidity of 19.5% (8/41 patients).Conclusion: We have reviewed the initial results of our experience in colorectal robotic surgery in a reduced number of cases but sufficient to evaluate the security and reproducibility of the methodic learning of a learning curve.

Robotic thoracic surgery for resection of thymoma and tumors of the thymus: technical development and initial experience / Cirurgia torácica robótica para ressecção de timoma e tumores tímicos: desenvolvimento técnico e experiência inicial

ABSTRACT Objective: To evaluate the results of resection of tumors of the thymus by robotic thoracic surgery, analyzing the extent of resection, postoperative complications, time of surgery, and length of stay. Methods: Retrospective study from a database involving patients diagnosed with a tumor of the thymus and undergoing robotic thoracic surgery at one of seven hospitals in Brazil between October of 2015 and June of 2018. Results: During the study period, there were 18 cases of resection of tumors of the thymus: thymoma, in 12; carcinoma, in 2; and carcinoid tumor, in 1; high-grade sarcoma, in 1; teratoma, in 1; and thymolipoma, in 1. The mean lesion size was 60.1 ± 32.0 mm. Tumors of the thymus were resected with tumor-free margins in 17 cases. The median (interquartile range) for pleural drain time and hospital stay, in days, was 1 (1-3) and 2 (2-4), respectively. There was no need for surgical conversion, and there were no major complications. Conclusions: Robotic thoracic surgery for resection of tumors of the thymus has been shown to be feasible and safe, with a low risk of complications and with postoperative outcomes comparable to those of other techniques.

RESUMO Objetivo: Avaliar os resultados da ressecção de tumores tímicos por cirurgia torácica robótica, verificando a radicalidade da ressecção, complicações pós-operatórias, tempo de cirurgia e tempo de internação. Métodos: Estudo retrospectivo a partir de um banco de dados envolvendo pacientes com diagnóstico de tumor tímico e submetidos à cirurgia torácica robótica em sete hospitais no Brasil entre outubro de 2015 e junho de 2018. Resultados: Durante o período estudado, houve 18 casos de ressecção de tumores tímicos (timomas, em 12; carcinoma tímico, em 2; e tumor carcinoide tímico, sarcoma tímico de alto grau, teratoma tímico e timolipoma, em 1 cada). A média do tamanho das lesões foi de 60,1 ± 32,0 mm. Tumores tímicos foram ressecados com margens livres em 17 casos. As medianas (intervalos interquartis) de tempo de dreno pleural e de internação, em dias, foram 1 (1-3) e 2 (2-4), respectivamente. Não houve necessidade de conversão cirúrgica nem complicações maiores. Conclusões: A cirurgia torácica robótica para a ressecção de tumores tímicos demonstrou ser factível e segura, com baixo risco de complicações e desfechos pós-operatórios comparáveis aos de outras técnicas.