End-Effector Contact and Force Detection for Miniature Autonomous Robots Performing Lunar and Expeditionary Surgery.

INTRODUCTION: The U.S. Space Force was stood up on December 20, 2019 as an independent branch under the Air Force consisting of about 16,000 active duty and civilian personnel focused singularly on space. In addition to the Space Force, the plans by NASA and private industry for exploration-class long-duration missions to the moon, near-earth asteroids, and Mars makes semi-independent medical capability in space a priority. Current practice for space-based medicine is limited and relies on a "life-raft" scenario for emergencies. Discussions by working groups on military space-based medicine include placing a Role III equivalent facility in a lunar surface station. Surgical capability is a key requirement for that facility. MATERIALS AND METHODS: To prepare for the eventuality of surgery in space, it is necessary to develop low-mass, low power, mini-surgical robots, which could serve as a celestial replacement for existing terrestrial robots. The current study focused on developing semi-autonomous capability in surgical robotics, specifically related to task automation. Two categories for end-effector tissue interaction were developed: Visual feedback from the robot to detect tissue contact, and motor current waveform measurements to detect contact force. RESULTS: Using a pixel-to-pixel deep neural network to train, we were able to achieve an accuracy of nearly 90% for contact/no-contact detection. Large torques were predicted well by a trained long short-term memory recursive network, but the technique did not predict small torques well. CONCLUSION: Surgical capability on long-duration missions will require human/machine teaming with semi-autonomous surgical robots. Our existing small, lightweight, low-power miniature robots perform multiple essential tasks in one design including hemostasis, fluid management, suturing for traumatic wounds, and are fully insertable for internal surgical procedures. To prepare for the inevitable eventuality of an emergency surgery in space, it is essential that automated surgical robot capabilities be developed.

Outcomes and impact of laparoscopic inguinal hernia repair versus open inguinal hernia repair on healthcare spending and employee absenteeism.

BACKGROUND: This study compares the impact of open (OIHR) versus laparoscopic (LIHR) inguinal hernia repair on healthcare spending and postoperative outcomes. METHODS: The TRUVEN database was queried using ICD9 procedure codes for open, laparoscopic, and robotic-assisted IHR, from 2012 to 2013. Patients > 18 years of age and continuously enrolled for 12 months postoperatively were included. Demographics, patient comorbidities, postoperative complications, pain medication use, length of hospital stay, missed work hours, postoperative visits, and overall expenditure were collected, and assessed at time of surgery and at 30-, 60-, 90-, 180-, and 365-days postoperatively. Statistical analysis was conducted using SAS, with α = 0.05. RESULTS: 66,116 patients were included (LIHR: N = 23,010; OIHR: N = 43,106). Robotic-assisted procedures were excluded due to small sample size (N = 61). The largest demographic was males between 55 and 64 years. LIHR had fewer surgical wound complications than OIHR (LIHR: 0.3%; OIHR: 0.5%, p = 0.007), less utilization of pain medication (LIHR: 23.3%; OIHR: 28.5%; p < 0.001), and fewer outpatient visits. In the 90-day postoperative period, LIHR had significantly fewer missed work hours (LIHR: 12.1 ± 23.2 h; OIHR: 12.9 ± 26.7 h, p = 0.023). LIHR had higher postoperative urinary complications (LIHR: 0.2%; OIHR: 0.1%; p < 0.001), consistent with the current literature. LIHR expenditures ($15,030 ± $25,906) were higher than OIHR ($13,303 ± 32,014), p < 0.001. CONCLUSIONS: The results highlight the benefits of laparoscopic repair with regard to surgical wound complications, postoperative pain, outpatient visits, and missed work hours. These improved outcomes with respect to overall healthcare spending and employee absenteeism support the paradigm shift toward laparoscopic inguinal hernia repairs, in spite of higher overall expenditures.

Long-Term Effectiveness of Strattice in the Laparoscopic Closure of Paraesophageal Hernias.

