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.

Telementoring systems in the operating room: a new approach in medical training / "Telementoring" en el quirófano: un nuevo enfoque en la formación médica

This paper discusses the challenges and innovations related to the use of telementoring systems in the operating room. Most of the systems presented leverage on three types of interaction channels: audio, visual and physical. The audio channel enables the mentor to verbally instruct the trainee, and allows the trainee to ask questions. The visual channel is used to deliver annotations, alerts and other messages graphically to the trainee during the surgery. These visual representations are often displayed through a telestrator. The physical channel has been used in laparoscopic procedures by partially controlling the laparoscope through force-feedback. While in face to face instruction, the mentor produces gestures to convey certain aspects of the surgical instruction, there is not equivalent of this form of physical interaction between the mentor and trainee in open surgical procedures in telementoring systems. Even that the trend is to perform more minimally invasive surgery (MIS), trauma surgeries are still necessary, where initial resuscitation and stabilization of the patient in a timely manner is crucial. This paper presents a preliminary study conducted at the Indiana University Medical School and Purdue University, where initial lexicons of surgical instructive gestures (SIGs) were determined through systematic observation when mentor and trainee operate together. The paper concludes with potential ways to convey gestural information through surgical robots.

Este artículo discute los desafíos e innovaciones relacionadas al uso de sistemas de tutoría en telecirugía (telementoring). La mayoría de los sistemas presentados se basan en tres tipos de canales de interacción: auditivo, visual y físico. El canal auditivo permite al instructor instruir verbalmente al alumno, y a este último hacer preguntas. El canal visual es usado para transmitir al alumno anotaciones, alertas y otro tipo de mensajes gráficos durante la cirugía. Estas representaciones visuales aparecen en un marcador de vídeo (telestrator). El canal físico ha sido usado en cirugías laparoscópicas por medio de retroalimentador de fuerza (forcefeedback). Mientras que en la instrucción cara a cara, el instructor hace gestos para transmitir ciertos aspectos de la instrucción quirúrgica, esta forma de interacción no tiene un equivalente en la interacción entre instructor y alumno en sistemas de telementoring. Si bien la tendencia es conducir procedimientos mínimamente invasivos (MIS) con estos sistemas, se deben tener en cuenta cirugías de trauma, todavía necesarias, especialmente donde la resucitación inicial y estabilización del paciente es un tema crítico y urgente. Este artículo presenta un estudio preliminar conducido en la Escuela de Medicina de Indiana (EE.UU.) y en la Universidad Purdue, donde el vocabulario de gestos (lexicons) usados en instrucción quirúrgica (SIGs) se determinaron por medio de observaciones sistemáticas mientras el instructor y el alumno operaban juntos. Se concluye discutiendo maneras alternativas de presentar esta información de gestos por medio de robots quirúrgicos.

Pathologic outcomes during the learning curve for robotic-assisted laparoscopic radical prostatectomy

OBJECTIVE: We report our initial experience with 62 patients undergoing robotic-assisted laparoscopic prostatectomy (RALP), focusing on the primary parameter of positive surgical margins. The authors demonstrate that excellent oncologic outcomes can be attained with a less steep learning curve than previously hypothesized. MATERIALS AND METHODS: The first 62 patients undergoing RALP by a single physician (DPD) at our institution between November 2005 and August 2007 were retrospectively assessed. Surgical pathology records were reviewed for Gleason score, pathologic tumor stage, nodal status, location of prostate cancer within the specimen, extracapsular extension, surgical margin status, presence of perineural invasion, tumor volume, and weight of the surgical specimen. Margin status was determined using surgical specimens only, and not intraoperative frozen sections. All cases in this series were completed using the four-arm da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California). RESULTS: Sixty-one patients had prostate cancer on their final surgical pathology specimens. Pathologic stage T2 and stage T3 patients were 88.7 percent and 9.7 percent of all cases, respectively. The pathologic Gleason score was 7 or greater in 62.3 percent. Our overall positive surgical margin rate was 3.3 percent. Patients with pathologic T2 and T3 disease had a positive surgical margin rate of 1.8 percent and 16.7 percent, respectively. CONCLUSIONS: Our study suggests that RALP can have equal if not better pathologic outcomes compared to open radical prostatectomy even during the initial series of cases. We argue that the learning curve for RALP is shorter than previously thought with respect to oncologic outcomes, and concerns asserting that lack of tactile feedback leads to poor oncologic outcomes are unfounded.

Desarrollo de simuladores de cirugía laparoscópica de bajo costo / Development of laparoscopic surgery simulator low cost

Antecedentes: Dentro de la enseñanza quirúrgica los simuladores laparoscópicos abarcan un papel importante como medio de aprendizaje, capacitación y perfeccionamiento de los futuros cirujanos. Por ésto ha surgido la necesidad de crear un simulador de alta performance y de bajo costo para la educación de un número mayor de profesionales. Objetivos: Desarrollar un simulador para el entrenamiento de cirugía laparascópica. Disminuir el costo de creación del simulador. Evaluar la eficacia del aprendizaje del médico residente en cirugía laparoscópica en este simulador. Lugar de aplicacíón: Sanatorio 9 de Julio, Tucumán. Diseño: Estudio descriptivo, prospectivo de corte transversal. Población: Médicos residentes de distintas especialidades quirúrgicas. Resultados: Se logró el desarrollo de un nuevo simulador de cirugía laparoscópica usando una mini-cámara de video, dismimuyendo ampliamente su costo. Se valoró a 20 médicos residentes, la adquisición de de habilidad y destreza, mediante la realización de maniobras laparascópicas. Conclusión: El uso de simuladores de cirugía laparoscópica está altamente comprobado, pero su costo los hace inaccesibles para el sistema de residencia. El simulador desarrollado por nosotros posee las mismas ventajas pero menor costo por lo que lo hace accesible para todos.