Multilocular thymic cyst detected during COVID­19 treatment in an HIV­positive adult man: A case report and literature review.

A multilocular thymic cyst (MTC) is a rare mediastinal tumor with multiloculated cyst-like structures in the anterior mediastinum. This tumfor is associated with inflammatory diseases, including human immunodeficiency virus (HIV) infection. The present study reports a case of MTC detected during coronavirus disease 2019 (COVID-19) treatment in an adult who was tested HIV positive. An anterior mediastinal tumor was incidentally detected on computed tomography in a 52-year-old man with a 20-year history of HIV infection on the 9th day of COVID-19. The patient was asymptomatic with no notable physical findings. Magnetic resonance imaging revealed a 28-mm bilocular cyst. Robot-assisted thoracoscopic tumor resection was performed. Pathological examination showed that the cyst was lined with squamous or cuboidal epithelium, and the cystic lesion wall was mainly composed of thymic tissue with follicular hyperplasia. Based on these findings, the patient was diagnosed with MTC. To date, only 15 MTC cases have been reported in patients with HIV, and the majority of cases showed HIV infection-related symptoms such as lymphoid interstitial pneumonia and parotid gland enlargement. The present case was atypical for an HIV-related MTC because it did not involve HIV infection-related symptoms, suggesting the possibility for an alternative etiology such as COVID-19. Further reports on MTC development in patients with COVID-19 are required to elucidate the relationship between MTC and COVID-19.

New Paradigm in Robotic Prostatectomy: Planned Same Day Discharge in All Patients

INTRODUCTION AND OBJECTIVE: In 2016 we began offering optional same-day discharge (SDD) to all robotic prostatectomy (RP) patients with increasing acceptance that accelerated during the COVID pandemic. Our resulting 98% SDD rate for RP after COVID facilitated initiation of an ambulatory surgery center (ASC) robotic urology program without overnight capability and planned SDD in all patients. We assessed our outcomes with planned outpatient RP in all patients in both the hospital and ASC settings. METHOD(S): We reviewed one year of consecutive RPs performed by a single surgeon at either a free-standing ASC or one of three hospitals between October 2021-October 2022. Pelvic lymphadenectomy was performed in all patients. Assignment to ASC versus hospital RP was based primarily on insurance eligibility. ASC policy for robotic or non-robotic procedures alike excluded history of severe cardiac disease, difficult airway, malignant hyperthermia, or BMI >45kg/m2 with no additional limitations applied to robotic surgery. All patients were instructed to expect same-day discharge (SDD) directly from the recovery room regardless of ASC or hospital location with overnight stay only for unexpected complications or side effects of anesthesia. RESULT(S): Among 359 RP cases (162 ASC and 197 hospital), 356 (99%) were successfully discharged the same day as surgery with 3 overnight stays in the hospital group and none in the ASC group. Patients in the ASC group were younger (61.4yrs vs 67.1yrs, p<001) with no statistically-significant difference in BMI (29.2 kg/m2 vs 29.3 kg/ m2, p=0.3), preoperative Gleason Score (p=0.1), operative time (131min vs 134min, p=0.2) or blood loss (87.5cc vs 84.8cc, p=0.71). Excluding the three overnight patients in the hospital group, the mean postoperative recovery room stay among SDD patients was shorter in the ASC group (1.7hrs vs 2.3hrs, p<0.0001). The 90-day readmission rate was 2.5% in both groups (4/162 and 5/197, p=0.93). No readmissions occurred within 24 hours of surgery and only one within the first week. CONCLUSION(S): Same day discharge as a routine following robotic prostatectomy is feasible and safe with readmission rates no higher than series with overnight stays. SDD may enable ASC RP when overnight stay capabilities are not available at an ASC with minimal risk of need for hospital transfer.

Last Resort from Nursing Shortage? Comparative Cost Analysis of Open vs. Robot-Assisted Partial Nephrectomies with a Focus on the Costs of Nursing Care.