Prosthetic reinforcement reduces the recurrence rate of large paraesophageal hernias (PEH), but the use of synthetic or biosynthetic mesh in the repair remains controversial. PEH repair has reported recurrence rates of 12% to 42%, and primary repair of PEH by suture closure under tension is at high risk of disruption. Synthetic mesh use in large PEH repair has shown to reduce recurrence but can lead to problems including mesh erosion, ulceration, stricture, and dysphagia. The objective of this study was to examine the long-term safety and efficacy of Strattice biologic mesh, a porcine acellular dermal matrix, in crural reinforcement of laparoscopic large PEH repair. Thirty-five patients with symptomatic PEH (>5 cm) were consented to receive Strattice for PEH repair. Patients were seen in clinic preoperatively, at surgery, and 2 weeks, 6 months, and 12 months postoperatively. Patients were given a standard subjective reflux test at each visit and a 12-month barium swallow X-ray to test for recurrence. Hernia recurrence was documented in 14.3% of cases by the end of the 1-year follow-up. Symptoms improved in 75% to 100% of patients by 6 months, and 33% to 100% of patients were still reporting symptom improvement at 12 months. Strattice mesh in PEH repair results in similar outcomes to other absorbable meshes, and the recurrence rate is within the 12% to 42% range of recurrences reported in studies outside of our institution. The use of Strattice mesh in large PEH repair had results similar to other biomaterial meshes and successfully decreased patients' symptom scores through surgical intervention.

Telesurgery With Miniature Robots to Leverage Surgical Expertise in Distributed Expeditionary Environments.

This study aimed to evaluate the capability of performing telesurgery via radio transmission for military arenas where wired internet connections may not be practical. Most existing robotic surgery systems are too large to effectively deploy with first responders. The miniature surgical platform in this study consists of a multifunctional robot suite that can fit easily into a briefcase. METHODS: The focus of this study is to explore the implications of radio control of the robot. The hypothesis is that an in vivo robot and its control boards can be controlled using off-the-shelf wireless components. An experiment was designed with off-the-shelf wireless components to test the capability of our newest generation of miniature surgical robot to become battery-operated and wireless. RESULTS: Wireless transmission of control signals has provided proof of concept and has exposed areas of the software that can be built upon to improve responsiveness. Wireless transmission of the video feed can be adequately performed with basic off-the-shelf components.

Can surgical performance benchmarking be generalized across multiple outcomes databases: a comparison of University HealthSystem Consortium and National Surgical Quality Improvement Program.

BACKGROUND: Surgeon's performance is tracked using patient outcomes databases. We compared data on patients undergoing laparoscopic cholecystectomy from 2 large databases with significant institutional overlap to see if either patient characteristics or outcomes were similar enough to accurately compare performance. METHODS: Data from 2009 to 2011 were collected from University HealthSystem Consortium (UHC) and National Surgical Quality Improvement Program (NSQIP). UHC and NSQIP collect data from over 200 and 400 medical centers, respectively, with an overlap of 70. Patient demographics, pre-existing medical conditions, operative details, and outcomes were compared. RESULTS: Fifty-six thousand one hundred ninety-seven UHC patients and 56,197 NSQIP patients met criteria. Groups were matched by age, sex, and pre-existing comorbidities. Outcomes for NSQIP and UHC differed, including mortality (.20% NSQIP vs .12% UHC; P < .0001), morbidity (2.0% vs 1.5%; P < .0001), wound infection (.07% vs .33%; P < .0001), pneumonia (.38% vs .75%; P < .0001), urinary tract infections (.62% vs .01%; P < .0001), and length of hospital stay (1.8 ± 7.5 vs 3.8 ± 3.7 days; P = .0004), respectively. CONCLUSIONS: Surgical outcomes are significantly different between databases and resulting performance data may be significantly biased. A single unified national database may be required to correct this problem.

Molecular identification of Mycobacterium chimaera as a cause of infection in a patient with chronic obstructive pulmonary disease.

This report describes a case of Mycobacterium chimaera infection in a patient with a history of chronic obstructive pulmonary disease where the organism was identified by using molecular methods. M. chimaera was identified from fresh lung tissue and from an instrument-negative mycobacterial growth indicator tube broth culture. The utility of using sequence analysis of the internal transcribed spacer region for the rapid identification of a slow-growing nontuberculous Mycobacterium spp. where conventional culture methods were not successful was shown.