Laparoscopic Morgagni hernia repair in children using robotic instruments.

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

Computer-assisted, robot-enhanced open microsurgery in an animal model.

BACKGROUND: Computer-assisted, robot-enhanced surgery improves laparoscopic and thoracoscopic surgery through tremor filtration, motion scaling, articulation, and improved ergonomics. Surgeons perform many open cases under magnification that magnifies the tremor present in all surgeons' hands, so the tremor filtration and motion scaling of robotic surgery may improve microsurgery. Our goal was to compare microvascular anastomoses performed with a robot-enhanced technique with a standard technique. METHODS: We performed end-to-end anastomoses in 1-mm rat femoral arteries with interrupted 10-0 suture. We compared the anastomotic time, patency, and leak rates between traditional microsurgery techniques (by hand) and a robot-enhanced technique using the Zeus robotic surgery system (Computer Motion, Goleta, California). The surgeon used an operative microscope for visualization in both techniques. RESULTS: We performed 30 anastomoses by hand and 31 with Zeus. We observed a remarkable degree of tremor filtration in the robot-enhanced cases. Anastomotic times for both techniques demonstrated a learning curve. Anastomoses done by hand (mean time, 17.2 minutes) were significantly faster than those done with Zeus (mean time, 27.6 minutes) (P = 0.0006). All anastomoses from both groups were patent, and none leaked after 3 minutes. CONCLUSION: The Zeus system is effective at performing complex, open, microsurgery tasks in vivo. There was no measurable benefit from the remarkable tremor filtration and motion scaling offered by robot-enhanced surgery.

Totally minimally invasive robot-assisted unstented pyeloplasty using the Zeus Microwrist Surgical System: an animal study.

BACKGROUND: Minimally invasive pyeloplasty is a difficult procedure even for an expert laparoscopic surgeon. The major difficulty is associated with the limitations of intracorporeal suturing and knot tying. Surgical robots, which hold minimally invasive surgical instruments, have wrists and provide tremor filtration and motion scaling that might be expected to facilitate complex procedures in newborns. METHODS: Seven survival piglets (4.0-7.5 kg) underwent a totally minimally invasive robot-assisted unstented pyeloplasty employing the Zeus Robotic Microwrist System. The ureter was transected at the level of the ureteropelvic junction and 8 mm was resected. The unstented anastomosis was fashioned with running suture and intracorporeal knot tying. The animals were recovered and intravenous urography was performed at 1 month. After sacrifice, the anastomosis and the kidney were evaluated grossly and histologically for leak, caliber, and healing. RESULTS: All animals survived the procedure without postoperative complications. The mean robotic setup time was 19 minutes (range, 10-30 min), mean anastomosis time 51 minutes (range, 39-63 min), and mean total operation time 76 minutes (range, 57-87 min). The urography showed hydronephrosis in the first animal. The other 6 animals had no abnormalities. Histopathology demonstrated severe hydronephrosis in the first pig and moderate hydronephrosis in the sixth and seventh. All other animals had no sign of hydronephrosis. All anastomoses were well healed and intact. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty is a technically feasible procedure with acceptable morbidity in an animal model. The robotic technology enhances surgical dexterity and precision. Robotic assistance can increase the applicability of minimally invasive surgery to complex procedures in children.

Robot-enhanced fetoscopic surgery.

BACKGROUND: Fetoscopic surgery carries with it less maternal morbidity than open fetal surgery. Robotic surgery facilitates endoscopic surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. The goal of the authors was to explore using a robotic surgery platform in a fetal animal model. METHODS: Using the Zeus Robotic Surgery System (Computer Motion, Santa Barbara, CA), fetoscopic surgery in pregnant sheep was performed using a variety of techniques: uterus exteriorized or totally percutaneous and with liquid or gas insufflation. Using the percutaneous technique and gas insufflation, the authors created and sutured fetal skin and fascial defects. The ewes were recovered and killed 2 weeks postoperatively, and autopsies were performed on them and their fetuses. RESULTS: In the exteriorized uterus model, instrument movement was unpredictable and fluid leaked. In the fluid environment, clouding of the visual field and difficulty in immobilizing the fetus were major difficulties. In the survival model, 4 of the 6 fetuses survived to autopsy at 2 weeks and showed good healing grossly and histologically. CONCLUSIONS: The Zeus Robotic Surgery System can be used for fetoscopic surgery in a sheep model. The percutaneous approach with a nitrous oxide environment is the most effective. Advantages of robotic surgery may be applicable in fetoscopic surgery, but further work in a primate model is required.

Robotically assisted esophago-esophagostomy in newborn pigs.

PURPOSE: Repair of esophageal atresia and tracheoesophageal fistula (TEF) in the newborn is challenging when done as an open procedure but only a few surgeons have attempted this with minimally invasive surgery (MIS). Surgical robots that hold MIS instruments have wrists and provide tremor filtration and motion scaling, which might be expected to facilitate complex procedures in small spaces such as an esophageal anastomosis in a newborn. METHODS: Seven newborn pigs weighing 2 to 3 kg were used as a model. The authors performed an esophageal resection and end-to-end anastomosis using the Zeus Microwrist Robotic Surgical System. The authors monitored the following data-Zeus robotic set-up time, operating time, esophageal dissection time, and anastomosis time. After 1 month, the animals were anesthetized to perform esophagram and than were killed. RESULTS: In these very small animals the space available for performing an anastomosis is very limited, approximately 2 cm3. Two pigs each died 18 days postoperatively. One animal could not eat and died during esophageal dilation. The second pig died of unrelated enteritis. Neither had evidence of anastomotic leak at autopsy. The esophagram of the 5 pigs that survived for 30 days showed no narrowing or proximal dilation in 2. In 3 there was some stenosis requiring dilation. Histopathology was done on each operated animal. Two of the anastomoses were well healed, and 5 showed only focal small ulceration. CONCLUSIONS: Robotic assistance facilitates an MIS approach to the upper esophagus even in the limited space of the infant chest.

Computer-assisted robot-enhanced laparoscopic fundoplication in children.

BACKGROUND/PURPOSE: Robotic surgery improves laparoscopic surgery through a more natural interface, tremor filtration, motion scaling, and additional degrees of freedom of the instruments. Here, the authors report that experience with robot-assisted fundoplication in children. METHODS: The authors have performed 15 laparoscopic fundoplications with the Zeus Robotic Surgery System and retrospectively reviewed prospectively collected data on set-up time, operating time, and outcome. RESULTS: All cases were completed successfully: one Heller myotomy with Dor fundoplication and 14 Nissen fundoplications. Patients ranged from 2 months to 18 years old (mean, 4.3 years) and from 3.4 kg to 37.7 kg (mean, 13.0 kg). There were no technical errors, equipment errors, or conversions. There were no complications in the first 30 days after surgery. The operating time declined from 323 minutes for the first case to 180 minutes for the last (mean, 195 minutes). The 14th case was the shortest at 123 minutes. Setting up the robotic surgery system took an average of 11 minutes. The surgeons perceived benefits of greater ease and confidence in suture placement and knot tying. CONCLUSIONS: The authors have successfully used surgical robots for gastric fundoplication at a pediatric teaching hospital. Our experience with this operation has shown the additional dexterity that the robot provides and will pave the way to more complex procedures.