Despite perioperative advantages, robot-assisted surgery is associated with high costs. However, the lower morbidity of robotic surgery could lead to a lower nursing workload and cost savings. In this comparative cost analysis of open retroperitoneal versus robot-assisted transperitoneal partial nephrectomies (PN), these possible cost savings, including other cost factors, were quantified. Therefore, patient, tumor characteristics, and surgical results of all PN within two years at a tertiary referral center were retrospectively analyzed. The nursing effort was quantified by the local nursing staff regulation and INPULS® intensive care and performance-recording system. Out of 259 procedures, 76.4% were performed robotically. After propensity score matching, the median total nursing time (2407.8 vs. 1126.8 min, p < 0.001) and daily nursing effort (245.7 vs. 222.6 min, p = 0.025) were significantly lower after robotic surgery. This resulted in mean savings of EUR 186.48 in nursing costs per robotic case, in addition to savings of EUR 61.76 due to less frequent administrations of erythrocyte concentrates. These savings did not amortize the higher material costs for the robotic system, causing additional expenses of EUR 1311.98 per case. To conclude, the nursing effort after a robotic partial nephrectomy was significantly lower compared to open surgery; however, this previously unnoticed savings mechanism alone could not amortize the overall increased costs.

Concept renovation: a new perspective of minimally invasive surgery. TT -:.

The development and innovation of laparoscopic vision platform has promoted the innovation of surgical concept and technology from laparotomy to minimally invasive surgery. From the initial use of reflector device with candlelight to observe the interior of the human body cavity, to the high-definition and ultra-high-definition laparoscopic vision system, from laparoscopic cholecystectomy, to the popularization and promotion of various laparoscopic surgery for malignant tumor, surgery has undergone great changes due to minimally invasive technology. In the new era, the application of three-dimensional and 4K laparoscope brings a new perspective to minimally invasive surgery, so as to promote the development of surgery in the direction of accurate anatomy and functional protection. In the future, stimulated by concept renovation in post-epidemic era of COVID-19, virtual reality technology and robotic surgery supported by the fifth generation wireless systems, as well as tele-surgery and distance training and teaching based on it, will become a new perspective for the development of minimally invasive surgery.Copyright © 2020 by the Chinese Medical Association.

Role of Robotics in Health Care System during Covid-19 Pandemic

The essential part of robots in the medical services framework is principal limiting individual to individual contact defilement and guaranteeing cleaning disinfection. Robots can be defined as an artificially intelligent physical systems capable of interrelating with the environment. The term robot was coined from the Czech what "robota" which implies serf/worker. Robots are classified as Receptionist robots, Surgical robots, Ambulance robots, Service robots, Telemedicine robots. During this pandemic, these mechanical frameworks can diminish the danger of irresistible illness transmission among forefront medical services laborers and afterward make it a potential advance to assess, accentuate, screen, and treat the patients from a safe distance, accordingly bringing down the responsibility of medical care staff. Robots are all around planned with UV light to sanitize the rooms and even themselves. Teleoperated robots in the medical care framework turn into the laborers' eyes, ears, and bodies in the Isolation Ward, which might be dependable during this COVID-19 pandemic. This mechanical innovation will assume a vital part during this basic stage in certain spaces of medical care framework like estimating pulse, oxygen immersion, observing essential signs. Low-cost, miniature robots can be easily assembled and controlled via remote, and this system includes an active end effector, a passive positioning arm and a detachable swap gripper with integrated force sensing capability. Robot execution in the fight against COVID-19 has received positive criticism from medical services laborers for its potential to obstruct disease and is successful in easing clinical specialists from repeated tasks. Copyright © 2022 Society of Pharmaceutical Sciences and Research. All rights reserved.

Safety of uro-oncology practice and robot-assisted surgery during the peak of COVID-19 pandemic: A report from India.

