Unique robotic vascular surgery procedures.

INTRODUCTION: Based on their experience with robot-assisted vascular surgery, the authors present some unique types of procedures they have performed in this area. METHODS: From November 2005 to February 2022, a total of 560 robotic vascular procedures were performed, of which 70 were orphan operations, corresponding to 12.5%. The most common was robotic decompression of the coeliac trunk (18 times) in Dunbar syndrome, followed by robotic repair of type II endoleak after stent graft implantation (15 times) and robotic repair of splenic artery aneurysm (11 times). Less common were isolated pelvic artery aneurysm surgery (8 times), aortic thromboenderectomy and abdominal aortic patch repair (8 times) and hybrid surgery (6 times). Completely unique are renal artery reconstruction (2 times), operation of internal mammary artery aneurysm (1 time) in a patient with Marfan syndrome and paracaval biopsy (1 time) in a cancer patient. RESULTS: In 3 cases (4.2%) the operation had to be converted to open surgery. Twice in the management of splenic artery aneurysm due to flat adhesions in the abdominal cavity and once in the endoleak operation, when due to the very fragile wall of the dilated and pulsating abdominal aortic aneurysm sac, we considered manipulation with robotic instruments to be highly risky. There was zero mortality in this cohort; one patient had to undergo laparoscopic diaphragm repair for diaphragmatic hernia at another institution after deliberation of the coeliac trunk and in one case open surgery was needed for persistent endoleak. CONCLUSION: The use of the robotic system can be beneficial also in less frequent procedures, offering the patients all the advantages of robotic surgery. However, the need of extensive experience in robotic surgery should be emphasized because these operations are rare and perfect anatomical knowledge of the area is necessary.

Surgical treatment of thoracoabdominal aortic pathology - retrospective study of 300 patients.

INTRODUCTION: Thoracoabdominal aortic surgery is a technically demanding and extensive treatment that has its place in the era of endovascular techniques. To ensure the best possible outcomes, it requires a well-coordinated team of surgeons, anaesthetists, intensive care physicians and other medical staff. METHODS: The authors present a series of 300 patients operated on between 1 January 2003 and 15 March 2022. Although the group included sporadic cases of severe obliterating involvement of the visceral aorta, patients with thoracoabdominal aortic aneurysms (TAAA) constituted the vast majority. All known organ preservation procedures were used during the operations. The thoraco-phreno-retroperitoneal approach was chosen in almost all TAAA cases; the thoraco-phreno-transperitoneal approach was used only in two reoperations. RESULTS: In this cohort, type II thoracoabdominal aneurysm according to Crawford classification was most common (33%). This was followed by type IV (32%), type III (15.3%), type I (8.7%), type V (6.7%) and other thoracoabdominal aortic procedures (4.3%). Thirty-day mortality rate was 9.6% (2019 - 6%, 2020 - 9.5%, 2021 - 3.8%) in this group; surgical postoperative complications occurred in 36 patients (12%). Neurological complications were reported in 16 cases (5.3%), of which postoperative paraplegia was noted 6 times (2%). Temporary postoperative dialysis due to renal insufficiency was performed in 19 patients (6.3%) and 4 patients (1.3%) have entered the chronic dialysis programme. In 67 patients (23.3%), temporary tracheostomy was done postoperatively due to prolonged withdrawal from the lung ventilator. CONCLUSION: Surgical treatment of the thoracoabdominal aorta is one of the most extensive procedures in vascular surgery and the mortality and morbidity rates still remain relatively high. A multidisciplinary approach, sufficient experience and a dedicated team are essential for a successful outcome of these highly specialised operations.

Improving network approaches to the study of complex social-ecological interdependencies.

Achieving effective, sustainable environmental governance requires a better understanding of the causes and consequences of the complex patterns of interdependencies connecting people and ecosystems within and across scales. Network approaches for conceptualizing and analyzing these interdependencies offer one promising solution. Here, we present two advances we argue are needed to further this area of research: (i) a typology of causal assumptions explicating the causal aims of any given network-centric study of social-ecological interdependencies; (ii) unifying research design considerations that facilitate conceptualizing exactly what is interdependent, through what types of relationships, and in relation to what kinds of environmental problems. The latter builds on the appreciation that many environmental problems draw from a set of core challenges that re-occur across contexts. We demonstrate how these advances combine into a comparative heuristic that facilitates leveraging case-specific findings of social-ecological interdependencies to generalizable, yet context-sensitive, theories based on explicit assumptions of causal relationships.

