Multi-wavelength fluorescence imaging with a da Vinci Firefly-a technical look behind the scenes.

The field of fluorescence-guided surgery builds on colored fluorescent tracers that have become available for different clinical applications. Combined use of complementary fluorescent emissions can allow visualization of different anatomical structures (e.g. tumor, lymphatics and nerves) in the same patient. With the aim to assess the requirements for multi-color fluorescence guidance under in vivo conditions, we thoroughly characterized two FDA-approved laparoscopic Firefly camera systems available on the da Vinci Si or da Vinci Xi surgical robot. In this process, we studied the cameras' performance with respect to the photophysical properties of the FDA-approved dyes Fluorescein and ICG. Our findings indicate that multi-wavelength fluorescence imaging of Fluorescein and ICG is possible using clinical-grade fluorescence laparoscopes, but critical factors for success include the photophysical dye properties, imaging system performance and the amount of accumulated dye. When comparing the camera performance, the Xi system provided more effective excitation (adaptions in the light source) and higher detection sensitivity (chip-on-a-tip and/or enhanced image processing) for both Fluorescein and ICG. Both systems can readily be used for multi-wavelength fluorescence imaging of Fluorescein and ICG under clinically relevant conditions. With that, another step has been made towards the routine implementation of multi-wavelength image-guided surgery concepts.

Orsi Consensus Meeting on European Robotic Training (OCERT): Results from the First Multispecialty Consensus Meeting on Training in Robot-assisted Surgery.

To improve patient outcomes in robotic surgery, robotic training and education need to be modernised and augmented. The skills and performance levels of trainees need to be objectively assessed before they operate on real patients. The main goal of the first Orsi Consensus Meeting on European Robotic Training (OCERT) was to establish the opinions of experts from different scientific societies on standardised robotic training pathways and training methodology. After a 2-d consensus conference, 36 experts identified 23 key statements allotted to three themes: training standardisation pathways, validation metrics, and implementation prerequisites and certification. After two rounds of Delphi voting, consensus was obtained for 22 of 23 questions among these three categories. Participants agreed that societies should drive and support the implementation of benchmarked training using validated proficiency-based pathways. All courses should deliver an internationally agreed curriculum with performance standards, be accredited by universities/professional societies, and, trainees should receive a certificate approved by professional societies and/or universities after successful completion of the robotic training courses. This OCERT meeting established a basis for bringing surgical robotic training out of the operating room by seeking input and consensus across surgical specialties for an objective, validated, and standardised training programme with transparent, metric-based training outcomes. PATIENT SUMMARY: The Orsi Consensus Meeting on European Robotic Training (OCERT) is an international, multidisciplinary, Delphi-panel study of scientific societies and experts focused on training in robotic surgery. The panel achieved consensus that standardised international training pathways should be the basis for a structured, validated, replicable, and certified approach to implementation of robotic technology.

Multispectral-Fluorescence Imaging as a Tool to Separate Healthy from Disease-Related Lymphatic Anatomy During Robot-Assisted Laparoscopy.

To reduce the invasive nature of extended pelvic lymph node (LN) dissections in prostate cancer, we have developed a multispectral-fluorescence guidance approach that enables discrimination between prostate-draining LNs and lower-limb-draining LNs. Methods: In 5 pigs, multispectral-fluorescence guidance was used on da Vinci Si and da Vinci Xi robots. The animals received fluorescein into the lower limb and indocyanine green-nanocolloid into the prostate. Results: Fluorescein was detected in 29 LNs (average of 3.6 LNs/template), and indocyanine green-nanocolloid was detected in 12 LNs (average of 1.2 LNs/template). Signal intensities appeared equal for both dyes, and no visual overlap in lymphatic drainage patterns was observed. Furthermore, fluorescein supported both the identification of leakage from damaged lymphatic structures and the identification of ureters. Conclusion: We demonstrated that the differences in lymphatic flow pattern between the prostate and lower limbs could be intraoperatively distinguished using multispectral-fluorescence imaging.