Aim: The pandemic by novel coronavirus disease 2019 (COVID-19) is the biggest threat to global health care. Routine care of cancer patients is affected the most. Our institute, situated in Mumbai, declared as the hotspot of COVID-19 in India, continued to cater to the needs of cancer patients. We did an observational study to review the experience of managing uro-oncology patients and who underwent either open, endoscopic, or robot-assisted surgery for urological malignancy. Materials and Methods: During the peak of COVID-19 pandemic from March 21, 2020, to June 21, 2020, all the uro-oncology cases managed in our tertiary care hospital were analyzed. Teleconsultation was started for follow-up patients. All patients requiring surgery underwent reverse transcription-polymerase chain reaction for COVID-19. Institutional protocol was formulated based on existing international guidelines for patient management. Adequate personal protection and hydroxychloroquine prophylaxis were provided to health-care professionals. Results: During the study period, 417 outpatient consultations were made. Forty-nine patients underwent surgery for different urological malignancies. Majority of the surgeries were robot-assisted surgeries (59.2%, 29 patients), followed by endoscopic procedures (28.5%, 14 patients) and few open procedures (10.2%, five patients). Most of our patients were elderly males (mean, 62.5 years). With a median follow-up of 55 days (interquartile range, 32-77), there was no report of COVID-19 infection in any patient or health-care provider. Conclusions: We can continue treating needy cancer patients with minimal risk by taking all precautions. Our initial experience of managing uro-oncology cases during this pandemic is encouraging. Robotic surgeries can be safely performed.

R-Tapp as a Training Model in Robotic Surgery

Aim: Themain aimof the project will be evaluating the effectiveness of an experimental structured didactic program in robotic surgery in filling the training gap caused by the pandemic. We intend to evaluate how establishing a training pathway could improve young surgeons' robotic skills and implement their participation in robotic procedures during the COVID-19 pandemic. We will also evaluate the learning curve of robotic transabdominal preperitoneal inguinal hernia repair (TAPP) for young surgeons with limited experience as first operators at the dual console. Matherials and Methods:Wedesigned an experimental stepwise training program in robotic surgery that starts from a first step of theoretical and laboratory lessons, followed by a second phase of bedside assistance training, and finally the completion of low complexity procedures by the trainees proctored at the dual console by senior surgeons. Robotic TAPP was selected as training model. The performance of each trainee will be registered in an evaluation data sheet and Learning scores will be recorded by the tutor with the evaluation of 6 corner steps of the procedure. Result(s): Preliminary results showed improved technical skills and increased team spirit and wellbeing. Conclusion(s): TAPP is a good training model because involves technical steps useful for more complex procedures. The robotic dual console represent an extraordinary training tool and a structured training program positively impacts technical skills and could help filling the training gap caused by the pandemic.

The Impact of Extended Reality on Surgery: A Scoping Review

Aim: Extended reality (XR) is a spectrum of technologies encompassing augmented reality (AR), virtual reality (VR), augmented virtuality (AV), mixed reality (MR). This scoping review maps out current utilisation and future prospects of XR-assisted surgery. Method: A systematic search of PubMed, Scopus, Embase was performed. Primary studies describing surgical procedures on human subjects, dentistry, anaesthetic procedures for surgery were included. Non-surgical, rehabilitation, bedside, veterinary procedures, robotic surgery were excluded. Studies were classified into preoperative planning, intraoperative navigation/guidance, patient pain, patient anxiety, surgical training, surgeon confidence. Results: 213 studies were included for analysis. Thirty-six studies on pre-operative planning noted VR improved surgeon's understanding of anatomical sites, leading to reduced operating time and surgical trauma. Fifty-nine studies on intra-operative planning noted AR headsets highlight 'negative structures', reducing chance of accidental incision. Fourteen studies on patients' pain found VR-induced meditative state resulted in less analgesics for patient comfort. Twelve studies on patient anxiety found VR failed to change patients' physiological parameters such as arterial blood pressure, cortisol levels, heart rate. Sixty-eight studies explored surgical training, with VR being most cost-effective. Thirteen studies documented increased surgeon confidence. Conclusions: XR-assisted surgery's growth is fuelled by hardware and software innovations. Training and pre-operative planning are mostly achieved by VR;intraoperative guidance is mostly supplemented with AR. The other sections of XR spectrum, AV and MR, are underexplored. Working time restrictions during surgical training, COVID-19's impact on limiting physical presence and increasing complexity of surgical procedures means that XR-assisted surgery may assume a greater role in coming decades.