Titanium isotopic evidence for felsic crust and plate tectonics 3.5 billion years ago.

Earth exhibits a dichotomy in elevation and chemical composition between the continents and ocean floor. Reconstructing when this dichotomy arose is important for understanding when plate tectonics started and how the supply of nutrients to the oceans changed through time. We measured the titanium isotopic composition of shales to constrain the chemical composition of the continental crust exposed to weathering and found that shales of all ages have a uniform isotopic composition. This can only be explained if the emerged crust was predominantly felsic (silica-rich) since 3.5 billion years ago, requiring an early initiation of plate tectonics. We also observed a change in the abundance of biologically important nutrients phosphorus and nickel across the Archean-Proterozoic boundary, which might have helped trigger the rise in atmospheric oxygen.

[The da Vinci robot in the field of vascular surgery]. / Uplatnení robotického systému da Vinci v cévní chirurgii.

INTRODUCTION: The aim of this study was to evaluate the clinical experience with 379 robot-assisted vascular procedures performed from November 2005 to December 2016 at our institution. METHODS: A total of 366 cases (96.6%) were successfully completed using the robotic surgical systems da Vinci Standard and da Vinci Xi. RESULTS: Conversion was necessary in 13 patients (3.4%). The 30-day mortality was 0.26% and 2 (0.5%) late prosthetic infections occurred. CONCLUSIONS: From a practical point of view, the greatest advantage of robot-assisted procedures has been the speed and relative simplicity of vascular anastomosis construction. Our experience with robot-assisted surgery has demonstrated the safety and feasibility of this technique in different areas of vascular surgery.Key words: robotic vascular surgery aortic and non-aortic surgery.

Robot assisted Aortic and Non-aortic Vascular Operations.

BACKGROUND: The aim of this study was to evaluate the clinical experience with 310 robot assisted vascular procedures. The da Vinci system has been used by a variety of disciplines for laparoscopic procedures but the use of robots in vascular surgery is still relatively uncommon. METHODS: From November 2005 to May 2014, 310 robot assisted vascular operations were performed. Two hundred and twenty four patients were prospectively evaluated for occlusive disease, 61 patients for abdominal aortic aneurysm, four for a common iliac artery aneurysm, four for a splenic artery aneurysm, one for a internal mammary artery aneurysm, and after the unsuccessful endovascular treatment five for hybrid procedures, two patients for median arcuate ligament release and nine for endoleak II treatment post EVAR. Among these patients, 224 underwent robotic occlusive disease treatment (Group I), 65 robotic aorto-iliac aneurysm surgery (Group II) and 21 other robotic procedures (Group III). RESULTS: A total of 298 cases (96.1%) were successfully completed robotically. In 10 patients (3.2%) conversion was necessary. The 30 day mortality was 0.3%, and two (0.6%) late prosthetic infections were seen. Targeted Group I and Group II patients were compared. Robotic ilio-femoral bypass, aorto-femoral bypass, or aorto-iliac thrombo-endarterectomy with prosthetic patch (Group I) required an operative time of 194 (range, 127-315) minutes and robotic aorto-iliac aneurysm surgery (Group II), 253 (range, 185-360) minutes. The mean aortic cross clamping time was 37 minutes in Group I and 93 minutes in Group II. The mean blood loss was more significant in Group II (1,210 mL) than in Group I (320 mL). CONCLUSION: From a practical point of view, the greatest advantage of the robot assisted procedure has been the speed and relative simplicity of construction of the vascular anastomosis. This experience with robot assisted laparoscopic surgery has demonstrated the feasibility of this technique in different areas of vascular surgery.

Robotic vascular surgery, 150 cases.

