Endoscopic exploration and repair of brachial plexus with telerobotic manipulation: a cadaver trial.

OBJECT: The aim of this paper was to develop an effective minimally invasive approach to brachial plexus surgery and to determine the feasibility of using telerobotic manipulation to perform a diagnostic dissection and microsurgical repair of the brachial plexus utilizing an entirely endoscopic approach. METHODS: The authors performed an endoscopic approach using 3 supraclavicular portals in 2 fresh human cadaver brachial plexuses with the aid of the da Vinci telemanipulation system. Dissection was facilitated inflating the area with CO(2) at 4 mm Hg pressure. The normal supraclavicular plexus was dissected in its entirety to confirm the feasibility of a complete supraclavicular brachial plexus diagnostic exploration. Subsequently, an artificial lesion to the upper trunk was created, and nerve graft reconstruction was performed. Images and video of the entire procedure were obtained and edited to illustrate the technique. RESULTS: All supraclavicular structures of the brachial plexus could be safely dissected and identified, similar to the experience in open surgery. The reconstruction of the upper trunk with nerve graft was successfully completed using an epineural microsurgical suture technique performed exclusively with the aid of the robot. There were no instances of inadvertent macroscopic damage to the vascular and nervous structures involved. CONCLUSIONS: An endoscopic approach to the brachial plexus is feasible. The use of the robot makes it possible to perform microsurgical procedures in a very small space with telemanipulation and minimally invasive techniques. The ability to perform a minimally invasive procedure to explore and repair a brachial plexus injury may provide a new option in the acute management of these injuries.

Early, intermediate, and late effects of a surgical skills "boot camp" on an objective structured assessment of technical skills: a randomized controlled study.

BACKGROUND: Surgical interns enter residency with variable technical abilities and many feel unprepared to perform necessary procedures. We hypothesized that interns exposed to a preinternship intensive surgical skills curriculum would demonstrate improved competency over unexposed colleagues on a test of surgical skills and that this effect would persist throughout internship. STUDY DESIGN: We designed a 3-day intensive skills "boot camp" with simulation-based training on 10 topics. Interns were randomized to an intervention group (boot camp) or a control group (no boot camp). All interns completed a survey including demographic information, previous experience, and comfort with basic surgical skills. Both groups completed a clinical skills assessment focused on 4 topics: chest tube insertion, central line placement, wound closure, and the Fundamentals of Laparoscopic Surgery peg transfer task. We assessed both groups immediately (month 0), early postcurriculum (month 1), and late postcurriculum (month 6). RESULTS: Fifteen participants were in the intervention group and 13 were in the control group. Before boot camp, mean comfort levels were similar for the groups. All participants had minimal prior experience. Competency for chest tube insertion and central line placement were considerably higher for the boot camp group at months 0 and 1, although much of this difference disappeared by month 6. There was no substantial difference between the 2 groups in the Fundamentals of Laparoscopic Surgery peg transfer and wound closure skills. CONCLUSIONS: A surgical skills boot camp accelerates the learning curve for interns in basic surgical skills as measured by a technical skills examination for some skills, although these improvements diminished over time. This can augment traditional training and translate into fewer patient errors.

Totally robotic laparoscopic Roux-en-Y Gastric bypass: results from 75 patients.

BACKGROUND: A technique for Totally Robotic Laparoscopic Roux-en-y Gastric Bypass (TRL-RYGBP) has been reported previously. In this paper, we report our experience with our first 75 TRLRYGBP operations, including the training of three laparoscopic fellows. We describe changes in technique that have evolved with more experience, lessons learned, and the results from a larger series. METHODS: A retrospective review was conducted of the first 75 TRLRYGBP procedures performed at our institution using the da Vinci surgical robot. We recorded demographics including patient age, gender, preoperative BMI, and numbers of NIH-defined co-morbidities. Data were collected on operative time, length of stay, complications, and postoperative weight loss. Results were compared between the three fellows to examine learning curves. RESULTS: The average patient age was 44 years (23-61), average BMI was 46.1 kg/m(2) (34.3-65.5), and the median number of NIH defined co-morbidities was 1 (0-3). Median operative time was 140 minutes (80-312) with mean operative time per BMI of 3.1 minutes (1.6-5.7). Excess weight loss was 48% at 3 months, 64% at 6 months, and 82% at 1 year. The overall complication rate was 22.6% (5.3% intraoperative, 8.0% major, and 9.3% minor including a 2.9% stricture rate and 0% leak rate). Each fellow demonstrated a learning curve of 10-15 cases. CONCLUSION: The authors' continued experience with the TRLRYGBP has confirmed our early results that the use of the da Vinci robot for laparoscopic gastric bypass is a superior alternative to the standard laparoscopic RYGBP, and that the learning curve is significantly faster.