COMBINED ENDOSCOPIC ROBOTIC SURGERY FOR COMPLEX COLON POLYPS: A RETROSPECTIVE STUDY

Purpose/Background: Combined endoscopic robotic surgery (CERS) is a novel surgical technique that modifies traditional endoscopic laparoscopic surgery with robotic assistance to aid in removal of complex colonic polyps. Hypothesis/Aim: This study aimed to evaluate the safety and outcomes of combined endoscopic robotic surgery. Methods/Interventions: A retrospective review of a prospective database was conducted. Patients underwent CERS by a single colorectal surgeon from March 2018 to October 2021. Polyps were initially found by a referring gastroenterologist and deemed unresectable by traditional endoscopy. Complex polyps were identified in the colon endoscopically while the da Vinci Xi robot was utilized to aid in polyp resection. Once complete, the resection site was over-sewn with absorbable Lembert sutures under endoscopic supervision. Based on pathology, patients were instructed to undergo repeat colonoscopy 3 to 12 months from their operative date. Results/Outcome(s): Combined endoscopic and robotic surgery was successfully completed in 85 of 93 (91%) cases. Patients were converted to other procedures due to discovery of a smaller polyp than anticipated, concern for malignancy, involvement of the ileocecal valve, inability to lift the polyp, or involvement of the appendiceal stump. Among the 85 participants seeing CERS to completion, average age was 66 years (SD=10), body mass index was 29 (SD=6), and history of abdominal surgeries was 1 (SD=1). Median operative time and polyp size were 73 mins (range 31-184 mins) and 40 mm (range 5-180 mm), respectively. Most common polyp locations were cecum, ascending, and transverse colon (29%, 29%, 24%). Pathology mainly demonstrated tubular adenoma (76%). To date, 40 patients underwent follow-up colonoscopy, with an average follow-up time of 7 months (range 3-22 months). Of those, one patient (2.5%) had resection site polyp recurrence. Limitations: Limitations for our study include lack of randomization and follow-up rate to assess for recurrence. The low compliance rate may be due to patient reluctance to get a colonoscopy or procedure cancelations/ difficulty scheduling due to changing COVID-19 regulations. Conclusions/Discussion: Most recent literature reports median operative times for combined endoscopic laparoscopic surgery (CELS) as 85 mins (range 50-225 mins) and 135 mins (range 120-170 mins). Resection site polyp recurrence for traditional endoscopic mucosal resection and CELS ranges from 13.1% and 3.3-10%, respectively. Our findings suggest that CERS is associated with decreased operating time and resection site polyp recurrence. Overall, CERS is a practical technique that enhances current methods for the resection of complex colonic polyps.

DOES QUALITY ASSURED ELEARNING PROVIDE ADEQUATE PREPARATION FOR ROBOTIC SURGICAL SKILLS;A PROSPECTIVE, RANDOMIZED AND MULTI-CENTER STUDY

INTRODUCTION AND OBJECTIVE: In particular after the onset of the COVID-19 pandemic, there was a precipitous rush to implement virtual and online learning strategies in surgery and medicine. It is essential to understand whether this approach is sufficient and adequate to allow the development of robotic basic surgical skills. The main aim of the authors was to verify if the quality assured eLearning is sufficient to prepare individuals to perform a basic surgical robotic task. METHODS: A prospective, randomized and multi-center study conducted in September 2020 in the ORSI Academy, International surgical robotic training center. 47 participants with no experience but a special interest in robotic surgery, were matched and randomized into 4 groups who underwent a didactic preparation with different formats before carrying out a robotic suturing and anastomosis task. Didactic preparation methods, ranged from a complete eLearning path to peer-reviewed published manuscripts describing the suturing, knot tying and task assessment metrics. RESULTS: The primary outcome was the percentage of trainees who demonstrated the quantitatively defined proficiency benchmark after learning to complete an assisted but unaided robotic vesico-urethral anastomosis task. The quantitatively defined benchmark was based on the objectively assessed performance (i.e., procedure steps completed, errors and critical errors) of experienced robotic surgeons for a proficiency based progression (PBP) training course. None of the trainees in this study demonstrated the proficiency benchmarks in completing the robotic surgery task (Figure 1a-c). CONCLUSIONS: Quality assured online learning is insufficient preparation for robotic suturing and knot tying anastomosis skills.