BACKGROUND: Based on their experience of 150 robot-assisted vascular reconstructions, the authors not only reflect on the current uses of the da Vinci robotic system in vascular surgery, but also discuss options for the further expansion of this cutting-edge technology in their area of expertise. METHODS: To date there has not been the same level of development in laparoscopy in vascular surgery as in general surgery and, despite the numbers of published studies showing interesting results, laparoscopic vascular surgery has never been generally accepted. Robot-assisted surgery represents a new stage of progress in mini-invasive methods. During the period November 2005-September 2009, the authors performed 150 robot-assisted vascular reconstructions in the aortoiliac area. The most significant include aortofemoral reconstructions and surgery on aneurysms of the abdominal aorta, the pelvic arteries and the splenic artery, as well as their first attempts to perform hybrid interventions. RESULTS: Four cases (2.7%) required conversion to standard surgery and four patients (2.7%) experienced more serious postoperative complications. On one occasion (0.7%) the robotic equipment broke down during the operation and surgery had to be completed laparoscopically. In one case (0.7%) the operation had to be abandoned because the finding on the aorta proved to be inoperable. In the cohort under consideration, the median operating time was 228 min, the median time taken to suture the anastomosis was 27 min and the median clamp time was 39 min. CONCLUSIONS: Robotic operating systems improve the precision, control and dexterity of the surgical procedure and offer patients a higher quality of operating interventions.

[Current potential of robot-assisted vascular surgery]. / Soucasné moznosti roboticky asistované cévní chirurgie.

AIM: Based on experience with 150 robot-assisted vascular reconstructions, the authors discuss current potential applications of the Da Vinci robotic system in vascular surgery, as well as a potential for further use of this new technology in vascular surgery. MATERIAL AND METHODOLOGY: In vascular surgery, laparoscopic methods have never been used as much as in general surgery. Although many studies presenting interesting outcomes have been published, laparoscopic vascular surgery has not been generally accepted. Its main problems include duration of the procedure and, in particular, the vascular staple size and associated difficulties with the vascular anastomosis suturing. However, recently, there have been many revolutionary advancements in medicine, including vascular surgery. Robot-assisted surgery is the next step in the development of miniinvasive methods. From November 2005 to August 2009, the authors performed 150 robot-assisted vascular reconstructions in the aorto-iliac region. Besides aorto-femoral reconstructions, the most significant procedures also included aortic aneurysm procedures, procedures on pelvic and splenic arteries, as well as hybrid procedures. RESULTS: In four cases (2.7%) conversion to classical procedures were required and four subjects (2.7%) developed serious postoperative complications. In a single case (0.7%), the robotic apparatus had a defect during the procedure and the procedure was completed using laparoscopy. In a single case (0.7%), the procedure had to be cancelled because of an inoperable finding on the aorta. The average duration of the procedure in this study group was 228 minutes, the average time required for anastomosis suturing was 27 minutes and the average stapling time was 39 minutes. CONCLUSION: Robotic systems increase accuracy, control and quality of surgical procedures and offer higher quality surgery to patients. The authors managed to reach the world primacy in the field of vascular surgery and the Czech Republic has become a significant world leader in this superspecialized surgical specialty.

Is robotic surgery appropriate for vascular procedures? Report of 100 aortoiliac cases.

AIM: The aim of our study was to evaluate our clinical experience of the da Vincitrade mark system for robot-assisted aortoiliac reconstructions to treat occlusive disease and aneurysm. MATERIAL AND METHODS: Between November 2005 and January 2008 100 consecutive patients were scheduled to undergo robot-assisted laparoscopic aortoiliac procedures. Patients with serious medical problems and those who had previously undergone major abdominal surgery were excluded from the clinical study. Ninety patients were prospectively evaluated for arterial occlusive disease (AOD), seven patients for abdominal aortic aneurysms (AAA), two for common iliac artery aneurysms (CIAA) and one for a combination of CIAA and AOD. RESULTS: Ninety-seven of 100 procedures (97%) were successfully completed robotically, while conversions were necessary in three patients (3%). The median operating time was 235 minutes (range 150 to 360 minutes), with a median clamp-time of 42 minutes (range 25 to 120 minutes). The median anastomosis time was 29 minutes (range 12 to 60 minutes) and median blood loss was 430mL (range 50 to 1500mL). The median intensive care unit stay was 1.7 days and the median hospital stay was 5.1 days. A regular oral diet was resumed after a mean of 2.4 days. Thirty-day survival was 100% and non-lethal postoperative complications were observed in three patients (3%). CONCLUSIONS: Robotic aortoiliac surgery appears to be safe, with a high technical success rate, with operative times and success rates comparable to conventional open surgery. The creation of the aortoiliac anastomosis appears to be quicker, and more accurate than regular laparoscopic techniques.