Totally robotic Roux-en-Y gastric bypass.

HYPOTHESIS: We hypothesized that we could develop a safe and effective technique for performing a totally robotic laparoscopic Roux-en-Y gastric bypass procedure using the da Vinci surgical system. We anticipated that the learning curve for this totally robotic procedure could be shorter than the learning curve for standard laparoscopic bariatric surgery. DESIGN: Retrospective case comparison study. SETTING: Academic tertiary care center. PATIENTS: Consecutive samples of patients who met National Institutes of Health (NIH) criteria for morbid obesity and who completed the Stanford Bariatric Surgery Program evaluation process. INTERVENTION: A port placement and robot positioning scheme was developed so that the entire case could be performed robotically. The first 10 patients who underwent a totally robotic laparoscopic Roux-en-Y gastric bypass were compared with a retrospective sample of 10 patients who had undergone laparoscopic Roux-en-Y gastric bypass surgery. MAIN OUTCOME MEASURES: Patient age, gender, body mass index (BMI), numbers of NIH-defined comorbidities, operative time, length of stay, and complications. RESULTS: No significant differences existed between the 2 patient series with regard to age, gender, or BMI. The median surgical times were significantly lower for the robotic procedures (169 vs 208 minutes; P = .03), as was the ratio of procedure time to BMI (3.8 vs 5.0 minutes per BMI for the laparoscopic cases; P = .04). CONCLUSIONS: This study details the first report, to our knowledge, of a totally robotic laparoscopic Roux-en-Y gastric bypass and demonstrates the feasibility, safety, and potential superiority of such a procedure. In addition, the learning curve may be significantly shorter with the robotic procedure. Further experience is needed to understand the long-term advantages and disadvantages of the totally robotic approach.

Comparison of totally robotic laparoscopic Roux-en-Y gastric bypass and traditional laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic gastric bypass is a technically demanding operation, especially when hand-sewing is required. Robotics may help facilitate the performance of this difficult operation. This study was undertaken to compare a single surgeon's results using the daVinci Surgical System with those using traditional laparoscopic Roux-en-Y gastric bypass (LRYGB) when the techniques were learned simultaneously. METHODS: From July 2004 to April 2005, the new laparoscopic fellow's first 50 patients were randomized to undergo either LRYGB or totally robotic laparoscopic Roux-en-Y gastric bypass (TRRYGB). Data were collected on patient age, gender, body mass index (BMI), co-morbidities, operative time, complication rates, and length of stay. Student's t test with unequal variances was used for statistical analysis. RESULTS: No significant differences in age, gender, co-morbidities, complication rates, or length of stay were found between the two groups. The mean operating time was significantly shorter for TRRYGB than for LRYGB (130.8 versus 149.4 minutes; P = 0.02), with a significant difference in minutes per BMI (2.94 versus 3.47 min/BMI; P = 0.02). The largest difference was in patients with a BMI >43 kg/m(2), for whom the difference in procedure time was 29.6 minutes (123.5 minutes for TRRYGB versus 153.2 minutes for LRYGB; P = 0.009) and a significant difference in minutes per BMI (2.49 versus 3.24 min/BMI; P = 0.009). CONCLUSION: Our data indicate that the use of the daVinci Surgical System for TRRYGB is safe and feasible. The operating room time is shorter with the use of the robotic system during a surgeon's learning curve, and that decrease is maximized in patients with a larger BMI. TRRYGB may be a better approach to gastric bypass when hand-sewing is required, especially early in a surgeon's experience.