Artificial intelligence in preventive and managed healthcare

Increasing application on account of the rapid progress made by artificial intelligence (AI) in healthcare has brought upon a progressive paradigm shift. By combining relevant AI architectures with digitized data acquisition and sophisticated data validation techniques, AI-based technologies are expanding to unchartered areas. This chapter focuses on understanding recent novel innovations and practical clinical applications of AI in aiding the conventional healthcare industry. Breakthrough AI-based platforms that aid in critical sectors of the healthcare industry like disease diagnosis, robot-assisted surgery, patient rehabilitation, and use of smartphones/smart wearables for health monitoring and AI’s role in controlling and tackling COVID-19 like pandemics are summarized. © 2021 Elsevier Inc. All rights reserved.

Does quality assured eLearning provide adequate preparation for robotic surgical skills;A prospective, randomized and multi-center study

Introduction & Objectives: After the onset of the COVID-19 pandemic there was a precipitous rush to implement virtual and online learning strategies in surgery and medicine. In response there appears to be a precipitous rush to implement virtual and online learning strategies in surgery and medicine which many educators (particularly in industry) appear to believe can mitigate or supplant the necessity of skills laboratory training. It is therefore essential to have a robust and evidence-based understanding of this premise and to evaluate whether this approach is sufficient and adequate for learning basic robotic surgical skills and to prepare individuals to perform a basic surgical robotic task. Materials & Methods: A prospective, randomized and multi-center study 47 participants were matched and randomized into 4 groups who underwent proficiency based progression (PBP) eLearning, eLearning without benchmarks, traditional lectures and learning from peer-reviewed published manuscripts describing the suturing, knot tying and task assessment metrics. Afterwards the PBP group had skills training under COVID secure conditions. Results: The primary outcome was the percentage of trainees who demonstrated the quantitatively defined proficiency benchmark after didactic learning. (i.e., 5-Procedure Steps completed, <10 Errors and 0 = Critical Errors). Figure 1a-c shows that none of the trainees in this study demonstrated all three proficiency benchmarks (Procedure Steps p<0.001 – 0.000;Errors, p=0.403 – 0.001;Critical Errors, 0.016 – 0.001) (Figure 1a-c). After six hands-on training trials and ~ 3 hours training all PBP trained participants met all three proficiency benchmarks. Figure 1a-c. The mean and 95% CI of procedure Steps, Errors and Critical Errors made by the four groups of trainees on the robotic surgery vesico-urethral anastomosis model relative to the proficiency benchmark for each performance metric. Also shown are how far off the proficiency benchmark performance was. (Figure Presented) Conclusions: Although better than traditional learning strategies, quality assured online learning is insufficient preparation for basic robotic surgical skills. Medicine in general but surgery and procedure-based medicine specifically would be imprudent to be overly optimistic about how effective quality assured online learning is without skills lab. training.

Mirrors study: A prospective cohort study assessing the feasibility of robotic interval debulking surgery for advanced-stage ovarian cancer