[Hybrid robot-assisted surgery, aorto-bifemoral bypass with reconstruction of incisional hernia]. / Hybridní roboticky asistovaná operace, aortobifemorální bypass s rekonstrukcí kýly v jizve.

The authors describe their first hybrid, combined robot-assisted surgical procedure. The procedure included robot-assisted aorto-bifemoral reconstruction and robot-assisted incisional hernioplasty in one step. The procedure has not been published in the literature yet, and it indicates that, with certain experience, concomittant management of a secondary disorder may be performed together with a minimally invasive procedure for a primary condition, with a very good outcome.

[Initial experience with da Vinci robotic system in vascular surgery]. / Uvodní zkusenosti s robotickým systémem da Vinci v cévní chirurgii.

Robotic operational systems improve accuracy, control of and skilful management of surgical procedures up to levels unachievable by a human factor itself. A surgeon is also allowed to conduct the types of miniinvasive procedures, which cannot be conducted using contemporary technologies. High degree of the procedure's safety can be achieved. Currently, the robotic surgical systems are used in top clinics worldwide and the concept of the robotic operating theatre is considered to become standard for some procedures in future. In October 2005, a multispecialist robotic centre was opened in the Hospital Na Homolce, which then created a new qualitative standard in the miniinvasive surgical management. The authors present the initial group of patients, who were operated from November 2005 to January 2006 with employement of the da Vinci robotic system, listing its pros and cons.

A modified technique of transperitoneal direct approach for totally laparoscopic aortoiliac surgery.

OBJECTIVE: To present our modification of the transperitoneal direct approach (TDA) for totally laparoscopic aortoiliac surgery. METHODS AND RESULTS: From September 2003 to August 2005 a total of 52 patients underwent laparoscopic operations for aortoiliac disease (50 aortoiliac occlusive disease; two abdominal aortic aneurysm). The modified TDA was used in 20 patients. CONCLUSION: The main advantage of TDA is reduced dissection of the aorta and pelvic arteries resulting in lowered blood loss and lymphatic injury.

[Laparoscopic resection of the abdominal aortic aneurysm]. / Laparoskopická resekce výdute brisní aorty.

Some 500 aortoiliac aneurysms are mostly electively operated in the Czech Republic each year. Miniinvasive approaches already widely accepted in general surgery are gradually becoming more routine in vascular surgery as well. Better patient comfort hand in hand with reduced hospital stay represent the major advantages of these procedures. The authors present their initial experience with laparoscopic AAA resection with the use of their own modification of the transperitoneal-retroperitoneal approach. Ischemic preconditionning's techniques with regard to the expected prolonged aortic clamping time were used during surgery.

[Laparoscopic ilio-femoral by-pass. A case-review]. / Laparoskopicky vedený ilikofemorální bypass. Kazuistika.

The authors introduce a laparoscopically conducted ilio-femoral by-pass operation for the external iliac artery occlusion. The common pelvic artery preparation, the clips application, the arteriotomy and the central anastomosis, all were conducted laparoscopically, the peripheral anastomosis was then carried out through a standard inguinal incision. The laparoscopic approach represents, together with angioplasties and stentgraft implantations, yet another technical variation in vascular surgery.

[Laparoscopic vascular reconstructions--initial experience]. / Laparoskopické cévní rekonstrukce--úivodní zkusenosti.

Laparoscopic techniques, which have been found useful in the general surgical procedures, have influenced the vascular surgical procedures with a certain delay. The main reason for the delay were technical difficulties of the vascular anastomosis, which resulted in a reluctant acceptance of the laparoscopic procedures by vascular surgeons. However, with respect to clear benefits of the miniinvasive procedures, including reduction of the postoperative pain, faster recovery rates and reduction of the total treatment costs, the laparoscopic procedures are finally being applied in the vascular surgery as well. The authors introduce operative results and outcome of ten laparoscopic vascular procedures for aortoiliac occlusive disease, which were conducted from September 2003 to April 2004. In five cases, iliofemoral bypasses were conducted, fourtimes unilateral aortofemoral bypasses (AF) and once an aortobifemoral bypass (ABF). All the IF and AF reconstructions were conducted via laparoscopy and the ABF reconstruction was conducted as laparoscopy-assisted.