Introduction/Background MIRRORS (Minimally Invasive Robotic surgery, Role in optimal debulking Ovarian cancer, Recovery & Survival) is the largest prospective cohort study of robotic interval debulking surgery (IDS) in women with advanced-stage epithelial ovarian cancer (EOC) to date. MIRRORS has investigated the feasibility of obtaining consent from women, the acceptability and success of robotic IDS and its impact on short-term surgical outcomes and quality of life. Methodology Eligibility Women with FIGO IIIc-IVb EOC undergoing neoadjuvant chemotherapy and suitable for IDS. Exclusions: pelvic mass >8cm, extensive HPB and/or extensive bowel involvement. Surgery commenced with an initial laparoscopic assessment, for all women recruited, followed by a decision to proceed immediately to robotic or open IDS. Result(s) 23/24 eligible women recruited. Following initial diagnostic laparoscopy, 20 women proceeded directly to robotic IDS, 3 women received open IDS. All patients were debulked with maximal surgical effort to R<1, 39% to R=0. No robotic cases were converted to open. Median EBL for robotic IDS: 50ml, open: 2026ml, median operating time 05:58 robotic vs 05:38 open, length of stay (LOS) 1.5 days robotic vs 6 days open. Bowel resection with stapled anastomosis 15% (3/20), diaphragmatic stripping 60% (12/20), fullthickness diaphragmatic resection 5% (1/20), pelvic peritoneal stripping 70% (14/20). Conclusion MIRRORS has shown significantly enhanced recovery with short LOS, reduced blood loss and reduced HDU/ITU demands, enabling faster re-commencement of chemotherapy in women with FIGO IIIc-IVb EOC. This proved to be greatly beneficial during the COVID-19 pandemic. In experienced hands robotic IDS proved feasible in cases with a pelvic mass up to 8cm. Robotic surgery is not suitable for peritoneal disease covering the anterior abdominal wall close to port sites but does facilitate pelvic and diaphragmatic stripping and arguably provides better visualisation of these peritoneal surfaces in women with high BMI. The planned multicentre MIRRORS-RCT will assess whether robotic IDS offers improved quality of life and recovery with non-inferior progression-free and overall survival. We present the evolution of our surgical technique with illustrative surgical videos and qualitative patient feedback, supported by the objective surgical outcomes for this trial.

The impact on minimally invasive urological cancer surgery during the CIVID-19 pandemic

Aim: Learned bodies recommended restricted use of, or extensive precautions when using, laparoscopic/robotic surgery during the Covid-19 pandemic. We aimed to determine whether minimally invasive surgery (MIS) in uro-oncology patients was safe for patients and staff. Method: From 16 March to 16 June 2020, patients having MIS in a tertiary referral urology centre were identified from a prospectively collected database. Patient characteristics, operative details and 30-day follow-up for adverse events were recorded including Covid-19 tests and results. Any theatre staff Covid-19 event was traced back 14 days to determine any involvement in these cases. Results: 87 patients were eligible for inclusion (33 robotic prostatectomies, 38 laparoscopic prostatectomies, 11 laparoscopic nephrectomies, 5 robotic nephrectomies). All patients were assessed for symptoms of Covid-19 on the day of theatre. 18(21%) patients had pre-operative screening (all swabs, no CT chest). 46(53%) underwent 14 days pre-operative self-isolation. 38(44%) cases were performed with FFP3 protection. No modification to operating procedure was made for any cases. No patients tested positive for Covid-19 in the 30-day postoperative period. No staff member involved tested positive in the postoperative period. 1 patient tested positive pre-operatively, delaying the operation by 7 weeks. No patients tested positive after the introduction of mandatory screening. Conclusions: Based on our case-series MIS urological surgery appears to be safe for patients and staff, with no increased risk of Covid-19 complications in patients who are asymptomatic pre-operatively. The introduction of mandatory pre-operative swabs for elective patients, and the use of FFP3 protection, did not significantly alter results.

Robot assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: a statement of the Society of European Robotic Gynaecological Surgery (SERGS).

All surgery performed in an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, irrespective of the known or suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) status of the patient, should be regarded as high risk and protection of the surgical team at the bedside should be at the highest level. Robot assisted surgery (RAS) may help to reduce hospital stay for patients that urgently need complex-oncological-surgery, thus making room for COVID-19 patients. In comparison to open or conventional laparoscopic surgery, RAS potentially reduces not only contamination with body fluids and surgical gasses of the surgical area but also the number of directly exposed medical staff. A prerequisite is that general surgical precautions under COVID-19 circumstances must be taken, with the addition of prevention of gas leakage: • Use highest protection level III for bedside assistant, but level II for console surgeon. • Reduce the number of staff at the operation room. • Ensure safe and effective gas evacuation. • Reduce the intra-abdominal pressure to 8 mmHg or below. • Minimize electrocautery power and avoid use of ultrasonic sealing devices. • Surgeons should avoid contact outside theater (both in and out of the hospital).